A 22-year-old pregnant woman at 36 weeks was treated with MgSO4 for preeclampsia. She then became somnolent with decreased deep tendon reflexes and respiratory rate. After managing her airway, the next best step is to administer calcium gluconate, as these are signs of MgSO4 toxicity that calcium can help treat.

1. Acute complications of pregnancy Ibtisam Al Hoqani EM – R1 22/6/2010

2. Outline: Complications in Early Pregnancy: Miscarriges Ectpic pregnancy Molar pregnancy :Complications in late pregnancy Abruption placenta Placenta Previa Preeclampsia and Eclampsia Medical & Surgical problems in pregnancy

3. Question 1: Which of following is the most common cause of first trimester vaginal bleeding? Abruptio placenta Ectopic pregnancy Placenta previa Spontaneous abortion Ovarian torsion

5. Inevitable

6. Incomplete

7. Complete

9. Miscarriage Threatened abortion is most common cause of PV bleeding in primi It is PV bleeding, cervical os closed, IU normal pregnancy Mx: Bed rest for 48 hrs F/U with obs/gyne in 2-3 days

10. Miscarriage Inevitable abortion: Vaginal bleeding with open cervical os Mx: D&C Incomplete abortion: Vaginal bleeding with open cervical os and some POC passed or in the os or vaginal canal Mx: Remove visible POC to control bleeding, D&C

11. Miscarriage Complete abortion: All POC passed, os closed, uterus firm, non tender, and the bleeding almost stopped Mx: confirm by U/S , discharge or D&C if needed Missed abortion: Failure to pass POC after 2 months of fetal death Mx: medical or surgical D&C

12. Sonographic “discriminatory Zone”: The quantitive hCG at which a normally developing IUP should be seen; =6500 mIU/ml for TA U/S =3000 mIU/ml for TV U/S Criteria for abnormal pregnancy for TV U/S

13. Question: 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: Administer IV antibiotics and arrange admission Check CBC, ESR, urinanalysis and continue fluid resuscitation Discharge home with antibiotics and analgesia Obtain TV U/S Immediate OB/GYN referral for laparoscopic surgery

14. Qusetion Which of following is not a risk factor for ectopic pregnancy: Previous C-section Pharmacological assisted conception Previous ectopic pregnancy Previous h/o PID Having IUCD

15. Ectopic pregnancy: Leading cause of maternal death in 1st trimester and 2nd overall cause of mortality in pregnant ladies Risk factors: Advanced age Pelvic inflammatory disease Smoking Prior spontaneous abortionor ectopic pregnancy Medically induced abortion History of infertility Intrauterine device Tubal Surgery

16. Question: 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: Serum hCG Speculum and bimanual examination Culdocentesis CBC and blood group Pelvic ultrasound

18. Question: 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: Emergency U/S with immediate gyne referral Emergency U/S then call gyne accordingly Reassure and D/C with threatened abortion instructions Send CBC, cross match as appropriate and f/u with gyne within 24 hr

19. Ectopic pregnancy Management: Stable pt with un-ruptured EP <4cm by U/S ,,,, Methotrexate therapy Stable pt un-ruptured or minimally ruptured >4cm EP ,,,, Laparoscopic salpingectomy Unstable ,,, Laparotomy

20. Abruption placenta The cause of 30% of PV bleeding in 3rd trimester Premature separation of normally implanted placenta causing seen or hidden bleeding Usually associated with painfull uterine bleeding

21. Abruption placenta Stages: Grade 1: 40%, slight bleeding, no pain or fetal distress Grade 2: 45%, moderate bleeding, increase uterine irritability with fetal distress Grade 3: 15% tetanic uterine contraction, hypotension, coagulopathy, possible fetal death

22. Question: Which of following is not associated with increase incidence of Abruptio placenta? Cocaine Heroin Hypertension Smoking Advance age and Multiparty Abdominal trauma

23. Question: 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? Ultrasound and outpatient OB F/U Urgent U/S with OBS/GYN refferal Send for CBC, blood group and weight result PV examination and send swap for c/s

25. Grand Multiparty

26. Previous placenta previa

27. Multiple gestation

28. Multiple induce abortion

30. Question: 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? Hydralazine 10mg IV push Lorazepam 2mg IV push Phenytoin 20mg/kg IV MgSO4 6grm slow iv push Labetolol 20mg slow iv push

31. Preeclampsia and Eclampsia Pre-eclampsia: Elevated BP systolic >=140 or >=20 above baseline, and diastolic >=90 or 10 above baseline With proteinuria >0.3gm/24 hr Eclampsia Pre- eclamsia with grand-mal seizure or coma

33. Visual disturbance

34. Hyperreflexia

36. Management: Pre- eclampsia: Anti-HTN not needed unless systolic BP >170 or diastolic >150, target BP sys 130-150 and dias 90-100 Hydralazine is most commonly used but (Labetolol, nifedipine, nitroprusside) can be used ACE inhibitor are contraindicated Prophylactics MgSO4 is recommended

37. Question: 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? Frusmide 40mg iv stat Maintained IV fluid Hydrochlorothiazide 25mg oral Mannitol 0.5mg/kg iv push 25% albumin 1g/kg iv

38. Management: Eclampsia: Definitive Tx is delivery MgSO4: antiepileptic and anti-HTN Loading dose: 6mg IV over 15-20min then continuous infusion 2g/hr, Cardiac monitoring, and maintain urine output at rate >25ml/hr Follow DTR stop infusion if disappear Phenytoin or diazepam may be used for seizure resistant to MgSo4

39. Question: Which of following is sign of MgSO4 toxicity? Atrial Fibrillation Somnolence Increase Hyperventilation Diarrhea

40. Question: 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? Dexamethasone Lidocaine Labetolol Calcium gluconate Atropine