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

2. 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

3. 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

4. What is Preeclampsia With Severe Features?
Pregnancy > 20 weeks
Blood pressure > 160/110
Proteinuria (Proteins in the Urine)
Photo: Sears.com,

5. 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

6. 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

7. 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.

8. Recognition and Treatment
SBP > 160
DBP >110
Requires Aggressive Treatment
Magnesium
BP Control
Deliver in 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.

9. 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

10. 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.

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

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

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

14. 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

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

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

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

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

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

20. 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

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

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

23. 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

24. 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 min

25. 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

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

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

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

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

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

31. 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)

32. 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

33. 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

34. 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

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

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

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

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

39. 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

40. Title - 36
Detail - 24