Obstetric Emergencies

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Obstetric Emergencies
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Obstetric Emergencies We will cover...

• Normal Pregnancy
• Common medical and surgical complications of
  pregnancy

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Normal pregnancy

• All females of childbearing age are presumed to
  be pregnant until proven otherwise.
• All pregnancy tests detect B-HCG which is
  produced at the time of implantation (8-9 days
  post conception)
• B-HCG should double every day for the first
  weeks, peak at week 8 and remain elevated up to
  60 days post-partum

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• False Negatives
• Too early in pregnancy
• Dilute/old urine
• Ectopic
• Incomplete Ab.

• False Positives
• Urine hematuria/proteinuria
• Serum
• T.O.A.
• Thyrotoxicosis
• Molar pregnancy
• Drugs (MJ, ASA, Phenothiazines, anticonvulsants,
  antidepressants, methadone

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Some Important Physiological Changes in Pregnancy

• Cardiac increased heart rate, decreased blood
  pressure. CO increases
• Respiratory rate increases, TV increases, FRV
  decreases, pCO2 decreases
• Heme Volume increases, HCT drops, WBC increases

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Drugs in Pregnancy A, B, C, D, X

• Considered Safe in pregnancy
• PCN
• Cephalosporins
• Azithro/Erythromycin
• Acetaminophen
• Narcotics
• Heparin
• Asthma Drugs
• Reglan (Metoclopramide)
• Immunizations derived from killed viruses
  (tetanus, diptheria, Hep. B, Rabies)

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Radiation in Pregnancy

• lt5-10 rads no significant risk of birth defects
• Beams aimed 10cm away from fetus pose no
  additional risk
• Initial trauma X-rays each deliver lt1 rad
• One never withholds necessary radiography.
• Use MRI or U/S if available.

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Transvaginal Ultrasound Images
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Normal, non-pregnant uterus on T/V U/S
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The Double-Ring Sign or Double Decidual Sign
of normal early pregnancy
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Normal Pregnancy T/V Ultrasound Showing
Gestational and Yolk Sac. No fetus is seen. 5w
2d
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6w 1d T/V U/S showing yolk sac
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Normal T/V U/S with embryo at 10w 3d
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Complications of Pregnancy Vaginal Bleeding

• 1st Trimester Causes
• Ectopic
• Abortion
• Molar Pregnancy
• Non-pregnancy Related
• a. Infectious
• b. Trauma
• c. Neoplasm

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The work-up is the same!

• Pelvic Exam
• Beta HCG
• Transvaginal ultrasound
• Rh
• CBC, CMP
• PT/PTT/INR
• UA

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Ectopic Pregnancy A surgical emergency of
pregnancy

• The leading cause of first trimester maternal
  death
• Usually 5-8 weeks after LMP
• High Risk History of ectopic, tubal surgery or
  sterilization procedure, Known tubal scarring or
  pathology, Diethylstilbestrol exposure, IUD.

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Signs/Symptoms

• Symptoms (in decreasing order of frequency)
  Abdominal pain, amenorrhea, vaginal bleeding
  (50-80), dizziness, pregnancy symptoms, urge to
  defecate, passing tissue
• Signs Adnexal tenderness, abdominal tenderness,
  adnexal mass, enlarged uterus, orthostatic
  changes, fever

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Testing

• Beta gt 6000 mIU/ml empty uterus on
  transabdominal ultrasound
• OR
• Beta gt 1200 mIU/ml empty uterus on transvaginal
  ultrasound
• Ectopic Pregnancy Laparoscopy

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• Beta lt6000 empty uterus on transabdominal
  ultrasound
• OR
• Beta lt 1200 empty uterus on transvaginal
  ultrasound serial outpatient beta measurements
  to ensure normal rise.
• This only applies to stable patients and should
  be done in consult with ob/gyn

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A heterotopic pregnancy (to compare normal vs.
abnormal)
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Ectopic Pregnancy
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2nd Trimester

• Causes are abortion and non-pregnancy causes.
• Work-up is the same
• Management of threatened AB is the same
• If complete, may be DC candidate
• If other types of AB, patient may undergo
  oxytocin induced labor as inpatient.

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3rd Trimester (gt28 weeks)

• Placental Abruption
• Placenta separates from uterine wall
• Painful dark or clotted blood
• Risks HTN, smoking, ETOH, cocaine, multiparity,
  previous abruption, trauma, mom gt 40
• Management U/S, Ob consult, cardiac/fetal
  monitoring, IV, pre-op labs, delivery if possible

• Placenta Previa
• Placenta implants too low
• Painless bright red bleeding
• Risks prior C-section, grand multiparity,
  previous previa, multiple gestations, multiple
  induced abortions, mom gt40.
• Management U/S, Ob consult, pre-op labs, avoid
  pelvic exam, c-section

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3rd Trimester Bleeding contd

• Uterine Rupture Can be seen in scarred and
  unscarred uteri. (uteruses? uterata?)

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Complications of Pregnancy Trauma

• Key Concept Although you have two patients,
  maternal circulation is to be maintained at the
  expense of the fetus. Without mom, the baby will
  surely die.
• Mom should be kept in left lateral decubitus
• This is where knowing the physiologic changes of
  pregnancy becomes extremely important ! Mom can
  lose up to 35 of her blood volume before showing
  any signs of shock!

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Management

• Over 20 weeks Goes to Ob for 4 hours of
  cardiotocographic monitoring
• All women with abdominal trauma get Rhogam
  (fetomaternal hemorrhage present in 30 of these
  patients)
• Kleihauer-Betke test Used in women gt12w to
  determine and quantify the amount of fetomaternal
  hemorrhage that occurred

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Perimortem C-Section

• Fetus greater than 28weeks, maternal death less
  than 15 minutes perimortem c-section

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Complications of Pregnancy Hypertension

• Can be chronic (meaning it began prior to
  conception or began during gestation and persists
  gt6 weeks post-partum) or gestational.
• We care about this because HTN in pregnancy is
  associated with pre-eclampsia, abruption,
  prematurity, IUGR and stillbirth

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Pre-eclampsia To be considered in those gt20wks
with HTN

• Mild
• SBP gt 140 (or 20 from baseline. Or DBP gt90 (or
  10 from baseline)
• Proteinuria .3g/24h
• /- Edema
• No Oliguria
• No Associated symptoms
• Normal labs
• No IUGR

• Severe
• BPgt160/90
• Proteinuria gt5g/24h
• Edema Present
• Oliguric
• Associated symptoms (H/A, visual symptoms,
  abdominal pain, pulm. edema
• Associated labs (dec. plts, inc. LFT, inc. bili,
  inc. creatinine, increased uric acid)
• IUGR present
• HELLP syndrome very severe. Above RUQ pain,
  n/v

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Management

• Isolated HTN requires a 24h urine and close Ob
  f/u
• With other findings, admit, 24h urine, bed rest
  and HTN management in consult with ob/gyn.
• Hydralazine common though diazoxide, labetalol,
  nifedipine and nitroprusside also used
• /- Mag to prevent seizures

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Complications of Pregnancy Eclampsia

• Preeclampsia seizures or coma
• May occur without proteinuria, may occur up to 10
  days postpartum
• ICH is the major cause of maternal death
• Warning signs H/A, visual changes,
  hyperreflexia, Abd. pain
• Tx Delivery. Magnesium, Phenytoin or Diazepam,
  Hydralazine or Labetalol

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Complications of Pregnancy UTI/Pyelo

• Pregnant women more prone to UTI secondary to
  physiologic changes of pregnancy
• Treat both symptomatic and asymptomatic bacturia
  (untreated up to 40 risk of progression to
  pyelo)
• Culture urine, give 7 day course
• We admit pregnant women with pyelonephritis
  because of its increased risk of of progressing
  to preterm labor or septic shock.

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Complications of Pregnancy Appendicitis

• Appendicitis is the most frequent surgical
  emergency of pregnancy
• Incidence is the same as non-pregnant population
  but the complications are more frequent secondary
  to delayed diagnosis
• Again, the physiologic changes of pregnancy
  complicate the clinical picture (leukocytosis,
  displaced appendix)
• Picture mimics pyelo. When patients dont
  improve with IV abx, the diagnosis is
  reconsidered.
• Laparotomy is the preferred diagnostic procedure.
  Ultrasound can used

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References

• 1. Preparing for the Written Board Exam in
  Emergency Medicine. 5th ed. Vol 1. Rivers,
  Carol. pp 550-574
• 2. learnobultrasound.com/3trimesterbleed.htm
• 3. www.smbs.buffalo.edu/emed/emed/ultrasound.html
  
• 4. Harwood Nuss Clinical Practice of Emergency
  Medicine 4th ed. Wolfson, Alan B Lippincott,
  Williams and Wilkins, Philadelphia, 2005.
  pp.496-497
• 5. home.flash.net/drrad/tf/122396.htm
• 6. www.pwc-sii.com/Research/death/ribs.htm
• 7. www.jaapa.com/.../article/130146/
• 8. www.advancedfertility.com/ultraso1.htm
• 9. Ma, John O. Emergency Ultrasound via access
  emergency medicine at http//0-www.accessem.com.i
  nnopac.lsuhsc.edu/content.aspx?aID100900