Obstetric Emergencies
Obstetric Emergencies: We will
cover...
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Normal Pregnancy
Common medical and surgical
complications of pregnancy
Normal pregnancy
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All females of childbearing age are
presumed to be pregnant until proven
otherwise.
All pregnancy tests detect B-HCG which is
produced at the time of implantation (8-9
days post conception)
B-HCG should double every day for the
first weeks, peak at week 8 and remain
elevated up to 60 days post-partum
False Negatives
Too early in pregnancy
Dilute/old urine
Ectopic
Incomplete Ab.
False Positives
Urine:
hematuria/proteinuria
Serum:
T.O.A.
Thyrotoxicosis
Molar pregnancy
Drugs (MJ, ASA,
Phenothiazines,
anticonvulsants,
antidepressants,
methadone
Some Important Physiological
Changes in Pregnancy
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Cardiac: increased heart rate, decreased
blood pressure. CO increases
Respiratory: rate increases, TV increases,
FRV decreases, pCO2 decreases
Heme: Volume increases, HCT drops, WBC
increases
Drugs in Pregnancy: A, B, C, D, X
Considered Safe in pregnancy:
PCN
Cephalosporins
Azithro/Erythromycin
Acetaminophen
Narcotics
Heparin
Asthma Drugs
Reglan (Metoclopramide)
Immunizations derived from killed viruses
(tetanus, diptheria, Hep. B, Rabies)
Radiation in Pregnancy
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<5-10 rads = no significant risk of birth
defects
Beams aimed 10cm away from fetus pose
no additional risk
Initial trauma X-rays each deliver <1 rad
One never withholds necessary
radiography.
Use MRI or U/S if available.
Transvaginal Ultrasound Images
Normal, non-pregnant uterus on
T/V U/S
The “Double-Ring” Sign or “Double
Decidual” Sign of normal early
pregnancy
Normal Pregnancy T/V Ultrasound
Showing Gestational and Yolk Sac.
No fetus is seen. 5w 2d
6w 1d T/V U/S showing yolk sac
Normal T/V U/S with embryo at
10w 3d
Complications of Pregnancy –
Vaginal Bleeding
1st Trimester Causes:
1. Ectopic
2. Abortion
3. Molar Pregnancy
4. Non-pregnancy Related
a. Infectious
b. Trauma
c. Neoplasm
The work-up is the same!
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Pelvic Exam
Beta HCG
Transvaginal ultrasound
Rh
CBC, CMP
PT/PTT/INR
UA
Ectopic Pregnancy – A surgical
emergency of pregnancy
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The leading cause of first trimester
maternal death
Usually 5-8 weeks after LMP
High Risk: History of ectopic, tubal surgery
or sterilization procedure, Known tubal
scarring or pathology, Diethylstilbestrol
exposure, IUD.
Signs/Symptoms
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Symptoms (in decreasing order of
frequency): Abdominal pain, amenorrhea,
vaginal bleeding (50-80%), dizziness,
pregnancy symptoms, urge to defecate,
passing tissue
Signs: Adnexal tenderness, abdominal
tenderness, adnexal mass, enlarged
uterus, orthostatic changes, fever
Testing
Beta > 6000 mIU/ml + empty uterus on
transabdominal ultrasound
OR
Beta > 1200 mIU/ml + empty uterus on
transvaginal ultrasound =
Ectopic Pregnancy = Laparoscopy
Beta <6000 + empty uterus on
transabdominal ultrasound
OR
Beta < 1200 + empty uterus on transvaginal
ultrasound = serial outpatient beta
measurements to ensure normal rise.
This only applies to stable patients and
should be done in consult with ob/gyn
A heterotopic pregnancy (to
compare normal vs. abnormal)
Ectopic Pregnancy
2nd Trimester
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Causes are abortion and non-pregnancy
causes.
Work-up is the same
Management of threatened AB is the same
If complete, may be D&C candidate
If other types of AB, patient may undergo
oxytocin induced labor as inpatient.
3rd Trimester (>28 weeks)
Placental Abruption
Placenta Previa
Placenta separates from uterine
wall
Painful dark or clotted blood
Placenta implants too low
Risks: HTN, smoking, ETOH,
cocaine, multiparity, previous
abruption, trauma, mom >
40
Risks: prior C-section, grand
multiparity, previous previa,
multiple gestations, multiple
induced abortions, mom
>40.
Management: U/S, Ob consult,
cardiac/fetal monitoring, IV,
pre-op labs, delivery if
possible
Painless bright red bleeding
Management: U/S, Ob consult,
pre-op labs, avoid pelvic
exam, c-section
3rd Trimester Bleeding cont’d
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Uterine Rupture: Can be seen in scarred
and unscarred uteri. (uteruses? uterata?)
Complications of Pregnancy:
Trauma
Key Concept: Although you have two
patients, maternal circulation is to be
maintained at the expense of the fetus.
Without mom, the baby will surely die.
Mom should be kept in left lateral decubitus
This is where knowing the physiologic
changes of pregnancy becomes extremely
important ! Mom can lose up to 35% of
her blood volume before showing any
signs of shock!
Management
Over 20 weeks: Goes to Ob for 4 hours of
cardiotocographic monitoring
All women with abdominal trauma get
Rhogam (fetomaternal hemorrhage
present in 30% of these patients)
Kleihauer-Betke test: Used in women >12w
to determine and quantify the amount of
fetomaternal hemorrhage that occurred
Perimortem C-Section
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Fetus greater than 28weeks, maternal
death less than 15 minutes = perimortem
c-section
Complications of Pregnancy:
Hypertension
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Can be chronic (meaning it began prior to
conception or began during gestation and
persists >6 weeks post-partum) or
gestational.
We care about this because HTN in
pregnancy is associated with preeclampsia, abruption, prematurity, IUGR
and stillbirth
Pre-eclampsia: To be considered in
those >20wks with HTN
Mild
SBP > 140 (or +20 from baseline.
Or DBP >90 (or +10 from
baseline)
Proteinuria .3g/24h
+/- Edema
No Oliguria
No Associated symptoms
Normal labs
No IUGR
Severe
BP>160/90
Proteinuria >5g/24h
Edema Present
Oliguric
Associated symptoms (H/A, visual
symptoms, abdominal pain,
pulm. edema
Associated labs (dec. plts, inc.
LFT, inc. bili, inc. creatinine,
increased uric acid)
IUGR present
HELLP syndrome = very severe.
Above +RUQ pain, n/v
Management
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Isolated HTN requires a 24h urine and close Ob
f/u
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With other findings, admit, 24h urine, bed rest
and HTN management in consult with ob/gyn.
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Hydralazine common though diazoxide,
labetalol, nifedipine and nitroprusside also used
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+/- Mag to prevent seizures
Complications of Pregnancy:
Eclampsia
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Preeclampsia +seizures or coma
May occur without proteinuria, may occur
up to 10 days postpartum
ICH is the major cause of maternal death
Warning signs = H/A, visual changes,
hyperreflexia, Abd. pain
Tx = Delivery. Magnesium, Phenytoin or
Diazepam, Hydralazine or Labetalol
Complications of Pregnancy:
UTI/Pyelo
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Pregnant women more prone to UTI secondary
to physiologic changes of pregnancy
Treat both symptomatic and asymptomatic
bacturia (untreated = up to 40% risk of
progression to pyelo)
Culture urine, give 7 day course
We admit pregnant women with pyelonephritis
because of its increased risk of of progressing to
preterm labor or septic shock.
Complications of Pregnancy:
Appendicitis
Appendicitis is the most frequent surgical
emergency of pregnancy
Incidence is the same as non-pregnant population
but the complications are more frequent
secondary to delayed diagnosis
Again, the physiologic changes of pregnancy
complicate the clinical picture (leukocytosis,
displaced appendix)
Picture mimics pyelo. When patients don’t
improve with IV abx, the diagnosis is
reconsidered.
Laparotomy is the preferred diagnostic procedure.
Ultrasound can used
References
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Preparing for the Written Board Exam in Emergency Medicine. 5th ed. Vol 1. Rivers, Carol. pp 550-574
learnobultrasound.com/3trimesterbleed.htm
www.smbs.buffalo.edu/emed/emed/ultrasound.html
Harwood &Nuss’ Clinical Practice of Emergency Medicine 4th ed. Wolfson, Alan B Lippincott, Williams and Wilkins,
Philadelphia, 2005. pp.496-497
home.flash.net/~drrad/tf/122396.htm
www.pwc-sii.com/Research/death/ribs.htm
www.jaapa.com/.../article/130146/
www.advancedfertility.com/ultraso1.htm
Ma, John O. Emergency Ultrasound via access emergency medicine at http://0www.accessem.com.innopac.lsuhsc.edu/content.aspx?aID=100900