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Emergencies During Pregnancy and the Postpartum Period

Emergencies During Pregnancy and the Postpartum Period. Chapter 106. 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

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Emergencies During Pregnancy and the Postpartum Period

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  1. Emergencies During Pregnancy and the Postpartum Period Chapter 106

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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)

  7. Ectopic • Positive betaHCG; quant > 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

  8. Ectopic • Medical (Methotrexate) vs. Surgical Tx. (D&C/D&E) • Surgical: (1) ruptured ectopic pregnancy, (2) inability / unwillingness to comply with or contraindications to medical therapy, (3) lack of timely access toa medical institution (4) failed medical therapy • Medical and surgical therapy are equally successful in women who are hemodynamically stable and hCG concentration < 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

  9. 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)

  10. 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: D&C / D&E; 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

  11. Incomplete or Missed Abortion • Expectant Management: • Women with early pregnancy failure at < 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

  12. 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

  13. Post Spontaneous Abortion • ALL WOMEN WHO ARE Rh(D) negative should receive 300 micrograms Rhogam, some give 150 micrograms if <12 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

  14. 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

  15. 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

  16. HTN Disorders • 2nd most common cause of maternal death • HTN in Pregnancy – BP > 140/90 or > 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 > 0.1 g/dL in to separate urines 6h apart)

  17. 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 >140/90 & 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)

  18. 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

  19. 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

  20. 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: • > 30% blood loss; shock/oliguria/fetal death or distress • Shock Tx and Cesarean section; prepare for possible hysterectomy

  21. Placenta Previa • Moderate: • 15-30% blood loss; orthostatic changes / clammy / agitation / dyspnea / pallor • Volume repletion & > 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

  22. Transabdominal US showing a placenta over the cervical os

  23. 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

  24. 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 @ 200cc/hr

  25. 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

  26. 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

  27. 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

  28. 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

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