Headaches, Elevated Blood Pressure and Convulsions1.

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Hypertensive syndromes Hypertensive syndromes during pregnancyduring pregnancy

New approaches in the field of New approaches in the field of health of mother and the childhealth of mother and the child

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Goal of lecture:

•Discuss methods of diagnosis and management of hypertension, pre-eclampsia and eclampsia

•Describe the tactics of control of hypertension

•The approaches to the prevention and treatment of seizures in pre-eclampsia and eclampsia

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Problems:Pregnant or have recently given birth  a woman who:Has high blood pressureComplains of a headache or blurred visionFound 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 in mild 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 Prevention of pregnancy-induced hypertensionhypertension

• 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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PreeclampsyPreeclampsy

• 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 preeclampsyMild preeclampsy

• Double marked rise in diastolic pressure to 90-110 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)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-eclampsiaManagement of mild pre-eclampsia (Before 37 weeks). (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 pre-

eclampsia.• While pregnant will not rodorazreshena, symptoms of

preeclampsia disappear.

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Mild preeclampsia (after 37 weeks).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-eclampsiasevere 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-eclampsiasevere 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 - C-

section!

• Do not use local anesthesia or ketamine in women

with pre-eclampsia and eclampsia.

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EclampsiaEclampsia

• 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

• 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 Initial evaluation and management of eclampsiaeclampsia

• 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 WOMANUNATTENDED

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Eclampsia: ConclusionsEclampsia: 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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AnticonvulsantsAnticonvulsants

magnesium sulphatediazepamphenytoin

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Magnesium sulfateMagnesium 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 sulfateMagnesium 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 sulphatemagnesium sulphate

Before the re-introduction, ensure that:Respiratory rate is not less than 16 minutesknee reflexes are presenturine 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 minuteknee reflexes are absenturine output less than 30 ml per hour and last 4

hoursHave 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, Diazepam? (Valium, dormikum, sibazon, seduksen, Relanium)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, Diazepam? (Valium, dormikum, sibazon, seduksen, Relanium)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.

     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 seizureKeeping after seizure

• Prevent the recurrence of seizures• Monitor blood pressure• Prepare for delivery (if it has not happened yet)

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AntihypertensivesAntihypertensives

When blood pressure> 110 mm Hg

Hydralazine (apressin) 5mg / in 5 min., Until blood pressure is not reduced. Repeat every hour for 5 mg or 12.5 mg \ m every 2 hours.

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 (5x6 = 30 mg).

principles:Start antgipertenzivnye

money if diastolic blood pressure> 110 mm Hg

Keep in diastolic pressure at 90-100 mmHg for the prevention of bleeding in the brain

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summarysummary 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