Title: Headaches, Blurred Vision, Convulsions, Loss of Consciousness or Elevated Blood Pressure
1Headaches, Blurred Vision, Convulsions, Loss of
Consciousness or Elevated Blood Pressure
- Managing Complications in Pregnancy and Childbirth
2Session 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
3Problem
- Pregnant or recently postpartum woman who
- Has elevated blood pressure
- Complains of headache or blurred vision
- Is found unconscious or convulsing
4General 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
5Diagnosis 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
6Management 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
7Pre-Eclampsia
- Woman over 20 weeks gestation with
- Diastolic blood pressure gt 90 mm Hg AND
- Proteinuria
8Mild 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
9Management 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
10Management 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
11Management 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
12Severe 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
13Management 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
14Management 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
15Management 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
16Magnesium 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.
17Magnesium 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
18Guidelines 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
19IV 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
20Rectal 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
21Administration 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
22Childbirth
- 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
23Childbirth (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
24Postpartum 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
25Referral 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
26Complications 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
27Chronic 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
28Chronic 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