OBJeff Rundio D.O.

Arrowhead Regional Medical Center

1-8-14

Adapted from Intensive Review for the Emergency Medicine Qualifying Examination

Physiologic changes in pregnancy

Cardiovascular system Increased cardiac output

Blood volume increases Resting hear rate increases by 10-15bpm

SVR increases Decreased BP in 1st trimester

Diastolic falls more than systolic Left lateral decubitus positioning may relieve hypotension

Uterus places pressure on the IVC and decreases blood return to the heart

Physiologic changes in pregnancy

Respiratory system Increased tidal volume but decreased FRC because of

elevated diaphragm Minute ventilation increases this leads to respiratory

alkalosis However, RR remains mostly unchanged

Physiologic changes in pregnancy

Gastrointestinal system Gastric reflux is common secondary to delayed gastric

emptying, decreased lower esophageal sphincter tone and decreased intestinal motility

Increased risk of gallstones

Physiologic changes in pregnancy

Renal-metabolic system Increased kidney size, renal blood flow and GFR Increased peripheral resistance to insulin Compensatory metabolic acidosis (to counteract the

respiratory alkalosis) In addition to relative insulin resistance, pregnant women

are more prone to DKA

Physiologic changes in pregnancy

Hematopoietic system Hemoglobin decreases secondary to volume dilution Leukocyte count increases mildly although polymorph

leukocyte function is depressed beginning in the 2nd trimester

Coagulation factors and ESR increase

Diagnosis

B-hCG Serum levels double about every two days in normal early

Pregnancy Failure to double suggests ectopic or nonviable

pregnancy Levels peak in 2-3 months and plateaus at 4 months

Urine testing is sensitive at 20 mIU/mL and in serum at 10mIU/mL Can have false negative in dilute urine or early in

pregnancy

Diagnosis

Ultrasound in ED used to rule in an IUP not rule out an ectopic Transabdominal U/S

Gestational sac at 6 wks Yolk sac, fetal pole, fetal heart motion at 8 wks

Transvaginal U/S Gestational sac at 5 wks: hCG 1000 Yolk sac 6 wks :hCG 2500 Fetal pole and heartbeat 7 to 8 wks: hCG 5000-17000

Discriminatory zone: B-hCG level above which an IUP can confidently be expected to be apparent on US Transvaginal level is 1500 Transabdominal is 6000

After abortion B-hCG levels may take up to 2 months to return to negative

Complications of Pregnancy

Vaginal bleeding in pregnancy Abortion

Loss of pregnancy <20 wks or <500g About 30% of pregnancies abort spontaneously

Usually 2/2 chromosomal abnormalities Risk increases with increasing maternal age, toxin

exposure, smoking, ETOH, cocaine), multiparous women, endocrine and autoimmune disorders

Complications in Pregnancy

Types of abortions Threatened ab: vaginal bleeding with closed os Inevitable ab: vaginal bleeding with open os Incomplete ab: passage of parts of POC Complete ab: passage of all fetal tissue Missed ab: fetal death <20wks without passage of fetal

tissue

Complications in Pregnancy

Management of abortions Threatened ab: DC with close follow up Incomplete ab: Uterine evacuation Complete ab: DC with close follow up Missed ab: D&C if infection or POC > 4wks otherwise, DC

with close follow up RhoGAM for all Rh-neg women

Must be given within 72hrs of fetal blood exposure Dose 50mcg if <12wks Otherwise 300mcg

Ectopic Pregnancy

Extra uterine implantation of pregnancy

Risk factors PID Tubal surgery Prior ectopic IUD In vitro fertilization

Ectopic Pregnancy

Signs and symptoms Classic triad of vaginal bleeding, abdominal pain and

pregnant/amenorrhea May have a relative bradycardia 2/2 vagal effects May have no vaginal bleeding May have a normal pelvic exam

Ectopic Pregnancy

Diagnosis hCG

Levels will likely decrease or not rise normally US findings suggestive of ectopic

Ectoopic fetal heart beat Free fluid and absent IUP Adenxal mass and absent IUP

US should be done despite low hCG levels

Ectopic Pregnancy

Management Surgical Medical

methotrexate

Abruptio placentae

Separation of the placenta from the uterine wall

Signs and symptoms PAINFUL vaginal bleeding

But bleeding not always present Uterine tenderness Uterine contractions Rising fundus (indicates active bleeding) Fetal distress

Abruptio placentae

Diagnosis Based on clinical suspicion US not great because blood and placenta look similar 50% will have coagulopathy on labs

Management IV fluids FFP as needed Emergent OB consult Emergent delivery if fetus or mother in distress

Placenta Previa

Implantation of placenta over cervical os

Signs and symptoms PAINLESS bright red vaginal bleeding

Diagnosis Transvaginal US Never perform digital or speculum exam if suspected

Management Stabilize mother Fetal monitoring Emergent OB consult

How was Chuck Norris Born?

How was Chuck Norris Born?

Uterine Rupture

Becoming more common 2/2 VBAC still less than 1%

Sudden pain and termination of contractions, tearing sensation, vaginal bleeding

Management, C-section

Preeclampsia

Hypertension (sbp >140) and proteinuria >20 wks gestation +/- pedal edema

Headache, visual changes, edema and/or abdominal pain

May occur up to 6 weeks partum

Becomes eclampsia when seizures occur Management mag sulfate 4 to 6 grams Follow DTRs

Postpartum Complications

Retained POC May cause post partum bleeding If causes infection, leads to pain, fever and discharge

Diagnosis Clinical suspicion and diagnosis US

Management Supportive Removal of POC by D&C

Endometritis

Inflammation of the uterine endometrium Acute endometritis caused by S. aureus or Strep infections

Develop fever, foul smelling discharge, abdominal pain

Diagnosis by Clinical suspicion, obtain US to r/o retained POC

Management Supportive IV ABX

Clindamycin and Aminoglycoside or 2nd or 3rd generation cephalosporin

Mastitis

Inflammation of mammary gland

Must distinguish cellulitis from abscess

Management Anti-staph PCN (dicloxacillin) Cephlasporin Warm compresses Continue nursing

Medications in pregnancy

Tylenol is safe

ABX Sulfonamides: near term, may cause kernicterus Aminoglycocide: ototoxicity and renal tox Tetracyline: maternal- liver disease. Fetus- yellow discoloration

of teeth and other congenital defects Quinolones: musculoskeletal dysfunction (tendons) Fluconazole: craniofacial bone abnormalities

Antihistamines are safe except for meclizine in 1st trimester

Oral hypoglycemics are unsafe, but insulin is safe

The END