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

Pressure

Managing Complications in Pregnancy and Childbirth

2Headaches, Blurred Vision, Convulsions

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 help—mobilize personnel

! Evaluate woman’s 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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Pre-Eclampsia

! Woman over 20 weeks gestation with:

$ Diastolic blood pressure > 90 mm Hg AND

$ Proteinuria

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Mild Pre-Eclampsia

! Two readings of diastolic blood pressure 90–110 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 > 110 mm Hg

! Proteinuria > 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 4–6 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 > 16 breaths/min.

$ Patellar reflex present

$ Urine output > 30 mL/hour over 4 hours

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Guidelines for Administration of Magnesium Sulfate

! Withhold magnesium sulfate temporarily if:

$ Respiration rate < 16 breaths/min.

$ Patellar reflexes are absent

$ Urine output < 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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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