2Obstetric Emergencies: We will cover... Normal PregnancyCommon medical and surgical complications of pregnancy
3Normal pregnancyAll 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
4False Negatives False Positives Urine: hematuria/proteinuria Too early in pregnancyDilute/old urineEctopicIncomplete Ab.False PositivesUrine: hematuria/proteinuriaSerum:T.O.A.ThyrotoxicosisMolar pregnancyDrugs (MJ, ASA, Phenothiazines, anticonvulsants, antidepressants, methadone
5Some Important Physiological Changes in Pregnancy Cardiac: increased heart rate, decreased blood pressure. CO increasesRespiratory: rate increases, TV increases, FRV decreases, pCO2 decreasesHeme: Volume increases, HCT drops, WBC increases
6Drugs in Pregnancy: A, B, C, D, X Considered Safe in pregnancy:PCNCephalosporinsAzithro/ErythromycinAcetaminophenNarcoticsHeparinAsthma DrugsReglan (Metoclopramide)Immunizations derived from killed viruses (tetanus, diptheria, Hep. B, Rabies)
7Radiation in Pregnancy <5-10 rads = no significant risk of birth defectsBeams aimed 10cm away from fetus pose no additional riskInitial trauma X-rays each deliver <1 radOne never withholds necessary radiography.Use MRI or U/S if available.
17Ectopic Pregnancy – A surgical emergency of pregnancy The leading cause of first trimester maternal deathUsually 5-8 weeks after LMPHigh Risk: History of ectopic, tubal surgery or sterilization procedure, Known tubal scarring or pathology, Diethylstilbestrol exposure, IUD.
18Signs/SymptomsSymptoms (in decreasing order of frequency): Abdominal pain, amenorrhea, vaginal bleeding (50-80%), dizziness, pregnancy symptoms, urge to defecate, passing tissueSigns: Adnexal tenderness, abdominal tenderness, adnexal mass, enlarged uterus, orthostatic changes, fever
20Beta <6000 + empty uterus on transabdominal ultrasound ORBeta < 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
21A heterotopic pregnancy (to compare normal vs. abnormal)
232nd Trimester Causes are abortion and non-pregnancy causes. Work-up is the sameManagement of threatened AB is the sameIf complete, may be D&C candidateIf other types of AB, patient may undergo oxytocin induced labor as inpatient.
243rd Trimester (>28 weeks) Placental AbruptionPlacenta separates from uterine wallPainful dark or clotted bloodRisks: HTN, smoking, ETOH, cocaine, multiparity, previous abruption, trauma, mom > 40Management: U/S, Ob consult, cardiac/fetal monitoring, IV, pre-op labs, delivery if possiblePlacenta PreviaPlacenta implants too lowPainless bright red bleedingRisks: prior C-section, grand multiparity, previous previa, multiple gestations, multiple induced abortions, mom >40.Management: U/S, Ob consult, pre-op labs, avoid pelvic exam, c-section
253rd Trimester Bleeding cont’d Uterine Rupture: Can be seen in scarred and unscarred uteri. (uteruses? uterata?)
28Complications 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 decubitusThis 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!
29ManagementOver 20 weeks: Goes to Ob for 4 hours of cardiotocographic monitoringAll women with abdominal trauma get Rhogam (fetomaternal hemorrhage present in 30% of these patients)Kleihauer-Betke test: Used in women >12w to determine and quantify the amount of fetomaternal hemorrhage that occurred
30Perimortem C-SectionFetus greater than 28weeks, maternal death less than 15 minutes = perimortem c-section
31Complications of Pregnancy: Hypertension Can be chronic (meaning it began prior to conception or began during gestation and persists >6 weeks post-partum) or gestational.We care about this because HTN in pregnancy is associated with pre-eclampsia, abruption, prematurity, IUGR and stillbirth
32Pre-eclampsia: To be considered in those >20wks with HTN MildSBP > 140 (or +20 from baseline. Or DBP >90 (or +10 from baseline)Proteinuria .3g/24h+/- EdemaNo OliguriaNo Associated symptomsNormal labsNo IUGRSevereBP>160/90Proteinuria >5g/24hEdema PresentOliguricAssociated symptoms (H/A, visual symptoms, abdominal pain, pulm. edemaAssociated labs (dec. plts, inc. LFT, inc. bili, inc. creatinine, increased uric acid)IUGR presentHELLP syndrome = very severe. Above +RUQ pain, n/v
33Management 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
34Complications of Pregnancy: Eclampsia Preeclampsia +seizures or comaMay occur without proteinuria, may occur up to 10 days postpartumICH is the major cause of maternal deathWarning signs = H/A, visual changes, hyperreflexia, Abd. painTx = Delivery. Magnesium, Phenytoin or Diazepam, Hydralazine or Labetalol
35Complications of Pregnancy: UTI/Pyelo Pregnant women more prone to UTI secondary to physiologic changes of pregnancyTreat both symptomatic and asymptomatic bacturia (untreated = up to 40% risk of progression to pyelo)Culture urine, give 7 day courseWe admit pregnant women with pyelonephritis because of its increased risk of of progressing to preterm labor or septic shock.
36Complications of Pregnancy: Appendicitis Appendicitis is the most frequent surgical emergency of pregnancyIncidence is the same as non-pregnant population but the complications are more frequent secondary to delayed diagnosisAgain, the physiologic changes of pregnancy complicate the clinical picture (leukocytosis, displaced appendix)Picture mimics pyelo. When patients don’t improve with IV abx, the diagnosis is reconsidered.Laparotomy is the preferred diagnostic procedure. Ultrasound can used
38References1. Preparing for the Written Board Exam in Emergency Medicine. 5th ed. Vol 1. Rivers, Carol. pp2. learnobultrasound.com/3trimesterbleed.htm3.4. Harwood &Nuss’ Clinical Practice of Emergency Medicine 4th ed. Wolfson, Alan B Lippincott, Williams and Wilkins, Philadelphia, pp5. home.flash.net/~drrad/tf/ htm220.127.116.11. Ma, John O. Emergency Ultrasound via access emergency medicine at