Transcript Safe Motherhood Initiative collaborative project of ACOG District II

Complications of Hypertensive Disease:
A Focus on Intracranial Hemorrhage
Safe Motherhood Initiative
collaborative project of ACOG
District II and New York State DOH
• Initiated in 2001
• Voluntary Program
• Onsite maternal mortality reviews
– confidential, protected
• Review of aggregate de-identified data
• Educational programs
Results of 2008 Reviews
Cause
Hemorrhage
HTN with ICH
Cardiac
Sickle Cell
ICH/Aneurysm
TTP with CVA
Lung Ca
AIDS/PCP
Total
Preventable
3
4
3
1
2
1
1
1
16
3
3
0
0
0
0
0
0
6/16 (37.5%)
Case 1
 32 y/o Para 3 with chronic HTN c/o headache, vaginal
bleeding at 31 wks with BP 205/100.
 Rx’d with hydralazine, MgSO4, and delivered
 POD#1 BP 126-150/75-85
 POD#2 12pm c/o HA, BP 148/83 Rx’d with tylenol
 4pm c/o pain in back of head BP 147/94
 6pm pt unresponsive BP190/120, seizures. CT scan –
ICH
 Brain Death
Case 2
 31 y/o Para 1 at 33 wks admitted with BP 250/130
 Rx with labetalol, MgSO4 BP’s 140-160/80-106.
HELLP syndrome, platelets 44,0000
 C/o headache, transfused platelets, cesarean
delivery, GET
 Pt not responsive postop. CT scan – ICH,
herniation
 Brain death
Case 3
 26 y/o P1 2 wks postpartum from uncomplicated
NSD
 BIBEMS with seizure at home, family reported 5
days of headache.
 12 hours prior seen in ED of non OB hospital with
high BP, given lasix and sent home
 CT – ICH, herniation
 Brain death
Hypertensive Disorders in Pregnancy
 Background
 Significant contributors to maternal morbidity and mortality
 Classification and Incidence:
 Preeclampsia (5-8% of pregnancies)
 Chronic HTN (3% of pregnancies)
 CHTN with superimposed Preeclampsia
 Gestational HTN (6% of pregnancies)
 Eclampsia (4 to 6 per 10,000 live births)
CNS Complications of Hypertensive Disorders
in Pregnancy
 Can result in significant maternal morbidity and
mortality
 Seen with increasing frequency in recent statewide
maternal mortality reviews
 Learning objectives:
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Raise awareness of potential CNS complications of
hypertensive disorders in pregnancy
Improve prevention, early recognition, accurate diagnosis
and prompt aggressive management of CNS emergencies.
Preeclampsia-Associated CNS Complications
 Eclampsia
 Intracranial hemorrhage
 Cerebral edema
 Encephalopathy
 Visual disturbances, usually transient
 Ischemia including ischemic stroke
 Vascular thrombosis
Eclampsia: Background
 Remains a leading cause of maternal mortality
 4-6/10,000 live births
 Severity of preeclampsia is a predictor
 0.5% of mild, 2% of severe preeclampsia
 Additional risk factors: Nonwhite, nulliparous, lower socioeconomic,
teens
 Up to 1/3 unheralded by HTN or proteinuria
 Historically, 80% prior to delivery and 20% postpartum (up to 4 weeks)
 Recent data demonstrates increase in late postpartum eclampsia >48
hours after delivery
 Prodrome is common
 Opportunities for prevention:
 Magnesium sulfate
 Timely delivery
Eclampsia: Management
 Prevent aspiration and injury
 Maintain airway, oxygenation, lateral position
 Do not need to try to stop 1st convulsion
 Prevent recurrent seizure with Magnesium sulfate
 10% will have 2nd seizure
 Recurrent seizure first line is rebolus Magnesium sulfate (2g over 15-20 minutes)
 Recurrent seizures refractory to Magnesium or Intractable seizure
 use benzodiazepine, sodium amobarbital, phenytoin
 Any of the following should raise suspicion of another process and prompt
investigation with imaging:
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Atypical presentation
Focal seizures
Postictal focal deficit
Failure to regain consciousness
Eclampsia: Medications
Medication
Indication
Dosage
Mg Sulfate
Seizure prophylaxis
IV: 4-6 g load IV over 15-20 min,
then 2 g/hr maintenance
IM: 5g into each buttock (10g)
Recurrent seizure: rebolus 2g over
15-20 min
Ca Gluconate
Mg toxicity
1 g IV over 10 min
Benzodiazepin
e
Intractable seizure,
status eclampticus
Ativan (lorazepam) 0.02-0.03 mg/kg
IV (1-2 mg), allow 1 min to assess
effect additional (up to a cumulative
dose of 0.1 mg/kg) at a max rate of 2
mg/min
Valium (diazepam) 0.1-0.3 mg/kg
over 1 min, max cumulative dose 20
mg
Cerebral Edema: Background
 Proposed etiologies include
 Vasogenic
 Hyperperfusion from failure of autoregulation
 Ischemia related to vasospasm
 Endothelial damage
 Varying degrees of severity with predilection for occipital
and posterior parietal lobes
 Explains prominence of visual symptoms
 Wide variety described : blurriness, scotomata, cortical blindness,
more rarely distortions of size or color etc.
 Monocular deficits should prompt examination for ocular, retinal or
CN II pathology
Cerebral Edema: Management
 Typically diagnosed based on imaging study
obtained
 PRES
 Diagnose on CT or MRI
 Secondary to anoxia post eclamptic seizure
 Secondary to loss of cerebral autoregulation
 Treatment:
 Aggressive blood pressure control
 Preeclampsia management
Temporary Blindness
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Occurs in 1-3 % of preeclampsia/eclampsia
Majority follow eclampsia
Tends to resolve within 8 days
Differential diagnosis:
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retinal vasculature damage
retinal detachment
occipital lobe ischemia
occipital lobe edema
 Management:
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Neurology consult
Ophthalmology consult
Image with CT or MRI
CNS Bleeding in Preeclampsia
 Variety of types of bleeding reported:
 Petechial hemorrhages without clinically notable
bleeding are commonly seen in imaging studies,
especially in areas of edema
 Subarachnoid hemorrhage and bleeding related to
vascular anomalies reported
 Intracerecral hemorrhage=Intraparenchymal bleeding
responsible for the majority of CNS mortality and
morbidity
Bateman,BT et al Neurology 2006;67:424
Intracerebral hemorrhage: Risk factors
 Highest risks for intracerebral hemorrhage in
pregnancy:
 Preeeclampsia with or without preexisting hypertension
 Coagulopathy
 Other risks include: advanced maternal age, chronic
and gestational hypertension, tobacco abuse, African
American race
Bateman,BT et al Neurology
2006;67:424
Mechanisms for Increased Risk of Intracerebral
Hemorrhage in Pregnancy, Pre-Eclampsia and
Eclampsia
Impaired cerebral autoregulation and alteration of the
blood-brain barrier in pregnancy (animal data):
 Arterial vasoconstriction rather than vasodilatation in response to
serotonin in pregnancy and post-partum
 Impaired arterial remodeling: lack of medial hypertrophy in
pregnant females with chronic hypertension.
 Enhanced permeability of the blood-brain barrier with acute
hypertension in pregnant females.
CBF autoregulatory curves (hypothetical) under various
conditions Solid black line: normal CBF as a function
of CPP. CBF remains relatively constant
between 60 and 150 mm Hg of CPP,
whereas above and below these limits,
autoregulation is lost and CBF changes
linearly with pressure.
Solid red lines: chronic hypertension
(chronic HTN). autoregulatory curve is
shifted to the higher pressures.
Solid blue line: potential shift in the
autoregulatory curve during normal
pregnancy.
Dashed blue line: Loss of autoregulation in
which CBF changes linearly with pressure
and is thought to occur during eclampsia.
The arrows point to pressures at which
cerebral perfusion breakthroughs occur,
demonstrating a large, steep increased in
CBF.
Copyright ©2007 American Heart Association
Modified after Cipolla, M. J. Hypertension 2007;50:14-24
Control of hypertension in obstetrics
 Due to the physiologic changes described, aggressive
treatment of severe hypertension in pregnancy and
postpartum is crucial and may reduce or prevent
complications.
 When is medical management indicated?
- Systolic blood pressure 160-180
- Diastolic blood pressure 105-110
- MAP>125
First Line Agents for Blood Pressure Control
in Obstetrics
Medication
Indication
Dosage
Labetalol
Severe HTN
10-20 mg IV q 10 min, then 40
mg, 60 mg, 80 mg IV q 10 min
up to 300 mg total; IV gtt 1-2
mg/min
Hydralazine
Severe HTN
5-10 mg IV q 20 min up to 40
mg total; IV gtt 5-10 mg/hr
Neurological Warning Signs and Examination
Warning signs
Neurological examination
Sudden confusion, trouble speaking or
understanding
• Level of consciousness
• Language (fluency, comprehension,
naming, repetition, reading, writing)
Sudden weakness or numbness of the
face, arm or leg, especially on one side
of the body
• Facial asymmetry
• Muscle strength in arms and legs
• Sensation (light touch, pin prick)
Sudden trouble seeing in one or both
eyes
• Confrontational visual field testing of
each eye individually
Sudden trouble standing, walking,
dizziness, loss of balance or
coordination
• Nystagmus
• Romberg testing
• Walking (including toe, heel, and
tandem)
• Finger-to-nose and heel-to-shin
testing
Sudden, severe headache with no
known cause
• Fundoscopy
• Evaluate for nuchal rigidity
Immediate action to take when neurological
warning signs or symptoms are identified
Setting
In-Hospital
Action
• Activate acute stroke page
STAT
or
• Call neurology consult
STAT
Outpatient office • Call 911
Home
• Call 911
ICH in the OB patient
 Principles:
 Recognition of the signs and symptoms by the obstetric
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team is crucial
Prompt evaluation and consultation required
Interdisciplinary management including: obstetrics, critical
care, neurology, neurosurgery
Guidelines exist for treating elevated blood pressure in
spontaneous ICH
Monitoring of intracranial pressure may be indicated
Safe medication options exist for the antepartum patient
?maintain cerebral perfusion while prevention extension?
Summary: ICH in the OB Patient
 Prevention
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Recognize and optimally treat HTN
Diagnose preeclampsia and institute seizure prophylaxis
Recognize and optimally treat HTN
Recognize and appropriately treat coagulopathy
 Recognition
 Patients and providers must appreciate the seriousness of
neurologic warning signs
 Management
 Immediate evaluation of neurologic warning signs
 Immediate consultation with neurology
 Imaging
Decreasing Hypertensive CNS
Complications in Pregnancy:
Health Care Providers
 Recognize and optimize chronic hypertension, appropriate baseline
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work up to use for later comparison
Screen for risk factors and consider increased surveillance
Recognize abnormal blood pressure and/or proteinuria
Appreciate trends: increasing bp, protein, excessive weight
gain/edema
Appreciate intrauterine growth restriction as an early sign
Ask about signs and symptoms
Be aware of atypical presentations
Acknowledge persistent risk in the postpartum period
Patient education
Decreasing Hypertensive CNS
Complications in Pregnancy:
Patients
 All pregnant patients should understand signs and
symptoms of preeclampsia:
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edema, nausea, epigastric or right upper quadrant pain
visual disturbances, headache, seizure, temporary blindness
 Signs and symptoms should be reviewed with all
postpartum patients.
 Patients must understand that if symptoms present, need
emergent evaluation.
Key Points
 Hypertensive disorders in pregnancy can lead to CNS
complications which can result in significant
morbidity and mortality.
 Improved patient and provider recognition of
hypertension and preeclampsia may help to improve
outcomes.
Key Points
 Preeclampsia and coagulopathy pose the highest risks
of intracerebral hemorrhage in pregnancy.
 The presence of neurologic warning signs or symptoms
in a pregnant patient requires immediate medical
attention.
 Immediate evaluation by neurology/stroke service is
indicated if neurologic warning signs are identified.