Complications of Pregnancy
Lee Graham
January 22, 2009
What’s Covered
•
•
•
•
•
Miscarriage
Ectopic
Hyperemesis
preeclampsia/eclampsia/HELLP
Throboembolus
What’s not covered
•
•
•
•
•
•
•
Abruption
Previa
Amniotic fluid embolism
Surgical disease of pregnancy
Fetal monitoring
Delivery
US
Case 1
• 32 yo with vaginal bleeding
• ~7/52 pregnant
– (positive home preg test 1 week ago)
– no prenatal care
• Vaginal spotting X 2 days
• Diffuse abdominal cramping 2hrs before
arrival
• Pmed / Pobs / Psurg = non contributory
Case 2
• Vitals = 37 C, HR=93, BP=110/70
• Abdo = soft/non-tender
• Pelvic =
– Cervic closed
– Moderate amount of blood at the os
– No adenexal mass and mild cervical
motion tenderness
Case 2
• US - no visible IUP
General approach
• In all women presenting with:
–
–
–
–
Abdominal/pelvic pain
Vaginal bleeding
Syncope
Shock
• You must consider the dx of Pregnancy
– Obtain a Urine hCG
Lower abdominal pain and/or vaginal
bleeding
- urine hCG
+ urine hCG
Diagnosis of pregnancy
• Fertilization occurs in the fallopian tube within
minutes to hours after follicular ovulation.
• Implantation in the endometrium > ~6 days
• Trophoblast secretes hCG > ~7 days
• Augments corpus luteal production of
progesterone until the trophoblastic
production of progesterone is capable of
maintaining pregnancy
hCG
• The initial doubling time is fast
– attributed to the actual process of implantation.
• This is followed by a slower rate of doubling
as trophoblast hCG and maternal circulatory
hCG equilibrate
• hCG levels peak at 7 to 10 weeks of
– mean value of 50,000 IU/L
– range of 20,000 to 200,000 IU/L
Urine Pregnancy Test
• Monoclonal antibodies are selected that act
against the purified β subunit of hCG
• Sensitivity between 25 and 50 IU/L.
• Normal hCG levels in men and
premenopausal women range from 0.02 to
0.8 IU/L.
• Postmenopausal women may have higher
levels.
Urine Pregnancy Test
• hCG testing becomes positive in 98% of
patients 7 days after implantation, which
coincides with the time of the expected
period.
• Negative result 1 week from the expected
time of the missed period essentially
guarantees that a woman is not pregnant.
• Doubling time
– 4 wk = 2.2 days (sd ± 0.8 d)
– 9 wk = 3.5 days (sd ± 1.2 d)
False Positive
• postmenopausal status
• abortion in the first trimester
• exogenous hCG for induction of
ovulation
• hCG-secreting tumor
• Molar pregnancy
False Negative
•
•
•
•
•
•
•
Expired test
Too early
Murse (color blind)
Dilute urine? (SG < 1.010, use 20 drop test)
High vitamin C
gross hematuria
protein > 2+
“Effect of low urine specific
gravity on pregnancy testing”
• J Am Coll Health 1998 Nov;47(3):138-9.
• Urine pregnancy tests with a low urine
specific gravity (<1.015) were compared with
a serum specimen.
• 410 urine specimens were evaluated. Eighty
of the women with a specific gravity under
1.015 had negative urine pregnancy tests
with a concomitant serum specimen. 0%
False Negative.
Signs of Pregnancy
• Uterine enlargement
–
–
–
–
–
–
–
–
Non pregnant - size of ping pong
4-6 weeks - size of baseball
8-10 weeks - size of softball
12 weeks - symphysis pubis
16 - 20 weeks - umbilicus
36 - 38 weeks xiphoid process of the sternum
>38 weeks - fetus descends into the pelvis
• Hegar’s sign (6-8 weeks) softening of the
lower uterine segment
• Chadwick's sign (6-8 weeks) vaginal walls
Lower abdominal pain and/or vaginal
bleeding
Workup as
- urine hCG
+ urine hCG
non-pregnant
Lower abdominal pain and/or vaginal
bleeding
Workup as
- urine hCG
+ urine hCG
non-pregnant
Hemodynamicaly
stable
Hemodynamicaly
unstable
Lower abdominal pain and/or vaginal
bleeding
Workup as
- urine hCG
+ urine hCG
non-pregnant
Hemodynamicaly
stable
Hemodynamicaly
unstable
?Ruptured ectopic
pregnancy or
hemorrhage
Resuscitate,
EDTU
and surgical
consultation
Lower abdominal pain and/or vaginal
bleeding
Workup as
- urine hCG
+ urine hCG
non-pregnant
Hemodynamicaly
stable
Cervix open
Or
Products of
Conception
History and
physical examination
Cervix Closed
Ultrasound
Ultrasound
Inevitable or
Complete
Miscarriage
IUP
Miscarriage or
Physiologic
NonDiagnostic
Ectopic
Treat
Ectopic Pregnancy
• Gestation that implants outside the
endometrial cavity
• Incidence in ED
– among women presenting with vaginal
bleeding or pain in the first trimester is 10%
• 2nd leading cause of maternal death
Ectopic Pregnancy
• Incidence of ectopic pregnancy is highest in
women aged 25 to 34
• The rate is highest among older women and
women belonging to minority groups.
• Heterotopic pregnancy
– Natural birth 1 in 4000
– IVF - 1-4/100
Ectopic and hCG
• The embryo grows at a slower rate than
normal pregnancies
• Usually resulting in a low hCG level and
rise
• Rupture can occur at any level
– Documented at less than 100 mIU/mL
– Unruptured ectopics documented at 50,000
Risk Factors
• No risk factors in 50% confirmed ectopics
• High
Odds Ratio
–
–
–
–
–
Previous ectopic pregnancy
Previous tubal surgery
Tubal ligation
Tubal pathology
Current IUD use
9.3 - 47
6.0 - 11.5
3.0 - 139
3.5 - 25
1.1 - 45
Risk Factors
• Moderate
–
–
–
–
–
Odds Ratio
Infertility
Previous cervicitis
History of pelvic inflammatory disease
Multiple sexual partners
Smoking
1.1 - 28
2.8 - 3.7
2.1 - 3.0
1.4 - 4.8
2.3 - 3.9
•
• Low
– Previous pelvic/abdominal surgery
– Vaginal douching
– Early age of intercourse (<18 years)
0.9 - 3.8
1.1 - 3.1
1.1 - 2.5
Symptoms
• In one representative series of 147
patients with ectopic pregnancy
•
• Abdominal pain
(99%)
•
• Amenorrhea
(74%)
•
• Vaginal bleeding (56%)
J Reprod Med 1982 Feb;27(2):101-6.
Signs
• PE often unremarkable in small, unruptured
ectopics
• Adnexal masses are felt in only 10% to 20%
of patients with ectopic pregnancy
• Vital signs – orthostatic changes
– occasionally, low grade fever
• Mild uterine enlargement
• Tenderness
– adnexal / cervical motion /abdominal
Ectopics and Vaginal Bleeding
• Heavy bleeding with clots or tissue
usually suggests a threatened or
incomplete miscarriage
• Endometrial sloughing can be mistaken
for passage of fetal tissue (dropping
hormone levels)
• Passed tissue should
be examined in saline
Diagnostics
• Consider in any female of reproductive
age in the ED with
– abdo pain
– vaginal bleeding
– shock
– syncope
• All women with a positive hCG and
these symptoms need an US
Ruptured Corpus
Luteum Cyst
• 1st - trimester bleeding with pain
• Corpus luteum normally supports the
pregnancy during the first 7 to 8 weeks
• Rupture causes pelvic pain and
peritoneal irritation
• US is helpful if it reveals an IUP (except
in patients with in vitro fertilization)
Lower abdominal pain and/or vaginal
bleeding
Workup as
- urine hCG
+ urine hCG
non-pregnant
Hemodynamicaly
stable
Cervix open
Or
Products of
Conception
History and
physical examination
Cervix Closed
Ultrasound
Ultrasound
Inevitable or
Complete
Miscarriage
IUP
Miscarriage or
Physiologic
NonDiagnostic
Ectopic
Treat
Non-diagnostic US
>1500
Quantitative hCG
<1500
Discriminatory zone
• Serum hCG level above which a
gestational sac SHOULD be visualized
by ultrasound examination if an
intrauterine pregnancy is present
• Institutional dependent
– Trans-vaginal 1500 or 2000 IU/L
– Trans-abdominal 6500 IU/L
Discrimatory zone
• -ve US below the discriminatory zone can be
– early viable intrauterine pregnancy
– ectopic pregnancy
– nonviable intrauterine pregnancy
• Such cases are termed "pregnancy of
unknown location" and 8 to 40 percent are
ultimately diagnosed as ectopic pregnancies
• Gestatinal sac can be seen as low as 800
hCG rises like an IUP
21% EP
Abnormal rise hCG
71% EP
hCG
0
Minimal rise IUP
hCG falls like a SAB
8% EP
0
Day’s after presentation
Minimal fall SAB
Non-diagnostic US
>1500
Quantitative hCG
<1500
Non-diagnostic US
>1500
Suspicious
mass
in adnexa
Quantitative hCG
No adnexal mass
and no IUP
Repeat BHCG + and US
in 2 days
Treat
as EP
IUP
hCG or
plateaued
Ectopic
No IUP
hCG
decreasing
Failed Pregnancy
(IUP vs Ectopic)
<1500
hCG > 1500
• i)IUP
– Visualiztion of IUP rules out ectopic
– Exceptions include
• heterotopic pregnancies
• misdiagnoses
– rudimentary uterine horn
– Cornua
hCG > 1500
• ii)Adnexal Mass
– Embryonic cardiac activity or a gestational
sac with a definite yolk sac or embryo at an
extrauterine location is certain evidence of
an ectopic gestation
hCG >1500
•
•
•
•
iii) Neither
NO IUP or Anexal Mass
May represent multiple gestations
Repeat US and hCG concentration two days
later.
– No IUP - ABNORMAL
– hCG increasing or plateaued - ECTOPIC
– hCG decreasing - failed pregnancy
•
•
•
•
arrested pregnancy,
blighted ovum,
tubal abortion,
spontaneously resolving ectopic
Non-diagnostic US
>1500
Quantitative hCG
<1500
Non-diagnostic US
>1500
Quantitative hCG
<1500
hCG in 72hr
<2X  hCG
US
IUP
EP
hCG
2X
hCG
Follow US until
IUP or EP
Nondiagnostic
Failed
Pregnancy
(IUP vs
Ectopic)
Failed Pregnancy
(IUP vs Ectopic)
Weekly hCG
until negative
Female patient with positive urine BHCG
Lower abdominal pain and/or vaginal bleeding
Hemodynamicaly
stable
Cervix open
Or
Products of
Conception
Inevitable or
Complete
Miscarriage
Hemodynamicaly
unstable
History and
physical examination
Cervix Closed
?Ruptured ectopic
pregnancy or
hemorrhage
Ultrasound
IUP
Miscarriage or
Physiologic bleeding
NonDiagnostic
Ectopic
Treat
Resuscitate,
EDTU
and surgical
consultation
Management
• Surgical vs Methotrexate
• Equivalent outcomes
• Approximately 35 percent of women
with ectopic pregnancy are eligible for
medical treatment
Ectopic - Medical
• MTX is a folic acid antagonist
• Inhibits DNA synthesis and cell reproduction,
primarily in actively proliferating cells such as
malignant cells, trophoblasts, and fetal cells.
• Rapidly renally cleared
• With renal insufficiency, a single dose of MTX
can lead to death or severe complications
– bone marrow suppression
– acute respiratory distress syndrome
– bowel ischemia.
Contraindications to MTX
• Hemodynamically unstable
• Impending or ongoing ectopic mass rupture
(ie, severe or persistent abdominal pain or
>300 mL of free peritoneal fluid outside the
pelvic cavity)
• Hematologic, renal or hepatic disease
– (need BW before treatment)
• Immunodeficiency, active pulmonary disease,
peptic ulcer disease
• Coexistent viable intrauterine pregnancy
• No post-therapeutic monitoring
Relative contraindications
• High hCG concentration
– A high serum hCG concentration is the most
important factor associated with treatment failure
– hCG concentration greater than 5000 are more
likely to require multiple courses of medical
therapy or experience treatment failure
• Fetal cardiac activity
• Large ectopic size (>3.5cm)
Follow up
• Patients may require multiple doses
• Require frequent bloodwork monitoring
• Followed until hCG to zero
– Can be 2 to 3 months
• Patients still at risk of tubal rupture
Surgical
• Salpingostomy versus salpingectomy
• Laparoscopy versus laparotomy
• Indications:
–
–
–
–
–
–
–
Hemodynamic instability
Impending or ongoing rupture of ectopic mass
Contraindications to use of methotrexate
Coexisting intrauterine pregnancy
No posttreatment follow-up
Desire for permanent contraception
Known tubal disease with planned in vitro
fertilization for future pregnancy
– Failed medical therapy
Surgical
• Post surgery persistent ectopic
pregnancy reported in case series
ranges from 4 to 15 percent
• Weekly measurement of serum betahCG concentration to r/o persistent
disease
Case 2
• 25 yr old Female with 1 day of moderate
vaginal bleeding
• Thought last menstrual period was 6/52
• ROS
– Nausea and vomiting X 2/52
– Lower abdo cramping X 3/7
• Pmed / Pobs / Psurg = non contributory
Case 2
• Vitals = 37 C, HR=70, 110/60
• Abdo = soft/non-tender
• Pelvic =
– blood clots in vault
– Cervic closed
– no adenexal mass or tenderness
• Positive urine B-HCG
Case 2
• Luckily it is during the day and your able
to get an Ultrasound showing an IUP
Lower abdominal pain and/or vaginal
bleeding
Workup as
- urine hCG
+ urine hCG
non-pregnant
Hemodynamicaly
stable
Cervix open
Or
Products of
Conception
Inevitable or
Complete
Miscarriage
Threatened
Miscarriage
History and
physical examination
Cervix Closed
Ultrasound
IUP
Nonviable
Ectopic
NonDiagnostic
Treat
Miscarriage
• 25-30% of pregnancy’s experience 1st
trimester bleeding
– about half will go on to miscarry
– although the risk is probably higher in the
emergency department population.
• Risk Factors for misscariage
– increase in age and parity, the risk of miscarriage
also will increase
– <20 =12%
– >40 = 26%
Miscarriage
• Cause
– uterine malformations
– chromosomal abnormalities (40%)
– anembryonic gestation
• ovum itself never develops
• Fetal death precedes clinical miscarriage
– Sonographic (8weeks)
– Clinically (8-12weeks)
Miscarriage
• Risk factors
– increasing maternal and paternal age,
– tobacco and alcohol use,
– increased parity,
– history of vaginal bleeding;
• About 80% of miscarriages occur during
the first trimester; the rest occur before
20 weeks of gestation.
Workup
• CBC
– Baseline, quantify degree of bleeding
• Type and Screen
– Determine Rh type
• US
– Evaluate fetal health, location, r/o ectopic
Physical exam
• The cervix should be gently probed with
a ring forceps / finger whether the
internal os (1.5 cm deep to the external
os) is open or closed
• Can be safely performed during the first
trimester as long as the forceps are
used gently and do not penetrate the
cervix more than 2 or 3 cm
Terminology
•
•
•
•
<20 weeks = miscarriage
>20 weeks = premature birth.
Miscarriage versus abortion
~1/3 of pregnancies end before they are
even recognized (before the first missed
menses)
Terminology
• Threatened Miscarriage
– Bleeding but a closed internal cervical os.
– 35% to 50% eventually miscarry
• Inevitable Miscarriage
– Internal cervical os is open
• Incomplete Miscarriage
– products of conception are present at the
cervical os or in the vaginal canal
Terminology
• Missed abortion (1st or 2nd trimester fetal death)
– in-utero death of the embryo or fetus prior to the
20th week of gestation, with retention
– failure to see fetal heart activity in a fetus with at
least a 5-mm crown-rump length
• Complete Miscariage
– Uterus has expelled all fetal and placental material,
the cervix is closed, and the uterus is contracted
• Blighted ovum = anembryonic gestation
– suspected with gestational sac > 25 mm with no
fetal pole gestation
• Septic Miscariage - maternal infection
Terminology
• Lithopedian - ?
Stone baby
• Ectopic pregnancy, is too
large to be reabsorbed by
the body, and calcifies on
the outside, shielding the
mother's body from the
dead tissue of the baby
and preventing infection
• Fewer than 300 cases
have been noted in 400
years of medical
literature.
Lower abdominal pain and/or vaginal
bleeding
Workup as
- urine hCG
+ urine hCG
non-pregnant
Hemodynamicaly
stable
Cervix open
Or
Products of
Conception
Inevitable or
Complete
Miscarriage
Threatened
Miscarriage
History and
physical examination
Cervix Closed
Ultrasound
IUP
Nonviable
Ectopic
NonDiagnostic
Treat
**If patient utilizing artificial
reproductive assistance consider
dx of Heterotopic Pregnancy
IUP
Pelvic Exam
Internal Os
CLOSED
Threated
Miscarriage
Internal Os
OPEN
Inevitable
Miscarriage
Products
Of
Conception
Incomplete
Miscarriage
Vs
Complete
Miscarriage
Signs of
Infection
Cervical or
Vaginal
Bleeding
Septic
Miscarriage
Threatened Miscarriage
• Bleeding
• Pain
• Etiology of bleeding often cannot be
determined and is frequently attributed to
marginal separation of the placenta
• With fetal cardiac activity and vaginal
bleeding
– 7 weeks 90% success
– 11 weeks 96% success
Hum Reprod 1997 Dec;12(12):2820-3.
Threatened Abortion
• Serial U/S and hCG if no definitive IUP
seen on u/s (r/o out ectopic)
• Managed expectantly until:
A) their symptoms resolve
or
B) progression to an inevitable,
incomplete, or complete abortion.
Threatened Abortion
• Return immediately for fever, abdominal pain,
or a significant increase in bleeding.
• If the patient passes tissue, it should be
brought to a provider to examine for POCs,
because differentiation of fetal parts or villi
from decidual slough or casts is difficult.
Threatened abortion
• No evidence for bedrest
• Women are advised to maintain pelvic
rest (ie, nothing per vagina) until two
weeks after evacuation or passage of
the products of conception, at which
time coitus and use of tampons may be
resumed
Threatened Abortion
• Patient counseling is paramount with
threatened miscarriage.
• Patients should be reassured that they
have done nothing to cause
miscarriage.
Complete vs Incomplete
• <12 weeks
– common for the entire contents of the
uterus to be expelled
– one third of all cases are complete
• >12 weeks
• significant amounts of placental tissue
may be retained
Incomplete, Inevitable, Missed
• Management:
– Surgical, Medical or Expectant
• All effective
• Surgical > Medical > Expectant
• MIST trail (RCT comparing all three
groups)
– Rate of infection in all three groups 2-3%
BMJ. 2006 May 27;332(7552):1235-40. Epub 2006 May 17.
Surgical
• INDICATIONS:
– patient does not want to wait for spontaneous or
medically induced evacuation of the uterus
– heavy bleeding or intrauterine sepsis in whom
delaying therapy could be harmful.
• Pre-operative ab reduce the risk of
postabortal sepsis
– doxycycline (100 mg orally for two doses 12 hours
apart on the day of the surgical procedure)
Medical
• Misoprostol (a prostaglandin E1 analog)
that acts by causing uterine
contractions, which evacuate the uterine
contents.
• Misoprostol 400 mcg per vagina every
four hours for four doses
Expectant
• Less than 13 weeks of gestation who have
stable vital signs and no evidence of infection
• Recent cochrane review:
– higher risk of incomplete miscarriage
– need for unplanned surgical emptying of the
uterus
– increased bleeding
– reasonable approach if the woman preferred
nonintervention
Complete Miscarriage
• Less than 20 weeks
• Closed cervix
• And any of:
– intact gestation is passed and recognized
• Send tissue for Pathology
– dilation and curettage (D&C)
– a sonogram demonstrating an empty uterus with a
prior known intrauterine pregnancy (IUP)
– or by reversion to a “negative” pregnancy test
Complete Miscarriage
• Difficult to dx in ED
• The routine use of ultrasound in women who
were thought to have a complete miscarriage
by clinical criteria—closed cervical os and
decreasing pain and bleeding after reported
or observed passage of tissue—has found
that up to 30% will have retained products of
conception
• Follow serial BHCG b/c could be ectopic
Septic Miscarriage
• Stabilizing the patient
• Obtaining blood and endometrial
cultures
• Gram +ves, -ves, anaerobes, STD bugs
– clindamycin + gentamycin ampicillin
Hemorrhagic shock
•
•
•
•
•
•
Resuscitate
+/- blood
Crossmatch
PT / PTT
STAT O/G consult
Oxytocin - Uterine contraction and
vasoconstriction
– 20 - 40 units / 1L NS: run at 500-1000 ml/hr
• Methyergonovine - Vasoconstriction and
increased uterine contractions
– 0.2mg im/po/iv
Prognosis
• Most, but not all, studies have found an
association between first trimester bleeding
and various adverse outcomes (eg,
miscarriage, preterm birth, premature rupture
of membranes, growth restriction) later in
pregnancy.
• The overall risk of miscarriage in future
pregnancy is approximately 20 percent after
one miscarriage, 28 percent after two
miscarriages, and 43 percent after three or
more miscarriages
Counseling
• Validate feelings of loss and guilt
– Warn about anniversary phenomenon
• Emphasize that guilt is unfounded
– NOT caused by stress, exercise, trauma, sexual
activity
• Risk minimization for FUTURE pregnancies
– Emphasize prenatal care
– Early treatment of infections
• Complications:
– Bleeding, retained POC, infection
Who can wait until tomorrow
•
•
•
•
•
minimal pain
minimal bleeding
easy to RTED
no strong risks for ectopic
no strong findings of ectopic
– unilateral pain, tenderness, mass
Rh Immunization
• When an Rh-negative woman is exposed to an Rhpositive fetus, the woman’s immune system may
become stimulated to produce anti-Rh antibodies.
• Approximately 15% of women will develop
sensitization
• events that cause maternal transplacental bleeding
– trauma
– threatened or spontaneous miscarriage
– ectopic pregnancies
RhoGAM
• RhoGAM = anti-D immune globulin
• < 12 weeks gestation = 50 micrograms
– No harm giving the full dose
• > 12 weeks or unknown how far along
the full dose of 300 micrograms.
• administer within 72 hours of the
sensitization
Case 3
• 22 yo G3P4
• 22 weeks pregnant (confirmed with US)
• 3 weeks of nausea and vomiting
• Had this problem last 2 pregnancies
36.9, P=105, RR=18, BP=110/60
Urine dip = 2+ ketones
Nausea and Vomiting
• Most common medical condition in
pregnancy, affecting 50%–90% of women
• Serious causes must be ruled out,
–
–
–
–
–
gastrointestinal
genitourinary
central nervous system, and
toxic/metabolic problems
pregnancy related
• hydatidiform mole or multiple gestation.
Hyperemesis Gravidarum
• no clear demarcation between common
pregnancy-related "morning sickness" and
the infrequent pathologic disorder
• Dx hyperemesis gravidarum (HG)
– persistent vomiting that leads to weight loss
greater than 5% of pre-pregnancy weight
– electrolyte imbalance
– ketonuria,
• occurs in about 1% of pregnancies
Hyperemesis Gravidarum
• Non-Prescription
– Stimulation of the P6 (Neiguan) point
• located three-fingers’ breadth proximal to the wrist, has
been used for thousands of years by acupuncturists to
treat nausea and vomiting from a variety of causes.
– Ginger
• Powdered ginger (1 to 1.5 grams in divided doses over
24 hours) is more effective than placebo, and equivalent
to vitamin B6 (pyridoxine)
– Avoidance of triggers
– Dietary changes
Hyperemesis Treatment
• i)
Diclectin
(up to 4 tablets per day)
• iii) Then add Gravol or Promethazine
• iv) Dehydration
No dehydration
IV fluid
Multivitamin
IV gravol
Metoclopromide
Zofran
Chlorpromazine
• v) At any time add non-pharmacological
• vi) Thiamine if vomiting > 3/52
Case 4
• 32 yo G3P2, 28 weeks GA
• Sent from walk in clinic with
hypertension and weight gain (5 lb/past
week)
• New-onset mild headache, dizziness
• V/S T 36.9, HR 115, RR 22, BP 162/98
• Urine dip 2+ protein
Hypertensive disorders of
Pregnancy
• No pre-exsisting HTN • Pre-exsisting HTN
• Gestational HTN
• Pre-eclampsia
• Chronic HTN
• Pre-eclampsia
(superimposed on
chronic)
Pre-eclampsia
• New onset after 20 weeks of gestation
• Hypertension
– Systolic blood pressure 140 mmHg or
– Diastolic blood pressure 90 mmHg
AND
• Proteinuria of 0.3 grams or greater in a 24hour urine specimen
– A random urine protein determination of 30 mg/dL
or 1+ on dipstick is suggestive, but not diagnostic
• Edema no longer required - up to 1/3 never
develop
Etiology
•
•
•
•
Abnormal placental development
Placental ischemia
Altered ratio of prostacyclin and thromboxane
Platelet aggregation thrombin activation
fibrin depostition in systemic vascular be
• Vasospasm and thrombosis organ
dysfunction
Risk Factors
•
•
•
•
•
•
Nulliparity
Multiple gestations
Age extremes
DM
Molar pregnancy
Family history
Pre-eclampsia
• Clinical spectrum
– Mild vs Severe
• HELLP / Eclampsia related disease
process
Severe Pre-eclampsia
• DBP > 110
• Persistent proteinuria 2+
• Plus any of the following:
– Headache or visual disturbances
– Oliguria or increased creatinine
– HELLP
– Pulmonary edema
– Fetal growth retardation
Pre-eclampsia Complications
•
•
•
•
•
•
•
•
•
•
•
HELLP
Seizures
Pulmonary edema
CHF
Renal Failure
DIC
HELLP
Liver/splenic rupture (congestion)
Fetal
Premature delivery
Placental abruption
Pre-eclampsia Complications
• Stroke may occur at a systolic BP of 160.
• Stroke leading cause of death in
preeclampsia.
• Pulmonary edema from fluid administration is
also a leading cause
• Betamethasone should given to women with
preeclampsia at 24 to 34 weeks of gestation.
HELLP
•
•
•
•
Hemolysis,
Elevated Liver enzymes,
Low Platelets
?Severe form of pre-eclampsia.
Controversial
• 15 to 20% do not have prior
hypertension or proteinuria
HELLP
•
•
•
•
•
•
•
•
•
•
Proteinuria
Hypertension
86 to 100
82 to 88
RUQ/epigastric pain
40 to 90
Nausea, vomiting
29 to 84
Headache
33 to 61
Visual changes
10 to 20
HELLP
• No consensus regarding the degree of
laboratory abnormality to dx HELLP
– Platelets < 100, 000
– AST > 70
– LDH > 600 or total bili >1.2
– Evidence of hemolysis on peripheral smear
or in labs
Management
• Delivery pregnancies ≥34 weeks of
gestation
• Nonreassuring tests of fetal status
– biophysical profile, fetal heart rate testing
•
• Presence of severe maternal disease:
multiorgan dysfunction, DIC, liver
infarction or hemorrhage, renal failure,
or abruptio placenta.
Management
• Platelets if
– bleeding or less than 20
– less than 40 before C-section
• immediately prior (transient effect)
– FFP and PRBC’s as indicated
• Dexamethasone 10 mg IV q12h
Complications
• Progression to other organs / systems
–
–
–
–
–
–
DIC — 21 percent
Abruption — 16 percent
Acute renal failure — 8 percent
Pulmonary edema — 6 percent
Subcapsular liver hematoma — 1 percent
Retinal detachment — 1 percent
• Hepatic infarction — AST>1000 to 2000 IU/L
• Hepatic Rupture
– Presents (usually) as an acute abdomen
– 50% mortality
Eclampsia
• Eclampsia = seizures or coma in the setting
of signs and symptoms of preeclampsia
without other neuro symptoms.
• Almost always self-limiting
• Seldom last longer than 3 to 4 minutes
• Uusual duration 60 to 75 seconds.
• Warning signs for
–
–
–
–
Headache
nausea and vomiting
visual disturbances
and mean arterial pressure greater than 160
Eclampsia
• <32 weeks' gestation, seizures may develop
abruptly and hypertension may not be
associated
• <20 weeks of gestation is rare
– ?molar pregnancy or antiphospholipid syndrome
• Can occur after delivery
– usually during the first 48 hours
– Can be 28 days after delivery.
Treatment Priniciples
• Prevention of maternal hypoxia and trauma
•
• Manage severe HTN (160/110)
– hydralazine
• 5 mg IV, followed by 5 to 10 mg Q20
– labetalol
• 10 or 20 mg IV followed by 2X Q10 up to 80 mg
•
• Prevention of recurrent seizures
•
Eclamptic Seizure
• Magnesium sulfate was significantly
more effective than either diazepam or
phenytoin:
• 6g over 15 minutes
• 2g/hr infusion
– only if a patellar reflex is present
– respirations are greater than 12 per minute
– urine output is over 100 mL in four hours.
Additional seizure
• Bolus of 2 grams of magnesium sulfate
over 15 to 20 minutes
• After 2 doses of Mg
– Diazepam can be given at increments of 5
mg
– Phenytoin 10-20 mg/kg
Eclampsia
• Seizures resistant to magnesium
• CT head should be performed to
exclude cerebral venous thrombosis or
an intracranial bleed
• Also consider hypertenisve
encephlopathy
– Fundoscopic examination
Magnesium Toxicity
• Frequent monitoring
– loss of deep tendon reflexes at 4.0-5.0 (mmol/L)
– respiratory paralysis at 5-7.5 (mmol/L)
– cardiac arrest at 10-12.5 (mmol/L)
• Pts with renal disease should have their
levels checked every 2-4 hours
• If magnesium toxic,
– 10 mL IV of 10% calcium gluconate
– Hemodialysis lowers magnesium levels to the
nontoxic range within 3 to 4 hours.
Venous Thromboembolic
Disease
• There is a 4 to 50-fold increase in the
incidence in pregnancy
• Occurring in 0.5 to 3.0 per 1000
pregnancies
• Spread almost equally across all three
trimesters and peripartium
Pathophysiology
• Stasis
– venous pooling and valvular incompetence
– compression of large veins by the gravid uterus.
• Endothelial injury
– Delivery is associated with vascular injury and
changes at the uteroplacental surface
• Hypercoagulability
– increases in factors I, II, VII, VIII, IX, and X
– decrease in protein S
– increase in resistance to activated protein C in 2nd
and 3rd trimesters
Clinical Pitfalls
• The clinical exam notoriously insensitive and
nonspecific
• DVT
– lower extremity swelling and discomfort are
common in advanced pregnancy
• PE
– Dyspnea in up to 70 percent of normal
pregnancies
• Wells Score has not been validated in
pregnancy.
D-Dimer
• High Negative predictive value of a normal Ddimer when combined with a low pretest
probability of VTE.
• 149 pregnant women presenting with
suspected DVT, in whom this diagnosis was
ruled out by US. D-Dimer NEGATIVE in
• First
100%
• Second
76%
• Third
49%
Ann Intern Med. 2007 Aug 7;147(3):165-70.
Work Up
• Treatments for DVT and submassive PE
are identical
• If you Dx DVT. Stop diagnostics and
treat.
• If DVT -ve. You must continue.
– <30% with PE have DVT at presentation
Imaging
• No census - CT vs V/Q
• Lack of prospective studies in the pregnant
population,
• However - preference of CT
– superior performance in the general population
– availability
– and safety profile in pregnancy (less radiation
exposure to fetus)
Imaging
• Radiation dose to the fetus is 3 to 131 mcGy
• Less than those calculated for V/Q scanning
(<55mcGy)
• ~Fetal radiation exposure a chest radiograph,
V/Q scanning, and pulmonary arteriography
is less than 5000 mcGy
– <100 to 200 X dose of fetal anomalies.
• Possible small increase in the risk of
childhood leukemia from 1 in 2800 (baseline
risk) to 1 in 2000
Radiology 2002 Aug;224(2):487-92.
Treatment
•
•
•
•
Heparin - doesn’t cross placenta/breast milk
SC LMWH
- in most
IV UFH - hypotension due to acute PE or an
elevated risk of bleeding
•
• IV UFH or SC UFH with severe renal failure
• Thrombolytic therapy
– with life-threatening acute PE
• persistent and severe hypotension due to the PE
– maternal mortality rate = 1%