Obstetrics and Gynacologic emergencies.ppt

OBSGYN emergency

1. Obstetric EmergenciesObstetric Emergencies

2. Obstetric Emergencies: We will Obstetric Emergencies: We will
cover...cover...

Normal PregnancyNormal Pregnancy

Common medical and surgical Common medical and surgical
complications of pregnancycomplications of pregnancy

3. Normal pregnancyNormal pregnancy

All females of childbearing age are All females of childbearing age are
presumed to be pregnant until proven presumed to be pregnant until proven
otherwise.otherwise.

All pregnancy tests detect B-HCG which is All pregnancy tests detect B-HCG which is
produced at the time of implantation (8-9 produced at the time of implantation (8-9
days post conception)days post conception)

B-HCG should double every day for the B-HCG should double every day for the
first weeks, peak at week 8 and remain first weeks, peak at week 8 and remain
elevated up to 60 days post-partumelevated up to 60 days post-partum

4. False NegativesFalse Negatives
Too early in pregnancyToo early in pregnancy
Dilute/old urineDilute/old urine
EctopicEctopic
Incomplete Ab.Incomplete Ab.
False PositivesFalse Positives
Urine:Urine:
hematuria/proteinuriahematuria/proteinuria
Serum:Serum:
T.O.A.T.O.A.
ThyrotoxicosisThyrotoxicosis
Molar pregnancyMolar pregnancy
Drugs (MJ, ASA, Drugs (MJ, ASA,
Phenothiazines, Phenothiazines,
anticonvulsants, anticonvulsants,
antidepressants, antidepressants,
methadonemethadone

5. Some Important Physiological Some Important Physiological
Changes in PregnancyChanges in Pregnancy

Cardiac: increased heart rate, decreased Cardiac: increased heart rate, decreased
blood pressure. CO increasesblood pressure. CO increases

Respiratory: rate increases, TV increases, Respiratory: rate increases, TV increases,
FRV decreases, pCO2 decreasesFRV decreases, pCO2 decreases

Heme: Volume increases, HCT drops, WBC Heme: Volume increases, HCT drops, WBC
increasesincreases

6. Drugs in Pregnancy: A, B, C, D, XDrugs in Pregnancy: A, B, C, D, X
Considered Safe in pregnancy: Considered Safe in pregnancy:
PCNPCN
CephalosporinsCephalosporins
Azithro/ErythromycinAzithro/Erythromycin
AcetaminophenAcetaminophen
NarcoticsNarcotics
HeparinHeparin
Asthma DrugsAsthma Drugs
Reglan (Metoclopramide)Reglan (Metoclopramide)
Immunizations derived from killed viruses Immunizations derived from killed viruses
(tetanus, diptheria, Hep. B, Rabies)(tetanus, diptheria, Hep. B, Rabies)

7. Radiation in PregnancyRadiation in Pregnancy

<5-10 rads = no significant risk of birth <5-10 rads = no significant risk of birth
defectsdefects

Beams aimed 10cm away from fetus pose Beams aimed 10cm away from fetus pose
no additional riskno additional risk

Initial trauma X-rays each deliver <1 radInitial trauma X-rays each deliver <1 rad

One never withholds necessary One never withholds necessary
radiography.radiography.

Use MRI or U/S if available.Use MRI or U/S if available.

8. Transvaginal Ultrasound Transvaginal Ultrasound
ImagesImages

9. Normal, non-pregnant uterus on Normal, non-pregnant uterus on
T/V U/ST/V U/S

10. The “Double-Ring” Sign or The “Double-Ring” Sign or
“Double Decidual” Sign of normal “Double Decidual” Sign of normal
early pregnancyearly pregnancy

11. Normal Pregnancy T/V Normal Pregnancy T/V
Ultrasound Showing Gestational Ultrasound Showing Gestational
and Yolk Sac. No fetus is seen. and Yolk Sac. No fetus is seen.
5w 2d5w 2d

12. 6w 1d T/V U/S showing yolk 6w 1d T/V U/S showing yolk
sacsac

13. Normal T/V U/S with embryo Normal T/V U/S with embryo
at 10w 3dat 10w 3d

14. Complications of Pregnancy – Complications of Pregnancy –
Vaginal BleedingVaginal Bleeding
11
stst
Trimester Causes: Trimester Causes:
1.1.EctopicEctopic
2.2.AbortionAbortion
3.3.Molar PregnancyMolar Pregnancy
4.4.Non-pregnancy RelatedNon-pregnancy Related
a. Infectiousa. Infectious
b. Traumab. Trauma
c. Neoplasmc. Neoplasm

15. The work-up is the same!The work-up is the same!

Pelvic ExamPelvic Exam

Beta HCGBeta HCG

Transvaginal ultrasoundTransvaginal ultrasound

RhRh

CBC, CMPCBC, CMP

PT/PTT/INRPT/PTT/INR

UAUA

17. Ectopic Pregnancy – A surgical Ectopic Pregnancy – A surgical
emergency of pregnancyemergency of pregnancy

The leading cause of first trimester The leading cause of first trimester
maternal death maternal death

Usually 5-8 weeks after LMPUsually 5-8 weeks after LMP

High Risk: History of ectopic, tubal High Risk: History of ectopic, tubal
surgery or sterilization procedure, surgery or sterilization procedure,
Known tubal scarring or pathology, Known tubal scarring or pathology,
Diethylstilbestrol exposure, IUD.Diethylstilbestrol exposure, IUD.

18. Signs/SymptomsSigns/Symptoms

Symptoms (in decreasing order of Symptoms (in decreasing order of
frequency): Abdominal pain, frequency): Abdominal pain,
amenorrhea, vaginal bleeding (50-80%), amenorrhea, vaginal bleeding (50-80%),
dizziness, pregnancy symptoms, urge to dizziness, pregnancy symptoms, urge to
defecate, passing tissuedefecate, passing tissue

Signs: Adnexal tenderness, abdominal Signs: Adnexal tenderness, abdominal
tenderness, adnexal mass, enlarged tenderness, adnexal mass, enlarged
uterus, orthostatic changes, feveruterus, orthostatic changes, fever

19. TestingTesting
Beta > 6000 mIU/ml + empty uterus on Beta > 6000 mIU/ml + empty uterus on
transtransabdominal abdominal ultrasoundultrasound
OROR
Beta > 1200 mIU/ml + empty uterus on Beta > 1200 mIU/ml + empty uterus on
transtransvaginal vaginal ultrasound =ultrasound =
Ectopic Pregnancy = LaparoscopyEctopic Pregnancy = Laparoscopy

20. Beta <6000 + empty uterus on Beta <6000 + empty uterus on
transabdominal ultrasoundtransabdominal ultrasound
OROR
Beta < 1200 + empty uterus on transvaginal Beta < 1200 + empty uterus on transvaginal
ultrasound = serial outpatient beta ultrasound = serial outpatient beta
measurements to ensure normal rise.measurements to ensure normal rise.
This only applies to stable patients and This only applies to stable patients and
should be done in consult with ob/gynshould be done in consult with ob/gyn

21. A heterotopic pregnancy (to A heterotopic pregnancy (to
compare normal vs. abnormal)compare normal vs. abnormal)

22. Ectopic PregnancyEctopic Pregnancy

23. 22
ndnd
Trimester Trimester

Causes are abortion and non-pregnancy Causes are abortion and non-pregnancy
causes. causes.

Work-up is the sameWork-up is the same

Management of threatened AB is the sameManagement of threatened AB is the same

If complete, may be D&C candidateIf complete, may be D&C candidate

If other types of AB, patient may undergo If other types of AB, patient may undergo
oxytocin induced labor as inpatient.oxytocin induced labor as inpatient.

24. 33
rdrd
Trimester (>28 weeks) Trimester (>28 weeks)
Placental AbruptionPlacental Abruption
Placenta separates from Placenta separates from
uterine walluterine wall
Painful dark or clotted bloodPainful dark or clotted blood
Risks: HTN, smoking, ETOH, Risks: HTN, smoking, ETOH,
cocaine, multiparity, cocaine, multiparity,
previous abruption, previous abruption,
trauma, mom > 40trauma, mom > 40
Management: U/S, Ob Management: U/S, Ob
consult, cardiac/fetal consult, cardiac/fetal
monitoring, IV, pre-op labs, monitoring, IV, pre-op labs,
delivery if possibledelivery if possible
Placenta PreviaPlacenta Previa
Placenta implants too lowPlacenta implants too low
Painless bright red bleedingPainless bright red bleeding
Risks: prior C-section, grand Risks: prior C-section, grand
multiparity, previous previa, multiparity, previous previa,
multiple gestations, multiple gestations,
multiple induced abortions, multiple induced abortions,
mom >40.mom >40.
Management: U/S, Ob consult, Management: U/S, Ob consult,
pre-op labs, pre-op labs, avoid pelvic avoid pelvic
exam, exam, c-sectionc-section

25. 33
rdrd
Trimester Bleeding cont’d Trimester Bleeding cont’d

Uterine Rupture: Can be seen in scarred Uterine Rupture: Can be seen in scarred
and unscarred uteri. (uteruses? and unscarred uteri. (uteruses?
uterata?)uterata?)

28. Complications of Pregnancy: Complications of Pregnancy:
TraumaTrauma
Key Concept: Although you have two Key Concept: Although you have two
patients, maternal circulation is to be patients, maternal circulation is to be
maintained at the expense of the fetus. maintained at the expense of the fetus.
Without mom, the baby will surely die.Without mom, the baby will surely die.
Mom should be kept in left lateral decubitusMom should be kept in left lateral decubitus
This is where knowing the physiologic This is where knowing the physiologic
changes of pregnancy becomes extremely changes of pregnancy becomes extremely
important ! Mom can lose up to 35% of her important ! Mom can lose up to 35% of her
blood volume before showing any signs of blood volume before showing any signs of
shock!shock!

29. ManagementManagement
Over 20 weeks: Goes to Ob for 4 hours of Over 20 weeks: Goes to Ob for 4 hours of
cardiotocographic monitoringcardiotocographic monitoring
All women with abdominal trauma get All women with abdominal trauma get
Rhogam (fetomaternal hemorrhage Rhogam (fetomaternal hemorrhage
present in 30% of these patients)present in 30% of these patients)
Kleihauer-Betke test: Used in women >12w Kleihauer-Betke test: Used in women >12w
to determine and quantify the amount of to determine and quantify the amount of
fetomaternal hemorrhage that occurredfetomaternal hemorrhage that occurred

30. Perimortem C-Section Perimortem C-Section

Fetus greater than 28weeks, maternal Fetus greater than 28weeks, maternal
death less than 15 minutes = death less than 15 minutes =
perimortem c-sectionperimortem c-section

31. Complications of Pregnancy: Complications of Pregnancy:
HypertensionHypertension

Can be chronic (meaning it began prior Can be chronic (meaning it began prior
to conception or began during to conception or began during
gestation and persists >6 weeks post-gestation and persists >6 weeks post-
partum) or gestational. partum) or gestational.

We care about this because HTN in We care about this because HTN in
pregnancy is associated with pre-pregnancy is associated with pre-
eclampsia, abruption, prematurity, eclampsia, abruption, prematurity,
IUGR and stillbirthIUGR and stillbirth

32. Pre-eclampsia: To be considered Pre-eclampsia: To be considered
in those >20wks with HTNin those >20wks with HTN
MildMild
SBP > 140 (or +20 from SBP > 140 (or +20 from
baseline. Or DBP >90 (or +10 baseline. Or DBP >90 (or +10
from baseline)from baseline)
Proteinuria .3g/24hProteinuria .3g/24h
+/- Edema+/- Edema
No OliguriaNo Oliguria
No Associated symptomsNo Associated symptoms
Normal labsNormal labs
No IUGRNo IUGR
SevereSevere
BP>160/90BP>160/90
Proteinuria >5g/24hProteinuria >5g/24h
Edema PresentEdema Present
OliguricOliguric
Associated symptoms (H/A, Associated symptoms (H/A,
visual symptoms, abdominal visual symptoms, abdominal
pain, pulm. edemapain, pulm. edema
Associated labs (dec. plts, inc. Associated labs (dec. plts, inc.
LFT, inc. bili, inc. creatinine, LFT, inc. bili, inc. creatinine,
increased uric acid)increased uric acid)
IUGR presentIUGR present
HELLP syndrome = very severe. HELLP syndrome = very severe.
Above +RUQ pain, n/v Above +RUQ pain, n/v

33. ManagementManagement

Isolated HTN requires a 24h urine and close Ob Isolated HTN requires a 24h urine and close Ob
f/uf/u

With other findings, admit, 24h urine, bed rest With other findings, admit, 24h urine, bed rest
and HTN management in consult with ob/gyn. and HTN management in consult with ob/gyn.

Hydralazine common though diazoxide, Hydralazine common though diazoxide,
labetalol, nifedipine and nitroprusside also usedlabetalol, nifedipine and nitroprusside also used

+/- Mag to prevent seizures+/- Mag to prevent seizures

34. Complications of Pregnancy: Complications of Pregnancy:
EclampsiaEclampsia

Preeclampsia +seizures or comaPreeclampsia +seizures or coma

May occur without proteinuria, may May occur without proteinuria, may
occur up to 10 days postpartumoccur up to 10 days postpartum

ICH is the major cause of maternal deathICH is the major cause of maternal death

Warning signs = H/A, visual changes, Warning signs = H/A, visual changes,
hyperreflexia, Abd. painhyperreflexia, Abd. pain

Tx = Delivery. Magnesium, Phenytoin or Tx = Delivery. Magnesium, Phenytoin or
Diazepam, Hydralazine or LabetalolDiazepam, Hydralazine or Labetalol

35. Complications of Pregnancy: Complications of Pregnancy:
UTI/PyeloUTI/Pyelo

Pregnant women more prone to UTI secondary Pregnant women more prone to UTI secondary
to physiologic changes of pregnancyto physiologic changes of pregnancy

Treat both symptomatic and asymptomatic Treat both symptomatic and asymptomatic
bacturia (untreated = up to 40% risk of bacturia (untreated = up to 40% risk of
progression to pyelo)progression to pyelo)

Culture urine, give 7 day courseCulture urine, give 7 day course

We admit pregnant women with pyelonephritis We admit pregnant women with pyelonephritis
because of its increased risk of of progressing to because of its increased risk of of progressing to
preterm labor or septic shock.preterm labor or septic shock.

36. Complications of Pregnancy: Complications of Pregnancy:
AppendicitisAppendicitis
Appendicitis is the most frequent surgical Appendicitis is the most frequent surgical
emergency of pregnancyemergency of pregnancy
Incidence is the same as non-pregnant Incidence is the same as non-pregnant
population but the complications are more population but the complications are more
frequent secondary to delayed diagnosisfrequent secondary to delayed diagnosis
Again, the physiologic changes of pregnancy Again, the physiologic changes of pregnancy
complicate the clinical picture (leukocytosis, complicate the clinical picture (leukocytosis,
displaced appendix)displaced appendix)
Picture mimics pyelo. When patients don’t Picture mimics pyelo. When patients don’t
improve with IV abx, the diagnosis is improve with IV abx, the diagnosis is
reconsidered.reconsidered.
Laparotomy is the preferred diagnostic Laparotomy is the preferred diagnostic
procedure. Ultrasound can usedprocedure. Ultrasound can used

38. ReferencesReferences
1. Preparing for the Written Board Exam in Emergency Medicine. 51. Preparing for the Written Board Exam in Emergency Medicine. 5
thth
ed. Vol 1. Rivers, Carol. pp 550-574 ed. Vol 1. Rivers, Carol. pp 550-574
2. learnobultrasound.com/3trimesterbleed.htm 2. learnobultrasound.com/3trimesterbleed.htm
3. www.smbs.buffalo.edu/emed/emed/ultrasound.html 3. www.smbs.buffalo.edu/emed/emed/ultrasound.html
4. Harwood &Nuss’ Clinical Practice of Emergency Medicine 44. Harwood &Nuss’ Clinical Practice of Emergency Medicine 4
thth
ed. Wolfson, Alan B Lippincott, Williams and ed. Wolfson, Alan B Lippincott, Williams and
Wilkins, Philadelphia, 2005. pp.496-497Wilkins, Philadelphia, 2005. pp.496-497
5. home.flash.net/~drrad/tf/122396.htm 5. home.flash.net/~drrad/tf/122396.htm
6. www.pwc-sii.com/Research/death/ribs.htm 6. www.pwc-sii.com/Research/death/ribs.htm
7. www.jaapa.com/.../article/130146/ 7. www.jaapa.com/.../article/130146/
8. www.advancedfertility.com/ultraso1.htm 8. www.advancedfertility.com/ultraso1.htm
9. Ma, John O. Emergency Ultrasound via access emergency medicine at http://0-9. Ma, John O. Emergency Ultrasound via access emergency medicine at http://0-
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