07 Headaches and more


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  • EmOC Learning Resource Package These presentation graphics are based on the guide Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors (2000) by the World Health Organization.
  • EmOC Learning Resource Package
  • EmOC Learning Resource Package Pre-eclampsia and eclampsia are serious conditions that must be promptly identified and treated.
  • EmOC Learning Resource Package Hypertensive disorders of pregnancy include pregnancy-induced hypertension and chronic hypertension. Headaches, blurred vision, convulsions and loss of consciousness are often associated with hypertension in pregnancy, but are not necessarily specific to it. Other conditions that may cause convulsions or coma include epilepsy, complicated malaria, head injury, meningitis, encephalitis, etc.
  • EmOC Learning Resource Package The presence of proteinuria changes the diagnosis from pregnancy-induced hypertension to pre-eclampsia. Other conditions (e.g., urinary infection, severe anemia, heart failure and difficult labor) cause proteinuria and false positive results are possible. Dipstick test for protein is a useful screening tool.
  • EmOC Learning Resource Package
  • EmOC Learning Resource Package
  • EmOC Learning Resource Package
  • EmOC Learning Resource Package Close observation for toxicity is required.
  • EmOC Learning Resource Package Magnesium sulfate should only be stopped temporarily if there are certain side effects, such as respiratory depression, decreased urine output or absent reflexes. If a woman is in respiratory arrest, calcium gluconate can reverse the effect of magnesium. Ventilation will be needed.
  • EmOC Learning Resource Package Childbirth should take place as soon as the woman’s condition has stabilized. Delaying childbirth to increase fetal maturity will risk the lives of both the woman and the fetus.
  • 07 Headaches and more

    1. 1. Headaches, Blurred Vision, Convulsions, Loss of Consciousness or Elevated Blood Pressure Managing Complications in Pregnancy and Childbirth
    2. 2. Session Objectives <ul><li>To discuss best practices for diagnosing and managing hypertension, pre-eclampsia and eclampsia </li></ul><ul><li>To describe strategies for controlling hypertension </li></ul><ul><li>To describe strategies for preventing and treating convulsions in pre-eclampsia and eclampsia </li></ul>Headaches, Blurred Vision, Convulsions
    3. 3. Problem <ul><li>Pregnant or recently postpartum woman who: </li></ul><ul><ul><li>Has elevated blood pressure </li></ul></ul><ul><ul><li>Complains of headache or blurred vision </li></ul></ul><ul><ul><li>Is found unconscious or convulsing </li></ul></ul>Headaches, Blurred Vision, Convulsions
    4. 4. General Management <ul><li>Shout for help — mobilize personnel </li></ul><ul><li>Evaluate woman’s condition including vital signs </li></ul><ul><li>If not breathing, check airway and intubate if required </li></ul><ul><li>If unconscious, check airway and temperature, position her on her left side </li></ul><ul><li>If convulsing, position her on her left side, protect from injury but do not restrain </li></ul>Headaches, Blurred Vision, Convulsions
    5. 5. Diagnosis of Elevated Blood Pressure <ul><li>Before first 20 weeks of gestation: </li></ul><ul><ul><li>Chronic hypertension </li></ul></ul><ul><ul><li>Chronic hypertension with superimposed mild pre-eclampsia </li></ul></ul><ul><li>After 20 weeks gestation: </li></ul><ul><ul><li>Hypertension without proteinuria </li></ul></ul><ul><ul><li>Mild pre-eclampsia </li></ul></ul><ul><ul><li>Severe pre-eclampsia </li></ul></ul><ul><ul><li>Eclampsia </li></ul></ul>Headaches, Blurred Vision, Convulsions
    6. 6. Pre-Eclampsia <ul><li>Woman over 20 weeks gestation with: </li></ul><ul><ul><li>Diastolic blood pressure > 90 mm Hg AND </li></ul></ul><ul><ul><li>Proteinuria </li></ul></ul>Headaches, Blurred Vision, Convulsions
    7. 7. Mild Pre-Eclampsia <ul><li>Two readings of diastolic blood pressure 90 – 110 mm Hg 4 hours apart after 20 weeks gestation </li></ul><ul><li>Proteinuria up to 2+ </li></ul><ul><li>No other signs/symptoms of severe pre-eclampsia </li></ul>Headaches, Blurred Vision, Convulsions
    8. 8. Management of Mild Pre-Eclampsia: Gestation Less than 37 Weeks <ul><li>Monitor blood pressure, urine, reflexes and fetal condition </li></ul><ul><li>Counsel woman and family about danger signals of pre-eclampsia and eclampsia </li></ul><ul><li>Encourage additional periods of rest </li></ul><ul><li>Encourage woman to eat a normal diet </li></ul><ul><li>Do not give anticonvulsants, antihypertensives, sedatives or tranquilizers </li></ul>Headaches, Blurred Vision, Convulsions
    9. 9. Management of Mild Pre-Eclampsia: Gestation Less than 37 Weeks (continued) <ul><li>Admit woman to hospital if outpatient followup not possible: </li></ul><ul><li>Provide normal diet </li></ul><ul><li>Monitor blood pressure (twice daily) and urine for proteinuria (daily) </li></ul><ul><li>Do not give anticonvulsants, antihypertensives, sedatives or tranquilizers unless blood pressure or urinary protein level increases </li></ul><ul><li>Do not give diuretics </li></ul><ul><li>If diastolic pressure decreases to normal, send woman home </li></ul><ul><li>If signs remain unchanged, keep woman in hospital </li></ul><ul><li>If there are signs of growth restriction, consider early childbirth </li></ul><ul><li>If urinary protein level increases, manage as severe pre-eclampsia </li></ul>Headaches, Blurred Vision, Convulsions
    10. 10. Management of Mild Pre-Eclampsia: Gestation More than 37 Weeks <ul><li>If there are signs of fetal compromise, assess cervix and expedite childbirth: </li></ul><ul><ul><li>If cervix is favorable, rupture membranes with amniotic hook or a Kocher clamp and induce labor using oxytocin or prostaglandins </li></ul></ul><ul><ul><li>If cervix is unfavorable, ripen the cervix using prostaglandins or Foley catheter or deliver by cesarean section </li></ul></ul>Headaches, Blurred Vision, Convulsions
    11. 11. Severe Pre-Eclampsia <ul><li>Diastolic blood pressure > 110 mm Hg </li></ul><ul><li>Proteinuria > 3+ </li></ul><ul><li>Other signs and symptoms sometimes present: </li></ul><ul><ul><li>Epigastric tenderness </li></ul></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Visual changes </li></ul></ul><ul><ul><li>Hyperreflexia </li></ul></ul><ul><ul><li>Pulmonary edema </li></ul></ul><ul><ul><li>Oliguria </li></ul></ul>Headaches, Blurred Vision, Convulsions
    12. 12. Management of Severe Pre-Eclampsia <ul><li>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 </li></ul><ul><li>Start IV fluids </li></ul><ul><li>Maintain strict fluid balance chart and monitor amount of fluids administered and urine output </li></ul><ul><li>Catheterize bladder to monitor urine output and proteinuria </li></ul><ul><li>If urine output is less than 30 mL/hour: </li></ul><ul><ul><li>Withhold magnesium sulfate and infuse IV fluids at 1 L in 8 hours </li></ul></ul><ul><ul><li>Monitor for development of pulmonary edema </li></ul></ul>Headaches, Blurred Vision, Convulsions
    13. 13. Management of Severe Pre-Eclampsia (continued) <ul><li>Never leave woman alone </li></ul><ul><li>Observe vital signs, reflexes and fetal heart rate every hour </li></ul><ul><li>Auscultate lung bases every hour for rales indicating pulmonary edema. If rales are heard, withhold fluids and give frusemide 40 mg IV once </li></ul><ul><li>Perform bedside clotting test </li></ul>Headaches, Blurred Vision, Convulsions
    14. 14. Management During a Convulsion <ul><li>Give anticonvulsive drugs: </li></ul><ul><ul><li>Magnesium sulfate (first choice) </li></ul></ul><ul><ul><li>Diazepam </li></ul></ul><ul><li>Give oxygen at 4 –6 L/min. </li></ul><ul><li>Protect woman from injury but do not restrain her </li></ul><ul><li>Place woman on left side </li></ul><ul><li>After convulsion, aspirate mouth and throat as necessary </li></ul>Headaches, Blurred Vision, Convulsions
    15. 15. Magnesium Sulfate Loading Dose <ul><li>Give magnesium sulfate 20% solution 4 g IV slowly over 5 min. </li></ul><ul><li>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 </li></ul><ul><li>If convulsions recur after 15 min., give magnesium sulfate 50% solution 2 g IV over 5 min. </li></ul>Headaches, Blurred Vision, Convulsions
    16. 16. Magnesium Sulfate Maintenance Dose <ul><li>IM injections: </li></ul><ul><ul><li>Magnesium sulfate 50% solution 5 g IM + lignocaine 2% solution 1 mL </li></ul></ul><ul><ul><li>Give every 4 hours into alternating buttocks </li></ul></ul><ul><li>Continue treatment with magnesium sulfate for 24 hours after childbirth or after the last convulsion, whichever occurs last </li></ul><ul><li>Before each injection ensure that: </li></ul><ul><ul><li>Respirations > 16 breaths/min. </li></ul></ul><ul><ul><li>Patellar reflex present </li></ul></ul><ul><ul><li>Urine output > 30 mL/hour over 4 hours </li></ul></ul>Headaches, Blurred Vision, Convulsions
    17. 17. Guidelines for Administration of Magnesium Sulfate <ul><li>Withhold magnesium sulfate temporarily if: </li></ul><ul><ul><li>Respiration rate < 16 breaths/min. </li></ul></ul><ul><ul><li>Patellar reflexes are absent </li></ul></ul><ul><ul><li>Urine output < 30 mL/hour during preceding 4 hours </li></ul></ul><ul><li>If woman is unarousable or in case of respiratory arrest: </li></ul><ul><ul><li>Assist ventilation </li></ul></ul><ul><ul><li>Give calcium gluconate 1 g (10 mL of 10% solution) IV slowly </li></ul></ul>Headaches, Blurred Vision, Convulsions
    18. 18. Childbirth <ul><li>Assess cervix </li></ul><ul><li>If cervix is favorable, rupture the membranes with an amniotic hook or a Kocher clamp and induce labor using oxytocin or prostaglandins </li></ul><ul><li>Deliver by cesarean section if: </li></ul><ul><ul><li>Vaginal delivery is not anticipated within 12 hours (for eclampsia) or 24 hours (for severe pre-eclampsia) </li></ul></ul><ul><ul><li>Fetal heart rate is less than 100 or more than 180 beats/min. </li></ul></ul><ul><ul><li>Cervix is not favorable </li></ul></ul>Headaches, Blurred Vision, Convulsions
    19. 19. Childbirth (continued) <ul><li>If safe anesthesia is not available for cesarean section or if fetus is dead or too premature for survival: </li></ul><ul><ul><li>Attempt vaginal delivery </li></ul></ul><ul><ul><li>Ripen cervix (if necessary) using misoprostol, prostaglandins or Foley catheter </li></ul></ul>Headaches, Blurred Vision, Convulsions
    20. 20. Postpartum Care <ul><li>Anticonvulsive therapy should be maintained for 24 hours after childbirth or last convulsion, whichever occurs last </li></ul><ul><li>Continue antihypertensive therapy as long as diastolic pressure is 110 mm Hg or more </li></ul><ul><li>Continue to monitor urine output </li></ul>Headaches, Blurred Vision, Convulsions
    21. 21. Referral for Tertiary Level Care <ul><li>Consider referral of women who have: </li></ul><ul><ul><li>Oliguria that persists for 48 hours after childbirth </li></ul></ul><ul><ul><li>Coagulation failure </li></ul></ul><ul><ul><li>Persistent coma lasting more than 24 hours after convulsion </li></ul></ul>Headaches, Blurred Vision, Convulsions