1. Obstetric Emergencies

2. Obstetric Emergencies: We will cover...
Normal Pregnancy
Common medical and surgical complications of pregnancy

3. 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

4. False Negatives False Positives Urine: hematuria/proteinuria
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

5. 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

6. 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)

7. Radiation in Pregnancy
<5-10 rads = no significant risk of birth defects
Beams aimed 10cm away from fetus pose no additional risk
Initial trauma X-rays each deliver <1 rad
One never withholds necessary radiography.
Use MRI or U/S if available.

8. Transvaginal Ultrasound Images

9. Normal, non-pregnant uterus on T/V U/S

10. The “Double-Ring” Sign or “Double Decidual” Sign of normal early pregnancy

11. Normal Pregnancy T/V Ultrasound Showing Gestational and Yolk Sac
Normal Pregnancy T/V Ultrasound Showing Gestational and Yolk Sac. No fetus is seen. 5w 2d

12. 6w 1d T/V U/S showing yolk sac

13. Normal T/V U/S with embryo at 10w 3d

14. Complications of Pregnancy – Vaginal Bleeding
1st Trimester Causes:
Ectopic
Abortion
Molar Pregnancy
Non-pregnancy Related
a. Infectious
b. Trauma
c. Neoplasm

15. The work-up is the same! Pelvic Exam Beta HCG Transvaginal ultrasoundRh
CBC, CMP
PT/PTT/INR UA

17. 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.

18. 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

19. Ectopic Pregnancy = Laparoscopy
Testing
Beta > 6000 mIU/ml + empty uterus on transabdominal ultrasound OR
Beta > 1200 mIU/ml + empty uterus on transvaginal ultrasound =
Ectopic Pregnancy = Laparoscopy

20. Beta <6000 + empty uterus on transabdominal ultrasoundOR
Beta < 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

21. A heterotopic pregnancy (to compare normal vs. abnormal)

22. Ectopic Pregnancy

23. 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 D&C candidate
If other types of AB, patient may undergo oxytocin induced labor as inpatient.

24. 3rd Trimester (>28 weeks)
Placental Abruption
Placenta separates from uterine wall
Painful dark or clotted blood
Risks: HTN, smoking, ETOH, cocaine, multiparity, previous abruption, trauma, mom > 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 >40.
Management: U/S, Ob consult, pre-op labs, avoid pelvic exam, c-section

25. 3rd Trimester Bleeding cont’d
Uterine Rupture: Can be seen in scarred and unscarred uteri. (uteruses? uterata?)

28. 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!

29. 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 >12w to determine and quantify the amount of fetomaternal hemorrhage that occurred

30. Perimortem C-Section
Fetus greater than 28weeks, maternal death less than 15 minutes = perimortem c-section

31. Complications 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

32. Pre-eclampsia: To be considered in those >20wks with HTN
Mild
SBP > 140 (or +20 from baseline. Or DBP >90 (or +10 from baseline)
Proteinuria .3g/24h
+/- Edema
No Oliguria
No Associated symptoms
Normal labs
No IUGR
Severe
BP>160/90
Proteinuria >5g/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

33. 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

34. 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

35. 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.

36. 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 don’t improve with IV abx, the diagnosis is reconsidered.
Laparotomy is the preferred diagnostic procedure. Ultrasound can used

38. References
1. Preparing for the Written Board Exam in Emergency Medicine. 5th ed. Vol 1. Rivers, Carol. pp
2. learnobultrasound.com/3trimesterbleed.htm 3.
4. Harwood &Nuss’ Clinical Practice of Emergency Medicine 4th ed. Wolfson, Alan B Lippincott, Williams and Wilkins, Philadelphia, pp
5. home.flash.net/~drrad/tf/ htm 6. 7. 8.
9. Ma, John O. Emergency Ultrasound via access emergency medicine at