1. Obstetric emergency lecture 3
Dr. Miada Mahmoud Rady

2. special obstetric problems
Lecture 3
special obstetric problems

3. Topics supine hypotension syndrome . Cardiac problems during pregnancy
Hypertension during pregnancy
Seizers
Diabetes
Respiratory problem during pregnancy
Hyperemesis gravidarum

4. Supine hypotension syndrome
Definition: Decrease in blood pressure when pregnant women lies supine .
Timing : seen in third trimester when uterus is large and patient mobility is impaired.
Etiology : pressure of the gravid uterus on inferior vena cava
Pathogenesis :
Gravid uterus press in inferior vena cava .
Decrease venous return .
Which decrease cardiac out put .
Which decrease blood pressure .

5. Decrease blood pressure
Enlarged uterus
pathogenesis
Press on IVC
of supine
Decrease VR
Hypotension syndrome
Decrease COP
Decrease blood pressure

6. Supine hypotension syndrome
Complication : can result in significant maternal hypotension which can lead to fetal distress .
Clinical presentation :
it usually occurs 3-7 min. after lying down.
Early → nausea , dizziness and tachycardia.
Later → breathing difficulty and syncope.

7. Supine hypotension syndrome
Management :
Placing patient in the left lateral recumbent position
Treating underlying causes
Monitoring blood pressure and other vital signs
Obtaining an ECG
Caused by position
Treated by position

8. Cardiac diseases
When taking history of pregnant female with possible cardiac disease the following should be documented :
Cardiac medications.
Dysrhythmias or heart murmurs.
History of rheumatic fever.
Congenital heart defect : Could be deteriorated by pregnancy.
Dizziness, light-headedness, or syncope : may be signs of dysrhythmias that could be dangerous during labor.

9. Hypertension during pregnancy
Hypertension with pregnancy can cause great morbidity and mortality .
Border line and preexisting hypertension could be exacerbated by pregnancy.
Types :
Chronic HTN : hypertension before pregnancy , or occurring before 20th week .
Pregnancy induced HTN : occurring after 20th week of pregnancy.
Eclampsia and pre-eclampsia .

10. Chronic HTN
Pregnancy induced HTN
Present before pregnancy
Occurs before 20th gestational week
Persist postpartum
Occurs after 20th gestational week
Resolves spontaneously after labor.
Can cause stroke and cardiovascular problem
May be sign of pre-eclamspsia .
Blood pressure ≥ 140/90 .

11. Preeclampsia Incidence : occurs in about 8% of all pregnancies
Risk factors:
First pregnancy before age of 20 (highest risk factor).
Women with advanced maternal age.
History of multiple pregnancies.
Chronic hypertension or previous preeclampsia.
Renal disease.
Diabetes.
Young primipara
Old multipara
Htn , d.m , renal disease.

12. Clinical presentation :
Manifests after 20th week with a triad of symptoms :
Edema (usually of the face, ankles, and hands)
Gradual onset of hypertension
Protein in the urine
Other symptoms include:
Severe headache.
Nausea and vomiting.
Rapid weight gain.
Visual disturbances.

13. Preeclampsia Complication : Cerebral hemorrhage Placental abruption
HELLP syndrome (hemolysis, elevated liver enzymes, low platelets)
Retard growth of the fetus.
Impair liver and renal function .
pulmonary edema .
Progress to life-threatening seizure (eclamspia ) .

14. Preeclampsia Management : address ABCS and supportive care.
emergency antihypertensive may be necessary.
Eclampsia :
Seizers control : magnesium sulfate is recommended.
ICU admission in dark quiet room.
Immediate C.S may be necessary to save mother life.

15. Seizures Can be caused by: a. Hypertension b. Toxemia c. Preeclampsia
d. Preexisting seizure disorder
Treatment : difficult because drugs normally used for seizures cause fetal distress.
Magnesium sulfate is recommended , especially with eclampsia.
High-flow oxygen is needed to prevent hypoxia.

16. Diabetes Diabetes during pregnancy is either :
Preexisting before pregnancy ,or gestational diabetes mellitus.
Gestational diabetes : glucose intolerance due to effect of pregnancy hormone.
Patient may be asymptomatic or have the same signs as diabetes mellitus:
Polyuria
Polydipsia
Polyphagia
Intolerance means : inability to process carbohydrates.

17. Complication :
Fetal macrosomia ( large baby ) which may lead to obstructed labor .
prematurity and preterm labor .
May continue after delivery.
Treatment :
Diet control : first line .
Insulin .
Prehospital : supportive care , I.V D50 if hypoglycemia present .

18. Remember physiological changes
Respiratory problems
shortness of breath ( dyspnea ) :
Commonest complaint during pregnancy .
Due to the effect of hormones.
Careful history and examination is necessary to exclude other causes.
Treatment is assurance.
Remember physiological changes

19. Respiratory problems Asthma
Asthma is common condition that usually complicates pregnancy .
Patient may be known asthmatic or asthma may present for the first time during pregnancy.
Acute episode of asthma can cause serious maternal and fetal complication.

20. Complication of asthma
Maternal
Fetal
Premature labor
Preeclampsia, eclampsia
Respiratory failure
Vaginal hemorrhage
Premature birth
Low birth weight.
Growth retardation.
Fetal death.

21. Respiratory problems Pneumonia :
One of the leading indirect causes of maternal death in the United States.
More sever during pregnancy due to depressed immune system of pregnant female .
Caused by :
Infectious agent : bacterial , viral or parasitic.
Non-infectious : chemical inhalation.

22. Respiratory problems Low birth weight Premature labor Preterm delivery
complications of pneumonia :
Low birth weight
Premature labor
Preterm delivery

23. Hyperemesis gravidarum
Definition : persistent nausea and vomiting during pregnancy which is more serious than morning sickness .
Etiology : Exact cause is unknown, but possibly from:
Increased hormones (estrogen, human chorionic gonadotropin).
Stress.
Gastrointestinal system changes.

24. Hyperemesis gravidarum
Complication : dehydration , malnutrition and electrolyte imbalance.
Symptoms :
Severe and persistent vomiting more than three or four times daily.
Projectile vomiting, consisting of bile and sometimes blood.
Severe nausea.
Pallor.

25. Hyperemesis gravidarum
Prehospital treatment :
Administer 100% supplemental oxygen.
Start IV line of normal saline.
If protocols allow, administer diphenhydramine.
Check blood glucose levels.
Check orthostatic vital signs, obtain an ECG.
Transport to a hospital.

26. Summary
Supine hypotension syndrome could be avoided by lying on left lateral position.
Hypertension with pregnancy causes great morbidity and mortality
Gestational D.M could be controlled by diet .
Asthma is very common and dangerous in pregnancy.
Pregnancy can exacerbate asymptomatic congenital heart disease .
Delivery is the only line of treatment for eclampsia .