02/11/2016

Outline

.General Concepts Obstetrical .-related disorders Disorders .Trauma in the pregnant patient .Complications during labor and delivery

Michael J McCrea, MD, FACEP, FAAEM Mercy St. Vincent Medical Center Toledo, OH

Rule #1 Rule #2

.Exclude pregnancy in all patients .All are ECTOPICS until between 10-55 except those with proven otherwise a hysterectomy. .Previous Pregnancy History .“I can’t be pregnant” that can be . 15-17% recurrence rate of ectopic pregnant pregnancies . Tubal ligation . Regular menses

Rule #3 History Pearls

.Fetal heart tones (FHT) are a vital .Previous Pregnancy History sign in a pregnant patient. . 15-17% recurrence rate of ectopic pregnancies .LMP wrong in 50% of cases

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Physical Exam Diagnostic Evaluation

.VS changes in pregnancy .Pregnancy test . HR increases 15-20/min . Systolic BP ↓ 5-10 mmHg, diastolic 10-15 . Whole can be used for commercial .Fetal Heart Tones are a vital sign – POC urine tests! Rule #3 .CBC, Coags .Focus on abdominal and pelvic exam .Rh type and/or Type and Screen .: .UA and culture . 12 weeks just rising out of the pelvic , fetal heart tones . Pelvic exam swabs for cultures . 20 weeks fundus at umbilicus . GC, Chlamydia, HSV, Wet Prep

Radiographic Studies and Pregnancy Radiology Tests

American College of Radiology: .>100 Rads = CNS abnormalities “…no single diagnostic test results .>10 Rads = Reduction of fetal in radiation doses that threaten growth potential the well-being of the developing . Chest X-ray 0.02 - 0.07 mrad embryo or ” . Abdominal KUB 100 mrad . Hip X-ray, single view, 200 mrad . CT head <1 rad . CT abdomen/pelvis 3.5 rad

Radiology Tests

.NEVER withhold imaging if clinically indicated Pharmacology During .ALWAYS shield the abdomen if Pregnancy possible

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Pharmacology in Pharmacology in Pregnancy Pregnancy

.All drugs cross to some .FDA categories degree .A= controlled studies show no human risk .Key factor in determining .B= no evidence of risk to humans teratogenicity is fetal EGA at .C=risk cannot be ruled out exposure .D=positive evidence of risk . Organogenesis (18-60 days post .X=contraindicated in pregnancy conception)

“Safe Drugs” Red Flag Drugs

. .Anticonvulsants . most are teratogenic but must control . Penicillins, cephalosporins, macrolides, nitrofurantoin seizures .Analgesics – acetaminophen and opiates .ACE inhibitors . . .Oral .Antihypertensives .NSAIDs . Labetalol, hydralazine . Premature closure of ductus arteriosis . Exceptions - ACE inhibitors, diuretics

Ectopic Pregnancy

.Rule #2 – all pregnancies are ectopics… First Trimester Pregnancy- .95% fallopian tubes Related Conditions .17.4/1000 pregnancies .50% missed at 1st office visit .36% at 1st ED visit .3-5 % rate with gonadotropin therapy

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Ectopic Pregnancy Ectopic Pregnancy Risk Factors Presentation

.History of prior ectopic –7 fold .Symptoms increased risk .Unilateral , amenorrhea .PID – 6 fold increased risk .Vaginal bleeding .Assisted reproduction .Physical exam .IUD .Unilateral adnexal tenderness .Smoking Upon rupture, syncope, severe pain, .Recent elective . and hypotension may be present .Older age

Ectopic Pregnancy Ectopic Pregnancy Diagnosis Diagnosis

.Positive hCG .Discriminatory Zone .hCG normally doubles every 1-3 .hCG level above which you should see days for first 6 weeks an IUP. .Fall, plateau MAY indicate an . Depends on your hospital lab and US tech skills and machines abnormal pregnancy .Transvaginal US – 1,500-2,000 .Ultrasound=test of choice .Transabdominal US – 4,000-6,500

Yolk Sac Yolk Sac

Courtesy of Dr. Michael McCrea Courtesy of Dr. Michael McCrea

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EctopicEctopic Ectopic PregnancyPregnancy Pregnancy

Courtesy of Dr. John Russ, RDMS Courtesy of Dr. John Russ, RDMS

Ectopic Pregnancy Ectopic Pregnancy Management Management

.Unstable patient .Medical Treatment: Methotrexate . 2 large bore IV’s . Stable patient with unruptured ectopic . CBC, PT, PTT, platelets <4cm . Type and cross match . Transient pelvic pain 3-7 days post therapy .Stable patient normal . Low suspicion and inconclusive testing . Minimize # of pelvic exams . Outpatient follow up serial hCG and repeat ultrasound .Treatment-Surgery vs. Medical

First Trimester Bleeding First Trimester Bleeding . Threatened .50% spot or bleed in first trimester . Bleeding with normal pelvic exam, os closed .20% miscarry . Inevitable miscarriage .Once FHT heard, risk of miscarriage . Os open with excessive or prolonged bleeding drops . Incomplete miscarriage .Causes of miscarriage . Some POC remain . Fetal causes – most chromosomal . Complete miscarriage abnormalities . All POC expelled . Maternal factors-DM, incompetent , uterine abnormalities . Missed miscarriage . 90% of couples can have normal delivery . IUFD without expulsion of POC

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First Trimester Bleeding Septic Abortion

.Labs CBC, quant hCG , type and screen .Retained POCs from missed or .Rhogam for all Rh negative mothers incomplete miscarriage . Polymicrobial .Rho D immunoglobulin . Bleeding, cramping, fever, , malaise . Rh(d) antigen fully expressed at 30 days EGA . Purulent discharge . 25 µg/cc transfused fetal blood required for . Boggy, tender, enlarged uterus maternal sensitization (Kleihauer-Betke) .Treatment . Standard dose 300 µg IM within 72 hrs of event . Admission . If untreated, 1st trimester miscarriage carries 2- . Antibiotics-amp, gent, clinda 3% risk of sensitization for subsequent . D & C pregnancies

Hemorrhagic Uterine Incarceration

.Normally corpus luteum persists .Late first trimester – retroverted uterus until end of 1st trimester .Presentation . 3-4 cm mass in adnexa . Rare .May hemorrhage into itself or it may . Severe rectal pressure and back pain . Urinary obstruction rupture  presentation may mimic . Cervical prolapse ectopic .Treatment . Knee flexed position with rectal or vaginal .Diagnosis by ultrasound manipulation under general anesthesia

Hyperemesis Gravidarum

.Not just “bad ” .IV hydration .Antiemetics .Nausea and with . Class A / . with persistent vomiting  . Class B , , hypokalemia . Class C but no known harm . .Glucose to break .Pyridoxine (B6) .

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Eclampsia/Preeclampsia Etiology

.BP >140/90 with Second and Third Trimester .>20 weeks gestation, <4 weeks Related Conditions post partum . Earlier in trophoblastic disease .Occurs in 7% of pregnancies

Eclampsia/Preeclampsia Eclampsia/Preeclampsia Presentation Diagnostic Evaluation

.Proteinuria, , hypertension .Fetal heart tones (Rule 3) .Severe .CBC with peripheral smear . SBP>160, DBP>110 . Oliguria <40cc/hr .Electrolytes . Cerebral or visual disturbances .LFTs . Pulmonary edema . Cyanosis .Eclampsia = seizures

Eclampsia/Preeclampsia HELLP Syndrome Management

.Hemolysis .Immediate obstetric consultation . abnormal peripheral smear, schistocytes, burr cells .Emergent delivery is definitive therapy .Elevated .Hypertension controlled with . LDH > 600, Bili > 1.2, AST > 72 . HYDRALAZINE .Low Platelets . LABETOLOL . Less than 100,000 . Sodium nitroprusside . Diuretics are contraindicated

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Eclampsia/Preeclampsia Management Case

.Seizures=magnesium sulfate .27 year-old female with painless . 4-6 g over 15 min, then 2-3 g/hr vaginal bleeding . Monitor deep tendon reflexes, urine output, . Positive home pregnancy test, no prenatal respiratory rate, blood pressure and fetal care heart tones . About 20ish weeks by vague LMP . Prior C-section .Alternative treatment . Nontender abdominal exam with gravid . Benzodiazepines and phenobarbital uterus 3 cm above umbilicus . Beware of fetal sedation if emergent delivery . Phenytoin - relative contraindication

Placenta Previa Etiology

.Low implantation of placenta resulting in encroaching or covering of internal os .1:200 pregnancies

OpenStax College. Embryonic Development, OpenStax-CNX Web site. http://legacy.cnx.org/content/m46319/1.3/, Jun 4, 2013.

Placenta Previa Placenta Previa Risk Factors Evaluation

.Grand multips .DO NOT VAGINALLY EXAMINE ANY .Advanced maternal age PATIENT WITH LATE PREGNANCY .Previous history of C-section BLEEDING. delivery .Diagnosis by ultrasound but .D&C transabdominal US only by EP .Elective . OB may do a TV US .History of placenta previa

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Placenta Previa Management Case

.Emergency Obstetric consultation 37 year-old female 32 weeks .Focused on prep for C-section delivery pregnant with sudden onset of .2 large bore IV’s abdominal pain ◦ Fell down 2 steps and now has severe .CBC, PT, PTT, platelets, Type and abdominal pain Cross ◦ Presents with some vaginal bleeding .Monitor fetal heart tones (Rule 3)

Abruptio Placenta Etiology

.Separation of placenta from site of uterine implantation

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Abruptio Placenta Risk Abruptio Placenta Factors Presentation

.Cocaine .Painful bleeding .Smoking .Occasionally bleeding may be .Trauma absent .Pregnancy induced or chronic .Severe cases may develop hypertension disseminated intravascular .Previous history of placenta abruption coagulation (DIC)

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Abruptio Placenta Abruptio Placenta Evaluation Treatment

.Ultrasound .Emergent Obstetric consultation . Don’t waste time transporting the patient to .2 large bore IV’s radiology .CBC, PT, PTT, platelets .Fetal monitoring .Oxygen .Truly a clinical diagnosis .Type and cross .Serum for fetal hemoglobin (Kleinhauer-Betke) .Fibrinogen, fibrin split products

Gestational Trophoblastic Gestational Trophoblastic Disease Disease

.Hydatidiform mole (complete or .Clinical presentation partial) . Vaginal bleeding .Persistent/invasive GTD . Enlarged uterus more than expected for dates . Pelvic pressure and pain . . Theca lutein cysts .Placental site trophoblastic tumors . .Incidence: 1/1000 (US) . Hyperemesis gravidarum . Preeclampsia less than 20 weeks’ gestational age . Vaginal passage of hydropic vesicles

Gestational Trophoblastic Gestational Trophoblastic Disease Disease

.Diagnosis . B-hCG levels > 100,000 . Ultrasound shows no fetal pole . “Bunch of grapes” . “Snowstorm”

Wikimedia. Häggström, Mikael. "Medical gallery of Mikael Häggström 2014". Wikiversity Journal of Medicine

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Changes in Normal Physiology and Anatomy: Cardiac

.CO increases by 30-50% .CVP decreases to 4 mmHg by 3rd trimester .HR increases 15-20 BPM Medical Complications .SBP decreases 5-10 mmHg and DBP decreases 10-15 mmHg with nadir at end During Pregnancy of 2nd trimester .Vena cava compression occurs in 10-15% of patients when laying supine and flat

Changes in Normal Physiology and Changes in Normal Physiology and Anatomy : Respiratory Anatomy: Laboratory

.Maternal O2 increases by 15-20% .Anemia (Hgb 10.2-11.6) .Persistent alkalemia after .Creatinine drops (>1.0 = abnormal) metabolic compensation (pCO2 .ESR markedly elevated 27-32 mmHg) .Fibrinogen levels double .Decrease in FRC by 20-25% .pCO2 27-32 mmHg .Earlier risk for hypoxemia .D-dimer elevated

Urinary Tract Infection

.Most common medical .Treatment: 7-10 day course in pregnancy .Safe antibiotics in pregnancy: .Presentation . Suprapubic pain cephalosporins, nitrofurantoin, . Dysuria penicillins, macrolides, clindamycin . +/- hematuria .Not safe antibiotics: streptomycin, . Frequency .Diagnosis doxycycline, tetracycline, all . Urinalysis quinolones . Urine Culture: E. coli, Klebsiella, Proteus

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Pyelonephritis Thromboembolism

.1-2.5% occurrence in all pregnancies .A Leading cause of maternal mortality .10% of patients will have .1.8 relative risk vs. non-pregnant documented bacteremia .Requires admission females .Treatment: cephalosporin first-line .5.5 relative risk in .10-20% recurrence rate during

pregnancy

Thromboembolism Aortic Dissection

.Diagnosis .A leading cause of . D-dimer not helpful as elevated in normal .Hormonal and hemodynamic pregnancy weakening of intima and media layers . DVT evaluation, helpful if positive .TEE test of choice over . Radiographic testing – CT vs. V/Q . MRI must lay supine for prolonged time, stability .Treatment . CT radiation to mom and fetus . LMWH preferred over heparin .ACE Inhibitors contraindicated . Coumadin contraindicated

Cardiac Disease Cardiac Disease

.Becoming more prevalent .Presentation mimics normal .Increasing maternal age with pregnancy changes increased cardiac risk factors . Dyspnea . .Congenital heart disease patients . Edema reach adulthood and become .Results in delayed diagnosis and pregnant treatment

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Cardiac Disease Cardiac Dysrhythmias

.BNP rises normally in pregnancy but .Increased risk over non-pregnant >300 pg/ml is abnormal patients .Treatment unchanged from non- .Adenosine safe for SVT pregnant patients except no ACE .Cardioversion, transcutaneous, inhibitors or diuretics transvenous pacing all safe but use as little energy/current as possible .All other anti-dysrhythmics class C but avoid amiodarone if possible

Peri-mortem Cardiac Arrest Cesarean Section

.Displace uterus to the LEFT .Best chance of fetal survival is maternal resuscitation… .Chest compressions higher on the chest .Best chance of maternal survival is fetal delivery .Expect a difficult airway . 12 of 20 women had ROSC immediately .No changes to defibrillation energy after fetal delivery doses or in ALCS . 9 of 12 infants delivered within 5 minutes of maternal arrest had normal neurologic algorithms outcomes

Peri-mortem Peri-mortem Cesarean Section Cesarean Section

.Predictive values for success .After FOUR minutes of maternal . EGA > 28 weeks arrest, i.e. two cycles of ACLS . Less than 10 min from maternal death to .Goal of fetal delivery FIVE minutes delivery . Maternal cause of death not chronic hypoxia after maternal arrest . Fetal status prior to maternal death .In other words, you have ONE minute . Quality of maternal resuscitation to deliver the fetus

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Peri-mortem Cesarean Section Pneumonia

.Classical vertical incision “stem to .1:2000 incidence stern” .Can be associated with preterm .Get baby out, clamp cord labor .Now resuscitate mom and baby… .Varicella pneumonia

. Rash followed by respiratory distress . Chest x-ray diffuse miliary or nodular infiltrates . Maternal mortality 11-33%

Asthma HIV in Pregnancy

.May worsen, improve, or remain stable .Vertical transmission rate 25-59% during pregnancy .Risk of transmission ↑viral load .Remember, PCO2 levels fall in pregnancy, so a level of 40 in asthma indicates and ↓CD4 retention .Treatment same as non-pregnant .Multi-drug regimen decreases . Beta-agonists, magnesium safe in pregnancy . Risk-benefit with steroids as Class C/D transmission

. Minimum treatment with zidovudine (AZT)

Appendicitis

.No increased risk over non- .Ultrasound initial test of choice pregnant population but increased . CT if needed, MRI becoming increasingly used morbidity secondary to frequently .Preterm labor frequent after surgery delayed and misdiagnosis .Presentation .Don’t wait too long to involve surgery . Difficult history – lower abdominal pain, . Perforation 2-3x more likely in pregnant patients nausea, vomiting . Fetal mortality 20 - 35% with perforation . Normal WBC in pregnancy 12-15k . Fetal mortality 0 - 1.5% without perforation . McBurney’s point moves

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Cholecystitis

.1:1000 pregnancies .Occurs in third trimester or post- .Clinical presentation again clouded partum by pregnancy – heartburn, nausea, food intolerance .No differences in presentation .Diagnosis by ultrasound .Prefer serial exams and repeat .Treatment abdominal series over CT if possible . Conservative with delayed surgery if possible .Treatment unchanged . IV hydration, NPO, Antibiotics . 2nd trimester ideal if surgery is needed . NPO, NG placement, surgical consultation, admit

Trauma in Pregnancy

.MATERNAL DEATH IS THE MOST Trauma in Pregnancy COMMON CAUSE OF FETAL DEATH .FETAL ASSESSMENT IS SECONDARY TO MATERNAL RESUSCITATION . But fetal well being is a marker of

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Trauma in Pregnancy Primary Trauma in Pregnancy Survey Secondary Survey

.Airway .Pregnancy history . consider early intubation, it will be difficult .Breathing .Estimation of gestational age . 100% Oxygen due to decreased FRC and .Palpation of uterus increased O2 use . Chest tubes 1-2 rib spaces higher .Early administration of monitoring .Circulation . Minimum of 4 hours for patients > 20 WGA . FHT Rule 3 . Place patient in left lateral decubitus position or .Sterile speculum exam manually displace uterus to left . Maternal BP is preserved at expense of placental . Ferning, nitrazine paper, blood, cervix circulation . Changes in BP and HR occur only after 1.5L .Bimanual exam

Trauma in Pregnancy Trauma in Pregnancy Evaluation Blunt Trauma

.Do not withhold imaging studies .60% due to MVCs .DPL .ACOG endorses the use of three-point . Supraumbilical approach if uterus palpable safety restraints above pubis .Major threat is . Open or mini-laparotomy technique preferred over closed Seldinger . 2-4% in minor trauma, 30% in major trauma . Clinical symptoms unreliable and often .Ultrasound safe but remember absent does does not rule out abruption . Vaginal bleeding, abdominal pain, tenderness, back pain . US screening - sensitivity < 50%

Trauma in Pregnancy Trauma in Pregnancy Penetrating Trauma

. .Gunshot more common than knife . Fetal mortality ~100% .Pregnancy specific injury patterns . Maternal mortality 10% with developing gestational age . Risk factor - previous C-section . similar to abruption .Decisions for operative and . Uterine tenderness with irregular contours, palpable nonoperative management made fetal parts, +/- vaginal bleeding by trauma team and obstetrician . In unscarred uterus, rupture tends to be posterior and often associated with bladder injury

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Premature Labor

. Cervical change with contractions prior to 37 Complications During Labor WGA and Delivery . Risk Factors: PROM, local infection, cervical incompetence, uterine abnormalities, over distended uterus, fetal abnormalities, faulty presentation, IUFD, maternal disease . Treatment-hydration, beta agonists, monitoring

Preterm Rupture of Membranes Emergency Delivery

.90% of term and 50% of preterm .Transport to OB in mom’s uterus patients will be in labor 24 hours preferred if not imminent delivery after ROM .If cervical dilation > 6 cm prepare .Determination for delivery . pH vaginal fluid increases 4.5-6.0 to 7.1 to 7.3 . IV . Ferning . CBC .Prolonged ROM > 24 hours . Type and screen Monitor fetal heart rate . .Neonatal team/OB

Mechanics of Emergent Mechanics of Emergent Delivery Delivery

.Complete cervical dilation .Deliver shoulders .Dorsal lithotomy position preferred . Gentle downward traction to ease shoulders .Gentle perineum stretching . If resistance, pressure suprapubically .Episiotomy . Control posterior shoulder .No maternal pushing after head delivered .Stable grip .Palpate fetal neck -check for and reduce if needed before delivery of .Sterile cutting of cord shoulders

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Management of Management of Shoulder Dystocia

.Impaction of anterior shoulder behind pubic .Manually deliver posterior arm with symphysis episiotomy .Turtle sign-head against perineum .McRobert’s maneuver – hyperflex maternal .Fracture clavicle intentionally hips .Gaskin position – mom on “all fours” .Suprapubic pressure (Rubin I) .Zavanelli maneuver – manually push .Rotational maneuvers . Woods’ Corkscrew maneuver fetus back up into uterus and . Rubin II prepare for emergent C-section . Reverse Woods’ corkscrew

Breech Presentation Cord Prolapse

.DO NOT pull on the fetus .Place the patient in Trendelenburg .Mom push normally until baby and manually elevate the delivered to umbilicus then NO MORE presenting cord pushing .DO NOT push cord back in . Support baby elevated sacrum anteriorly .DO NOT pull on the cord .Deliver arms, posterior first, rotate, .Maintain manual elevation until other arm emergent C-section is completed .Suprapubic pressure to FLEX the fetal head

Postpartum Management Postpartum Complications

.Delivery of placenta . Endometritis . Pulling on cord risks inversion of uterus . fever, abdominal pain and foul smelling lochia . Placenta separation - gush of blood and . cultures, broad-spectrum antibiotics and hospitalization lengthening of cord . . - explore uterine cavity, . Inflammation , swelling of breast +/- fever and uterine massage, oxytocin, Methergine, chills carboprost, misoprostol . Staph aureus .Check for lacerations and repair . Keep breast feeding or pumping - will not hurt baby episiotomy

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Rules

.Rule #1 – All female patients are Summary and Pearls pregnant until proven otherwise

.Rule #2 – All pregnant patients have an ectopic pregnancy until proven otherwise

.Rule #3 – Measure fetal heart tones

Ectopic Pregnancy Pre-eclampsia/Eclampsia

.Remember rule #2 .Know diagnostic criteria .Sudden onset, UNILATERAL pelvic pain with nausea and vomiting .Control HTN with labetalol, hydralazine

.Get the ultrasound .Magnesium, magnesium, more .Know discriminatory zone numbers to magnesium! help answer disposition questions .Methotrexate indications – stable, .OB for emergent delivery unruptured, and less than 4 cm, otherwise surgery!

Placental Abruptio Admission Problems in Previa Placenta Pregnancy

.PAINLESS .PAINFUL vaginal .Pregnancy, ectopic vaginal bleeding bleeding after .Pelvic Inflammatory Disease (PID) abdominal trauma .Placenta Previa .Placental abruPtion .NO pelvic exam .Pneumonia, Varicella and Influenza .Ultrasound does NOT .Preterm labor rule out abruption .“Puking” (hyperemesis gravidarum) .NO transvaginal .Pulmonary US .Pyelonephritis .Fetal monitoring is .“Pump and Pipe” Problems – cardiovascular the answer!

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