Emergencies During Pregnancy and the Postpartum Period - PowerPoint PPT Presentation

Loading...

PPT – Emergencies During Pregnancy and the Postpartum Period PowerPoint presentation | free to download - id: 47d74a-Y2UxY



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Emergencies During Pregnancy and the Postpartum Period

Description:

Emergencies During Pregnancy and the Postpartum Period Chapter 106 Morbidity/Mortality Maternal Mortality Ratio (deaths per 100,000 infant births) is 7.3 Leading ... – PowerPoint PPT presentation

Number of Views:608
Avg rating:3.0/5.0
Slides: 29
Provided by: Cher195
Learn more at: http://www.sjem.org
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Emergencies During Pregnancy and the Postpartum Period


1
Emergencies During Pregnancy and the Postpartum
Period
  • Chapter 106

2
Morbidity/Mortality
  • Maternal Mortality Ratio (deaths per 100,000
    infant births) is 7.3
  • Leading causes of death hemorrhage, PE, HTN
    emergencies leading to CVA
  • We will divide emergencies of pregnancy by those
    that occur in the 1st 2nd halves of pregnancy

3
Vaginal Bleeding
  • All women of child bearing age should get HCG
    testing
  • Occurs in 20-40 of all pregnancies
  • Common Causes of 1st Trimester Bleeding
  • Abortion
  • Ectopic
  • Gestational Trophblastic disease
  • Implantation bleeding
  • Cervical Ectropion Cervicitis Infection

4
Vaginal Bleeding
  • Is the bleeding light or heavy is their pain
    any passed tissue? If yes, then more likely
    ectopic or spontaneous abortion.
  • Is there a Hx past ectopics, recurrent
    spontaneous abortions, or conditions such as
    chromosomal translocation, antiphospholipid
    antibody syndrome, uterine anomaly

5
Diff. 1st Trimester Vaginal Bleeding
  • Physical Examination
  • Vitals Stable
  • Abdominal Exam
  • Gravid uterus? (12wks)
  • Location of Pain (midline vs. lateral)
  • May try FHT with doppler if 12 wks
  • Vaginal Exam
  • External Genitalia
  • Internal Exam Blood clots ? POC?
    Vaginal/Cervical Lesions? Cervical OS (open vs.
    closed)
  • no obvious bleeding lesions, do a bimanual
    examination
  • Uterus Size and Shape

6
Diff. 1st Trimester Vaginal Bleeding
  • Urine BetaHCG Serum BetaHCG Quant.
  • CBC, PT/INR/PTT, Blood T C / RH, fibrinogen,
    D-dimer
  • ultrasonography is the cornerstone of the
    evaluation of bleeding in early pregnancy
  • 1500 IU/L (transvaginal) 6000 IU/L
    (transabdominal)

7
Ectopic
  • Positive betaHCG quant gt 1500 no gestational
    sac in the uterus may or may not have an adnexal
    mass
  • hCG levels that have plateau or are rising slowly
    suggests an ectopic pregnancy (increase 53-66 /
    48 hours)
  • hemodynamic instability and a tender abdomen
    suggests the ectopic pregnancy has ruptured
  • A serum hCG concentration less than 1500 IU/L
    with a negative transvaginal ultrasound
    examination repeat HCG in 48 hours with OB/GYN
    follow-up

8
Ectopic
  • Medical (Methotrexate) vs. Surgical Tx. (DC/DE)
  • Surgical (1) ruptured ectopic pregnancy, (2)
    inability / unwillingness to comply with or
    contraindications to medical therapy, (3) lack of
    timely access to a medical institution (4) failed
    medical therapy
  • Medical and surgical therapy are equally
    successful in women who are hemodynamically
    stable and hCG concentration lt 5000 mIU/mL, a
    small tubal diameter, and no fetal cardiac
    activity.
  • Contraindications to Medical Tx breastfeeding
    women, immunodeficiency, active pulmonary
    disease, peptic ulcer disease, hypersensitivity
    to the drug, and significant hepatic, renal, or
    hematologic disease

9
Spontaneous Abortion
  • Threatened Abortion Uterine bleeding in the
    presence of a closed cervix and sonographic
    visualization of an intrauterine pregnancy with
    detectable fetal cardiac activity is diagnostic
    of threatened miscarriage.
  • 90 to 96 percent of pregnancies with both fetal
    cardiac activity and vaginal bleeding at 7 to 11
    weeks of gestation will result in an ongoing
    pregnancy
  • Management is expectant bed rest avoid coitus
    (evidence does not support)

10
Incomplete or Missed Abortion
  • Cervix is dilated bleeding/pain is increasing
    gestational tissue often can be felt or seen
    through the cervical os
  • Tx Expectant, Medically, Surgically
  • Surgical DC / DE recommended for patients
    whom are unstable due to infection or blood loss,
    or likely to become unstable
  • Medical Misoprostol 800mcg intravaginally on
    day 1 if need be day 3 has a 84 success rate
  • Instructed to go to the ER if excessive bleeding
    or pain all POC be brought to the hospital for
    pathology

11
Incomplete or Missed Abortion
  • Expectant Management
  • Women with early pregnancy failure at lt 13 wks,
    with no signs of infection
  • Majority occur within 2 wks, but up to 4 wks is
    not unusual
  • If not completed in 1 month, or Pt unstable then
    surgical/medical management needed

12
Completed Abortion
  • Passage of an intact gestational sac or
    contraction of the uterus with mild bleeding and
    diminishing cramps
  • Tissue collected examined to determine POC
  • Abortions occurring before 12 wks usually result
    in a complete abortion
  • Ultrasonography / Suction curettage / Clinical
    Management

13
Post Spontaneous Abortion
  • ALL WOMEN WHO ARE Rh(D) negative should receive
    300 micrograms Rhogam, some give 150 micrograms
    if lt12 wks pregnant
  • Advise pelvic rest (NPV) for two weeks
  • Pregnancy be deferred 2-3 months
  • Contraception can be started immediately after
    abortion
  • Light bleeding for a couple of weeks is normal
  • Menses resume 6 weeks
  • Serum hCG levels normalize in 2-6 weeks

14
Gestational Trophoblastic Disease
  • Spectrum of conditions from partial hydatidiform
    molar pregnancy to choriocarcinoma with mets
  • Neoplasm arising from trophoblastic cells of the
    placenta
  • 11 per 1700 pregnancies
  • Hydatidiform Mole noninvasive complete (no
    fetus) or partial (parts of a fetus)
  • Vaginal Bleeding Hyperemesis is the usually
    presentation
  • Uterus larger than size HCG higher than
    expected
  • Preeclampsia before 24 wks
  • Tx D C

15
Second Half Emergencies
  • Bloody show associated with cervical
    insufficiency or preterm/term labor
  • Placenta previa
  • Abruptio placentae
  • Uterine rupture
  • Vasa previa
  • HTN, Preeclampsia, Eclampsia, and HELLP

16
HTN Disorders
  • 2nd most common cause of maternal death
  • HTN in Pregnancy BP gt 140/90 or gt 20 systolic
    or 10 diastolic rise from baseline
  • HTN defined as chronic, preeclampsia superimposed
    on chronic, transient, and preeclampsia/eclampsia
  • Preeclampsia HTN after 20 weeks along with
    proteinuria (urine protein gt 0.1 g/dL in to
    separate urines 6h apart)

17
HTN Disorders
  • Preeclampsia
  • Common symptoms headache, vision disturbance,
    edema, or abdominal pain
  • Tx delivery of the fetus little evidence that
    HTN meds change morbidity/mortality
  • HELLP
  • Hemolysis, elevated liver enzymes, and low
    platelets
  • Usually in multigravid
  • Eclampsia
  • Preeclampsia with Seizure
  • Seizures can occur from 20 wks through 7 days
    postpartum
  • Treat as eclamptic even w/o seizure BP gt140/90
    epigastric or liver tenderness, visual
    disturbance , or severe headache.
  • Tx 4-6 grams Mg2SO4 over 15 minutes followed by
    1-2 g/hr and delivery of the fetus (watch for
    respiratory depression)

18
Second Half Emergencies
  • Vaginal Bleeding in the Second Half of Pregnancy
  • unrelated to labor and delivery
  • complicates 4 to 5 percent of pregnancies
  • Placenta previa (20 percent)
  • Abruptio placentae (30 percent)
  • Uterine rupture (rare)
  • Vasa previa (rare)
  • The remainder of cases have an undetermined
    etiology and are attributed to marginal placental
    separation

19
Abruptio Placentae
  • Placental separation Bleeding with cramping
    suggest placental separation.
  • diagnosis is one of exclusion usually cannot be
    visualized on ultrasound examination
  • a subchorionic hematoma or a placenta that covers
    the internal cervical os suggests the diagnosis.
  • Exacerbated by HTN, trauma, increased maternal
    age, multiparity, smoking, cocaine, and previous
    abruptions
  • Complications fetal/maternal death, DIC,
    fetomaternal transfusion, amniotic fluid
    embolism
  • Tx OB/Consultation
  • Ectopic pregnancy Ectopic pregnancy is rare at
    this gestational age

20
Placenta Previa
  • Digital examination of the cervix should be
    avoided until placenta previa has been excluded
  • Placenta Previa absence of abdominal pain and
    uterine contractions
  • Rule is not absolute
  • Diagnosis via transabdominal ultrasound
  • Most important step is to determine the severity
    of bleeding
  • Severe
  • gt 30 blood loss shock/oliguria/fetal death or
    distress
  • Shock Tx and Cesarean section prepare for
    possible hysterectomy

21
Placenta Previa
  • Moderate
  • 15-30 blood loss orthostatic changes / clammy /
    agitation / dyspnea / pallor
  • Volume repletion gt 36 wks then deliver
  • delivery is indicated if there is a nonreassuring
    fetal heart rate tracing unresponsive to
    resuscitative measures, life threatening
    refractory maternal hemorrhage, or any bleeding
    after 34 weeks in the presence of known or
    suspected fetal pulmonary maturity
  • In stable patients, amniocentesis is performed at
    36 weeks to assess pulmonary maturity. If testing
    suggests lung immaturity, then the procedure is
    repeated weekly until maturity
  • Mild
  • Same as moderate
  • Out patient if stopped for a minimum of 48
    hours and there are no other pregnancy
    complications live close to the hospital adult
    supervision 24 hrs understand risks be reliable
    maintain bed rest

22
Transabdominal US showing a placenta over the
cervical os
23
Thromboembolic Disease
  • Number one killer of pregnant women
  • 5 x risk of nonpregnant women
  • Risk is greatest in the postpartum period
  • ½ of DVTs arise from iliac veins, and ultrasound
    has a poor sensitivity MRA or CT
  • CTA OR VQ should be used to diagnose PE if
    suspected
  • Treatment with Heparin or LMWH

24
Postpartum Hemorrhage
  • Usually presents within 24 hour of delivery
  • After 24 hours usually due to retained products,
    uterine polyps, or a coagulopathy
  • Bleeding can occur up to 5 weeks after pregnancy
  • Uterine atony is the most common cause of
    postpartum hemorrhage
  • Oxytocin 20units in 1 liter of NS _at_ 200cc/hr

25
Postpartum Infections
  • Any fever over 38 C (100.4) should be considered
    a genital tract infection
  • C section drastically increases the risk of
    endometritis
  • Most common pathogens Gram - aerobes,
    anaerobes, and chlamydia trachomatis
  • Tx Gent Ampicillin or a 3rd-4th Generation
    Cephlosporin

26
Peripartum Cardiomyopathy
  • Heart failure during or shortly after pregnancy
  • Causes chronic HTN, mitral stenosis, Obesity,
    viral myocarditis, and preeclampsia
  • Tx fluids and diuretics
  • If no cause found, mortality is 50 at one year

27
Transfer of the Pregnant Patient
  • EMTALA states that any women having contractions
    are considered to have a emergency condition
    unstable for transfer
  • Therefore the patient should not be transferred
    unless the patient requests the transfer or the
    physician determines the risk delivery at the
    current facility outweighs the risk of transfer

28
Resources
  • Tintinalli Chapter 106
  • Benrubi, Guy I. Handbook of Obstetric and
    Gynecologic Emergencies. 3rd ed. Pp. 114-124.
  • Quilligan, Edward J., Zuspan, Frederick P.,
    Current Therapy in Obstetrics and Gynecology. 5th
    ed. Pp 360-364.
  • www.emedicine.com 5/3/3007
  • www.uptodate.com 5/3/2007
About PowerShow.com