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Acute complications of pregnancy Acute complications of pregnancy

Acute complications of pregnancy - PowerPoint Presentation

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Acute complications of pregnancy - PPT Presentation

Ibtisam Al Hoqani EM R1 2262010 Outline Complications in Early Pregnancy Miscarriges Ectpic pregnancy Molar pregnancy Complications in late pregnancy Abruption placenta Placenta Previa ID: 911965

pregnancy bleeding placenta question bleeding pregnancy question placenta abortion eclampsia vaginal mgso4 yrs fetal ectopic pain previa urine present

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Slide1

Acute complications of pregnancy

Ibtisam Al Hoqani

EM –

R1

22/6/2010

Slide2

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

Slide3

Question 1:

Which of following is the most common cause of first trimester vaginal bleeding?

Abruptio placenta

Ectopic pregnancy

Placenta previa

Spontaneous abortionOvarian torsion

Slide4

Miscarriage

It is common, the overall embryponic and fetal loss rate after implantation ranges up to 1/3 of detectable pregnancy

Spontaneous abortion:

Threatened

Inevitable Incomplete Complete

Missed

Slide5

Question 2:

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:

Discharge with insterctions to come back if bleeding increased

Bed rest fo

48 hrs

ReassuranceInpatient admission for observation

Slide6

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

Slide7

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

Slide8

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 deathMx: medical or surgical D&C

Slide9

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

Slide10

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

Slide11

Qusetion

Which of following is not a risk factor for ectopic pregnancy:

Previous C-section

Pharmacological assisted conception

Previous ectopic pregnancy

Previous h/o PIDHaving IUCD

Slide12

Ectopic pregnancy:

Leading cause of maternal death in 1

st

trimester and 2

nd

overall cause of mortality in pregnant ladiesRisk factors:     Advanced age Pelvic inflammatory disease     Smoking    Prior spontaneous abortion

or ectopic pregnancy

   Medically induced abortion

     History of infertility

   Intrauterine device

Tubal Surgery

Slide13

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

Slide14

Slide15

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

Slide16

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

Slide17

Abruption placenta

The cause of 30% of PV bleeding in 3

rd

trimester

Premature separation of normally implanted placenta causing seen or hidden bleeding

Usually associated with painfull uterine bleeding

Slide18

Abruption placenta

Stages:

Grade 1:

40%, slight bleeding, no pain or fetal distress

Grade 2:

45%, moderate bleeding, increase uterine irritability with fetal distressGrade 3: 15% tetanic uterine contraction, hypotension, coagulopathy, possible fetal death

Slide19

Question:

Which of following is not associated with increase incidence of Abruptio placenta?

Cocaine

Heroin

Hypertension

SmokingAdvance age and Multiparty

Abdominal trauma

Slide20

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

Slide21

Placenta Previa

Cause 20% of 3

rd

trimester bleeding

Painless bright red vaginal bleeding with soft non tender uterus

Risk factors:Prior C-sectionGrand Multiparty

Previous placenta previa

Multiple gestation

Multiple induce abortion

Maternal age >40 years

Slide22

Management

Establish IV access, draw blood for cross match and basic work up, establish cardiac and fetal monitoring

Immediately call for obstetric consultation if unstable otherwise do both ultrasound and OB referral

Never do PV digital or speculum exam unless placenta previa rolled out

Slide23

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 pushLabetolol 20mg slow iv push

Slide24

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

Slide25

Important facts:

Eclampsia may occur without prior proteinuria

Eclampsia can occur up to 10 days post partum

Intracranial bleeding is the major cause of maternal death

Warning sign of impending seizure:

HeadacheVisual disturbanceHyperreflexia

Abdominal pain

Slide26

Question:

Which of following is expected abnormality in HELLP syndrome?

Decrease HGB

Elevated PT

Decreased Fibrinogen

Elevated APTTAll of above

Slide27

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

Slide28

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

Slide29

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/hrFollow DTR stop infusion if disappear

Phenytoin or diazepam may be used for seizure resistant to MgSo4

Slide30

Question:

Which of following is sign of MgSO4 toxicity?

Atrial Fibrillation

Somnolence

Increase

HyperventilationDiarrhea

Slide31

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