HTN Complications of Pregnancy Essential EMS Training Program –Block 2, Lesson 7

What is Hypertension in Pregnancy Blood pressure > 140/90 If Blood pressure is elevated in a pregnant patient, Consider pre-eclampsia But, There is more than just blood pressure that we need to consider

Why is Elevated Blood Pressure Dangerous in Pregnancy? Can progress to preeclampsia with severe features and then to eclampsia Eclampsia Means the Mother (is/or will) have a seizure when she is in labor. Eclampsia is the third leading cause of death to mother and new born child PPH, Infection, Eclampsia

What is Preeclampsia With Severe Features? Pregnancy > 20 weeks Blood pressure > 160/110 Proteinuria (Proteins in the Urine) Photo: Sears.com, www.rcemlearning.co.uk/modules/management-of-haematuria/best-practice-points-urine-dipstick

What is Eclampsia? Convulsions Makes normal delivery impossible Pregnancy > 20 weeks Blood pressure > 160/110 Marked Edema (swelling or weight gain) Protein in the urine Convulsions Makes normal delivery impossible High maternal / child mortality

Importance of recognizing Pre-eclampsia If allowed to progress to Eclampsia then it becomes a Major cause of maternal and fetal morbidity and mortality Prompt recognition and treatment are key Recognition and rapid transport to a Maternal Hospital is essential

Steps in Recognizing Pre-eclampsia Step 1. Obtain History from Patient Patient often knows from Prenatal exam If no prenatal visits, examine patient Step 2. Obtain Vital signs SBP>160 ; DBP>110 Step 3. Examine Patient Evidence of swelling, edema, or large weight gain Protein in urine is easy to measure but impractical on the ambulance. Always ask patient for History. Ask if they have had prenatal visits, what did the DR. say. Were the Dr. concerned about the weight gain, swelling, did they test the urine, How many weeks pregnant are you? (at least 20 +) Testing for Protein in the urine is a simple as a simple dip stick test but it is not necessary to know in the emergency setting.

Recognition and Treatment SBP > 160 DBP >110 Requires Aggressive Treatment Magnesium BP Control Deliver in 12-24 hours . EDEMA (Swelling, Significant weight gain) Safe Motherhood recommends Magnesium treatment after 1 DBP reading > 110 or SBP > 160 ACOG Task force on HTN in pregnancy agrees with above, however recommends reassessing over 4 hour interval, however it can also be reconfirmed at short interval to aid in timely intervention Hypertension in Pregnancy. Report of the ACOG Task for on HTN in Pregnancy. Obstetrics and Gynecology Vol 122, No. 5 Nov 2013.

Assessment and Treatment Always remember to reassess the Initial assessment Assess airway, breathing and circulation every 5 to 15 minutes Further assessment Baseline vitals History Rapid Exam

Rapid Exam Is the Mother in Labor? Vital Signs SBP > 160, DBP > 110 Swelling, significant weight gain Is the Mother Crowning? No Transport rapidly to Maternal Hospital Yes Treatment requires Mg Sulfate and BP Control which most ambulances cannot provide yet.

Always check vital signs in a pregnant patient IMPORTANT POINT! . Always check vital signs in a pregnant patient

QUESTION? In a pregnant patient, which of the following blood pressures would prompt urgent treatment? 165/110 120/95 130/80 120/65

ANSWER! In a pregnant patient, which of the following blood pressures would prompt urgent treatment? 165/110 120/95 130/80 120/65

Advanced Treatment The following slides are advanced treatment options. This is currently only allowed by MD’s and Nurse Midwives. It is outlined here to refresh licensed caregivers in the emergency room and to demonstrate to EMTS the necessity of additional training and the importance of rapid identification and transport

High Risk Patient Care Treatment of high risk patients Place IV Magnesium Sulfate Blood pressure control Eclampsia + seizure treatment Rapid transport to hospital

All pregnant patients with IMPORTANT POINT! All pregnant patients with SBP >160 OR DBP>110 require magnesium .

QUESTION? What is the initial IV bolus dose of Magnesium Sulfate? 1 g

ANSWER! What is the initial IV bolus dose of Magnesium Sulfate? 1 g

Title - 36 1 Ampule 50% MgSO4 = 5 Grams (delivered in 10 ml, or 1 gm per 2 ml)

Magnesium Sulfate Administration 1 Ampule 50% MgSO4 = 10 mL = 5 Grams Initial Dose: 15 G Total (5 G IV+ 10 G IM) How? 5 Grams administered IV Slowly 5 Grams IM in right Gluteal 5 Grams in left Gluteal

IV Administration of Magnesium Sulfate Mix 1 10 mL Amp with 20 mL of injectable saline Inject the 30 mL solution slowly over 15-20 min Patient will complain about pain or hurting as medication is administered which is normal. Administer Slowly

IV Magnesium Sulfate Dosing 10 / 20 / 30 rule Mix 1 10 mL Amp MgSO4 20 mL of injectable saline Inject 30 mL slowly over 15-20 min Photo: Stanford University School of International Medicine

Magnesium Sulphate Dosing IM Infusion Draw 1 10 mL Amp MgSO4 Inject 10 mL into RIGHT buttock Inject 10 mL into LEFT buttock Photo: Stanford University School of International Medicine

If Patient Has another convulsion Administer another 2 gram dose of Magnesium Sulfate IV: 2 G HOW? Take 4 mL from 10 mL amp of 50% MgSO4 Amp Mix these 4 mL MgSO4 with 6 mL of injectable saline Inject the 10 mL of solution slowly over 15-20 min

Magnesium Sulfate Toxicity When giving Magnesium Sulfate watch for Side Effects Apnea / Bradypnea Hypotension Absent lower extremity reflexes (especially at the knee) Toxicity is extremely rare If dosed and administered appropriately Magnesium is very safe

DO NOT give MgSO4 rapidly push-increases risk of apnea Important Point DO NOT give MgSO4 rapidly push-increases risk of apnea .

Magnesium Toxicity If Respiratory Rate is <16/minute or loss of reflexes Stop MgSO4 If the patient stops breathing Open Airway Ventilate with BVM

Magnesium Toxicity If available give calcium gluconate Dose: 1 Gram Administer IV over 10 minutes

Blood Pressure Control Reassess BP after Magnesium Sulfate administration If diastolic BP is >100 mmHg Give antihypertensive medication Medication of choice may be hydralazine

Blood Pressure Control Hydralazine Dosing Initial Dose: 5 mg IV Push over 3-4 minutes May give same dose by IM if no IV

Blood Pressure Management Recheck blood pressure If DBP > 90 mmHg at 30 minutes 2nd Dose: 5 mg IV Repeat to obtain DBP ~90 every 30 minutes Total Max Dose: 20 mg (4 doses)

QUESTION? What is the most important first step in the seizing pregnant patient? 1) Assess airway 2) Check for a pulse 3) Start IV Fluids 4) Check pt.'s Blood Glucose

ANSWER! What is the most important first step in the seizing pregnant patient? 1) Assess airway 2) Check for a pulse 3) Start IV Fluids 4) Check pt.'s Blood Glucose

Additional steps in the Seizing Pregnant Patient Reassess airway, breathing and circulation If drowsy consider place airway adjunct (NPA best tolerated) Provide supplemental oxygen Ensure IV access Check blood glucose If <70 administer dextrose solution Left lateral decubitus position

Question? What is the definitive treatment for Eclampsia? 1) Hydralazine 2) Magnesium 3) Diazepam 4) Delivery

ANSWER! What is the definitive treatment for Eclampsia? 1) Hydralazine 2) Magnesium 3) Diazepam 4) Delivery

Important Point Women with pre-eclampsia and eclampsia must be cared for at a Specialty hospital .

Summary Identify high risk patients >20 weeks Pregnancy AND Severe Hypertension (>160/110) OR Seizures

SUMMARY Treat high risk patients Magnesium (IV and IM) Blood pressure control Hydralazine Further seizure control Control ABC’s Re-dose magnesium Assess glucose Rapid Transport to Specialty Hospital

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