Emergencies During Pregnancy and the Postpartum Period

1
Emergencies During Pregnancy and the Postpartum
Period

• Chapter 106

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Morbidity/Mortality

• 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

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Vaginal Bleeding

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

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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

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

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Diff. 1st Trimester Vaginal Bleeding

• Urine BetaHCG Serum BetaHCG Quant.
• CBC, PT/INR/PTT, Blood T C / RH, fibrinogen,
  D-dimer
• ultrasonography is the cornerstone of the
  evaluation of bleeding in early pregnancy
• 1500 IU/L (transvaginal) 6000 IU/L
  (transabdominal)

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Ectopic

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

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Ectopic

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

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

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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
  pathology

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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

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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
  Management

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

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Gestational Trophoblastic Disease

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

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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

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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)

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

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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
  separation

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

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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
  distress
• Shock Tx and Cesarean section prepare for
  possible hysterectomy

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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

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

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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

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Postpartum Infections

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

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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

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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

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Resources

• 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