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Emergencies During Pregnancy and the Postpartum Period


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

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Title: Emergencies During Pregnancy and the Postpartum Period

Emergencies During Pregnancy and the Postpartum
  • Chapter 106

  • 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

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

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

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.
  • no obvious bleeding lesions, do a bimanual
  • Uterus Size and Shape

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

  • Positive betaHCG quant gt 1500 no gestational
    sac in the uterus may or may not have an adnexal
  • 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

  • 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
  • Contraindications to Medical Tx breastfeeding
    women, immunodeficiency, active pulmonary
    disease, peptic ulcer disease, hypersensitivity
    to the drug, and significant hepatic, renal, or
    hematologic disease

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
  • Management is expectant bed rest avoid coitus
    (evidence does not support)

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

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

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

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
  • Light bleeding for a couple of weeks is normal
  • Menses resume 6 weeks
  • Serum hCG levels normalize in 2-6 weeks

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

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

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)

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
  • Hemolysis, elevated liver enzymes, and low
  • Usually in multigravid
  • Eclampsia
  • Preeclampsia with Seizure
  • Seizures can occur from 20 wks through 7 days
  • 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)

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

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
  • Complications fetal/maternal death, DIC,
    fetomaternal transfusion, amniotic fluid
  • Tx OB/Consultation
  • Ectopic pregnancy Ectopic pregnancy is rare at
    this gestational age

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
  • Shock Tx and Cesarean section prepare for
    possible hysterectomy

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

Transabdominal US showing a placenta over the
cervical os
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
  • Treatment with Heparin or LMWH

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

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

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

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

  • 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
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