Transcript Pregnancy-induced hypertension

Headaches, Elevated Blood Pressure
and Convulsions
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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
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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
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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
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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%.
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Hypertensive disorders of pregnancy
Classification:
• Chronic hypertension (hypertension before 20
weeks)
• Pregnancy-induced hypertension
• Pregnancy-induced hypertension without
proteinuria
• easy preeclampsia
• severe pre-eclampsia
• eclampsia
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• 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!
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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 Headaches,
in mildElevated
preeclampsia.
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• 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!
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Pregnancy-induced hypertension
Pregnancy-induced hypertension - which began
after 20 weeks of pregnancy hypertension
(systolic blood pressure> 140 mmHg and / or
diastolic blood pressure> 90 mm Hg), and
continuing up to 6 weeks after birth..
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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
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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
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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
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Mild preeclampsy
• Double marked rise in diastolic pressure to 90110 mmHg with an interval of 4 hours after the
20th week of pregnancy
• Proteinuria and 2 + (1 g / l)
• Other signs / symptoms of severe preeclampsia
are absent
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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!
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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:
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- If the FGR, the show early delivery
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- 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.
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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.
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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
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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.
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Eclampsia
• Seizures that occur after the 20th 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
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PHASES OF ECLAMPTIC SEIZURE
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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
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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
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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.
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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.
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Initial evaluation and management of
eclampsia
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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
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Eclampsia: Conclusions
 Mean blood pressure or diastolic blood pressure
in the second trimester can not be used as a
prognostic sign of eclampsia
 Eclampsia begins suddenly, without warning
signs, about 20% of women.
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Anticonvulsants
magnesium sulphate
diazepam
phenytoin
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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
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Magnesium sulfate
 loading dose
 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!
 Then once with 20 ml in each buttock / m to novocaine!
 If convulsions recur after 15 minutes to enter an
additional 8 ml of magnesia on nat. solution / in 5
minutes!
 maintenance dose
 20 ml of magnesium sulfate / m every 4 hours
 Continue introduction of magnesium within 24 hours of
birth, the last convulsions.
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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 MgSO4, 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.
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Diazepam? (Valium, dormikum, sibazon,
seduksen, Relanium)
• Only in the absence of MgSO4!
• 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.
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Diazepam? (Valium, dormikum,
sibazon, seduksen, Relanium)
 if the dose exceeds 30 mg per hour may occur
respiratory depression:
 AVL
 Do not use more than 100 mg of diazepam in 24 hours.
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rectal: when in / impossible, 20 mg in 10 mL syringe
reg rectum, for 10 minutes. syringe reserve in the
rectum. If convulsions recur - an additional 10 mg per
hour extra.
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Keeping after seizure
• Prevent the recurrence of seizures
• Monitor blood pressure
• Prepare for delivery (if it has not happened yet)
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Antihypertensives
When blood pressure> 110
principles:
mm Hg
Start antgipertenzivnye
Hydralazine (apressin) 5mg
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 mmHg 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
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of 5 mg (5x6 = 30 mg). and Convulsions
summary
 There are many symptoms of high blood pressure in
pregnancy
 It is impossible to predict which patients are at risk to
develop severe pre-eclampsia or eclampsia
 Careful monitoring for diagnosis
 After the diagnosis, appropriate treatment can reduce
morbidity and mortality
 Should be used anticonvulsant drugs, particularly
magnesium sulfate
 Antihypertensive drugs should be used as needed
 Careful monitoring of the side effects of drugs
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