pregnancy complications - whitney lewis
TRANSCRIPT
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%
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
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
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
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
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
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%
DDx 3rd Trimester Hemorrhage
3rd Trimester Hemorrhage
PAINLESS
Placenta Previa
Vasa Previa
PAINFUL
Placental Abruption
Uterine Rupture
Labor
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
Uterine rupture
Rare (prior c/s, trauma, HTN)
Physical examination:
VB
SEVERE ABDOMINAL PAIN
Loss of fetal station
Uterine defect
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
ED Delivery
ABCs, IV, O2, monitor
HPI: G&P's, prenatal care, complications
Precipitous delivery kit and Peds cart
OB and NICU consults
Postpartum Hemorrhage (PPH)
SVD >500 mL
IVx2, O2, monitor
Labs: CBC, CMP, coags, T&S, FDP, fibrinogen
IVF 1-2L LR, PRBCs/MTP
Tone: Uterine Atony
80% PPH
Boggy uterus
Management:
Bimanual uterine massage
DOC Oxytocin 20U in 1L @ 10mL/min
Tissue
Examine placenta
Management:
Manually explore uterus
Uterine packing or balloon tamponade
OR for exploration vs. IR embolization
Thrombin
Coagulation disorders:
Hereditary
DIC, HELLP
Management:
Replace PRBCs, platelets, FFP, Cryo, Factors VIIa, VIII or IX
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
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
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
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
Critical Care in the Pregnant Patient
Intubation:
Dec FRV 25%
Increased risk aspiration
Respiratory alkalosis
Chest tubes:
Diaphragm 4cm higher
3rd or 4th ICS
Management of Abdominal Trauma
in Pregnancy
2o Survey:
Head to toe exam
Speculum exam
Fetal monitoring
OB and Trauma surgery consults
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
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
References: pictures
community. babycenter.com
community.freescale.com
http://http://en.wikipedia.org/wiki/Coagulation#mediaviewer/File:Coagulation_full.svg
www.brooksidepress.org/Products/Obstetric_and_Newborn_Care_1/lesson_5_Section_1.htm
http://radiology.med.miami.edu/documents/2009Lungs.pdf
http://accessmedicine.mhmedical.com.foyer.swmed.edu/ViewLarge.aspx?figid=39621558
http://accessmedicine.mhmedical.com.foyer.swmed.edu/content.aspx?bookid=351§ionid=39619709
http://thedefinitionofnerd.blogspot.com/2013/08/life-matters-true-blood-pros-and-cons.html
www.theamericanmama.com
www.webmd.boots.com
http://accessmedicine.mhmedical.com.foyer.swmed.edu/book.aspx?bookid=351
www.merkmanuals.com
http://mdcurrent.in/primary-care/practical-advice-on-preventing-maternal-death-due-to-postpartum-hemorrhage/
www.medpagetoday.com
http://www.trauma.org/archive/thoracic/CHESTdrain.html
www.wisegeek.com
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.