07 Headaches and more
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Transcript of 07 Headaches and more
Headaches, Blurred Vision, Convulsions, Loss of Consciousness or Elevated Blood
Pressure
Managing Complications in Pregnancy and Childbirth
2Headaches, 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
3Headaches, 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
4Headaches, 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
5Headaches, 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
6Headaches, Blurred Vision, Convulsions
Pre-Eclampsia
! Woman over 20 weeks gestation with:
$ Diastolic blood pressure > 90 mm Hg AND
$ Proteinuria
7Headaches, 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
8Headaches, 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
9Headaches, 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
10Headaches, 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
11Headaches, 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
12Headaches, 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
13Headaches, 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
14Headaches, 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
15Headaches, 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.
16Headaches, 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
17Headaches, 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
18Headaches, 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
19Headaches, 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
20Headaches, 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
21Headaches, 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