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Late complications in pregnancy management
- 1. Late Complications in Pregnancy Grand Rounds Presentation Whitney Lewis DO, MS
- 3. UCC transfer for CP 25yo G3P2 39 wks, no PMH with acute onset of sharp, non- radiating R sided chest pain PTA, SOB and LLE edema. EKG: ST VS: HR 110, RR 26, BP 108/76, Temp 36.8, SpO2 94%
- 4. Pulmonary Embolism Leading cause of morbidity/mortality High pretest probability of DVT/PE = HIGH RISK Aortic Dissection PTX Pneumonia/URTI ACS/UA Esophageal Perforation Pericarditis/Myocarditis Pleuritis Cardiac Tamponade
- 6. High probability VQ scan Positive CTPA
- 7. PE Treatment in Pregnancy Heparin wt based LD/gtt LMWH 1mg/kg q12hrs SQ
- 8. POD 4 Booth 32 19yo G1P0 black female at 36 wks, no PMH presents to the ED s/p 3 minute GTC seizure with headache, MEG abd pain and blurry vision. VS: HR 100, RR 16, BP 160/115, Temp 37.3, SpO2 100% POC Glucose 85
- 9. Elevated Blood Pressure in Pregnancy 1. Eclampsia: Pre-eclampsia plus seizures and/or coma 2. Pre-eclampsia: New onset HTN >140/90 mmHg and proteinuria or end organ dysfunction >20 wks
- 10. Pre-eclampsia
- 11. Management ABCs, IV, O2, monitor Labs: CBC, CMP, coags, LDH, T&S Imaging: MR/CT abd and pelvis, US, CT head OB consult: 1. Nonsevere Pre-eclampsia Serial BPs, US, bed rest
- 12. Management 2. Severe Pre-eclampsia SBP 140-155 mmHg and DBP 90-105 mmHg Tx: Labetalol, Hydralazine, Nifedipine, Nicardipine gtt DOC ppx or Eclampsia Magnesium sulfate Toxicity: Calcium gluconate Continued seizures = benzos DELIVERY per OB >34 wks
- 13. POD 2 28yo F G2P1 at 37 wks, no PMH presents with painless bright red vaginal bleeding. VS: HR 90, RR 14, BP 110/70, Temp 37.1, SpO2 99%
- 14. DDx 3rd Trimester Hemorrhage 3rd Trimester Hemorrhage PAINLESS Placenta Previa Vasa Previa PAINFUL Placental Abruption Uterine Rupture Labor
- 15. Placenta Previa Placenta implantation over cervix PAINLESS BRIGHT RED VB and NONTENDER ABDOMEN
- 16. Vasa Previa Fetal membranes over internal os PAINLESS BRIGHT RED VB and NONTENDER ABDOMEN
- 17. Placental Abruption Separation placenta from uterine wall Etiology: Traumatic Spontaneous (cocaine, HTN, pre-eclampsia) Physical examination DARK RED VB ABDOMINAL PAIN • Uterine irritability fetal distress
- 18. Uterine rupture Rare (prior c/s, trauma, HTN) Physical examination: VB SEVERE ABDOMINAL PAIN Loss of fetal station Uterine defect
- 19. Management ABCs, IVx2, O2, Monitor NO BIMANUAL EXAMINATION Labs: CBC, CMP, coags, T&S, fibrinogen, FDP Imaging: US r/o previa does NOT r/o abruption, FAST IVF, PRBCs/MTP, Rhogam OB consult: C/S delivery (>37 wks or unstable mother) Expectant management
- 21. POD 1: WBPW from triage 38yo F, holding her abdomen in a wheelchair screaming "no puedo.”
- 22. ED Delivery ABCs, IV, O2, monitor HPI: G&P's, prenatal care, complications Precipitous delivery kit and Peds cart OB and NICU consults
- 27. 38yo F G8P8, SVD, placenta delivered, baby APGARs 9 and 10, vaginal bleeding continues...
- 28. Postpartum Hemorrhage (PPH) SVD >500 mL IVx2, O2, monitor Labs: CBC, CMP, coags, T&S, FDP, fibrinogen IVF 1-2L LR, PRBCs/MTP
- 29. PPH 4 T's: 1. Tone 2. Tissue 3. Trauma 4. Thrombin
- 30. Tone: Uterine Atony 80% PPH Boggy uterus Management: Bimanual uterine massage DOC Oxytocin 20U in 1L @ 10mL/min
- 31. Tissue Examine placenta Management: Manually explore uterus Uterine packing or balloon tamponade OR for exploration vs. IR embolization
- 32. Trauma 1. Lacerations 2. Uterine inversion 3. Uterine rupture OB OR repair uterine defect
- 33. Thrombin Coagulation disorders: Hereditary DIC, HELLP Management: Replace PRBCs, platelets, FFP, Cryo, Factors VIIa, VIII or IX
- 34. Postpartum Hemorrhage Hemorrhagic Shock: Signs of shock develop after 30% blood volume lost CO maintained until Hgb <7 or HCT <20% Management: Give PRBCs if HCT < 25-30% with ongoing bleeding Platelets <50,000 replace Fibrinogen <100 mg/dL FFP, Cryo PT/INR, PTT Cryo, recombinant factor VIIa, PCC
- 35. POD 3, Level 1 Trauma 23yo pregnant F BIB EMS s/p front-end MVC at 50 mph, restrained driver, no airbag deployment and pt not ambulatory on the scene
- 36. Anatomic Changes Uterus: >12wks intra-abdominal >20 wks fundus at umbilicus > 24wks viable Uterine rupture and placental abruption: 5% minor and 50% major blunt trauma incidents 4-5x incidence FMH Injured uterus contractions, preterm labor and pregnancy loss
- 37. Management of Abdominal Trauma in Pregnancy IVx2, O2, monitor, trauma labs, 1L LR, Tetanus and Rhogam prn L tilt 15-30o 1o Survey: Airway Breathing Circulation Disability: GCS Exposure FAST
- 38. Critical Care in the Pregnant Patient Intubation: Dec FRV 25% Increased risk aspiration Respiratory alkalosis Chest tubes: Diaphragm 4cm higher 3rd or 4th ICS
- 39. Management of Abdominal Trauma in Pregnancy 2o Survey: Head to toe exam Speculum exam Fetal monitoring OB and Trauma surgery consults
- 40. Imaging and Disposition Imaging: CXR/PXR Selective scanning with shielding Mother and viable fetus STABLE 4hrs monitoring 3 contractions/hr, uterine TTP, VB, ROM obs 24hrs Mother STABLE and fetus UNSTABLE optimize maternal condition, C/S >24 wks Mother and fetus UNSTABLE attend mother, +FAST= OR ex- lap vs. C/S
- 41. Perimortem Caesarian Section Perimortem C/S maternal cardiac arrest and viable fetus Continue ATLS/ACLS <5 min = best prognosis, 98% neuro intact 0% survival >25 min Equipment: scalpel, Mayo scissors, retractors, towels, chromic #0 or 1 and needle holder
- 43. Questions?
- 45. References: sources American College of Surgeons Committee on Trauma. ATLS, Student Course Manual. 8th Ed.2008. Pgs 260-265. Anderson J.M., and Etches D. (2007). Prevention and management of postpartum hemorrhage. American Family Physician. 75(6), 875-882. Brown, Carlos MD. Trauma in Pregnancy. EM:RAP. January 2013. Cunningham, F., Leveno, K., Bloom, S., Spong, C., Dashe, J. Williams Obstetrics, 24th Ed. McGraw-Hill Education, 2014. Chapter 47. Knoop, Kevin, Stack, S., Storrow, A. The Atlas of Emergency Medicine, 3rd Ed. McGraw-Hill Companies, Inc, 2010. Chapter 10. Marx, John MD, Hockberger, R. MD, Walls, R. MD. Rosens Emergency Medicine-Concepts and Clinical Practice 8th Ed. Elsevier, 2013. Chapters 34, 37, 178, 179. Orman, Rob, Jasumback, M. VQ in Pregnancy? A Rant and Response. EM:RAP. March 2011. Orman, Rob. Klien, J. Chest Pain in Pregnancy. EM:RAP. December 2011. Rivers, Carol M.D. Preparing For the Written Board Exam. Urogenital Emergencies. 6th Ed., Vol. 1. Ohio ACEP. 2011. Pgs 556-575. Tintinalli, Judith E., J. Stephan Stapczynski, O. John Ma, David M. Cline, Rita K. Cydulka, Garth D. Meckler, The American College of Emergency Physicians. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7th Ed. The McGrw-Hill Companies, Inc. 2011. Chapters 103-104.
Notas del editor
- 4 million pregnancies per year in the US Random pregnancy tests completed on female trauma pts find 2% were pregnant and had no idea they were 30% R3 class was pregnant or had a spouse who was pregnancy therefore with these statistics in mind it is unlikely that any of us will escape taking care of a pregnant patient over the course of our career
- Countless physiologic changes that occur during pregnancy specifically referring to CV system: HR increases (80-90 bpm by 3rd tri), increase in SV and CO Supine hypotension syndrome >20 wks compression on IVC 30% drop in CO, tilt 15-30o to L side Increased blood volume by 40%, increased levels of fibrinogen and increased coagulation factors (7, 8, 9, 10, 12) Hypercoagulopathic: compression of IVC by gravid uterus, venous stasis, makes pregnant women 5-10 x more likely to develop DVT/PE
- Suspected DVT 3 points Alternative dx less likely than PE 3 points HR >100 bpm 1.5 points No Immobilization/Surgery in past 4 weeks 0 points No previous DVT/PE 0 points No hemoptysis 0 points No h/o malignancy 0 points EMRAP VQ scan in Pregnancy 2011: Dr. Orman Pneumonia/URTI ACS/UA Aortic Dissection Esophageal Perforation PTX Pericarditis/Myocarditis Cardiac Tamponade Rosens: d dimer not used in preg pts to r/o PE, d dimer levels increased cutoffs + PERC criteria in studies show increased Sn 94-98% to rule out PE when normal
- American Thoracic Society Algorithm to work-up suspected PE in pregnancy/EMRAP podcast from 2011 Dr. Orman and Dr Klein First with LE symptoms obtain CUS: compression Doppler US Second CXR Normal CXR order VQ scan: use with renal insufficiency and contrast allergy, less nondiagnostic studies Abnormal CXR order CTPA because more Sn: expose fetus to less radiation but increased breast cancer risk 1.5% Abs amount fetal radiation 0.1 gray = threshold to avoid b/c congenital deformities occur, 100 dollars value to avoid CXR = 1/10 of a penny CTPA= 25-50 cents VQ scan = 50-75 cents
- Pre-eclampsia: previously normal BP, >140/90 x2 measurements 4-6 hrs apart, HTN <20wks= Chronic or Gestational HTN Pathophysiology: vasospasm, ischemia, thrombosis
- Preventing eclampsia and recognizing severe pre-eclampsia Increased risk placental abruption and progressing 1/50 to eclampsia Proteinuria >300 mg/24hrs, urine/protein ratio > 0.3, +1 dipstick protein EOD: hepatic hematoma/stretching of Glisson’s capsule, ARF/ Cr > 1.1, HELLP syndrome, decreased platelets <100K, increase LFTs x2, fetal growth restriction/placental abruption, pulmonary edema Caused by loss of autoregulation of cerebral BF which leads to increased BP, endo damage and extracellular damage seizures
- Imaging: symptom specific US to evaluate fetal growth CT head for recurrent sz r/o intracranial pathology
- Sustained >140/90 + EOD <34wks expectant management, hospitalize/bed rest Labetalol 10-20mg IV q10min, Hydralazine 5mg IV q20min, Nifedipine 10mg po q10min Magnesium LD 4-6g IV and MD 1-2g qhr, or 10g IM divided and administered in gluteus maximus, monitor patellar DTRs and RR >12, monitor UOP >100 mL q4hrs, decrease MD with renal insufficiency Magnesium toxicity= Calcium gluconate 1g IV
- Stable or unstable?
- (marginal/partial/complete) Prior c/s and multiple gestations
- (marginal/partial/complete)
- (complete/partial/concealed) Spontaneous MCC: inc risk pts (HTN, Pre-eclampsia, Cocaine and Tobacco use, Trauma) DIC and AFE
- (Prior C/S, Trauma, HTN)
- GPs, prenatal care, GA, hx trauma CAN LOOK BUT DON”T TOUCH (Rh- mother): Rhogam (Anti-D) Rh neg mother and Rh pos fetal blood exposure, can occur 0.1mL fetal cells, 300 microg Rh Ig >12 wks, protects 30 mL whole blood exposure within 72hrs, give with abortions, abdominal trauma, ectopic pregnancies, 3rd tri bleeding, delivery
- Another expected cause of vaginal bleeding in 3rd trimester is onset of labor- “bloody show,” blood tinged cervical mucus plug during the 1st stage of labor
- “No bueno” as this pt was clearly mistriaged! 2nd stage of labor: complete dilation of the cervix to delivery Cyclic uterine contractions 1-2 minutes apart
- suction, blankets, O2
- 1. Deliver head (Ritgin maneuver, check for nuchal cord, suction)
- Delivery anterior shoulder
- 2. Deliver posterior shoulder- hands on sides of head, push down ant shoulder then up post shoulder, clamp cord
- 3. Deliver placenta- fundal massage, <30 minutes, (cord lengthens, uterus moves up, gush of blood), inspect placenta for missing segments/3 vessel cord
- Increased risk PPH 4th stage labor after placenta delivery to 1hr Foley monitor UOP
- 2o overdistension need uterine contraction to VC spiral arteries Can start Oxytocin after delivery of ant shoulder, dec PPH 40% Oxytocin 10U IM Methergine 0.2 mg IM Misoprostol 1000 mcg rectal
- (Bakri balloon or foley 60 mL NS)
- Repair absorbable sutures Uterine inversion caused by excessive traction on cord, replace immed with fist, don’t start Oxytocin until uterus replaced Ob-Gyn to OR for repair/hysterectomy
- Hereditary Hemophilia, Von Willebrand Disease
- 1U PRBCs increase HCT 3-4% 1U platelets increase 5,000 FFP: fibrinogen (250mL, 30min thaw) Cryo: fibrinogen and CF (15mL, 3g inc fibrinogen 150)
- Implications of blunt abd trauma in preg woman as this is the #1 cause of nonobstetric morbidity/mortality in preg F
- Anatomic changes can pose specific challenges when examining a preg F Anatomic changes Physiologic Changes Management changes when evaluating for intra-abd injuries damages myometrial cells contain PGs
- FOCUS ON THE MOTHER THEN FETUS BECAUSE IF MOM DIES FETUS DIES- Dr. Brown EMRAP in 2012 Trauma in Pregnancy Circulation: Hemorrhage control Rhogam massive FMH >30 mL, Kleihauer-Betke test detect fetal cells in maternal circulation (Sn 56%, Sp 71%), may require >300 microg Rhogam FMH 8-30% trauma pts Isoimmunization Rh- mother at risk 2nd pregnancy with Rh+ fetus KB test look for fetal cells in mothers blood, 30 mL 300 mcg, consult OB if higher dose needed, poor Sn and Sp Rh negative = Rhogam
- 100% O2 difficult airway Inc TV, (pCO2 30-33mmHg) Decreased gastric emptying, LES tone and intestinal mobility
- FOCUS ON THE MOTHER THEN FETUS BECAUSE IF MOM DIES FETUS DIES- Dr. Brown EMRAP in 2012 Rhogam massive FMH >30 mL, Kleihauer-Betke test detect fetal cells in maternal circulation (Sn 56%, Sp 71%), may require >300 microg Rhogam FMH 8-30% trauma pts Isoimmunization Rh- mother at risk 2nd pregnancy with Rh+ fetus KB test look for fetal cells in mothers blood, 30 mL 300 mcg, consult OB if higher dose needed, poor Sn and Sp Rh negative = Rhogam
- Radiology- get images needed, shielding, pan CT scan <5 rads, no matter GA no fetal effects, selective scanning Bedside US: FAST, FHT, FM OR same indications as nonpregnant F, c/s uterine rupture, placental abruption (US or CT scan)
- Viable fetus (>22-24 wks) fundus above umbilicus CO 100%, CA 0%, CPR 30%, pregnancy 10%
- Midline incision epigastrum to pubis, incise uterus, deliver fetus, clamp cord, deliver placenta