Headaches Elevated Blood Pressure and Convulsions 1

Headaches, Elevated Blood Pressure and Convulsions 1

Hypertensive syndromes during pregnancy New approaches in the field of health of mother and the child

Goal of lecture: • Discuss methods of diagnosis and management of hypertension, preeclampsia and eclampsia • Describe the tactics of control of hypertension • The approaches to the prevention and treatment of seizures in preeclampsia and eclampsia Headaches, Elevated Blood Pressure and Convulsions 3

Ø Ø Problems: Pregnant or have recently given birth a woman who: Has high blood pressure Complains of a headache or blurred vision Found unconscious or convulsing Headaches, Elevated Blood Pressure and Convulsions 4

Terminology? Old new • preeclampsia • EPN-preeclampsia • Late pregnancy toxemia • toxemia of pregnancy • nephropathy • "Hypertensive disorders of pregnancy, " according to the International Classification of Diseases, X th review • chronic hypertension • Pregnancy-induced hypertension • easy preeclampsia • severe pre-eclampsia • eclampsia Headaches, Elevated Blood Pressure and Convulsions 5

According to WHO • With hypertensive disorders of pregnancy due to 20 -33%, and according to some estimates up to 40% of maternal deaths. • The perinatal mortality associated with preeclampsia - 13 -30%. • The frequency of hypertensive state in pregnant women ranges from 15 to 20%. Headaches, Elevated Blood Pressure and Convulsions 6

Hypertensive disorders of pregnancy Classification: • Chronic hypertension (hypertension before 20 weeks) • Pregnancy-induced hypertension without proteinuria • easy preeclampsia • severe pre-eclampsia • eclampsia Headaches, Elevated Blood Pressure and Convulsions 7

• Diastolic blood pressure is an indicator for policy making of pregnancy • Diastolic pressure shows peripheral resistance and does not change depending on the emotional state of women • If DBP of 90 mm Hg or more at two consecutive measurements at intervals of 4 hours, it hypertension. • If hypertension develops after 20 weeks, during birth or within 48 hours after birth - is pregnancy-induced hypertension! • If DBP 90 -110 mm Hg up to 20 weeks to 2 proteinuria (1 g l) - Chronic hypertension with mild preeclampsia join! Headaches, Elevated Blood Pressure and Convulsions 8

chronic hypertension • extra rest • Reduction of blood pressure leads to a reduction in renal and placental perfusion. BP should not be reduced below the level that was available at the woman before pregnancy. • If a woman is taking antihypertensive medications before pregnancy, go on! • If DBP 110 mm Hg and more and SBP 160 and assign more antihypertensive drugs • If proteinuria is detected, it is joined as preeclampsia and maintenance in mild preeclampsia. Headaches, Elevated Blood Pressure and Convulsions 9

• Watch for growth and fetal • If no complications – delivery on time • If s / b fetus <100 and> 180 bpm. per minute - disstres fetus! • If severe IUGR fetus shown early delivery • Determination of gestational age in late pregnancy on ultrasound is not accurate! Headaches, Elevated Blood Pressure and Convulsions 10

Pregnancy-induced hypertension - which began after 20 weeks of pregnancy hypertension (systolic blood pressure> 140 mm. Hg and / or diastolic blood pressure> 90 mm Hg), and continuing up to 6 weeks after birth. . Headaches, Elevated Blood Pressure and Convulsions 11

Pregnancy-induced hypertension Maintain outpatient Blood pressure, urine proteinuria fetal weekly! If the blood pressure is raised, as in the management of mild pre-eclampsia In severe IUGR fetus or fetal impairment, to the hospital for pre-term delivery Advise pregnant and her family regarding danger signs of pre-eclampsia and eclampsia If the pregnant woman is shown holding a stable normal labor and delivery Headaches, Elevated Blood Pressure and Convulsions 12

Prevention of pregnancy-induced hypertension • Limitation of , fluid and salt does not prevent the development of IBG and even harmful to the fetus • Not proven positive effects of aspirin, calcium, and other drugs to prevent IBG • Early identification and assistance for women with risk factors is crucial for the treatment of IBG • family Education • Social support Headaches, Elevated Blood Pressure and Convulsions 13

Preeclampsy • Woman with a pregnancy of more than 20 weeks, or have recently given birth, in which: • Diastolic blood pressure> 90 mm. rt. and • Proteinuria 1 g / l • Predisposing factors to the development of eclampsia Headaches, Elevated Blood Pressure and Convulsions 14

Mild preeclampsy • Double marked rise in diastolic pressure to 90110 mm. Hg with an interval of 4 hours after the 20 th week of pregnancy • Proteinuria and 2 + (1 g / l) • Other signs / symptoms of severe preeclampsia are absent Headaches, Elevated Blood Pressure and Convulsions 15

Mild preeclampsia (Less than 37 weeks gestation) If the symptoms are the same and the state normal case 2 times a week on an outpatient basis: Blood pressure, urine for proteinuria, reflexes and fetal Education pregnant and her family regarding danger signs of pre -eclampsia and eclampsia Encourage extra rest! Encouraging proper nutrition! Do not set: anticonvulsants, antihypertensives, sedatives and tranquilizers If outpatient impossible to send to the hospital! Headaches, Elevated Blood Pressure and Convulsions 16

Management of mild pre-eclampsia (Before 37 weeks). • Normal diet (water, salt as you want) • Control of blood pressure 2 times a day • Do not set: anticonvulsants, antihypertensives, sedatives, tranquilizers, to increase blood pressure and proteinuria • Do not set diuretics • If the DBP to normal and the patient's condition improved - Check home • If symptoms do not change, the hospital monitoring of the fetus: • - If the FGR, the show early delivery • - FGR if not, then in the hospital before giving birth • If proteinuria is high, the maintenance of a severe preeclampsia. • While pregnant will not rodorazreshena, symptoms of preeclampsia disappear. Headaches, Elevated Blood Pressure and Convulsions 17

Mild preeclampsia (after 37 weeks). • If there are signs of deterioration of the fruit: it is necessary to assess the state of the cervix and speed up delivery. • If the cervix is ripe possible opening of membranes, in the absence of progression of labor for a few hours, you can apply the induction of labor prostaglandins or oxytocin • If the cervix is immature training opportunities, using prostaglandins, with no effect on labor induction in a few days, so far as the condition of the woman and the fetus, or to schedule a C-section. Headaches, Elevated Blood Pressure and Convulsions 18

severe pre-eclampsia • Diastolic blood pressure> 110 mm Hg • Proteinuria> 3 + • Sometimes the presence of other signs and symptoms: • Epigastric pain • Nausea, vomiting • headache • blurred vision • hyperreflexia • pulmonary edema • oliguria • Precordial pain Headaches, Elevated Blood Pressure and Convulsions 19

severe pre-eclampsia • Delivery should occur within 24 hours of the onset of symptoms. • Eclampsia delivery should occur within 12 hours of the occurrence of seizures. • if birth vaginally are not expected in the specified time -limits indicated cesarean section (eclampsia). • If fetal heart rate <100 or> 180 beats per minute - Csection! • Do not use local anesthesia or ketamine in women with pre-eclampsia and eclampsia. Headaches, Elevated Blood Pressure and Convulsions 20

Eclampsia • Seizures that occur after the 20 th week of pregnancy in women, or within 48 hours after birth, did not have a history of seizures • A small group of women with eclampsia had normal blood pressure Headaches, Elevated Blood Pressure and Convulsions 21

PHASES OF ECLAMPTIC SEIZURE • • Prodromal - 10 -20 seconds Tonic - 20 -30 seconds Clonic - 1 -2 minutes Comatose - lasts minutes to hours, depending on the individual • Resolution period - 20 -30 seconds Headaches, Elevated Blood Pressure and Convulsions 22

PHASES OF ECLAMPTIC SEIZURE(2) • Prodromal - lasts 10 -20 seconds eyes observed reduction of the facial muscles and arms, lost consciousness • Tonic - lasts 20 -30 seconds, the muscles become rigid and unyielding, spasms of the diaphragm, stops breathing, mucous membranes, lips and limbs turn blue, the back can bend, teeth clenched, eyes bulging • Clonic - lasts 1 -2 minutes, strong muscles, increased salivation, frothing at the mouth, shortness of breath, saliva can inhale, his face full of blood, can bite his tongue Headaches, Elevated Blood Pressure and Convulsions 23

PHASES OF ECLAMPTIC SEIZURE(3) • Comatose - lasts minutes to hours, depending on the individual, noisy and fast breathing, her face swollen, but not blue. The possibility of further attacks, so you need diligent care and sedation. Headaches, Elevated Blood Pressure and Convulsions 24

PHASES OF ECLAMPTIC SEIZURE(4) • Resolution period - cramps stop, is intermittent deep breath, his mouth appears foam, often mixed with blood, breathing becomes regular, disappears cyanosis, coma condition develops post eclamptic varying length, to allow, for the restoration of a favorable outcome of consciousness. After an attack develops amnesia. Therefore, if an attack occurred in the absence of others, something about it may indicate only physical injuries (bruises, beaten tongue) and sometimes available at the time of inspection coma. Headaches, Elevated Blood Pressure and Convulsions 25

Initial evaluation and management of eclampsia • • Call for help - mobilize staff Quickly assess breathing and state of mind Check the airway, measure blood pressure and pulse Place the woman on her left side Protect from injury, but do not hold it to actively Start / v infusion needle of large caliber (№ 16) Give oxygen at a rate of 4 liters per minute NEVER LEAVE WOMAN UNATTENDED Headaches, Elevated Blood Pressure and Convulsions 26

Eclampsia: Conclusions Ø Mean blood pressure or diastolic blood pressure in the second trimester can not be used as a prognostic sign of eclampsia Ø Eclampsia begins suddenly, without warning signs, about 20% of women. Headaches, Elevated Blood Pressure and Convulsions 27

Anticonvulsants Ø magnesium sulphate Ø diazepam Ø phenytoin Headaches, Elevated Blood Pressure and Convulsions 28

Magnesium sulfate • Use of magnesium sulfate for the treatment of • Women with eclampsia • Women with urgent delivery because of severe eclampsia • Start the introduction of magnesium sulfate as soon as the decision to delivery is • Continue treatment for 24 hours after delivery or after the last seizure, depending on what was the last Headaches, Elevated Blood Pressure and Convulsions 29

Magnesium sulfate Ø loading dose Ø 15 ml of a 25% solution of magnesium sulfate diluted in three syringes: 5 ml of magnesium and 5 ml of isotonic solution in / jet, very slowly for 5 minutes! Ø Then once with 20 ml in each buttock / m to novocaine! Ø If convulsions recur after 15 minutes to enter an additional 8 ml of magnesia on nat. solution / in 5 minutes! Ø maintenance dose Ø 20 ml of magnesium sulfate / m every 4 hours Ø Continue introduction of magnesium within 24 hours of birth, the last convulsions. Headaches, Elevated Blood Pressure and Convulsions 30

magnesium sulphate Before the re-introduction, ensure that: Respiratory rate is not less than 16 minutes knee reflexes are present urine output less than 30 ml per hour in last 4 hours cancel or postpone the introduction of Mg. SO 4, if: respiratory rate less than 16 per minute knee reflexes are absent urine output less than 30 ml per hour and last 4 hours Have at the ready antidote! Calcium gluconate in / 10% slow to restore breathing and mechanical ventilation if necessary. Headaches, Elevated Blood Pressure and Convulsions 31

Diazepam? (Valium, dormikum, sibazon, seduksen, Relanium) • Only in the absence of Mg. SO 4! • Loading dose: • 10 mg (2 ml), diazepam / in 2 minutes • if convulsions resumed, repeat loading dose. • Maintenance dose: • Diazepam 40 mg in 500 ml saline. solution / drip to maintain the state of sedation, but must be in the mind. Headaches, Elevated Blood Pressure and Convulsions 32

Diazepam? (Valium, dormikum, sibazon, seduksen, Relanium) Ø if the dose exceeds 30 mg per hour may occur respiratory depression: Ø AVL Ø Do not use more than 100 mg of diazepam in 24 hours. Ø rectal: when in / impossible, 20 mg in 10 m. L syringe reg rectum, for 10 minutes. syringe reserve in the rectum. If convulsions recur - an additional 10 mg per hour extra. Headaches, Elevated Blood Pressure and Convulsions 33

Keeping after seizure • Prevent the recurrence of seizures • Monitor blood pressure • Prepare for delivery (if it has not happened yet) Headaches, Elevated Blood Pressure and Convulsions 34

Antihypertensives When blood pressure> 110 principles: mm Hg Start antgipertenzivnye Hydralazine (apressin) 5 mg money if diastolic blood / in 5 min. , Until blood pressure> 110 mm Hg pressure is not reduced. Keep in diastolic pressure at Repeat every hour for 5 90 -100 mm. Hg for the mg or 12. 5 mg m every prevention of bleeding in 2 hours. the brain Labetalol (Atenolol) 100 -25 mg 3 times / day Nifedipine (korinfar, Adalat), 5 mg sublingually, if blood pressure is not reduced, every 15 minutes for up to 6 doses of 5 mg (5 x 6 = Headaches, Elevated Blood Pressure and Convulsions 35 30 mg).

summary ü There are many symptoms of high blood pressure in pregnancy ü It is impossible to predict which patients are at risk to develop severe pre-eclampsia or eclampsia ü Careful monitoring for diagnosis ü After the diagnosis, appropriate treatment can reduce morbidity and mortality ü Should be used anticonvulsant drugs, particularly magnesium sulfate ü Antihypertensive drugs should be used as needed ü Careful monitoring of the side effects of drugs Headaches, Elevated Blood Pressure and Convulsions 36