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Acute complications of pregnancy

Acute complications of pregnancy. Ibtisam Al Hoqani EM – R1 22/6/2010. Outline:. Complications in Early Pregnancy: Miscarriges Ectpic pregnancy Molar pregnancy :Complications in late pregnancy Abruption placenta Placenta Previa Preeclampsia and Eclampsia

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Acute complications of pregnancy

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  1. Acute complications of pregnancy Ibtisam Al Hoqani EM – R1 22/6/2010

  2. 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

  3. Question 1: • Which of following is the most common cause of first trimester vaginal bleeding? • Abruptio placenta • Ectopic pregnancy • Placenta previa • Spontaneous abortion • Ovarian torsion

  4. 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

  5. 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 • Reassurance • Inpatient admission for observation

  6. 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

  7. 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

  8. 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 death Mx: medical or surgical D&C

  9. 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

  10. 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

  11. Qusetion • Which of following is not a risk factor for ectopic pregnancy: • Previous C-section • Pharmacological assisted conception • Previous ectopic pregnancy • Previous h/o PID • Having IUCD

  12. Ectopic pregnancy: • Leading cause of maternal death in 1st trimester and 2nd overall cause of mortality in pregnant ladies • Risk factors:     Advanced age Pelvic inflammatory disease     Smoking    Prior spontaneous abortionor ectopic pregnancy    Medically induced abortion     History of infertility   Intrauterine device Tubal Surgery

  13. 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

  14. 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

  15. 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

  16. Abruption placenta • The cause of 30% of PV bleeding in 3rd trimester • Premature separation of normally implanted placenta causing seen or hidden bleeding • Usually associated with painfull uterine bleeding

  17. Abruption placenta • Stages: Grade 1: 40%, slight bleeding, no pain or fetal distress Grade 2: 45%, moderate bleeding, increase uterine irritability with fetal distress Grade 3: 15% tetanic uterine contraction, hypotension, coagulopathy, possible fetal death

  18. Question: • Which of following is not associated with increase incidence of Abruptio placenta? • Cocaine • Heroin • Hypertension • Smoking • Advance age and Multiparty • Abdominal trauma

  19. 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

  20. Placenta Previa • Cause 20% of 3rd trimester bleeding • Painless bright red vaginal bleeding with soft non tender uterus • Risk factors: • Prior C-section • Grand Multiparty • Previous placenta previa • Multiple gestation • Multiple induce abortion • Maternal age >40 years

  21. 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

  22. 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 push • Labetolol 20mg slow iv push

  23. 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

  24. 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: • Headache • Visual disturbance • Hyperreflexia • Abdominal pain

  25. Question: • Which of following is expected abnormality in HELLP syndrome? • Decrease HGB • Elevated PT • Decreased Fibrinogen • Elevated APTT • All of above

  26. 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

  27. 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

  28. 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/hr • Follow DTR stop infusion if disappear • Phenytoin or diazepam may be used for seizure resistant to MgSo4

  29. Question: • Which of following is sign of MgSO4 toxicity? • Atrial Fibrillation • Somnolence • Increase • Hyperventilation • Diarrhea

  30. 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

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