Complications of Hypertensive Disease: A Focus on Intracranial Hemorrhage

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 preeclampsia

Additional risk factors: Nonwhite, nulliparous, lower socioeconomic, teens

Up 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 maintenanceIM: 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 autoregulation Ischemia 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 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

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 AssociationModified 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 blindness

Signs 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.