Post on 22-Nov-2014
description
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