1. Pregnancy Complications…
DR.WASEEM AHMED ABUJAMEA
ER CONSULTANT
SBEM ,ABEM
Program director SBEM
ED DEPUTY Chairman

2. Abnormal Vaginal Bleeding (Non-Pregnant)
• Non-uterine: Cervix, vagina, urinary, Gl, coagulation disorders
• Ovulatory: Menorrhagia (heavy bleeding),
metrorrhagia (outside cycle); polyps, tumors,
cancer, infection, fibroids, endometriosis, dyscrasias
• Anovulatory (DUB): Prolonged amenorrhea with
intermittent menorrhagia; endocrine disorders,
OCPs, liver/renal diseases, polycystic ovary,
extremes of reproductive age, eating disorders.
Treatment: OCP, NSAIDs or D&C
• Peri- & postmenopausal: Cancer should be
considered

3. ON
Definition A
Any vaginal bleeding before 20 wks period of gestation is defined as early pregnancy bleeding

4. Related to pregnant state
abortion
ectopic
Vesicular mole
Abortion
Ectopic pregnancy
Molar pregnancy

5. Ectopic Pregnancy

6. Ectopic Pregnancy
Any pregnancy that occurs outside of the uterine cavity
Tubal
Ampulla (55%)
Isthmus (25%)
Fimbria (17%)
Cervical
Ovarian
Abdominal
97% 3%

7. Ectopic Pregnacy 1.9% of reported pregnancies
Leading cause of pregnancy-related death in the first trimester
Ruptured ectopic pregnancy accounts for 10-15% of all maternal deaths

8. Ectopic Pregnancy HIGH Risk Factors Previous tubal surgery
Previous ectopic pregnancy
In utero DES exposure
diethylstilbestrol (used until 1971;
miscarriage & premature delivery)
Previous genital infections
Infertility
Current smoking
Previous IUD use
HIGH

9. Ectopic Pregnancy Most common presentation: Woman of reproductive age
Abdominal pain
Vaginal bleeding
Approx 7 weeks after amenorrhea
*Nonspecific… DDx is important

10. Ectopic Pregnancy Differential Diagnosis Acute appendicitis
Miscarriage
Ovarian torsion
Pelvic inflammatory disease
Ruptured corpus luteum cyst or follicle
Tubo-ovarian abcess
Urinary calculi

11. Ectopic Pregnancy Exam Findings Normal or slightly enlarged uterus
Vaginal bleeding
Pelvic pain with manipulation of the cervix
Palpable adnexal mass (fallopian tube)

12. Ectopic Pregnancy Suspect Rupture… Significant abdominal tenderness
*Especially if accompanied by:
Hypotension
Abdominal guarding
Rebound tenderness

13. Ectopic Pregnancy Diagnositc Tests Ultrasound (*test of choice) bHCG
No intrauterine gestational sac
bHCG
Do not increase appropriately
Urine pregnancy test
Pregnant / not pregnant
Progesterone level (less reliable)

14. Ectopic Pregnancy Treatment Expectant management Medical treatment
Monitor progress
Medical treatment
Methotrexate – folic acid antagonist
Disrupts rapidly dividing trophoblastic cells
Surgery
Laparoscopy with salpingostomy, without fallopian tube removal

15. Ectopic Pregnancy ~30% have later difficulty conceiving
No difference between treatment options
5-20% rate of recurrence
32% risk of recurrence if she’s had 2 consecutive ectopic pregnancies

16. Spontaneous Abortion

17. Spontaneous Abortion Pregnancy loss at less than 20 weeks’ gestation
aka “miscarriage”, “spontaneous pregnacy loss”, “early pregnancy failure”
Pregnancy loss at less than 20 weeks’ gestation

18. Definitions Threatened abortion Inevitable abortion
A pregnancy complicated by bleeding before 20 weeks’ gestation Os is closed.
Inevitable abortion
The cervix has dilated, but the products of conception have not been expelled

19. Definitions Complete abortion Incomplete abortion Missed abortion
All products of conception have been passed without need for surgical or medical intervention
Incomplete abortion
Some, but not all, of the products of conception have been passed; retained products may be part of the fetus, placenta, or membranes
Missed abortion
A pregnancy in which there is a fetal demise (usually for a number of weeks) but no uterine activity to expel the products of conception

20. Definitions Septic abortion Recurrent spontaneous abortion
A spontaneous abortion that is complicated by intrauterine infection
Recurrent spontaneous abortion
Three (3) or more consecutive pregnancy losses

21. Spontaneous Abortion Etiology and Risk Factors Chromosomal abnormality
49% of spontaneous abortions
*most are random events
NOTE:
Stress
Sexual activity
Do NOT increase risk

22. Spontaneous Abortion Risk Factors Advanced maternal age Alcohol use
Anesthetic gas use (nitrous oxide)
Caffeine use (heavy)
Chronic maternal diseases
poorly controlled diabetes
celiac disease
autoimmune diseases
Cigarette smoking
Cocaine use
Conception within 3-6 months after delivery
IUD use
Maternal infections
Bacterial vaginosis
TORCH
STD’s
Medications
Multiple previous elective abortions
Previous spontaneaous abortions
Toxins
Uterine abnormalities

23. Spontaneous Abortion Up to 20% of recognized pregnancies
~30% actual miscarriage rate
Often mistaken for late onset of menses
~50% of pregnancies complicated by bleeding before 20 weeks’ gestation will end in spontaneous abortion
DDx?

24. Differential Diagnosis: First Trimester Vaginal Bleeding
Idiopathic bleeding in a viable pregnancy
Ectopic pregnancy
Molar pregnancy
Spontaneous abortion
Subchorionic hemorrhage
Infection of the vagina or cervix
Cervical abnormalities
Malignancy, polyps, trauma
Vaginal trauma

25. Spontaneous Abortion Diagnosis HCG levels Progesterone levels labs
Ultrasound
Status of the pregnancy
Intrauterine? Ectopic?
Exam: dilated cervix ~> inevitable abortion
*the risk for spontaneous abortion decreases from 50% to 3% when a fetal heartbeat is identified on ultrasound
labs

26. Abortion? or not? Progesterone HCG Ultrasound Abortion?
>25 ng per mL
Increases (48 hours)
Normal No
<5 ng per mL
Plateau or decrease
Nonviable pregnancy
Yes

27. Spontaneous Abortion Management Surgical evacuation (D&C)
Patient is unstable
Heavy bleeding
Septic abortion
Patient choice
Medical therapy
Missed spontaneous abortion
Expectant management
Completed spontaneous abortion
Incomplete spontaneous abortion
No need for surgical intervention 80-95% of the time

28. Spontaneous Abortion Considerations… Feelings of guilt
Grieving process
Anxiety & depression
counseling

29. Spontaneous Abortion - Tips
Acknowledge and attempt to dispel guilt
Acknowledge and legitimize grief
Assess level of grief and adjust counseling accordingly
Counsel how to tell family and friends of the miscarriage
Include the patient’s partner in psychologic care
Provide comfort, empathy, and ongoing support
Reassure about the future
Warn about the “anniversary phenomenon”

30. Hydatidiform Mole

31. Hydatidiform Mole Complete/Classic Mole No identifiable fetal tissue
Partial Mole
Some recognizable fetal or embryonic tissue

32. Hydatidiform Moles 1/1000-1500 pregnancies Risk factors Teenagers
Women over 35 (35+: 2x risk, 40+: 7x risk)
Previous miscarriage
*Only 1% of subsequent conceptions result in another molar pregnancy

33. Complete Hydatidiform Mole
Signs & Symptoms
Vaginal bleeding (97%)
*most common presenting symptom
Hyperemesis
due to elevated HCG
Hyperthyroidism (7%)
may present with tachycardia, tremor, warm skin
Preeclampsia (27%)
Large for date uterus

34. Incomplete Hydatidiform Mole
Signs & Symptoms
(similar to incomplete or missed abortion)
Vaginal bleeding
Absence of fetal heart tones
Uterine enlargement and preeclampsia
only 3% of patients
Hyperemesis and hyperthyroidism are rare

35. Hydatidiform Mole Diagnosis Ultrasound HCG levels
vesicular / “snowstorm” pattern
HCG levels
Elevated compared to a normal pregnancy of similar gestational age
_uploads/hmole2.jpg

37. Hydatidiform Mole Differential Diagnosis Painless vaginal bleeding:
Placenta previa
Missed abortion
Key differential?
Absence of identifiable fetal parts on ultrasound

38. Hydatidiform Mole Treatment Evacuation and curettage OR Hysterectomy
Must consider:
Age of the patient
Desire to preserve fertility

39. Hydatidiform Mole
Potential precursor to gestational trophoblastic disease and choriocarcinoma
20% develop a malignancy
metastasis occurs in 4% of complete moles
Choriocarcinoma may metastasize to:
Lungs
Vagina
Brain
Liver
Kidney

40. Hydatidiform Mole Follow-up bHCG* tested regularly Contraception
monthly for 6-12 months
*any rise in levels should prompt a chest radiograph and pelvic examination
Contraception
must be used during the entire follow-up period
at least 1 year

41. Placenta Previa
Ko P, Yoon Y. Placenta Previa. eMedicine. Retrieved 5 February 2006 from

42. Placenta Previa
Implantation of the placenta over or near the internal os of the cervix
Vaginal bleeding in the 2nd and 3rd trimesters
5/1,000 deliveries
Maternal mortality rate of 0.03%

43. Placenta Previa Total placenta previa Partial placenta previa
internal os is completely covered by the placenta
Partial placenta previa
internal os is partially covered by the placenta
self-correct? uterus enlarges, placental site moves cephalad
Marginal placenta previa
placenta is at the margin of the internal os
Low-lying placenta previa
placenta is implanted in the lower uterine segment
edge of the placenta is near the internal os but does not reach it

44. Placenta Previa Risk Factors Prior previa Multiparity
Multiple gestations
Advanced maternal age
Previous cesarean delivery
Prior induced abortion
Smoking

45. Placenta Previa History Exam Findings Vaginal bleeding
Bright red and painless (recurrent)
Occurs on average at weeks' gestation
Contractions may or may not occur simultaneously with the bleeding
Exam Findings
Profuse hemorrhage
Hypotension
Tachycardia
Soft and nontender uterus
Normal fetal heart tones (usually)

46. Placenta Previa Differentials Abruptio Placenta
Disseminated Intravascular Coagulation
Pregnancy, Delivery
Vasa previa
Infection
Vaginal bleeding
Lower genital tract lesions
Bloody show

47. Placenta Previa Diagnosis Management Ultrasound
<37 weeks without hemorrhage
expectant management
Hemorrhage or >37 weeks and in labor
delivery
C-section
trial of labor may be considered for anterior marginal previa

48. Abruptio Placentae
Gaufberg SV. Abruptio Placentae. eMedicine. Retrieved 5 February 2006 from

49. Abruptio Placentae
Separation of the normally located placenta after the 20th week of gestation (prior to birth)
1% of all pregnancies
Compromised blood supply to the fetus
Severity of fetal distress correlates with the degree of placental separation

50. Abruptio Placentae Clinical presentation Vaginal bleeding (80%)
Abdominal or back pain and uterine tenderness (70%)
Fetal distress (60%)
Abnormal uterine contractions (35%)
Idiopathic premature labor (25%)
Fetal death (15%)

51. Abruptio Placentae Diagnosis
Severe uterine pain and tenderness with mild vaginal bleeding in a patient with hypertension (HTN) indicates placental abruption
Difficult to identify on ultrasound
Can help differentiate from other causes of bleeding (i.e placenta previa)

52. Abruptio Placentae (Class 0-3)
Asymptomatic
Diagnosis is made retrospectively
organized blood clot or a depressed area on a delivered placenta

53. Abruptio Placentae (Class 0-3)
Mild
~48% of all cases
Characteristics :
No vaginal bleeding to mild vaginal bleeding
Slightly tender uterus
Normal maternal BP and heart rate
No coagulopathy
No fetal distress

54. Abruptio Placentae (Class 0-3)
Moderate
~27% of all cases
Characteristics:
Vaginal bleeding: none to moderate
Moderate-to-severe uterine tenderness with possible tetanic contractions
Maternal tachycardia with orthostatic changes in BP and heart rate
Fetal distress
Hypofibrinogenemia (ie, mg/dL)

55. Abruptio Placentae (Class 0-3)
Severe
~24% of all cases
Characteristics:
vaginal bleeding: none to heavy
Very painful tetanic uterus
Maternal shock
Hypofibrinogenemia (ie, <150 mg/dL)
Coagulopathy
Fetal death

56. Abruptio Placentae Causes Maternal hypertension (44%)
Maternal trauma ( %)
MVA, assaults, falls
Cigarette smoking
Alcohol consumption
Cocaine use
Short umbilical cord
Advanced maternal age
Retroplacental fibromyoma
Sudden decompression of the uterus
premature rupture of membranes, delivery of first twin
Retroplacental bleeding from needle puncture
postamniocentesis
Idiopathic
probable abnormalities of uterine blood vessels and decidua

57. Abruptio Placentae Maternal complications Fetal complications
Hemorrhagic shock
Coagulopathy/DIC
Uterine rupture
Renal failure
Ischemic necrosis of distal organs
(eg, hepatic, adrenal, pituitary)
Fetal complications
Hypoxia
Anemia
Growth retardation
CNS anomalies
Fetal death

58. Preeclampsia - Eclampsia
Morrison EH. Common Peripartum Emergencies. Am Fam Physician 1998; 58(7). Retrieved 16 November 2005 from
Wagner LK. Diagnosis and Management of Preeclampsia. Am Fam Physician 2004; 70(12):

59. Preeclampsia
Defined as a “pregnancy-specific multisystem disorder of unknown etiology.”
New onset of elevated blood pressure and proteinuria after 20 weeks’ gestation

60. Preeclampsia Affects 5-7% of pregnancies Increased risk of:
Placental abruption
Acute renal failure
Cerebrovascular/cardiovascular complications
Disseminated intravascular coagulation
Maternal death

61. Preeclampsia 3rd leading cause of pregnancy-related deaths
Maternal death due to:
Cerebrovascular events
Renal or hepatic failure
HELLP syndrome
Complications of hypertension

62. Preeclampsia Risk Factors Pregnancy-associated Maternal-specific
Paternal-specific

63. Preeclampsia Risk Factors
1. Pregnancy-associated
Chromosomal abnormalities
Hydatidiform mole
Hydrops fetalis
Multifetal pregnancy
Structural congenital anomalies
Urinary tract infection

64. Preeclampsia Risk Factors
2. Maternal-specific
Age >35 years
Age <20 years
Black
Family history of preeclampsia
Nulliparity
Preeclampsia in a previous pregnancy
Medical conditions:
Gestational diabetes
Type I diabetes
Obesity
Chronic hypertension
Renal disease
Stress

65. Preeclampsia Risk Factors
3. Paternal-specific
First-time father
Previously fathered a preeclamptic pregnancy (in another woman)

66. Preeclampsia Diagnosis
Blood pressure: 140 mmHg or higher systolic or 90 mmHg or higher diastolic
*Previously normal blood pressure
Proteinuria: 0.3 g or more of protein in a 24 hr urine collection

67. Severe Preeclampsia Diagnosis
Blood pressure: 160 mmHg or higher systolic or 110 mmHg or higher diastolic
Proteinuria: 5g or more of protein in a 24 hr urine collection
Other:
Oliguria
Cerebral or visual disturbances
Pulmonary edema or cyanosis
Epigastric or R upper quadrant pain
Impaired liver function
Thrombocytopenia
Intrauterine growth restriction

68. Hypertensive Disorders of Pregnancy

69. Preeclampsia Clinical Presentation Asymptomatic Severe Preeclampsia
Visual disturbances
Severe headache
Upper abdominal pain
HELLP

70. Preeclampsia – HELLP Syndrome
Hemolysis
Elevated Liver enzymes
Low Platelet count
4-14% of women with preeclampsia
Mortality or serious morbidity: 25%

71. Preeclampsia
History
“Pregnant women should be asked about specific symptoms, including visual disturbances, persistent headaches, epigastric or R upper quadrant pain, and increased edema.”

72. Preeclampsia Examination Blood pressure Fundal height NOTE
Growth retardation? Oligohydramnios?
NOTE
Increasing maternal facial edema
Rapid weight gain
Fluid retention is often associated with preeclampsia

73. Preeclampsia Medical Management Antihypertensive drug therapy*
/ or higher
*many are contraindicated for use during pregnancy…
Magnesium sulfate
During labor to prevent seizures

74. Preeclampsia Treatment If preterm… Delivery
Observed on an outpatient basis
Hospitalized
Delivery
Vaginal delivery is preferred
Avoid added physiological stress of C-section

75. Indications for Delivery
Fetus
Severe intrauterine growth retardation
Nonreassuring fetal surveillance
Oligohydramnios
Mother
Gestational age 38 weeks or greater
Low platelet count
Mother (cont’d)
Deterioration of hepatic or renal function
Suspected placental abruption
Persistent severe HA, visual changes
Persistent severe epigastric pain, nausea, or vomiting
Eclamspia

76. Preeclampsia Risk of recurrence Nulliparous may be as high as 40%
Multiparous even higher

77. Eclampsia Severe complication of preeclampsia
New onset of seizures in a woman with preeclampsia
Affects .05 to .3% of pregnancies
(developed countries)
Mortality rate: 2%
Serious complications: up to 35%

78. Eclampsia Clinical course is usually gradual BUT…
20% do not have classic preeclamptic triad (or only mild)

79. Eclampsia Treatment Magnesium sulfate Antihypertensive agents
Controls seizures
Antihypertensive agents
Decrease risk of maternal intracranial hemorrhage without jeopardizing uterine blood flow
As soon as the mother is stable…deliver the baby

80. Preterm Labor
Von Der Pool BA. Preterm labor: diagnosis and treatment. Am Fam Physician May 15;57(10):
Weismiller DG. Preterm Labor. Am Fam Physician Feb 1;59(3):

81. Preterm Labor
Cervical effacement and/or dilatation and increased uterine irritability before 37 weeks of gestation
Affects 8-10% of births in the US
Rate may be worsening but survival rates have increased and morbidity has decreased
Still remains a leading cause of perinatal morbidity and mortality in the US

82. Risk Factors Previous preterm delivery (greatest risk)
Low socioeconomic status
Non-white race
Maternal age <18 years or >40 years
Preterm premature rupture of the membranes (PPROM)
Multiple gestation
Maternal history of one or more spontaneous second-trimester abortions

83. Risk Factors (cont’d) Maternal complications Smoking Illicit drug use
Alcohol use
Lack of prenatal care
Uterine causes
Myomata
Uterine septum
Bicornuate uterus
Cervical incompetence
Exposure to diethylstilbestrol
Infectious causes
Chorioamnionitis
Bacterial vaginosis
Acute pyelonephritis
Fetal causes
Intrauterine fetal death
Intrauterine growth retardation
Congenital anomalies
Abnormal placentation
Presence of a retained intrauterine device

84. Preterm Labor Predicting preterm labor…
Monitor cervical change, uterine contractions, bleeding, and changes in fetal behavioral states ?
High false positive rate
Unnecessary and potentially hazardous treatment

85. Preterm Labor Management Tocolytic therapy Corticosteroid therapy
Inhibit labor, slow down or halt the contractions of the uterus
Delay delivery; time to administer corticosteroid therapy
Corticosteroid therapy
Enhance pulmonary maturity
Reduce severity of fetal RDS and intraventricular hemorrhage
Antibiotic Therapy
Women with PPROM sustain the pregnancy longer
Bed rest(?)
No conclusive studies documenting its benefit

86. Higher-risk Pregnancies*
Gestational diabetes
Hypertension
*Cannot be managed the same way as low-risk post-term pregnancies

87. Mcq The definition of bleeding in early pregnancy include
Any bleeding at any duration of pregnancy
Bleeding after 20 wks
Bleeding before 20 wks
All of the above

88. Young patient newly married came in with lower abdominal pain , the first step in ED?
To do abdominal xray
To do urinary pregnancy test to R/O possibility of ectopic pregnancy
To discharge patient with the pain killer
To do ultrasound

89. Which of the following statements best describes pregnancy-induced hypertension (PIH)?
Defined by blood pressure greater than 120/80
Eclamptic seizures do not occur postpartum
Greatest risk in women older than 20 years of age
Proteinuria is always present
Severe form is characterized by hemolysis, elevated liver enzymes and low platelets

90. Which of the following statements is the most accurate regarding placenta previa?
Most cases identified in the second trimester go on to spontaneous miscarriage.
Uterine contractions and pain are hallmarks of placenta previa.
Prolonged passage of dark vaginal blood is characteristic of placenta previa.
Sonography is not a sensitive diagnostic procedure.
Digital probing of the cervix should be avoided in the second half of pregnancy.