Acute complications of pregnancy

Ibtisam Al Hoqani

EM – R1

22/6/2010

Outline:Complications in Early Pregnancy:

MiscarrigesEctpic pregnancyMolar pregnancy

:Complications in late pregnancyAbruption placentaPlacenta PreviaPreeclampsia and Eclampsia

Medical & Surgical problems in pregnancy

Question 1:

Which of following is the most common cause of first trimester vaginal bleeding?

A. Abruptio placentaB. Ectopic pregnancyC. Placenta previaD. Spontaneous abortionE. Ovarian torsion

Miscarriage

It is common, the overall embryponic and fetal loss rate after implantation ranges up to 1/3 of detectable pregnancySpontaneous abortion:

Threatened Inevitable Incomplete Complete Missed

Question 2:

A 26 years G1P0, 11 wks, presents to ED with vaginal bleeding. Bedside U/S confirm IU fetus with cardiac activity, VE: close cervical os, minimal bleeding, no adenxal tendernress. Bhcg sent. Mx incloude all except:

A. Discharge with insterctions to come back if bleeding increased

B. Bed rest fo 48 hrsC. ReassuranceD. Inpatient admission for observation

Miscarriage

Threatened abortion is most common cause of PV bleeding in primi

It is PV bleeding, cervical os closed, IU normal pregnancy

Mx:

Bed rest for 48 hrs

F/U with obs/gyne in 2-3 days

Miscarriage

Inevitable abortion:Vaginal bleeding with open cervical osMx: D&C

Incomplete abortion:Vaginal bleeding with open cervical os and

some POC passed or in the os or vaginal canal

Mx: Remove visible POC to control bleeding, D&C

Miscarriage

Complete abortion:

All POC passed, os closed, uterus firm, non tender, and the bleeding almost stopped

Mx: confirm by U/S , discharge or D&C if needed

Missed abortion:

Failure to pass POC after 2 months of fetal death

Mx: medical or surgical D&C

Sonographic “discriminatory Zone”:

The quantitive hCG at which a normally developing IUP should be seen;

=6500 mIU/ml for TA U/S

=3000 mIU/ml for TV U/S

Criteria for abnormal pregnancy for TV U/S

Question : An 18 yrs present with sever LLQ pain and

dizziness starting 4 hrs ago. T=36, PR=110, RR=30, BP=82/40, after 2L of saline hCG return positive and repeat vitals; PR=120, RR=30, BP=76/40, the best Tx:

A. Administer IV antibiotics and arrange admissionB. Check CBC, ESR, urinanalysis and continue fluid

resuscitationC. Discharge home with antibiotics and analgesiaD. Obtain TV U/SE. Immediate OB/GYN referral for laparoscopic surgery

Qusetion

Which of following is not a risk factor for ectopic pregnancy:

A. Previous C-sectionB. Pharmacological assisted conceptionC. Previous ectopic pregnancyD. Previous h/o PIDE. Having IUCD

Ectopic pregnancy:Leading cause of maternal death in 1st trimester and 2nd overall cause of mortality in pregnant ladiesRisk factors:

    Advanced age Pelvic inflammatory disease

     Smoking    Prior spontaneous abortion

or ectopic pregnancy    Medically induced abortion

     History of infertility   Intrauterine device Tubal Surgery

Question: A 24 yrs female present to ED with 2

days vaginal bleeding and cramping. LMP 9 weeks ago, ED urine pregnancy test positive. Additional testing includes all except:

A. Serum hCGB. Speculum and bimanual examinationC. CuldocentesisD. CBC and blood groupE. Pelvic ultrasound

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Question: A 28 yrs present with acute onset of LLQ

pain after unusually heavy bleeding, LMP: 4 wks ago. Pt pale, PR=130, BP=108/60, RR=24, T=36, After 1L of saline her vitals: PR=92, BP=118/70, RR=24, Urine PT post; what is most appropriate next step:

A. Emergency U/S with immediate gyne referral

B. Emergency U/S then call gyne accordinglyC. Reassure and D/C with threatened abortion

instructionsD. Send CBC, cross match as appropriate and

f/u with gyne within 24 hr

Ectopic pregnancy

Management:

Stable pt with un-ruptured EP <4cm by U/S ,,,, Methotrexate therapy

Stable pt un-ruptured or minimally ruptured >4cm EP ,,,, Laparoscopic salpingectomy

Unstable ,,, Laparotomy

Abruption placenta

The cause of 30% of PV bleeding in 3rd trimester

Premature separation of normally implanted placenta causing seen or hidden bleeding

Usually associated with painfull uterine bleeding

Abruption placenta

Stages:Grade 1: 40%, slight bleeding, no pain

or fetal distressGrade 2: 45%, moderate bleeding,

increase uterine irritability with fetal distress

Grade 3: 15% tetanic uterine contraction, hypotension, coagulopathy, possible fetal death

Question:

Which of following is not associated with increase incidence of Abruptio placenta?

A. CocaineB. HeroinC. HypertensionD. SmokingE. Advance age and MultipartyF. Abdominal trauma

Question: A 25 yrs G2P1, 24 wk of pregnancy,

presents complaining of painless vaginal bleeding for 3 days, vitals: T=37.5, PR=92, BP=130/78, RR=20; what is best treatment plan for her?

A. Ultrasound and outpatient OB F/UB. Urgent U/S with OBS/GYN refferalC. Send for CBC, blood group and weight

resultD. PV examination and send swap for c/s

Placenta Previa

Cause 20% of 3rd trimester bleedingPainless bright red vaginal bleeding with soft non tender uterus Risk factors:

Prior C-section Grand Multiparty Previous placenta previa Multiple gestation Multiple induce abortion Maternal age >40 years

Management

Establish IV access, draw blood for cross match and basic work up, establish cardiac and fetal monitoring Immediately call for obstetric consultation if unstable otherwise do both ultrasound and OB referral Never do PV digital or speculum exam unless placenta previa rolled out

Question:

A 36 yrs primi, 32wks, present with epigastric pain, her vitals normal except for BP=150/100, in ED she begins to seize, the next best action in Mx is?

A. Hydralazine 10mg IV pushB. Lorazepam 2mg IV pushC. Phenytoin 20mg/kg IVD. MgSO4 6grm slow iv pushE. Labetolol 20mg slow iv push

Preeclampsia and Eclampsia

Pre-eclampsia:

Elevated BP systolic >=140 or >=20 above baseline, and diastolic >=90 or 10 above baseline

With proteinuria >0.3gm/24 hr

Eclampsia

Pre- eclamsia with grand-mal seizure or coma

Important facts:

Eclampsia may occur without prior proteinuriaEclampsia can occur up to 10 days post partumIntracranial bleeding is the major cause of maternal deathWarning sign of impending seizure:

Headache Visual disturbance Hyperreflexia Abdominal pain

Question:

Which of following is expected abnormality in HELLP syndrome?

A. Decrease HGBB. Elevated PTC. Decreased FibrinogenD. Elevated APTTE. All of above

Management:

Pre- eclampsia:Anti-HTN not needed unless systolic BP >170 or diastolic >150, target BP sys 130-150 and dias 90-100Hydralazine is most commonly used but (Labetolol, nifedipine, nitroprusside) can be usedACE inhibitor are contraindicatedProphylactics MgSO4 is recommended

Question : A 38 yrs obese primi, 34wk, present with

swelling leg and abdominal pain, BP=170/100, urine 3+protein, after giving MgSO4 and hydralazine, nurse toll u her urine output is low, what is best next step?

A. Frusmide 40mg iv statB. Maintained IV fluidC. Hydrochlorothiazide 25mg oralD. Mannitol 0.5mg/kg iv pushE. 25% albumin 1g/kg iv

Management:

Eclampsia:Definitive Tx is deliveryMgSO4: antiepileptic and anti-HTN

Loading dose: 6mg IV over 15-20min then continuous infusion 2g/hr, Cardiac monitoring, and maintain urine output at rate >25ml/hrFollow DTR stop infusion if disappearPhenytoin or diazepam may be used for seizure resistant to MgSo4

Question:

Which of following is sign of MgSO4 toxicity?

A. Atrial FibrillationB. SomnolenceC. IncreaseD. HyperventilationE. Diarrhea

Question: A 22 yrs, 36 wks pregnant after treating her

with MgSO4 for preeclampsia, pt become somnolent with markedly decrease deep tendon reflex, and decrease RR, after managing her airway what is next best step?

A. DexamethasoneB. LidocaineC. LabetololD. Calcium gluconateE. Atropine