Monthly CE for hypertensive emergencies in pregnancy for EMS providers. Please note it is broken into sections Also, Please note that the author has no problem with properly trained midwives, nurse midwives, and other providers with training in OB. The author does have a problem with providers who do not have specialty evidence-based training in OB presenting themselves as being able to provide appropriate care to a pregnant patient, particularly when such care is outside of guidelines and outside of the support of the larger healthcare system to handle the unexpected. The author has specifically been on cases where mothers and/or babies have been mismanaged by chiropractors, naturopathic doctors, and lay (unlicensed, minimally or completely untrained) midwives. Formally trained midwives, nurse-midwives, and other providers are an essential part of the larger healthcare system and provide culturally relevant and ethical care that is still supported by the larger healthcare system to reduce fetal and maternal mortality.

1. Over Pressure
ACCESS – CE – 2021 11
Hypertensive Emergencies in
Pregnancy

2. The Tragic Story of
Jenny

3. Case Intro
• Dispatched to local trailor
park for 16 y/o female with
c/o sick
• “Flu”: Nausea x 3 days,
headache, syncope.
• Lethargic. Obviously
pregnant. Slurred Speech.
• Approx. 32 weeks
pregnant (G1P0A0)
• No prenatal care
• Initial V/S:
HR: 130 B/P: 176/100
R: 24 SPO2: 97%

4. Questions to Ponder
• What was Jenny’s issue?
• Was it preventable?
• What were her risk factors?
• What would have been appropriate treatment?
• What do you think the outcome was for her and her baby?

5. Learning Outcomes
• How often does eclampsia occur?
• Describe the Epidemiology of PIH, Pre-Eclampsia, Eclampsia and HELLP syndrome
• Describe the risk factors for PIH, Pre-Eclampsia, Eclampsia and HELLP syndrome
• What is Pregnancy Induced Hypertension (PIH), Pre-Eclampsia, and
Eclampsia?
• Describe the characteristics of PIH, Pre-Eclampsia, Eclampsia and HELLP syndrome
• What causes pregnancy related hypertensive emergencies?
• Describe the Pathophysiology of PIH, Pre-Eclampsia, Eclampsia and HELLP syndrome
• How do I treat pre-eclampsia and Eclampsia?
• Describe the treatment of PIH, Pre-Eclampsia, Eclampsia and HELLP syndrome

6. How often does eclampsia
occur?
Describe the epidemiology of PIH, Pre-Eclampsia, Eclampsia and HELLP syndrome
Describe the risk factors for PIH, Pre-Eclampsia, Eclampsia and HELLP syndrome

7. Approximately 10% of all pregnancies are
complicated by Hypertension in some form.
• Hypertension is the most common medical problem encountered in
pregnancy
• Hypertension can increase maternal and fetal mortality.
• The most common hypertensive disorders are
• Chronic Hypertension in a patient who is pregnant
• Gestational hypertension, AKA Pregnancy induced hypertension (PIH)
• Pre-eclampsia
• Eclampsia
• HELLP syndrome

8. Gestational Hypertensive Disorders
• PIH -> Pre-Eclampsia -> Eclampsia
• Half of these (5%) evolve into pre-eclampsia
• 1-2.5 % evolve into eclampsia
• About ¼ of those who develop pre-eclampsia and eclampsia will also
develop HELLP Syndrome.
• HELLP (Hemolysis, Elevated Liver Enzymes and Low Platelets)
• A sub variant of Pre-eclampsia and eclampsia

9. Definitions
• PIH: Multisystem disorders of unknown etiology characterized by the
development of gestational hypertension after the 20th week of
pregnancy without prior hypertension.
• Note: 50% of cases occur/are detected late in pregnancy after the 36th week.
• Pre-Eclampsia: Multisystem disorders of unknown etiology
characterized by the development of gestational hypertension and
proteinuria after the 20th week of pregnancy without prior
hypertension.
• Eclampsia: Pre-eclampsia when complicated by tonic-clonic siezures
and/or coma.

10. Risk Factors (Gestational related)
• Previous Hx / Family PMHx of gestational hypertensive disorders
• Primigravida
• 75% of cases of pre-eclampsia and eclampsia occur in the first pregnancy.
• Chance of pre-eclampsia in subsequent pregnancies is 30%
• Teen Pregnancy
• Pregnancy >35 maternal age
• Prior damage to placenta in previous pregnancies (abrupto
placenta/placenta previa)
• History of placenta abnormalities

11. Other Factors
• lack of prenatal care
• 80% of cases of eclampsia are preceded by s/s of pre-eclampsia
• This highlights the predictive value of a good prenatal care and evaluation
• Pre-existing HTN
• Renal Disease
• Obesity
• Vascular and connective disorders (Fibromyalgia)
• Lupus
• Prior history of clots (PE, DVT, Stroke, CVA, etc)
• Alcohol and Drug use

12. Risk Factors and Mortality
• 20% of maternal mortality
• 3rd leading cause of maternal mortality world wide
• #1: Bleeding during pregnancy (PIH related disorders also increase this risk)
• #2: Post Partum Infections
• #3: Hypertensive disorders during pregnancy
• #4: Complications during delivery
• #5: Unsafe Abortion
• Source: WHO

13. Risk Factors and socio-
economic status
• Low socio-economic class and low
resourced areas
• 94% of maternal deaths
worldwide occur in low
resourced or low income areas.
• Lifetime risk of maternal death
is 1:5400 in high resourced
areas, 1:45 in low
resourced/low income areas.

14. CDC data

15. CDC data

16. Fetal Mortality
• 30-50% fetal mortality
• Most fetal deaths are due to:
• Delay in delivery
• Ideally w/in 6 hours of
SZ, or sooner.
• Pre-maturity
• Intrauterine asphyxia due to
decreased blood flow or SZ
• Side effects of drugs used to
manage maternal crisis
• Trauma during delivary

18. Over Pressure
ACCESS – CE – 2021 11
Hypertensive Emergencies in
Pregnancy

19. Pathophysiology
Describe the Pathophysiology of PIH, Pre-Eclampsia, Eclampsia and HELLP syndrome
Describe the characteristics of PIH, Pre-Eclampsia, Eclampsia and HELLP syndrome

20. What causes gestational
hypertensive disorders like pre-
eclampsia and eclampsia?
• Exact mechanism is “unclear”
• Primary mechanisms?
• Abnormal Placental
Development/Attachment
• Placental Hypoxia/Ischemia
• Endothelial dysfunction
• Other Factors
• Immunological response to fetus
(similar to graft vs. host d/o)
• Exagerated gestational
Inflammation
• Genetic factors

21. PIH is multi-
system

22. Hypertension in Pregnancy is different
• Remember that pregnant patients are normally hypotensive. Blood
pressure usually decreases by 10-15 mm Hg by end of first trimester -
Heart rate increases 10-15 beats per minute
• Therefore HTN in pregnancy is LOWER than expected.
• SBP 140 mm Hg / DBP 90 mm Hg (x2 separated by 4 hours)
Or
• SBP 160 mm Hg / DBP 110 mm Hg (Single Pressure)
Or
• Systolic ↑30 mm/Hg and/or Diastolic ↑15 mm/Hg
• Note: HTN > 200 SBP is independent predictor of mortality

23. Why do eclamptic patients seize?
• Also unclear
• Possible causes:
• Cerebral Vasospasm causes
anoxic injury and seizure.
• Fluid shift and cerebral edema
• “cerebral dysthymia” caused
by anoxia and edema both,
resulting in excessive release
of excitatory
neurotransmitters.
• Cerebral inflammation
• Put simply, the Brain is angry,
irritable and pissed off.

24. HELLP syndrome
• HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) syndrome
is a life-threatening pregnancy complication usually considered to be a
variant of preeclampsia/eclampsia.
• HELLP patients are more difficult to Dx.
• Mortality up to 25%
• Liver “rupture” and hemorrhagic shock
• Cerebral Hemorrhage
• Typically have most of the symptoms of preeclampsia and:
• Shoulder or chest pain
• Elevated liver enzymes
• S/S of hemolysis and even hemolytic shock
• This can cause the B/P to be low during crisis instead of high
• Tx includes standard Tx and Blood transfusions. Sometimes
corticosteroids as well.

26. Over Pressure
ACCESS – CE – 2021 11
Hypertensive Emergencies in
Pregnancy

27. Assessment
Describe the characteristics of PIH, Pre-Eclampsia, Eclampsia and HELLP
syndrome

28. Remember
Pre-eclampsia and Eclampsia can occur up to 4 weeks post partum.

29. A good assessment is
key
80% of cases of eclampsia are preceded by s/s
of pre-eclampsia

30. An ounce of
prevention
• Quality pre-natal care and management
of risk factors has reduced the
incidence of eclampsia and maternal
mortality.
• This only works if the patient actually
has access to quality pre-natal care AND
the means to manage the risk factors
• When their pre-natal care is not real
pre-natal care
• Chiropractor
• Naturopathic doctor
• Lay midwife

31. Symptoms
• Hypertensive/Cardiovascular S/S
• SBP 140 mm Hg / DBP 90 mm Hg (x2 separated by 4
hours)
Or
• SBP 160 mm Hg / DBP 110 mm Hg (Single Pressure)
Or
• Systolic ↑30 mm/Hg and/or Diastolic ↑15 mm/Hg
• Also: Tachycardia, dysrhythmias - Chest pain
• SYSTEMIC edema:
• Starts at feet and moves up till it becomes systemic.
• Pulmonary edema, JVD. (Think CHF)

32. Importance of accurate Blood Pressures

33. Symptoms
• Neurological and Encephalopathic s/s
• Severe frontal headache with photophobia.
• Visual disturbances
• Altered mentation
• SZ
• Hyperreflexia
• Syncope?
• Hepatic S/S
• Epigastric or RUQ pain,
• jaundice

34. Remember that Eclampsia is a form of
reversible Encephalopathy
• Eclampsia is thought to be a form of posterior reversible
encephalopathy syndrome (PRES) and similar to hypertensive
encephalopathy.
• HTN forces Cerebral edema while paradoxically pushing through
cerebral vasocontraction.

35. Seizures
• Is it a SZ?
• Syncope with confusion after? (Is this a post ictal period?)
• Head Ache, visual disturbances (is this an aura?)
• Seizures?
• A patient who is pregnant and seizing should be
presumed to have eclampsia, even in the presence of a SZ
history, and be transported.

36. Incidence of SZ
• 50% will occur prior to delivery
• 30% will occur for the first time during labor
• 20% will occur post partum.
• Most w/in 48 hours
• Some will occur out to 4 weeks “Late post-partum
Eclampsia”

38. Over Pressure
ACCESS – CE – 2021 11
Hypertensive Emergencies in
Pregnancy

39. Treatment
Describe the treatment of PIH, Pre-Eclampsia, Eclampsia and HELLP syndrome

40. Treatment for
pregnancy induced
hypertension
• Primarily supportive.
• Encourage transport
• Low stimulating
environment.
• Failing transport, stress
importance if immediate and
prompt f/u with OB/GYN

41. BLS Care/AEMT
• Basic care is focused on
assessment and detection
• In cases of suspected pre-
eclampsia (patient not actively
seizing) reduce/eliminate
noxious environmental stimuli
(light, noise, etc.)
• BLS care is otherwise unchanged
from other OB and SZ care

42. If CPR is needed

43. ALS Care: MgSO4
• (OB-02) The role of MgSO4:Different rates of administration in pre-
eclampsia and eclampsia
• Pre-eclampsia (Medical Control Order)
• To Mix: 4 GM/250 ml
• IV/IO: 4 g over 20 minutes (equal vent of 750 ml/hour). Requires a IV Pump
• Repeat as needed to max 8 grams
• Eclampsia (Standing Order)
• To Mix: 4 GM/250 ml
• IV/IO: 4 g over 5 minutes (equal vent of 750 ml/hour). Does not require an IV
pump
• Repeat as needed to max 8 grams
• Maint. Infusion (Both pre-eclampsia and eclampsia)
• To Mix: 5 GM/250 ml
• 2 gm/hour (1– ml/hr)
• Requires an IV Pump

44. How does MgSO4 work?
• Good Question. Anyone? Anyone?
• Longstanding history of use and efficacy. Well studied, but poorly understood.
• In some studies superior to Phenytoin and Benzos in treatment of
eclamptic SZ
• Not all patients respond to MgSO4
• Multifactorial and theoretical.
• Vasodilatation peripherally (reduces hypertension) and Cerebrally (reduces cerebral
vasospasms). May act through Ca channels
• Stabilize the blood brain barrier
• Limits/reduces cerebral edema
• Reduces neuromuscular transmission in pre-eclamptic and eclamptic patients

45. MgSO4 does a lot
• Vasodilatation
• Human uterine arteries from pregnant patients are 3-fold more reactive to
MgSO4 than uterine arteries from nonpregnant patients.
• The Splenic bed (mesenteric vasculature holding up to 6-% of TBV in reserve))
is especially vulnerable to MgSO4 in the pregnant patient.
• MgSO4 reduces level of ACE, thus lowering B/P as well

46. MgSO4: A caution
• Remember, magnesium sulfate can
cause respiratory depression/arrest
with cardiovascular collapse, especially
with rapid IV push.
• Therefore an Infusion via 250 cc over
5+ minutes is generally considered
safer

47. ALS Care: Benzos
• (OB-02) A patient who is pregnant and seizing should be presumed to have
eclampsia.
• If the patient is actively SZ on arrival, or in status seizure, then proceed aggressively
• (OB-02) Magnesium is a priority; however, benzos are quicker to administer
and may be given IM/IN when IV access has not been established or is
difficult
• (OB-02) one provider should administer IN/IM benzodiazepine while the other
provider establishes IV access for Magnesium.
• Valium
• IV/IO: 2-10 mg every 5-10 minutes as needed to maximum 20 mg
• PR: 5-10 mg every 5-10 minutes as needed to maximum of 20 mg
• Versed
• IV/IO: 0.5-2.5 mg every 5-10 minutes as needed to maximum of 5 mg
• IN (intranasal): 5mg (2.5 mg each nare) to maximum total dose 5 mg
• IM: 5mg to maximum dose 5 mg

48. ALS care
• (OB-01) A good history is essential:
• Gestational age and Expected due date
• How many pregnancies (gravida) How many live births (para) How many abortions or
miscarriages
• Pre-natal care
• Number of fetuses
• Any Recent trauma?
• Last fetal movement felt
• Other identified problems
• OB/primary physician & hospital choice
• Amount and type of bleeding/discharge (if applicable)
• If in (or having) Seized, then Basic SZ care (M-05)

49. Emergent IFT
considerations
• EMTALA
• Appropriate destination
• Appropriate staff
• Appropriate capability
• IFT to tertiary care facility
• MgSO4
• Anti-hypertensives
• Phenytoin Infusions
• Cortico-sterioids
• Strongly consider transport with OB
RN or at least additional assistance
in back

50. Transport Destinations (G-03)
• Pregnant Patients:
• A pregnant woman who has received pre-natal care and has an
established physician may be transported to the hospital of choice
• A pregnant woman who has a history of high-risk pregnancies should
be transported facilities with NICU capability.
• The current NICU facilities in the ACCESS response area are: SARMC, SLRMC,
SLMMC, SLNMC (Nampa), and Saint Alphonsus - Garrity.
• Complicated or imminent deliveries from home, medical facilities, or
birthing centers will be transported to the closest appropriate facility
• Question: Where does eclampsia fit in?

51. The Tragic Story of
Jenny
The conclusion

52. Some discussion
• What was Jenny’s issue?
• Pre-Eclampsia - > Eclampsia
• Dx based on 3rd Trimester HTN, SZ, recent Hx of pre-eclamptic s/s (H/A, edema,
syncope)
• Was it preventable?
• Likely Yes
• What were her risk factors?
• Age, Primagravid, Lack of Prenatal care, low socio economic class.
• What would have been appropriate treatment?
• Pre-Eclampsia: MgSO4 4 GM slow infusion on MC order
• Eclampsia: MgSO4 4 GM rapid infusion, Benzodiazepines for SZ, rapid transport to
NICU capable facility on standing order
• What do you think the outcome was for her and her baby?

53. Questions?