Obstetric Obstetric EmergenciesEmergencies

Obstetric Emergencies: We Obstetric Emergencies: We will cover...will cover...

Normal PregnancyNormal Pregnancy Common medical and surgical Common medical and surgical

complications of pregnancycomplications of pregnancy

Normal pregnancyNormal pregnancy

All females of childbearing age are All females of childbearing age are presumed to be pregnant until proven presumed to be pregnant until proven otherwise.otherwise.

All pregnancy tests detect B-HCG which All pregnancy tests detect B-HCG which is produced at the time of implantation is produced at the time of implantation (8-9 days post conception)(8-9 days post conception)

B-HCG should double every day for the B-HCG should double every day for the first weeks, peak at week 8 and remain first weeks, peak at week 8 and remain elevated up to 60 days post-partumelevated up to 60 days post-partum

False NegativesFalse Negatives

Too early in Too early in pregnancypregnancy

Dilute/old urineDilute/old urine

EctopicEctopic

Incomplete Ab.Incomplete Ab.

False PositivesFalse Positives

Urine:Urine: hematuria/proteinurihematuria/proteinuriaa

Serum:Serum: T.O.A.T.O.A.ThyrotoxicosisThyrotoxicosisMolar pregnancyMolar pregnancyDrugs (MJ, ASA, Drugs (MJ, ASA,

Phenothiazines, Phenothiazines, anticonvulsants, anticonvulsants, antidepressants, antidepressants, methadonemethadone

Some Important Physiological Some Important Physiological Changes in PregnancyChanges in Pregnancy

Cardiac: increased heart rate, decreased Cardiac: increased heart rate, decreased blood pressure. CO increasesblood pressure. CO increases

Respiratory: rate increases, TV increases, Respiratory: rate increases, TV increases, FRV decreases, pCO2 decreasesFRV decreases, pCO2 decreases

Heme: Volume increases, HCT drops, Heme: Volume increases, HCT drops, WBC increasesWBC increases

Drugs in Pregnancy: A, B, C, D, Drugs in Pregnancy: A, B, C, D, XXConsidered Safe in pregnancy: Considered Safe in pregnancy:

PCNPCNCephalosporinsCephalosporinsAzithro/ErythromycinAzithro/ErythromycinAcetaminophenAcetaminophenNarcoticsNarcoticsHeparinHeparinAsthma DrugsAsthma DrugsReglan (Metoclopramide)Reglan (Metoclopramide)Immunizations derived from killed viruses Immunizations derived from killed viruses

(tetanus, diptheria, Hep. B, Rabies)(tetanus, diptheria, Hep. B, Rabies)

Radiation in PregnancyRadiation in Pregnancy

<5-10 rads = no significant risk of birth <5-10 rads = no significant risk of birth defectsdefects

Beams aimed 10cm away from fetus Beams aimed 10cm away from fetus pose no additional riskpose no additional risk

Initial trauma X-rays each deliver <1 radInitial trauma X-rays each deliver <1 rad One never withholds necessary One never withholds necessary

radiography.radiography. Use MRI or U/S if available.Use MRI or U/S if available.

Transvaginal Ultrasound Transvaginal Ultrasound ImagesImages

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

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

Normal Pregnancy T/V Normal Pregnancy T/V Ultrasound Showing Ultrasound Showing

Gestational and Yolk Sac. No Gestational and Yolk Sac. No fetus is seen. 5w 2dfetus is seen. 5w 2d

6w 1d T/V U/S showing yolk 6w 1d T/V U/S showing yolk sacsac

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

Complications of Pregnancy – Complications of Pregnancy – Vaginal BleedingVaginal Bleeding

11stst Trimester Causes: Trimester Causes: 1.1. EctopicEctopic2.2. AbortionAbortion3.3. Molar PregnancyMolar Pregnancy4.4. Non-pregnancy RelatedNon-pregnancy Related

a. Infectiousa. Infectiousb. Traumab. Traumac. Neoplasmc. Neoplasm

The work-up is the same!The work-up is the same!

Pelvic ExamPelvic Exam Beta HCGBeta HCG Transvaginal ultrasoundTransvaginal ultrasound RhRh CBC, CMPCBC, CMP PT/PTT/INRPT/PTT/INR UAUA

Ectopic Pregnancy – A surgical Ectopic Pregnancy – A surgical emergency of pregnancyemergency of pregnancy

The leading cause of first trimester The leading cause of first trimester maternal death maternal death

Usually 5-8 weeks after LMPUsually 5-8 weeks after LMP High Risk: History of ectopic, tubal High Risk: History of ectopic, tubal

surgery or sterilization procedure, surgery or sterilization procedure, Known tubal scarring or pathology, Known tubal scarring or pathology, Diethylstilbestrol exposure, IUD.Diethylstilbestrol exposure, IUD.

Signs/SymptomsSigns/Symptoms

Symptoms (in decreasing order of Symptoms (in decreasing order of frequency): Abdominal pain, frequency): Abdominal pain, amenorrhea, vaginal bleeding (50-amenorrhea, vaginal bleeding (50-80%), dizziness, pregnancy symptoms, 80%), dizziness, pregnancy symptoms, urge to defecate, passing tissueurge to defecate, passing tissue

Signs: Adnexal tenderness, abdominal Signs: Adnexal tenderness, abdominal tenderness, adnexal mass, enlarged tenderness, adnexal mass, enlarged uterus, orthostatic changes, feveruterus, orthostatic changes, fever

TestingTesting

Beta > 6000 mIU/ml + empty uterus Beta > 6000 mIU/ml + empty uterus on transon transabdominal abdominal ultrasoundultrasound

OROR

Beta > 1200 mIU/ml + empty uterus Beta > 1200 mIU/ml + empty uterus on transon transvaginal vaginal ultrasound =ultrasound =

Ectopic Pregnancy = LaparoscopyEctopic Pregnancy = Laparoscopy

Beta <6000 + empty uterus on Beta <6000 + empty uterus on transabdominal ultrasoundtransabdominal ultrasound

ORORBeta < 1200 + empty uterus on Beta < 1200 + empty uterus on

transvaginal ultrasound = serial transvaginal ultrasound = serial outpatient beta measurements to outpatient beta measurements to ensure normal rise.ensure normal rise.

This only applies to stable patients and This only applies to stable patients and should be done in consult with ob/gynshould be done in consult with ob/gyn

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

Ectopic PregnancyEctopic Pregnancy

22ndnd Trimester Trimester

Causes are abortion and non-pregnancy Causes are abortion and non-pregnancy causes. causes.

Work-up is the sameWork-up is the same Management of threatened AB is the Management of threatened AB is the

samesame If complete, may be D&C candidateIf complete, may be D&C candidate If other types of AB, patient may undergo If other types of AB, patient may undergo

oxytocin induced labor as inpatient.oxytocin induced labor as inpatient.

33rdrd Trimester (>28 weeks) Trimester (>28 weeks)Placental AbruptionPlacental Abruption

Placenta separates from Placenta separates from uterine walluterine wall

Painful dark or clotted bloodPainful dark or clotted blood

Risks: HTN, smoking, ETOH, Risks: HTN, smoking, ETOH, cocaine, multiparity, cocaine, multiparity, previous abruption, previous abruption, trauma, mom > 40trauma, mom > 40

Management: U/S, Ob Management: U/S, Ob consult, cardiac/fetal consult, cardiac/fetal monitoring, IV, pre-op monitoring, IV, pre-op labs, delivery if possiblelabs, delivery if possible

Placenta PreviaPlacenta PreviaPlacenta implants too lowPlacenta implants too low

Painless bright red bleedingPainless bright red bleeding

Risks: prior C-section, grand Risks: prior C-section, grand multiparity, previous multiparity, previous previa, multiple gestations, previa, multiple gestations, multiple induced abortions, multiple induced abortions, mom >40.mom >40.

Management: U/S, Ob Management: U/S, Ob consult, pre-op labs, consult, pre-op labs, avoid pelvic exam, avoid pelvic exam, c-c-sectionsection

33rdrd Trimester Bleeding Trimester Bleeding cont’dcont’d

Uterine Rupture: Can be seen in Uterine Rupture: Can be seen in scarred and unscarred uteri. scarred and unscarred uteri. (uteruses? uterata?)(uteruses? uterata?)

Complications of Pregnancy: Complications of Pregnancy: TraumaTrauma

Key Concept: Although you have two Key Concept: Although you have two patients, maternal circulation is to be patients, maternal circulation is to be maintained at the expense of the fetus. maintained at the expense of the fetus. Without mom, the baby will surely die.Without mom, the baby will surely die.

Mom should be kept in left lateral Mom should be kept in left lateral decubitusdecubitus

This is where knowing the physiologic This is where knowing the physiologic changes of pregnancy becomes changes of pregnancy becomes extremely important ! Mom can lose up extremely important ! Mom can lose up to 35% of her blood volume before to 35% of her blood volume before showing any signs of shock!showing any signs of shock!

ManagementManagement

Over 20 weeks: Goes to Ob for 4 hours Over 20 weeks: Goes to Ob for 4 hours of cardiotocographic monitoringof cardiotocographic monitoring

All women with abdominal trauma get All women with abdominal trauma get Rhogam (fetomaternal hemorrhage Rhogam (fetomaternal hemorrhage present in 30% of these patients)present in 30% of these patients)

Kleihauer-Betke test: Used in women Kleihauer-Betke test: Used in women >12w to determine and quantify the >12w to determine and quantify the amount of fetomaternal hemorrhage amount of fetomaternal hemorrhage that occurredthat occurred

Perimortem C-Section Perimortem C-Section

Fetus greater than 28weeks, Fetus greater than 28weeks, maternal death less than 15 minutes maternal death less than 15 minutes = perimortem c-section= perimortem c-section

Complications of Pregnancy: Complications of Pregnancy: HypertensionHypertension

Can be chronic (meaning it began Can be chronic (meaning it began prior to conception or began during prior to conception or began during gestation and persists >6 weeks gestation and persists >6 weeks post-partum) or gestational. post-partum) or gestational.

We care about this because HTN in We care about this because HTN in pregnancy is associated with pre-pregnancy is associated with pre-eclampsia, abruption, prematurity, eclampsia, abruption, prematurity, IUGR and stillbirthIUGR and stillbirth

Pre-eclampsia: To be Pre-eclampsia: To be considered in those >20wks considered in those >20wks

with HTNwith HTNMildMild

SBP > 140 (or +20 from SBP > 140 (or +20 from baseline. Or DBP >90 (or baseline. Or DBP >90 (or +10 from baseline)+10 from baseline)

Proteinuria .3g/24hProteinuria .3g/24h+/- Edema+/- EdemaNo OliguriaNo OliguriaNo Associated symptomsNo Associated symptomsNormal labsNormal labsNo IUGRNo IUGR

SevereSevere

BP>160/90BP>160/90Proteinuria >5g/24hProteinuria >5g/24hEdema PresentEdema PresentOliguricOliguricAssociated symptoms (H/A, Associated symptoms (H/A,

visual symptoms, visual symptoms, abdominal pain, pulm. abdominal pain, pulm. edemaedema

Associated labs (dec. plts, inc. Associated labs (dec. plts, inc. LFT, inc. bili, inc. creatinine, LFT, inc. bili, inc. creatinine, increased uric acid)increased uric acid)

IUGR presentIUGR presentHELLP syndrome = very HELLP syndrome = very

severe. Above +RUQ pain, severe. Above +RUQ pain, n/v n/v

ManagementManagement

Isolated HTN requires a 24h urine and close Isolated HTN requires a 24h urine and close Ob f/uOb f/u

With other findings, admit, 24h urine, bed rest With other findings, admit, 24h urine, bed rest and HTN management in consult with ob/gyn. and HTN management in consult with ob/gyn.

Hydralazine common though diazoxide, Hydralazine common though diazoxide, labetalol, nifedipine and nitroprusside also labetalol, nifedipine and nitroprusside also usedused

+/- Mag to prevent seizures+/- Mag to prevent seizures

Complications of Pregnancy: Complications of Pregnancy: EclampsiaEclampsia

Preeclampsia +seizures or comaPreeclampsia +seizures or coma May occur without proteinuria, may May occur without proteinuria, may

occur up to 10 days postpartumoccur up to 10 days postpartum ICH is the major cause of maternal ICH is the major cause of maternal

deathdeath Warning signs = H/A, visual changes, Warning signs = H/A, visual changes,

hyperreflexia, Abd. painhyperreflexia, Abd. pain Tx = Delivery. Magnesium, Phenytoin Tx = Delivery. Magnesium, Phenytoin

or Diazepam, Hydralazine or Labetalolor Diazepam, Hydralazine or Labetalol

Complications of Pregnancy: Complications of Pregnancy: UTI/PyeloUTI/Pyelo

Pregnant women more prone to UTI Pregnant women more prone to UTI secondary to physiologic changes of secondary to physiologic changes of pregnancypregnancy

Treat both symptomatic and asymptomatic Treat both symptomatic and asymptomatic bacturia (untreated = up to 40% risk of bacturia (untreated = up to 40% risk of progression to pyelo)progression to pyelo)

Culture urine, give 7 day courseCulture urine, give 7 day course We admit pregnant women with We admit pregnant women with

pyelonephritis because of its increased risk of pyelonephritis because of its increased risk of of progressing to preterm labor or septic of progressing to preterm labor or septic shock.shock.

Complications of Pregnancy: Complications of Pregnancy: AppendicitisAppendicitis

Appendicitis is the most frequent surgical Appendicitis is the most frequent surgical emergency of pregnancyemergency of pregnancy

Incidence is the same as non-pregnant Incidence is the same as non-pregnant population but the complications are more population but the complications are more frequent secondary to delayed diagnosisfrequent secondary to delayed diagnosis

Again, the physiologic changes of pregnancy Again, the physiologic changes of pregnancy complicate the clinical picture complicate the clinical picture (leukocytosis, displaced appendix)(leukocytosis, displaced appendix)

Picture mimics pyelo. When patients don’t Picture mimics pyelo. When patients don’t improve with IV abx, the diagnosis is improve with IV abx, the diagnosis is reconsidered.reconsidered.

Laparotomy is the preferred diagnostic Laparotomy is the preferred diagnostic procedure. Ultrasound can usedprocedure. Ultrasound can used

ReferencesReferences

1. Preparing for the Written Board Exam in Emergency Medicine. 51. Preparing for the Written Board Exam in Emergency Medicine. 5 thth ed. Vol 1. Rivers, Carol. pp 550- ed. Vol 1. Rivers, Carol. pp 550-574574

2. learnobultrasound.com/3trimesterbleed.htm 2. learnobultrasound.com/3trimesterbleed.htm

3. www.smbs.buffalo.edu/emed/emed/ultrasound.html 3. www.smbs.buffalo.edu/emed/emed/ultrasound.html

4. Harwood &Nuss’ Clinical Practice of Emergency Medicine 44. Harwood &Nuss’ Clinical Practice of Emergency Medicine 4 thth ed. Wolfson, Alan B Lippincott, Williams ed. Wolfson, Alan B Lippincott, Williams and Wilkins, Philadelphia, 2005. pp.496-497and Wilkins, Philadelphia, 2005. pp.496-497

5. home.flash.net/~drrad/tf/122396.htm 5. home.flash.net/~drrad/tf/122396.htm

6. www.pwc-sii.com/Research/death/ribs.htm 6. www.pwc-sii.com/Research/death/ribs.htm

7. www.jaapa.com/.../article/130146/ 7. www.jaapa.com/.../article/130146/

8. www.advancedfertility.com/ultraso1.htm 8. www.advancedfertility.com/ultraso1.htm

9. Ma, John O. Emergency Ultrasound via access emergency medicine at http://0-9. Ma, John O. Emergency Ultrasound via access emergency medicine at http://0-www.accessem.com.innopac.lsuhsc.edu/content.aspx?aID=100900www.accessem.com.innopac.lsuhsc.edu/content.aspx?aID=100900