This document covers normal pregnancy physiology and common obstetric emergencies that emergency physicians need to be aware of. It discusses the signs and symptoms of early pregnancy, complications of bleeding in each trimester, ectopic pregnancy, preeclampsia, and other conditions like trauma and infections. For each complication, it provides the risk factors, diagnostic approach including appropriate use of ultrasound and labs, and initial management steps prior to OB/gyn consultation. Transvaginal ultrasound images of normal early pregnancy and common abnormalities are also presented.
2. Obstetric Emergencies: We will
cover...
Normal Pregnancy
Common medical and surgical
complications of pregnancy
3. Normal pregnancy
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
4. 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
5. Some Important Physiological
Changes in Pregnancy
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
6. 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)
7. Radiation in Pregnancy
<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.
14. 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
15. The work-up is the same!
Pelvic Exam
Beta HCG
Transvaginal ultrasound
Rh
CBC, CMP
PT/PTT/INR
UA
16.
17. Ectopic Pregnancy – A surgical
emergency of pregnancy
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.
18. Signs/Symptoms
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
19. Testing
Beta > 6000 mIU/ml + empty uterus on
transabdominal ultrasound
OR
Beta > 1200 mIU/ml + empty uterus on
transvaginal ultrasound =
Ectopic Pregnancy = Laparoscopy
20. 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
23. 2nd Trimester
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.
24. 3rd Trimester (>28 weeks)
Placental Abruption
Placenta separates from uterine
wall
Painful dark or clotted blood
Risks: HTN, smoking, ETOH,
cocaine, multiparity, previous
abruption, trauma, mom >
40
Management: U/S, Ob consult,
cardiac/fetal monitoring, IV,
pre-op labs, delivery if
possible
Placenta Previa
Placenta implants too low
Painless bright red bleeding
Risks: prior C-section, grand
multiparity, previous previa,
multiple gestations, multiple
induced abortions, mom
>40.
Management: U/S, Ob consult,
pre-op labs, avoid pelvic
exam, c-section
25. 3rd Trimester Bleeding cont’d
Uterine Rupture: Can be seen in scarred
and unscarred uteri. (uteruses? uterata?)
26.
27.
28. 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!
29. 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
31. Complications of Pregnancy:
Hypertension
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 pre-
eclampsia, abruption, prematurity, IUGR
and stillbirth
32. 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
33. Management
Isolated HTN requires a 24h urine and close Ob
f/u
With other findings, admit, 24h urine, bed rest
and HTN management in consult with ob/gyn.
Hydralazine common though diazoxide,
labetalol, nifedipine and nitroprusside also used
+/- Mag to prevent seizures
34. Complications of Pregnancy:
Eclampsia
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
35. Complications of Pregnancy:
UTI/Pyelo
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.
36. 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
37.
38. References
1. Preparing for the Written Board Exam in Emergency Medicine. 5th ed. Vol 1. Rivers, Carol. pp 550-574
2. learnobultrasound.com/3trimesterbleed.htm
3. www.smbs.buffalo.edu/emed/emed/ultrasound.html
4. Harwood &Nuss’ Clinical Practice of Emergency Medicine 4th ed. Wolfson, Alan B Lippincott, Williams and Wilkins,
Philadelphia, 2005. pp.496-497
5. home.flash.net/~drrad/tf/122396.htm
6. www.pwc-sii.com/Research/death/ribs.htm
7. www.jaapa.com/.../article/130146/
8. www.advancedfertility.com/ultraso1.htm
9. Ma, John O. Emergency Ultrasound via access emergency medicine at http://0-
www.accessem.com.innopac.lsuhsc.edu/content.aspx?aID=100900