Headaches, Blurred Vision, Convulsions, Loss of Consciousness or Elevated Blood Pressure

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Headaches, Blurred Vision, Convulsions, Loss of
Consciousness or Elevated Blood Pressure

• Managing Complications in Pregnancy and Childbirth

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Session Objectives

• To discuss best practices for diagnosing and
  managing hypertension, pre-eclampsia and
  eclampsia
• To describe strategies for controlling
  hypertension
• To describe strategies for preventing and
  treating convulsions in pre-eclampsia and
  eclampsia

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Problem

• Pregnant or recently postpartum woman who
• Has elevated blood pressure
• Complains of headache or blurred vision
• Is found unconscious or convulsing

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General Management

• Shout for helpmobilize personnel
• Evaluate womans condition including vital signs
• If not breathing, check airway and intubate if
  required
• If unconscious, check airway and temperature,
  position her on her left side
• If convulsing, position her on her left side,
  protect from injury but do not restrain

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Diagnosis of Elevated Blood Pressure

• Before first 20 weeks of gestation
• Chronic hypertension
• Chronic hypertension with superimposed mild
  pre-eclampsia
• After 20 weeks gestation
• Hypertension without proteinuria
• Mild pre-eclampsia
• Severe pre-eclampsia
• Eclampsia

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Management of Pregnancy-Induced Hypertension

• Monitor blood pressure, urine and fetal condition
• If blood pressure worsens, manage as mild
  pre-eclampsia
• If there are signs of severe fetal growth
  restriction or fetal compromise, admit woman to
  hospital for assessment
• Counsel woman and family about danger signals of
  pre-eclampsia and eclampsia

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Pre-Eclampsia

• Woman over 20 weeks gestation with
• Diastolic blood pressure gt 90 mm Hg AND
• Proteinuria

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Mild Pre-Eclampsia

• Two readings of diastolic blood pressure 90110
  mm Hg 4 hours apart after 20 weeks gestation
• Proteinuria up to 2
• No other signs/symptoms of severe pre-eclampsia

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Management of Mild Pre-Eclampsia Gestation Less
than 37 Weeks

• Monitor blood pressure, urine, reflexes and fetal
  condition
• Counsel woman and family about danger signals of
  pre-eclampsia and eclampsia
• Encourage additional periods of rest
• Encourage woman to eat a normal diet
• Do not give anticonvulsants, antihypertensives,
  sedatives or tranquilizers

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Management of Mild Pre-Eclampsia Gestation Less
than 37 Weeks (continued)

• Admit woman to hospital if outpatient followup
  not possible
• Provide normal diet
• Monitor blood pressure (twice daily) and urine
  for proteinuria (daily)
• Do not give anticonvulsants, antihypertensives,
  sedatives or tranquilizers unless blood pressure
  or urinary protein level increases
• Do not give diuretics
• If diastolic pressure decreases to normal, send
  woman home
• If signs remain unchanged, keep woman in hospital
• If there are signs of growth restriction,
  consider early childbirth
• If urinary protein level increases, manage as
  severe pre-eclampsia

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Management of Mild Pre-Eclampsia Gestation More
than 37 Weeks

• If there are signs of fetal compromise, assess
  cervix and expedite childbirth
• If cervix is favorable, rupture membranes with
  amniotic hook or a Kocher clamp and induce labor
  using oxytocin or prostaglandins
• If cervix is unfavorable, ripen the cervix using
  prostaglandins or Foley catheter or deliver by
  cesarean section

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Severe Pre-Eclampsia

• Diastolic blood pressure gt 110 mm Hg
• Proteinuria gt 3

• Other signs and symptoms sometimes present
• Epigastric tenderness
• Headache
• Visual changes
• Hyperreflexia
• Pulmonary edema
• Oliguria

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Management of Severe Pre-Eclampsia

• If diastolic blood pressure remains above 110 mm
  Hg, give antihypertensive drugs. Reduce diastolic
  blood pressure to less than 100 mm Hg but not
  below 90 mm Hg
• Start IV fluids
• Maintain strict fluid balance chart and monitor
  amount of fluids administered and urine output
• Catheterize bladder to monitor urine output and
  proteinuria
• If urine output is less than 30 mL/hour
• Withhold magnesium sulfate and infuse IV fluids
  at 1 L in 8 hours
• Monitor for development of pulmonary edema

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Management of Severe Pre-Eclampsia (continued)

• Never leave woman alone
• Observe vital signs, reflexes and fetal heart
  rate every hour
• Auscultate lung bases every hour for rales
  indicating pulmonary edema. If rales are heard,
  withhold fluids and give frusemide 40 mg IV once
• Perform bedside clotting test

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Management During a Convulsion

• Give anticonvulsive drugs
• Magnesium sulfate (first choice)
• Diazepam
• Give oxygen at 46 L/min.
• Protect woman from injury but do not restrain her
• Place woman on left side
• After convulsion, aspirate mouth and throat as
  necessary

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Magnesium Sulfate Loading Dose

• Give magnesium sulfate 20 solution 4 g IV slowly
  over 5 min.
• Follow promptly with magnesium sulfate 50
  solution 5 g deep IM injection in each buttock
  with lignocaine 2 solution 1 mL deep IM
  injection into each buttock
• If convulsions recur after 15 min., give
  magnesium sulfate 50 solution 2 g IV over 5 min.

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Magnesium Sulfate Maintenance Dose

• IM injections
• Magnesium sulfate 50 solution 5 g IM
  lignocaine 2 solution 1 mL
• Give every 4 hours into alternating buttocks
• Continue treatment with magnesium sulfate for 24
  hours after childbirth or after the last
  convulsion, whichever occurs last

• Before each injection ensure that
• Respirations gt 16 breaths/min.
• Patellar reflex present
• Urine output gt 30 mL/hour over 4 hours

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Guidelines for Administration of Magnesium
Sulfate

• Withhold magnesium sulfate temporarily if
• Respiration rate lt 16 breaths/min.
• Patellar reflexes are absent
• Urine output lt 30 mL/hour during preceding 4
  hours
• If woman is unarousable or in case of respiratory
  arrest
• Assist ventilation
• Give calcium gluconate 1 g (10 mL of 10
  solution) IV slowly

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IV Administration of Diazepam

• Loading dose
• 10 mg IV slowly over 2 min.
• If convulsions recur, repeat dose
• Maintenance dose
• 40 mg in 500 mL IV fluids
• Titrate to keep woman sedated but arousable

• Caution
• Do not give more than 100 mg in 24 hours
• Maternal respiratory depression may occur when
  dose exceeds 30 mg in 1 hour
• Assist ventilation, if necessary

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Rectal Administration of Diazepam

• Use when IV access not possible
• Loading dose is 20 mg in 10 mL syringe
• Remove needle, lubricate barrel and insert
  syringe into rectum to half its length
• Discharge contents and hold barrel in place for
  10 min.
• If convulsions are not controlled in 10 min.,
  repeat with 10 mg

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Administration of Antihypertensive Drugs

• Hydralazine 5 mg IV slowly every 5 min. until
  blood pressure less than 110 mm Hg (goal is to
  have between 90 and 100 mm Hg)
• Repeat hourly as needed or give hydralazine 12.5
  mg IM every 2 hours as needed
• Labetolol 10 mg IV
• If no response in 10 min., give 20 mg IV
• If no response, give 40 mg, then 80 mg IV to
  maximum dose of 300 mg
• Nifedipine 5 mg sublingually
• Repeat once if needed

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Childbirth

• Assess cervix
• If cervix is favorable, rupture the membranes
  with an amniotic hook or a Kocher clamp and
  induce labor using oxytocin or prostaglandins
• Deliver by cesarean section if
• Vaginal delivery is not anticipated within 12
  hours (for eclampsia) or 24 hours (for severe
  pre-eclampsia)
• Fetal heart rate is less than 100 or more than
  180 beats/min.
• Cervix is not favorable

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Childbirth (continued)

• If safe anesthesia is not available for cesarean
  section or if fetus is dead or too premature for
  survival
• Attempt vaginal delivery
• Ripen cervix (if necessary) using misoprostol,
  prostaglandins or Foley catheter

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Postpartum Care

• Anticonvulsive therapy should be maintained for
  24 hours after childbirth or last convulsion,
  whichever occurs last
• Continue antihypertensive therapy as long as
  diastolic pressure is 110 mm Hg or more
• Continue to monitor urine output

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Referral for Tertiary Level Care

• Consider referral of women who have
• Oliguria that persists for 48 hours after
  childbirth
• Coagulation failure
• Persistent coma lasting more than 24 hours after
  convulsion

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Complications of Pregnancy-Induced Hypertension

• Severe fetal growth restriction Expedite
  childbirth
• Increasing drowsiness or coma Suspect cerebral
  hemorrhage
• Reduce blood pressure slowly
• Provide supportive therapy
• Heart, kidney or liver failure Provide
  supportive therapy
• Failure of clot to form after 7 min. Suspect
  coagulopathy
• Woman has IV lines and catheters Use proper
  infection prevention techniques
• Woman is receiving IV fluids Maintain strict
  balance chart and monitor amount of fluids
  administered and urine output

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Chronic Hypertension

• Encourage additional rest
• Determine whether to lower blood pressure using
  medication
• If woman was on antihypertensive drugs before
  pregnancy and disease is well-controlled,
  continue same medication if acceptable in
  pregnancy
• If diastolic blood pressure is 110 mm Hg or more
  or systolic blood pressure is 160 mm Hg or more,
  treat with antihypertensive drugs
• If proteinuria or other signs and symptoms are
  present, consider superimposed pre-eclampsia and
  manage as mild pre-eclampsia

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Chronic Hypertension (continued)

• Monitor fetal growth and condition
• If there are no complications, deliver at term
• If pre-eclampsia develops, manage as mild
  pre-eclampsia or severe pre-eclampsia
• If there are fetal heart rate abnormalities,
  suspect fetal distress
• If fetal growth restriction is severe and
  pregnancy dating is accurate, assess the cervix
  and consider childbirth
• If cervix is favorable, rupture membranes and
  induce labor
• If cervix is unfavorable, ripen cervix
• Observe for complications