Saving Lives: Students Enhancing Patient Health Literacy Regarding Hypertension in Pregnancy and Prenatal Aspirin

Alex A. Francoeur MS4, Jodi Abbott MD MHCM, Pooja S. Vyas MD, Andrea L. Molina MD

Purpose Results

Introduction

Methods

• To reduce health inequities in obstetric outcomes by increasing patient's understanding regarding the complications of hypertension (HTN) in pregnancy and the benefits of prenatal aspirin (PNA).

• To increase medical student’s knowledge, behavior and belief systems regarding HTN in pregnancy and PNA.

Rising maternal morbidity and mortality in the United States disproportionately affects women of color. This has led to the need for obstetric providers to reflect on how to optimize all harm reducing interventions. At BMC, 30% of prenatal patients suffer from complications of preeclampsia, several times higher than the national rate. PNA (81 mg) has been recommended by ACOG at risk women. Only 15% of patients at BMC have heard of PNA, demonstrating high prevalence and low patient literacy regarding the topic. At BUSM, we have demonstrated that medical students can be successful change agents in motivational interviewing and education. Preeclampsia and gHTN: Risk Calculation and Counseling

Student Name: ________________________________________________

Pt MRN (if at BMC): ___________________________Date: ___________ Preceptor signature: ____________________________________________

☐ Prenatal visit ☐ Postpartum

☐ Patient’s risk is assessed, and student determines whether patient qualified for prenatal aspirin now or in a future pregnancy

If patient qualifies currently, compare to patient’s actual orders: do they reflect recommendations? ☐ Yes ☐ No: If no, what orders are inconsistent? Were they changed after discussion with team? Describe below:

Patient Counseling and Education:

Assess patient’s knowledge, teach, reassess. Does the patient:

Pre-counseling

Post-counseling

Know what high blood pressure, hypertension and preeclampsia are

Knows what the warning signs for eclampsia are (Severe headache, visual changes, altered mental status, RUQ pain, chest pain)

Understand that prenatal aspirin is effective and safe at preventing preeclampsia thus preventing complications to mother and baby

☐ Patient counseled about risk factors and need for Prenatal aspirin or not High risk for preeclampsia if any of the following Moderate risk for preeclampsia if 2 or more of the following

● History of preeclampsia ● High blood pressure ● Diabetes ● Multifetal gestation ● Renal disease ● Lupus or antiphospholipid antibody

syndrome

● Nulliparity ● Obesity (BMI >30) ● FHx of preeclampsia (mother or sister) ● African American ● On Medicaid ● 35 years or older ● History of miscarriage ● Previous IUGR, SGA, or other adverse

pregnancy outcome ● >10 years since last pregnancy

If at high or moderate risk, and between 12 to 28 weeks gestation, patient is eligible for prenatal aspirin

• Patients were educated on three key points regarding hypertension and preeclampsia and the effectiveness of the patient educational intervention was evaluated by pre and post intervention metrics.

• Medical students were taught how to perform the counseling in a lecture the first week of the clerkship and were given sample counseling scripts. The student intervention was evaluated with the following domains: satisfaction, knowledge, confidence, and belief systems by surveys at the beginning and end of the clerkship.

Figure 1. Sample form clerkship students filled out when counseling patients

• During the 2018-2019 academic year to date 122 students have counselled 215 patients in their 3rd year ObGyn Clerkship• As a whole, patients increased their knowledge of HTN 217%, warning signs of preeclampsia 440%, and understanding that PNA is safe and effective in

pregnancy by 469%• The QI initiative most increased student’s confidence in counseling patients and their awareness of increased maternal mortality and prenatal aspirin

as a way to prevent some complications in pregnancy• The initiative had the least amount of change in the student’s belief systems, as they were high at baseline• Students reported an average satisfaction level of 6.9 out of 10, and rated the amount of additional work at 3.4 out of 10

Patients are given a lot of information about their health in pregnancy. Provider surveys have identified time as a reason they do not always counsel patients on risk of preeclampsia and safety of PNA. This project found that clinical students could act as health literacy coaches to share important information about their health.

More work needs to be done identifying how to increase 3rd yearstudent satisfaction in performing the counseling. Additionally, patients were tested for comprehension immediately post counseling. It would be useful to see if the patients counseled had recall at a later time or if in their next pregnancy they took PNA and what their outcomes were.

Figure 2. Example of educational materials distributed to patients

Acknowledgements

I want to thank all the third year medical students that have participated in this project and increased patient’s health literacy. This could not have been done without you!

Your pregnancy was complicated by high blood pressure or preeclampsia

What is preeclampsia?▶ It’s a condition that develops during pregnancy

when you have:▶ High blood pressure and ▶ protein in your urine (a sign that your

kidneys aren’t working properly)

Preeclampsia does not always go away after you give birth▶ It can cause symptoms in new moms up to 6

weeks after giving birth(1)

▶ It is important to keep an eye out for symptoms while you are at home recovering from delivery

▶ Your provider might give you medicine to go home with to prevent high blood pressure

Preeclampsia Warning Signs

• Severe HEADACHE that does not go away with Tylenol or ibuprofen

• A change in your vision, for example blurry vision• Confusion • Severe pain in the right side of your stomach • Trouble breathing• Chest pain• Loss of consciousness with shaking movements (a

seizure)

How can I prevent preeclampsia in my next pregnancy?▶ Taking 1 prenatal aspirin (low-dose, 81mg)

every night starting week 12 has been proven to help prevent preeclampsia in at risk women(2)

If you experience any of these warning signs, come back to TRIAGE

References: (1) Delayed postpartum preeclampsia: An experience of 151 cases. Matthys et. Al. Am J Obstet Gynecol. 2004. (2) American College of Obstetricians and Gynecologists. Hypertension in pregnancy. Washington, DC: American College of Obstetricians and Gynecologists; 2013.

Additional postpartum materials available

Presented at QIgrand rounds in

front of students

Presented at QIgrand rounds in

front of students

Discussion