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Acute complications of pregnancy


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Dr Ibtisam

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Acute complications of pregnancy

  1. 1. Acute complications of pregnancy<br />Ibtisam Al Hoqani<br />EM – R1<br />22/6/2010<br />
  2. 2. Outline:<br />Complications in Early Pregnancy:<br />Miscarriges<br />Ectpic pregnancy<br />Molar pregnancy<br />:Complications in late pregnancy<br />Abruption placenta<br />Placenta Previa<br />Preeclampsia and Eclampsia<br />Medical & Surgical problems in pregnancy<br />
  3. 3. Question 1:<br />Which of following is the most common cause of first trimester vaginal bleeding?<br />Abruptio placenta<br />Ectopic pregnancy<br />Placenta previa<br />Spontaneous abortion<br />Ovarian torsion <br />
  4. 4. Miscarriage<br />It is common, the overall embryponic and fetal loss rate after implantation ranges up to 1/3 of detectable pregnancy<br />Spontaneous abortion: <br /><ul><li>Threatened
  5. 5. Inevitable
  6. 6. Incomplete
  7. 7. Complete
  8. 8. Missed</li></li></ul><li>Question 2:<br />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:<br />Discharge with insterctions to come back if bleeding increased<br />Bed rest fo 48 hrs<br />Reassurance<br />Inpatient admission for observation<br />
  9. 9. Miscarriage<br />Threatened abortion is most common cause of PV bleeding in primi<br />It is PV bleeding, cervical os closed, IU normal pregnancy<br />Mx:<br />Bed rest for 48 hrs<br /> F/U with obs/gyne in 2-3 days<br />
  10. 10. Miscarriage<br />Inevitable abortion:<br />Vaginal bleeding with open cervical os<br />Mx: D&C<br />Incomplete abortion:<br />Vaginal bleeding with open cervical os and some POC passed or in the os or vaginal canal <br />Mx: Remove visible POC to control bleeding, D&C<br />
  11. 11. Miscarriage<br />Complete abortion:<br />All POC passed, os closed, uterus firm, non tender, and the bleeding almost stopped<br />Mx: confirm by U/S , discharge or D&C if needed<br />Missed abortion:<br />Failure to pass POC after 2 months of fetal death<br />Mx: medical or surgical D&C<br />
  12. 12. Sonographic “discriminatory Zone”:<br />The quantitive hCG at which a normally developing IUP should be seen;<br />=6500 mIU/ml for TA U/S<br />=3000 mIU/ml for TV U/S<br />Criteria for abnormal pregnancy for TV U/S<br />
  13. 13. Question: <br />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: <br />Administer IV antibiotics and arrange admission<br />Check CBC, ESR, urinanalysis and continue fluid resuscitation<br />Discharge home with antibiotics and analgesia<br />Obtain TV U/S<br />Immediate OB/GYN referral for laparoscopic surgery<br />
  14. 14. Qusetion<br />Which of following is not a risk factor for ectopic pregnancy:<br />Previous C-section<br />Pharmacological assisted conception<br />Previous ectopic pregnancy<br />Previous h/o PID<br />Having IUCD<br />
  15. 15. Ectopic pregnancy:<br />Leading cause of maternal death in 1st trimester and 2nd overall cause of mortality in pregnant ladies<br />Risk factors:<br />     Advanced age<br /> Pelvic inflammatory disease     Smoking<br />    Prior spontaneous abortionor ectopic pregnancy<br />    Medically induced abortion     History of infertility   Intrauterine device Tubal Surgery<br />
  16. 16. Question:<br />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:<br />Serum hCG<br />Speculum and bimanual examination<br />Culdocentesis<br />CBC and blood group<br />Pelvic ultrasound <br />
  17. 17.
  18. 18. Question:<br />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:<br />Emergency U/S with immediate gyne referral<br />Emergency U/S then call gyne accordingly<br />Reassure and D/C with threatened abortion instructions<br />Send CBC, cross match as appropriate and f/u with gyne within 24 hr<br />
  19. 19. Ectopic pregnancy<br />Management:<br />Stable pt with un-ruptured EP <4cm by U/S ,,,, Methotrexate therapy<br />Stable pt un-ruptured or minimally ruptured >4cm EP ,,,, Laparoscopic salpingectomy<br />Unstable ,,, Laparotomy <br />
  20. 20. Abruption placenta<br />The cause of 30% of PV bleeding in 3rd trimester<br />Premature separation of normally implanted placenta causing seen or hidden bleeding<br />Usually associated with painfull uterine bleeding<br />
  21. 21. Abruption placenta<br />Stages:<br />Grade 1: 40%, slight bleeding, no pain or fetal distress<br />Grade 2: 45%, moderate bleeding, increase uterine irritability with fetal distress<br />Grade 3: 15% tetanic uterine contraction, hypotension, coagulopathy, possible fetal death<br />
  22. 22. Question:<br />Which of following is not associated with increase incidence of Abruptio placenta?<br />Cocaine<br />Heroin<br />Hypertension<br />Smoking<br />Advance age and Multiparty<br />Abdominal trauma<br />
  23. 23. Question:<br />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?<br />Ultrasound and outpatient OB F/U<br />Urgent U/S with OBS/GYN refferal<br />Send for CBC, blood group and weight result<br />PV examination and send swap for c/s<br />
  24. 24. Placenta Previa<br />Cause 20% of 3rd trimester bleeding<br />Painless bright red vaginal bleeding with soft non tender uterus<br />Risk factors:<br /><ul><li>Prior C-section
  25. 25. Grand Multiparty
  26. 26. Previous placenta previa
  27. 27. Multiple gestation
  28. 28. Multiple induce abortion
  29. 29. Maternal age >40 years</li></li></ul><li>Management<br />Establish IV access, draw blood for cross match and basic work up, establish cardiac and fetal monitoring <br />Immediately call for obstetric consultation if unstable otherwise do both ultrasound and OB referral <br />Never do PV digital or speculum exam unless placenta previa rolled out<br />
  30. 30. Question:<br />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?<br />Hydralazine 10mg IV push<br />Lorazepam 2mg IV push<br />Phenytoin 20mg/kg IV<br />MgSO4 6grm slow iv push<br />Labetolol 20mg slow iv push<br />
  31. 31. Preeclampsia and Eclampsia<br />Pre-eclampsia:<br />Elevated BP systolic >=140 or >=20 above baseline, and diastolic >=90 or 10 above baseline<br />With proteinuria >0.3gm/24 hr <br />Eclampsia <br />Pre- eclamsia with grand-mal seizure or coma<br />
  32. 32. Important facts:<br />Eclampsia may occur without prior proteinuria<br />Eclampsia can occur up to 10 days post partum<br />Intracranial bleeding is the major cause of maternal death<br />Warning sign of impending seizure:<br /><ul><li>Headache
  33. 33. Visual disturbance
  34. 34. Hyperreflexia
  35. 35. Abdominal pain</li></li></ul><li>Question:<br />Which of following is expected abnormality in HELLP syndrome?<br />Decrease HGB<br />Elevated PT<br />Decreased Fibrinogen<br />Elevated APTT<br />All of above<br />
  36. 36. Management:<br />Pre- eclampsia:<br />Anti-HTN not needed unless systolic BP >170 or diastolic >150, target BP sys 130-150 and dias 90-100<br />Hydralazine is most commonly used but (Labetolol, nifedipine, nitroprusside) can be used<br />ACE inhibitor are contraindicated<br />Prophylactics MgSO4 is recommended <br />
  37. 37. Question: <br />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?<br />Frusmide 40mg iv stat<br />Maintained IV fluid<br />Hydrochlorothiazide 25mg oral<br />Mannitol 0.5mg/kg iv push<br />25% albumin 1g/kg iv<br />
  38. 38. Management:<br />Eclampsia:<br />Definitive Tx is delivery<br />MgSO4: antiepileptic and anti-HTN<br />Loading dose: 6mg IV over 15-20min then continuous infusion 2g/hr, <br />Cardiac monitoring, and maintain urine output at rate >25ml/hr<br />Follow DTR stop infusion if disappear<br />Phenytoin or diazepam may be used for seizure resistant to MgSo4<br />
  39. 39. Question:<br />Which of following is sign of MgSO4 toxicity?<br />Atrial Fibrillation<br />Somnolence<br />Increase<br />Hyperventilation<br />Diarrhea <br />
  40. 40. Question:<br />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?<br />Dexamethasone<br />Lidocaine<br />Labetolol<br />Calcium gluconate<br />Atropine<br />