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Topic : Hypertensive emergencies and Hypertension in Pregnancy

Posted BY Dr. Emma Karari
01/09/2020
Posted in: Hypertension
58 Comments

Kindly share the biggest challenges you experience in taking care of hypertensive emergencies and hypertension in pregnancy and other special conditions.

Saddam Hassan

In hypertensive emergency what's the take on how fast high blood pressure should be lowered.

Dr. Fadhil Hussein

1. Unavailability of CT scan and ICU services. 2. Less effective case monitoring due to everlasting HCW:patient dispropotion. 3. Inadequate emergency response tools like sound systems and hosptal codes activation.

Effat Abdulwahab

Pregnancy and hypertension can be a challenge to deal with. Condition such as isolated systolic hypertension or persistent hypertension despite medicine can be a challenge. Monitoring the bp is also not very easy during these circumstances as well as detection of complications. There are times we are limited to certain drugs only ....and control of bp becomes a challenge in resource limited setups.

Mbarak Mbarak

No Emergency response and monitoring systems in place, leading to delayed diagnosis and management. Lack of emergency drugs such as Labetalol, only available option is hydralazine with its attendant adverse effects. No HDU/ICU for management of critical patients leading to high mortality rates in these conditions.

Dr. Mohamed Naji

Lack of first responders in our healthcare system leads to delays in the diagnosis and reaching of patients within the appropriate time lines. unavailability of ct scans leads to a further delay in confirming the diagnosis of cva thus delay in responding to the right treatment. lack of iv antihypertensives for management of hypertensive emergencies. lack of icu/hdu facilities for proper care and management of hypertensive emergencies.

Dr. QHALIB ALI ABDI

The biggest challenge in management of hypertensive emergency and hypertension in pregnancy are; 1. Unavailability of Icu space- In the whole of Embu county the only ICU facility available is at Embu Level 5 hospital which has 4 bed capacity that is not enough to care for critical care emergencies, for patients with hypertensive virus or eclampsia and other hypertensive complications in pregnancies it is hard to get space for the patients to be assisted. 2. Unavailability of drugs- sometimes labetolo and otherIv antihypertensive medications are not available in the hospital this makes it hard for us to manage patients. 3. Specialist/ cardiologist- for conditions which require a more specialist input interms of a cardiologist it is hard to get,most of the times patients are referred to a more specialised facility like Knh.

Dr. Ivy Barasa

The biggest challenge in taking care of hypertensive emergencies is in the offering of rehabilitative or palliative care to patients with end organ damage. Patients with CVD may receive physiotherapy which they may or may not adhere to. Those with intracerebral bleeds that can not be drained sadly circum to the complications. Individuals with cardiac complications arising from hypertensive emergencies also do have complex care plans that may not be feasible for their families. The biggest challenge in hypertension in pregnancy is the continuation of the Mg SO4 24 hrs from the time of delivery or last seizure in an Eclamptic mother. This is mostly due to lack of a clear understanding on the importance of this practice once the mother delivers by the nurses. This is however improving.

Zainab Bagha

1)lack of adequate equipment eg ct scan machine... sometimes present but broken down 2)lack of drugs eg labetalol... if present then patients are told to buy and most of them cannot afford 3)Timely management of severe preeclampsia not done hence progress to eclampsia which ends up having very adverse outcomes for both mother and baby 4)difficulty keeping up with MgSO4 schedule

STELLA SOITA

Lack of enough ICU space, Lack of drugs required to manage hypertension like labetalol Monitoring these patients in our setup is usually hard at times considering the amount of work load at the time Patience in adherence and follow up in the required clinics, Over bookings in the required clinics making TCA length unbearable and therefore patient fall out in follow ups, hence seeking medical advice elsewhere

Charles Ndirangu

Some of the main challenges in managing hypertensive emergencies and hypertension in pregnancy include: 1. Late presentation/delayed referrals- some patients for many reasons present to the hospital quite late and sometimes they present to the dispensaries,health centres or even some hospitals whose staff aren't well versed with management and so precious time is lost before they get to a facility where proper management can be done. Some facilities, due to improper triaging unnecessarily keep patients waiting in the queues. The decision to refer the patients is not made in time and most of the times, transport to the higher level hospital is unavailable. 2. Lack of knowledge by some health care workers at the first point of contact with tthe patient. Wrong medication, failure to recognize the emergency and other comorbidities,delayed referrals are some of the challenges at the Lower level facilities and also at casualty/A&E departments of the higher level facilities. 3. Lack of essential medications and other equipment. Some of the drugs required fror management of these emergencies such as labetalol, hydralazine are rarely available. Intensive monitoring equipment and services is ICU, HDU,monitors,Defibrillators, support services such as CT scan/MRI are unavailable in most facilities which derails and delays timely diagnosis and initiation of proper management.

Charles Ndirangu

Some of the main challenges in managing hypertensive emergencies and hypertension in pregnancy include: 1. Late presentation/delayed referrals- some patients for many reasons present to the hospital quite late and sometimes they present to the dispensaries,health centres or even some hospitals whose staff aren't well versed with management and so precious time is lost before they get to a facility where proper management can be done. Some facilities, due to improper triaging unnecessarily keep patients waiting in the queues. The decision to refer the patients is not made in time and most of the times, transport to the higher level hospital is unavailable. 2. Lack of knowledge by some health care workers at the first point of contact with tthe patient. Wrong medication, failure to recognize the emergency and other comorbidities,delayed referrals are some of the challenges at the Lower level facilities and also at casualty/A&E departments of the higher level facilities. 3. Lack of essential medications and other equipment. Some of the drugs required fror management of these emergencies such as labetalol, hydralazine are rarely available. Intensive monitoring equipment and services is ICU, HDU,monitors,Defibrillators, support services such as CT scan/MRI are unavailable in most facilities which derails and delays timely diagnosis and initiation of proper management.

Dr. Cedric Tumbo

Lack of majority of important medication especially at the specific time of the emergency. How fast to lower the BP especially in progressing preeclampsia. Lack of an ICU setting/bp monitoring personnel(human resource).

Dr. Haji Musuko

The challenges in Hypertensive emergencies management at the health facility levels is lack of standard operating procedures in blood pressure control.Different hospitals have different management protocol. In the public hospitals eg Kilifi County , there are no CT scan services available. We depend on private facilities for CT scan at very exorbitant cost. Lack of emergency drugs at the emergency department. Lack of resuscitation equipments at the emergency department is common in our public facilities. There is lack of rehabilitation and palliative care services in lower level health facilities. Hypertension in Pregnancy remain a common challenge in the public health sector.Lack of drugs and laboratory investigations is a big challenge. Late diagnosis in primary health care facilities remain a challenge .Hypertension in pregnancy has poor outcomes.

Naomi Munywoki

Lack of drugs and ICU/ HDU

Uzma Bagha

Challenges include: 1. Lack of resources eg labs, medications, fundoscope. 2. Lack of skills in fundoscopy. 3. Poor follow up for patients who are pregnant. 4. Lack of knowledge by health care workers on initial management of Patients who are pregnant. You get people on wrong medication

Geoffrey Sangany

We lack I.V anti hypertensives like labetalol, and as highlighted above... drugs such as hydralazine and nifedipine lower the pressures quite rapidly making it difficult to monitor our patients. There is also lack of devices for continuous monitoring of vitals and ICU facilities at the county level.

Michael Milimu

1. Dealing with hypertensive urgency with DKA at the same time. 2. Lack of proper monitoring capacity at the clinics and emergency cases. 3.lack of set up sops and protocols 4.finacial constraints on the patient side hindering investigations and limiting my prescriptions.

Dr. Maureen Maleche

1.The main challenge is unavailability of key intravenous drugs for hypertensive emergencies like labetalol, hydralazine and nicardipine in the facility 2. Unavailability of enough ICU care for the critically ill patients lack of diagnostic eqiupment and the skills to operate and interpret the results for example, CT scan/MRI brain, ECG/ECHO, fundoscopy and arterial blood gas analysis machines. 3. Inaccessibility to current updates/protocols on hypertension management in the county due to lack of specialists in internal medicine. 4. commorbidity conditions that would otherwise make it difficult to control blood pressure or initiate drugs to lower the blood pressure like contraindications to some medications because of side effects(hydralazine in a pregnant woman with SLE) ,massive infarcts in the brain or very old patients

Khuweillah Rudainy

The biggest challenges is in the late presentation of hypertensive emergencies. Once confirmed by imaging as hemorrhagic stroke, patients are usually kept on supportive management either within the wards due to unavailability of space in HDU or taken to under-equipped HDU where frequent monitoring is the only care given. Pre-eclampsia with severe features and eclampsia are the leading causes of maternal mortality and morbidity now, and late recognition by health care workers worsens the prognosis as it delays treatment.

Alfred Bikeri Manduku

1 lack of essential medication and equipment 2 unavailability of specialists wherever needed 3 financial constraint some patient can't afford ICU services / medications 4 unavailability of ICU/ HDu

Evans Wanyama

1. Patients present late for management. 2. Lack of essential medicines and where available patients' economic status cannot allow them to access the same on time. 3. Lack of diagnostic and necessary equipment for patient monitoring.

Pauline Kamau

1.late presentations and or delayed referrals from peripheral facilities. 2.Loss or lack of followup in patients with existing hypertension i.e most of patients who presents with Hypertensive emergencies were once on medications but reached a certain point and stopped 3.lack of knowledge about causes and course of hypertension with some healthcare givers in that once a patient bloodpressure normalizes,they are advised to stop medications and hence most presents with target organ damage esp subarachnoid hemorrhage and coupled with lack of diagnostics equipments ie CT SCAN and lack of advanced life support services ,it proves hard to manage this patients. 4.HTN in pregnancy is very common but a diagnosis made too late when patient is already in severe PET,it becomes a challenge when the essential drugs and lab investigations cannot be accessed on time resulting to mortalities. In addition to cormobidities and lack of ICU facilities. 5.lack of Health Education to patient with hypertension is a big challenge,most patient are not aware of what it means to be hypertensive ,repercussions of defaulting medications and loss of followup and hence they are not keen on bloodpressure checkup and at the end of the day they use the initial prescription possibly two years old as all they know is fillups. 6.lack of enough personnels ie approach to this patients requires amultidisciplinary approach . .

mutwiri rarama

1. The greatest challenge in my opinion is the unavailability of proper equipment and trained personnel to adequately evaluate and manage a patient who comes with a hypertensive emergency. In our set-up there's no ECG, Echo, CT scan, or Cardiac biomarkers in the facility and patients have to be referred which really makes it difficult to achieve good outcomes. 2. Primary delays in seeking healthcare also hinder our ability to handle these emergencies in a timely manner. This is more common among the male patients and our less educated mothers who show up with severe preclampsia and at times Eclampsia when it's already abit too late. 3. Unavailability of the appropriate emergency drugs in our Hospital to handle some of the HTN emergencies.

Dr. Aarif Varvani

As regards Hypertensive emergencies, the main problems are: 1) Lack of timely Head CT scans especially when it comes to CVA so that blood pressure lowering is done accordingly. 2) Unavailability of essential medications that can help lower blood pressures fast e.g. IV. Labetalol 3) Time of presentation: Most patients with ISCHEMIC CVA present after the window period of thrombolytic therapy. 4) Limited ICU bed space. 5) Limited availability of neurosurgical services especially when it comes to hemorrhagic strokes that can benefit from interventions like placement of an EVD As regards HTN in pregnancy: 1) Unavailability of drugs that are allowed. In most areas, the only available drugs are nifedipine and alpha methyldopa. Beta Blockers are widely unavailable. 2) Lack of appropriate referral and follow up leading to patients who continue use of drugs that are contraindicated during pregnancy eg ACE-i, ARBs etc.

Florence Karanja

Unavailability of required IV medication e.g labetalol , ICU/HDU system needed for close monitoring of the patient,lack of imaging modalities like CT scan leading to delayed diagnosis and management.

Jane Kenani

Unavailability of drugs especially labetalol in public facilities and them being quite expensive to most of the patients. Insufficient beds for the uncontrolled eclampsia cases and late laboratory results. Lack of or rather having non-functioning ECG machines and ECHO as well. Untimely diagnosis of hypertensive emergencies that renders poor management.

Dr. Timothy Kaleli

Late patient presentation especially for the strokes which inevitably leads to poor patient outcomes. Unavailability of imaging (CT), ECHO, ECG leads to delays in diagnosis. Lack of HDU, ICU services and IV drugs for BP control. Inefficient referral systems which delays intervention even after diagnosis.

Fredrick Otieno

Complications 1. Late presentations and maternal near miss cases: The antenatal care take is quite average w/ some mothers attending ANC one or twice the pregnancy period. This means that most cases present at the severe form or even in eclamptic state. 2. Drugs: The available parenteral anti-HTNs is Hydralazine, which most practitioners are not quick to use following the worrisome associated complications. The fear of crushing the BPs faster and the fact that it requires one to be at the point of care to be administered. 3. Feto-maternal surveillance requires more input including the introduction/ use of Livkan charts. 4. Investigations and Imaging modalities. Without appropriate Investigation and imaging the differentials are limited and thus most cases are missed. Examples: Missed case of hyperthyroidism in pregnancy. Treated for Preeclampsia several weeks later. Another case of AVM treated for eclampsia w/o response. Long lists just to mention but a few.

Caroline Bichii

1. Exactly how to administer drugs such as Labetalol in the acute setting to lower blood pressure within the allowed limits. We have encountered several episodes of hypotension necessitating inotropic support on patients put on Labetalol infusion. 2. Lack of enough ICU/HDU bed space to closely monitor the patients and/or provide airway protection. 3. Delay in performing necessary imaging like Head CT scans that make us miss the critical window for administering thrombolytic therapy in cases of ischemic stroke and delay adequate blood pressure lowering in cases of hemorrhagic stroke. 4. Management of patients who sustain severe cerebrovascular accidents who end up in ICU and remain in vegetative states for a long duration with little we can do to rehabilitate them.

Priscilla Mbigo

1. Late presentation in the cases where end organ damage has occurred owing to poor follow up and non compliance to medication by the patients. 2. Unavailability of drugs necessary to lower the BPs in the acute set up, coupled with lack of standardization in management which varies acoording to hospital protocols in the resource limited set up. 3. Lack of investigations for diagnosis and follow up of patients, some which have to be outsourced in the private facilities at the patients cost, which most can't afford and thus delaying the management and causing further ens organ damage.

Robert Ngasa

Lack of emergency iv antihypertensive drugs, Workups and intensive Unit makes the task uphill

Dr. Rajab Idris

Resource limitations- unavailability of essential drugs and lab work eg uecs for follow up of patients and initial assessment/management..lack of intensive care facilities plus a lot of beauracracy in the referral system.

Dr. Ngugi Wamuyu

The biggest challenge in managing Parients with hypertension in pregnancy especially PET and Ecclampsia is Lack of technical expertise on magnesium sulfate administration among nurses and clinicians thus its mostly administered wrongly even when prescribed accurately. Secondly ,lack of ICU facilities in our facilitiy has limited our capacity to handle efficiently patients who need ICU secondary to organ failure post PET/ecclampsia. Thirdly most practitioners fear administration of IV anti hypertensives like IV labetalil and IV hydralalazine thius delays jb treatment.. Haldling elevated blood pressures in the setting of DKA where aggresive rehydration is needed can ne a challange too.

Dr. Tendwa Ongas

1.Late presentation and issues with timely patient transfers whereby they arrive in critical condition due to prolonged transfer processes. 2. Unaivailability of imaging modalities and when there most times the patients are unable to afford it hence impeding management of the condition

Clement Kanyiri

The major issue is luck of proper medication in the facility, especially at night. Hence one has to use the medication available as per that time. Luck of supportive units i.e ICU when need be contribute to mortality or worsen the morbidity.

Bella Juma

No reagents in the lab,poor monitoring and follow up of patients

Ms. amina noor

The biggest challenge is the lack of parenteral antihypertensives and delayed presentation of the patients.lack of finances of patients to be initiated on hemodialysis.

tobias odhiambo

the biggest challenge in my set up is that most clients who present with hypextensive emergencies either lack nhif or financial power to afford the necessary imaging modalities such as head ct scan, this scenario makes it difficult to give the required treatment in time, since most hospitals don't waiver such clients. this has increased some avoidable mortalities.

Muthoni Maina-Luzing'a

Lack of capacity at the facility to handle the emergencies:erratic supply of lab reagents and meds. No CT scan radiology available. No ICU available. Late presentation of the emergencies, with sequelae already set in, hence nothing much can be done, also with high mortality.

Emily Ndiang'ui

access to prompt imaging eg ct scans as well as emergency drugs.

Umulker Haji

The greatest challenge i experience was l: 1) patient factors: late presentations and maternal near miss cases. Most patient dont believe in attending ANC visit throughout there pregnancies. As Some patient in my facility Attend 1 ANC visits , others even fail to attend completely, hence some come in with eclampsia and other complications during delivery. 2) Pt don’t attend clinic for followup postpartum 3) Bp monitoring not done in puerperal period as postpartum hypertension not picked 4)lack of some iv antihypertensive meds not available in the facility

Abdikadir A. Adow

Some of the challenges include: poor antenatal follow up in known HTN in pregnancy,lack of updates on when management of PET and eclampsia among different cadres. Lack of intensive care and proper investigations.

Tommy Temesi

Biggest challenge I gave in managing the said conditions is lack of IV drugs for rapid control of BP and unavailability of investigations required to assess target organ damage and evaluate progress of management

Dr. Pateti Kelvin

Late presentation of the cases, lack of diagnostic capability, CT scan and specialist to report the findings, Echo, ECG, lack of medications in the hospital. Inadequate specialists, no ICU and HDU. No supporting laboratories investigations in management of the patients and follow up. Above all cost implications in the patients to get the services done especially CT scan timely flow and management.

BONFACE ATANDI OMARE

In my set up we lack proper screening for early detection of hypertensive patients because 1.No proper medical out patient clinics MOPC monitored by medical officer due to shortages 2.cant do hypertensive lab investigations like UEC's ,lipids profile,LFT's 3.Lack of basic hypertensive drugs 4.Non compliance to medications 5.Pregnant mother never attended Clinic ANC. 6.social stigma especially pastrol community(when declared hypertensive) 7.we don't have ICU/HDU or CT 8.Economic constrains to purchase medications

BONFACE ATANDI OMARE

In my set up we lack proper screening for early detection of hypertensive patients because 1.No proper medical out patient clinics MOPC monitored by medical officer due to shortages 2.cant do hypertensive lab investigations like UEC's ,lipids profile,LFT's 3.Lack of basic hypertensive drugs 4.Non compliance to medications 5.Pregnant mother never attended Clinic ANC. 6.social stigma especially pastrol community(when declared hypertensive) 7.we don't have ICU/HDU or CT 8.Economic constrains to purchase medications

Benard Owino

1-many health workers are not familiar with guidance on how fast BP should be lowered in hypertensive emergency. 2-How low should the BP be lowered in hypertensive emergency 3-Lack of ideal drugs in remote settings is also a challenge

Winfred Nyanya

The main problem is poor monitoring of hypertension in pregnancy and subsequent late presentation either in labour or in ecclampsia. the other challenge is availability of guidelines in management of hypertension in pregnancy and the drugs to manage especially in lower level facilities.

Dr. Moenga Masese

1. Late presentation of patients. Most are usually unaware of their hypertension, , while others are lost to follow up, and noncompliant. 2. Essential supplies inadequacy- antihypertensives, adjunct medicine. Unavailable lab tests, imaging e.g ECGs, CT scans 3. Inadequacy of specialized services and specialists, mostly concentrating in Nairobi despite devolution. -dialysis, renal transplants, neurosurgeons, icus.

Dennis Nanyingi

1. Lack of access to intravenous antihypertensives such as hydralazine and labetalol 2. Patient outcome when he or she comes late 3. Inadequate monitoring tools such as unavailability of Ct-scan machine for those who present with CNS complications

Dr. Robbinson Nduati

1. A number of the clients have undiagnosed hypertension in pregnancy with the majority attending 1st ANC in their third trimester or even during labour. 2. Poor drug adherence due to lack of resources thus poor control of hypertension. Medicines in hospitals are subsidized but usually out of stock thus clientshave to buy at private facilities 3. Lack of reagents in laboratory to enable investigations in diagnosis and proper management of eclampsia or preeclampsia 4. Delays in the timely referral of clients for specialized services in the higher facilities due to lack of ambulance services 5. Mismanagement at the lower facilities due to lack of knowledge on the unsafe drugs to avoid in hypertension and pregnancy

Ruth Komu

1. Lack of proper diagnosis and management at first contact thus complicating the immediate management. 2. Lack of some recommended medication eg.IV labetalol 3. Lack of critical care services thus leading to avoidable mortalities.

Francis Soita

1. Lack of technical staff at emergency department to handle cases 2.Lack of parenteral rx to manage cases 3. Inadequate equipment to diagnose the condition eg BP machines 4. Inadequate investigative ability to guide patient management

David Okeyo

most facilities don't have BP machines, Adult weighing scales, lack of comprehensive laboratory investigation and imaging. more importantly emergency medicine and capacity building to improve the service delivery and management of the emergency conditions .

Abdulaziz Abeid

Challenges include: 1. Human resource: low nurse to patient ratios make it hard to manage these patients in public facilities 2. Critical care facilities: with few beds in ICU most of these patients are managed in normal wards with no proper monitoring. Our ICUs also lack invasive BP monitors. 3. Drugs: unavailability of parenteral medications makes it hard for doctors, we end up using oral medications

Dr. Magdalene Randa

lack of icu facilities,lack of machines to monitor bps, unavailability of lab reagents to perfom basilne tests, late presentation of patients

Dr. Ombati Mokua

1. low patient healthcare worker ratio 2. lack of the essential drugs for care of these patients. 3. patients delay in accessing the health facilities 4. lack of adequately trained personnel at the OPD or emergency department to deal with such cases

Peter Olyam

1. lack of essential drugs 2. lack of essential laboratory tests eg FHG,U/C/Es 3.lack of imaging eg CT scan, ECG, Echo 4.lack of personnel to monitor BP and/or do further examination eg fundoscopy 5. patients unable to afford drugs, laboratory tests, imaging etc 6. failure or delay in diagnosis at primary health level. 7. lack of ICU/HDU
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