02/11/2016 Outline .General Concepts Obstetrical .Pregnancy-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 pregnancies 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 1 02/11/2016 Physical Exam Diagnostic Evaluation .VS changes in pregnancy .Pregnancy test . HR increases 15-20/min . Systolic BP ↓ 5-10 mmHg, diastolic 10-15 . Whole blood 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 .Gestational age: .UA and culture . 12 weeks uterus 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 fetus” . 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 2 02/11/2016 Pharmacology in Pharmacology in Pregnancy Pregnancy .All drugs cross placenta 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 .Antibiotics .Anticonvulsants . most are teratogenic but must control . Penicillins, cephalosporins, macrolides, nitrofurantoin seizures .Analgesics – acetaminophen and opiates .ACE inhibitors .Antiemetics .Corticosteroids .Oral anticoagulants .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 3 02/11/2016 Ectopic Pregnancy Ectopic Pregnancy Risk Factors Presentation .History of prior ectopic –7 fold .Symptoms increased risk .Unilateral abdominal pain, amenorrhea .PID – 6 fold increased risk .Vaginal bleeding .Assisted reproduction .Physical exam .IUD .Unilateral adnexal tenderness .Smoking Upon rupture, syncope, severe pain, .Recent elective abortion . 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 4 02/11/2016 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 miscarriage .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 cervix, uterine abnormalities . Missed miscarriage . 90% of couples can have normal delivery . IUFD without expulsion of POC 5 02/11/2016 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, nausea, 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 Corpus Luteum 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 Hyperemesis Gravidarum .Not just “bad morning sickness” .IV hydration .Antiemetics .Nausea and vomiting with . Class A doxylamine/pyridoxine .Weight loss with persistent vomiting . Class B metoclopramide, prochlorperazine, hypokalemia ondansetron . Class C promethazine but no known harm .Dehydration ketonuria .Glucose to break ketosis .Pyridoxine (B6) .Ginger 6 02/11/2016 Eclampsia/Preeclampsia Etiology .BP >140/90 with proteinuria 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, edema, 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 Liver Function Tests .Hypertension controlled with . LDH > 600, Bili > 1.2, AST > 72 . HYDRALAZINE .Low Platelets . LABETOLOL . Less than 100,000 . Sodium nitroprusside . Diuretics are contraindicated 7 02/11/2016 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 abortions . OB may do a TV US .History of placenta previa 8 02/11/2016 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 Wikimedia. Blausen.com staff. "Blausen gallery 2014". Wikiversity Journal of Medicine. 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) 9 02/11/2016 Abruptio Placenta Abruptio Placenta Evaluation Treatment .Ultrasound .Emergent Obstetric consultation . Don’t waste time transporting the patient to .2 large bore