WILLS Pitfalls First Half of Pregnancy - UCSF CME · • Complications include massive bleeding,...
Transcript of WILLS Pitfalls First Half of Pregnancy - UCSF CME · • Complications include massive bleeding,...
Pitfalls in the First Half of Pregnancy
Charlotte Page Wills, MDAssociate Program Director
Alameda Health System-Highland Hospital EM Residency, Oakland, CA
Associate Clinical Professor of Emergency Medicine
University of California, San Francisco School of Medicine
Financial Disclosures: None!
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10 weeks pregnantSevere abdominal pain and vaginal bleeding
BP 70/30 HR 130 RR 22 O2 98% POC glu 98ETA 3 minutes
Goals!
• Go beyond the basics, and highlight diagnostic challenges with uncommon types of ectopic.
• Raise awareness of when pregnancy may make common complaints and conditions more dangerous.
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Ectopic Pregnancy in 2014
• Increasing rates of EP with increasing rates of STIs.
• 1.5‐2% of pregnancies
• Mortality 0.5/1000 pregnancies.
• Remains the cause of 6% of maternal deaths.
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Pain
Visit 1 •Normal vital signs•No bleeding•Mild suprapubic tenderness
WBC 8KHgb 11.9
WBC 10‐20+ LE
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Ectopics Hiding Near the Uterus
• More difficult to diagnose ‐ both can appear intrauterine.
• More likely to cause catastrophic bleeding.
• Higher rates in ART patients.
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Cervical Scar Ectopic
• Embryonic implantation at the site of a cesarean section scar in the lower uterine segment.
• ULS: uterine cavity and cervical canal empty.
• Complications include massive bleeding, uterine rupture, hysterectomy ‐ early in the first trimester.
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Heterotopic Pregnancy
• 1 in 4,000 pregnancies
• 1 in 100 pregnancies in patients using assisted reproductive technology
• cervical
• ovarian
• abdominal
• cornual
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Gestational Sac Pitfalls
• Pseudo‐gestational sac
• Irregular shape
• Lack of decidual reaction
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Avoiding Ultrasound Pitfalls
• Make sure you are oriented correctly!
• Find the uterine cavity.• Find the endocervical canal.
• Always look in the adnexa and ovaries.
• Look for free fluid.
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14 weeks pregnantHeadaches and nausea, GCS 15, no weakness
BP 146/90 HR 120 RR 22 O2 98% POC glu 80ETA 5 minutes
More Volume Under Less Pressure
• Blood pressure: decreases 10‐15 mm Hg
• Heart rate: increases 10‐15 bpm
• SVR: decreases by 10‐15%
• Cardiac output: increases by 30‐50%
• Blood volume: increases by 30‐50%
• Hematocrit: decreases to 32‐34%
Vital Signs
Cardiovascular Changes
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Pyelonephritis
• May complicate 2% of pregnancies.
• Asymptomatic bacteriuria occurs in a third.
• E.coli, Klebisiella, Group B strep.• Crucial to culture the specimen and know local resistance patterns.
• Treatment: avoid quinolones.
• Disposition: frequently admitted.
Pneumonia
• Incidence is the same but the complications are worse.
• Organisms are the same.– S. pneumo
• Tendency to avoid imaging which then delays diagnosis/treatment.
High Risk Pneumonia
• Varicella–Higher rates of morbidity and mortality; complications to the fetus
• Influenza–High rates of respiratory failure
• Coccidiomycosis–Higher rates of dissemination
Influenza and H1N1• Increased susceptibility.
• Increased complications.
Appendicitis
• Perforation rates increase with trimester
• 9% > 13% >26%
• Unreliable exam: displacement of the normal position of the appendix.
• Labs generally unhelpful.
• Associated morbidity and mortality to the fetus with rupture.
Pregnant
Visit 1 •Hypertensive•Intermittent bleeding•Severe nausea and vomiting
WBC 8KHgb 11.9
trace prot
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Pregnant
Headache Nausea
Molar Pregnancy
Gestational Trophoblastic Disease
• Hydatiform mole
• Invasive mole
• Choriocarcinoma
• Trophoblastic tumor
Moles in the ED
• One of the few causes of pre‐eclampsia occurring prior to 20 weeks.
• Should be suspected with:
• new onset hypertension
• very elevated hCG levels
• abnormal ULS
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