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

1. Headaches, Blurred Vision, Convulsions, Loss of Consciousness or Elevated Blood Pressure Managing Complications in Pregnancy and Childbirth These presentation graphics are based on the guide Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors (2000) by the World Health Organization. These presentation graphics are based on the guide Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors (2000) by the World Health Organization.

2. 2 Headaches, 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

3. 3 Headaches, Blurred Vision, Convulsions Problem Pregnant or recently postpartum woman who: Has elevated blood pressure Complains of headache or blurred vision Is found unconscious or convulsing Pre-eclampsia and eclampsia are serious conditions that must be promptly identified and treated.Pre-eclampsia and eclampsia are serious conditions that must be promptly identified and treated.

4. 4 Headaches, Blurred Vision, Convulsions 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

5. 5 Headaches, Blurred Vision, Convulsions 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 Hypertensive disorders of pregnancy include pregnancy-induced hypertension and chronic hypertension. Headaches, blurred vision, convulsions and loss of consciousness are often associated with hypertension in pregnancy, but are not necessarily specific to it. Other conditions that may cause convulsions or coma include epilepsy, complicated malaria, head injury, meningitis, encephalitis, etc.Hypertensive disorders of pregnancy include pregnancy-induced hypertension and chronic hypertension. Headaches, blurred vision, convulsions and loss of consciousness are often associated with hypertension in pregnancy, but are not necessarily specific to it. Other conditions that may cause convulsions or coma include epilepsy, complicated malaria, head injury, meningitis, encephalitis, etc.

6. 6 Headaches, Blurred Vision, Convulsions 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

7. 7 Headaches, Blurred Vision, Convulsions Pre-Eclampsia Woman over 20 weeks gestation with: Diastolic blood pressure > 90 mm Hg AND Proteinuria The presence of proteinuria changes the diagnosis from pregnancy-induced hypertension to pre-eclampsia. Other conditions (e.g., urinary infection, severe anemia, heart failure and difficult labor) cause proteinuria and false positive results are possible. Dipstick test for protein is a useful screening tool.The presence of proteinuria changes the diagnosis from pregnancy-induced hypertension to pre-eclampsia. Other conditions (e.g., urinary infection, severe anemia, heart failure and difficult labor) cause proteinuria and false positive results are possible. Dipstick test for protein is a useful screening tool.

8. 8 Headaches, Blurred Vision, Convulsions 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

9. 9 Headaches, Blurred Vision, Convulsions 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

10. 10 Headaches, Blurred Vision, Convulsions 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

11. 11 Headaches, Blurred Vision, Convulsions 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

12. 12 Headaches, Blurred Vision, Convulsions 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

13. 13 Headaches, Blurred Vision, Convulsions 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

14. 14 Headaches, Blurred Vision, Convulsions 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

15. 15 Headaches, Blurred Vision, Convulsions 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

16. 16 Headaches, Blurred Vision, Convulsions 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.

17. 17 Headaches, Blurred Vision, Convulsions 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 Close observation for toxicity is required.Close observation for toxicity is required.

18. 18 Headaches, Blurred Vision, Convulsions 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 Magnesium sulfate should only be stopped temporarily if there are certain side effects, such as respiratory depression, decreased urine output or absent reflexes. If a woman is in respiratory arrest, calcium gluconate can reverse the effect of magnesium. Ventilation will be needed.Magnesium sulfate should only be stopped temporarily if there are certain side effects, such as respiratory depression, decreased urine output or absent reflexes. If a woman is in respiratory arrest, calcium gluconate can reverse the effect of magnesium. Ventilation will be needed.

19. 19 Headaches, Blurred Vision, Convulsions 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 If magnesium sulfate is not available, diazepam may be used. If magnesium sulfate is not available, diazepam may be used.

20. 20 Headaches, Blurred Vision, Convulsions 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

21. 21 Headaches, Blurred Vision, Convulsions 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

22. 22 Headaches, Blurred Vision, Convulsions 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 Childbirth should take place as soon as the woman�s condition has stabilized. Delaying childbirth to increase fetal maturity will risk the lives of both the woman and the fetus.Childbirth should take place as soon as the woman�s condition has stabilized. Delaying childbirth to increase fetal maturity will risk the lives of both the woman and the fetus.

23. 23 Headaches, Blurred Vision, Convulsions 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

24. 24 Headaches, Blurred Vision, Convulsions 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

25. 25 Headaches, Blurred Vision, Convulsions 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

26. 26 Headaches, Blurred Vision, Convulsions 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

27. 27 Headaches, Blurred Vision, Convulsions 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

28. 28 Headaches, Blurred Vision, Convulsions 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