complications of hypertensive disease: a focus on intracranial hemorrhage
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Safe Motherhood Initiativecollaborative 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 PreventableHemorrhage 3 3HTN with ICH 4 3 Cardiac 3 0Sickle Cell 1 0ICH/Aneurysm 2 0TTP with CVA 1 0Lung Ca 1 0AIDS/PCP 1 0Total 16 6/16 (37.5%)
Case 132 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 231 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 326 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 PregnancyBackground
Significant contributors to maternal morbidity and mortality
Classification and Incidence:Preeclampsia (5-8% of pregnancies) Chronic HTN (3% of pregnancies)CHTN with superimposed PreeclampsiaGestational 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: BackgroundRemains a leading cause of maternal mortality4-6/10,000 live birthsSeverity of preeclampsia is a predictor
0.5% of mild, 2% of severe preeclampsiaAdditional risk factors: Nonwhite, nulliparous, lower
socioeconomic, teensUp to 1/3 unheralded by HTN or proteinuriaHistorically, 80% prior to delivery and 20% postpartum (up
to 4 weeks)Recent data demonstrates increase in late postpartum
eclampsia >48 hours after deliveryProdrome is commonOpportunities 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: MedicationsMedication 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
Benzodiazepine
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
VasogenicHyperperfusion from failure of autoregulationIschemia related to vasospasmEndothelial 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
PRESDiagnose on CT or MRI Secondary to anoxia post eclamptic seizureSecondary to loss of cerebral autoregulationTreatment:
Aggressive blood pressure control Preeclampsia management
Temporary BlindnessOccurs in 1-3 % of preeclampsia/eclampsiaMajority follow eclampsiaTends 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 PreeclampsiaVariety 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
Bateman,BT et al Neurology 2006;67:424
Intracerebral hemorrhage: Risk factorsHighest 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
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.
Copyright ©2007 American Heart Association
Modified after Cipolla, M. J. Hypertension 2007;50:14-24
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.
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 ExaminationWarning 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 Action
In-Hospital • Activate acute stroke page STAT
or• Call neurology consult
STAT
Outpatient office • Call 911
Home • Call 911
ICH in the OB patientPrinciples:
Recognition of the signs and symptoms by the obstetric team is crucial
Prompt evaluation and consultation requiredInterdisciplinary management including: obstetrics,
critical care, neurology, neurosurgeryGuidelines exist for treating elevated blood pressure in
spontaneous ICHMonitoring of intracranial pressure may be indicatedSafe medication options exist for the antepartum
patient?maintain cerebral perfusion while prevention
extension?
Summary: ICH in the OB PatientPrevention
Recognize and optimally treat HTNDiagnose preeclampsia and institute seizure
prophylaxisRecognize and optimally treat HTNRecognize and appropriately treat coagulopathy
RecognitionPatients and providers must appreciate the
seriousness of neurologic warning signsManagement
Immediate evaluation of neurologic warning signsImmediate consultation with neurologyImaging
Decreasing Hypertensive CNS Complications in Pregnancy:
Health Care ProvidersRecognize and optimize chronic hypertension, appropriate
baseline work up to use for later comparisonScreen for risk factors and consider increased surveillanceRecognize abnormal blood pressure and/or proteinuriaAppreciate trends: increasing bp, protein, excessive
weight gain/edemaAppreciate intrauterine growth restriction as an early signAsk about signs and symptomsBe aware of atypical presentationsAcknowledge persistent risk in the postpartum periodPatient education
Decreasing Hypertensive CNS Complications in Pregnancy:
PatientsAll pregnant patients should understand signs
and symptoms of preeclampsia: edema, nausea, epigastric or right upper quadrant pain visual disturbances, headache, seizure, temporary
blindnessSigns and symptoms should be reviewed with all
postpartum patients.Patients must understand that if symptoms
present, need emergent evaluation.
Key PointsHypertensive 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 PointsPreeclampsia 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.