Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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: 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: 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 Occurs in 1-3 % of preeclampsia/eclampsia Majority follow eclampsia Tends to resolve within 8 days Differential diagnosis: retinal vasculature damage retinal detachment occipital lobe ischemia occipital lobe edema Management: 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 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 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 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: 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.