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
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Slide1
Acute complications of pregnancy
Ibtisam Al Hoqani
EM –
R1
22/6/2010
Slide2Outline:
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
Slide3Question 1:
Which of following is the most common cause of first trimester vaginal bleeding?
Abruptio placenta
Ectopic pregnancy
Placenta previa
Spontaneous abortionOvarian torsion
Slide4Miscarriage
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
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
Slide6Miscarriage
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
Slide7Miscarriage
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
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
Slide9Sonographic “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
Slide10Question:
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
Slide11Qusetion
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
Slide12Ectopic 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
Slide13Question:
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
Slide14Slide15Question:
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
Slide16Ectopic 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
Slide17Abruption 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
Slide18Abruption 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
Slide19Question:
Which of following is not associated with increase incidence of Abruptio placenta?
Cocaine
Heroin
Hypertension
SmokingAdvance age and Multiparty
Abdominal trauma
Slide20Question:
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
Slide21Placenta 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
Slide22Management
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
Slide23Question:
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
Slide24Preeclampsia 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
Slide25Important 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
Question:
Which of following is expected abnormality in HELLP syndrome?
Decrease HGB
Elevated PT
Decreased Fibrinogen
Elevated APTTAll of above
Slide27Management:
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
Slide28Question:
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
Slide29Management:
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
Slide30Question:
Which of following is sign of MgSO4 toxicity?
Atrial Fibrillation
Somnolence
Increase
HyperventilationDiarrhea
Slide31Question:
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