Transcript Pregnancy Complications (C FW 06)12

Pregnancy Complications…
DR.WASEEM AHMED ABUJAMEA
ER CONSULTANT
SBEM ,ABEM
Program director SBEM
ED DEPUTY Chairman
Abnormal Vaginal Bleeding
(Non-Pregnant)
• Non-uterine:
Cervix, vagina, urinary, Gl, coagulation
disorders
• Ovulatory: Menorrhagia (heavy bleeding),
metrorrhagia (outside cycle); polyps, tumors,
cancer, infection, fibroids, endometriosis, dyscrasias
• Anovulatory (DUB): Prolonged amenorrhea with
intermittent menorrhagia; endocrine disorders,
OCPs, liver/renal diseases, polycystic ovary,
extremes of reproductive age, eating disorders.
Treatment: OCP, NSAIDs or D&C
• Peri- & postmenopausal: Cancer should be
considered
ON Definition
Any vaginal bleeding before 20
wks period of gestation is
A
defined as early pregnancy
bleeding
Related to pregnant state
Related to pregnant state

Abortion

Ectopic pregnancy
abortion
Molar pregnancy
ectopic

Vesicular
mole
Ectopic Pregnancy
Ectopic Pregnancy

Any pregnancy that occurs outside of the
uterine cavity

Tubal






Ampulla (55%)
Isthmus (25%)
Fimbria (17%)
Cervical
Ovarian
Abdominal
97%
3%
Ectopic Pregnacy

1.9% of reported pregnancies

Leading cause of pregnancy-related
death in the first trimester
Ruptured ectopic pregnancy accounts
for 10-15% of all maternal deaths

Ectopic Pregnancy
Risk Factors
 Previous tubal surgery
 Previous ectopic pregnancy
 In utero DES exposure





diethylstilbestrol (used until 1971;
miscarriage & premature delivery)
Previous genital infections
Infertility
Current smoking
Previous IUD use
HIGH
Ectopic Pregnancy
Most common presentation:
 Woman of reproductive age
 Abdominal pain
 Vaginal bleeding

Approx 7 weeks after amenorrhea
*Nonspecific… DDx is important
Ectopic Pregnancy
Differential Diagnosis
 Acute appendicitis
 Miscarriage
 Ovarian torsion
 Pelvic inflammatory disease
 Ruptured corpus luteum cyst or follicle
 Tubo-ovarian abcess
 Urinary calculi
Ectopic Pregnancy
Exam Findings
 Normal or slightly enlarged uterus
 Vaginal bleeding
 Pelvic pain with manipulation of the
cervix
 Palpable adnexal mass (fallopian tube)
Ectopic Pregnancy
Suspect Rupture…
 Significant abdominal tenderness
*Especially if accompanied by:
 Hypotension
 Abdominal guarding
 Rebound tenderness
Ectopic Pregnancy
Diagnositc Tests
 Ultrasound (*test of choice)


bHCG


Do not increase appropriately
Urine pregnancy test


No intrauterine gestational sac
Pregnant / not pregnant
Progesterone level (less reliable)
Ectopic Pregnancy
Treatment
 Expectant management


Monitor progress
Medical treatment

Methotrexate – folic acid antagonist


Disrupts rapidly dividing trophoblastic cells
Surgery

Laparoscopy with salpingostomy, without
fallopian tube removal
Ectopic Pregnancy

~30% have later difficulty conceiving


No difference between treatment options
5-20% rate of recurrence

32% risk of recurrence if she’s had 2
consecutive ectopic pregnancies
Spontaneous Abortion
Spontaneous Abortion
aka “miscarriage”, “spontaneous pregnacy
loss”, “early pregnancy failure”

Pregnancy loss at less than 20 weeks’
gestation
Definitions

Threatened abortion


A pregnancy complicated by bleeding before 20
weeks’ gestation Os is closed.
Inevitable abortion

The cervix has dilated, but the products of
conception have not been expelled
Definitions

Complete abortion


Incomplete abortion


All products of conception have been passed
without need for surgical or medical intervention
Some, but not all, of the products of conception
have been passed; retained products may be
part of the fetus, placenta, or membranes
Missed abortion

A pregnancy in which there is a fetal demise
(usually for a number of weeks) but no uterine
activity to expel the products of conception
Definitions

Septic abortion


A spontaneous abortion that is complicated by
intrauterine infection
Recurrent spontaneous abortion

Three (3) or more consecutive pregnancy losses
Spontaneous Abortion
Etiology and Risk Factors
 Chromosomal abnormality

49% of spontaneous abortions
*most are random events
NOTE:

Stress
Do NOT increase risk

Sexual activity
Spontaneous Abortion
Risk Factors





Advanced maternal age
Alcohol use
Anesthetic gas use
(nitrous oxide)
Caffeine use (heavy)
Chronic maternal diseases

poorly controlled diabetes
celiac disease
autoimmune diseases







Cigarette smoking
Cocaine use
Conception within 3-6
months after delivery

IUD use
Maternal infections







Bacterial vaginosis
TORCH
STD’s
Medications
Multiple previous elective
abortions
Previous spontaneaous
abortions
Toxins
Uterine abnormalities
Spontaneous Abortion

Up to 20% of recognized pregnancies

~30% actual miscarriage rate


Often mistaken for late onset of menses
~50% of pregnancies complicated by
bleeding before 20 weeks’ gestation
will end in spontaneous abortion

DDx?
Differential Diagnosis:
First Trimester Vaginal Bleeding







Idiopathic bleeding in a viable pregnancy
Ectopic pregnancy
Molar pregnancy
Spontaneous abortion
Subchorionic hemorrhage
Infection of the vagina or cervix
Cervical abnormalities


Malignancy, polyps, trauma
Vaginal trauma
Spontaneous Abortion
Diagnosis
 HCG levels
 Progesterone levels
 Ultrasound



labs
Status of the pregnancy
Intrauterine? Ectopic?
Exam: dilated cervix ~> inevitable abortion
*the risk for spontaneous abortion decreases from 50% to 3%
when a fetal heartbeat is identified on ultrasound
Abortion? or not?
Progesterone
HCG
Increases
>25 ng per mL
(48 hours)
Ultrasound Abortion?
Normal
Plateau or Nonviable
<5 ng per mL
decrease pregnancy
No
Yes
Spontaneous Abortion
Management
 Surgical evacuation (D&C)

Patient is unstable




Patient choice
Medical therapy


Heavy bleeding
Septic abortion
Missed spontaneous abortion
Expectant management


Completed spontaneous abortion
Incomplete spontaneous abortion

No need for surgical intervention 80-95% of the time
Spontaneous Abortion
Considerations…



Feelings of guilt
Grieving process
Anxiety & depression
counseling
Spontaneous Abortion - Tips








Acknowledge and attempt to dispel guilt
Acknowledge and legitimize grief
Assess level of grief and adjust counseling
accordingly
Counsel how to tell family and friends of the
miscarriage
Include the patient’s partner in psychologic care
Provide comfort, empathy, and ongoing support
Reassure about the future
Warn about the “anniversary phenomenon”
Hydatidiform Mole
Hydatidiform Mole
Complete/Classic Mole
 No identifiable fetal tissue
Partial Mole
 Some recognizable fetal
or embryonic tissue
Hydatidiform Moles

1/1000-1500 pregnancies
Risk factors
 Teenagers
 Women over 35 (35+: 2x risk, 40+: 7x risk)
 Previous miscarriage
*Only 1% of subsequent conceptions result
in another molar pregnancy
Complete Hydatidiform Mole
Signs & Symptoms
 Vaginal bleeding
(97%)
*most common presenting symptom

Hyperemesis


Hyperthyroidism



due to elevated HCG
(7%)
may present with tachycardia, tremor, warm skin
Preeclampsia
(27%)
Large for date uterus
Incomplete Hydatidiform Mole
Signs & Symptoms
(similar to incomplete or missed abortion)
 Vaginal bleeding
 Absence of fetal heart tones

Uterine enlargement and preeclampsia


only 3% of patients
Hyperemesis and hyperthyroidism are rare
Hydatidiform Mole
Diagnosis
 Ultrasound


vesicular / “snowstorm”
pattern
HCG levels

Elevated compared to a normal
pregnancy of similar gestational age
www.obgyn.net/us/ _uploads/hmole2.jpg
Hydatidiform Mole
Differential Diagnosis
 Painless vaginal bleeding:


Placenta previa
Missed abortion
Key differential?
Absence of identifiable fetal parts on
ultrasound
Hydatidiform Mole
Treatment
 Evacuation and curettage OR
 Hysterectomy
Must consider:
 Age of the patient
 Desire to preserve fertility
Hydatidiform Mole

Potential precursor to gestational trophoblastic
disease and choriocarcinoma



20% develop a malignancy
metastasis occurs in 4% of complete moles
Choriocarcinoma may metastasize to:





Lungs
Vagina
Brain
Liver
Kidney
Hydatidiform Mole
Follow-up
 bHCG* tested regularly


monthly for 6-12 months
*any rise in levels should prompt a chest
radiograph and pelvic examination
Contraception


must be used during the entire follow-up period
at least 1 year
Placenta Previa
Ko P, Yoon Y. Placenta Previa. eMedicine. Retrieved 5
February 2006 from www.emedicine.com/emerg/topic427.htm
Placenta Previa

Implantation of the placenta over or
near the internal os of the cervix


Vaginal bleeding in the 2nd and 3rd
trimesters
5/1,000 deliveries

Maternal mortality rate of 0.03%
Placenta Previa

Total placenta previa


internal os is completely covered by the placenta
Partial placenta previa

internal os is partially covered by the placenta


Marginal placenta previa


self-correct? uterus enlarges, placental site moves cephalad
placenta is at the margin of the internal os
Low-lying placenta previa


placenta is implanted in the lower uterine segment
edge of the placenta is near the internal os but does
not reach it
Placenta Previa
Risk Factors







Prior previa
Multiparity
Multiple gestations
Advanced maternal age
Previous cesarean delivery
Prior induced abortion
Smoking
Placenta Previa
History

Vaginal bleeding
 Bright red and
painless (recurrent)
 Occurs on average
at 27-32 weeks'
gestation
 Contractions may
or may not occur
simultaneously with
the bleeding
Exam Findings





Profuse hemorrhage
Hypotension
Tachycardia
Soft and nontender
uterus
Normal fetal heart
tones (usually)
Placenta Previa
Differentials








Abruptio Placenta
Disseminated Intravascular Coagulation
Pregnancy, Delivery
Vasa previa
Infection
Vaginal bleeding
Lower genital tract lesions
Bloody show
Placenta Previa
Diagnosis

Ultrasound
Management

<37 weeks without hemorrhage


expectant management
Hemorrhage or >37 weeks and in labor

delivery


C-section
trial of labor may be considered for anterior marginal previa
Abruptio Placentae
Gaufberg SV. Abruptio Placentae. eMedicine. Retrieved 5
February 2006 from www.emedicine.com/emerg/topic12.htm
Abruptio Placentae

Separation of the normally located placenta
after the 20th week of gestation (prior to
birth)

1% of all pregnancies

Compromised blood supply to the fetus

Severity of fetal distress correlates with the
degree of placental separation
Abruptio Placentae
Clinical presentation






Vaginal bleeding (80%)
Abdominal or back pain and uterine
tenderness (70%)
Fetal distress (60%)
Abnormal uterine contractions (35%)
Idiopathic premature labor (25%)
Fetal death (15%)
Abruptio Placentae
Diagnosis
 Severe uterine pain and tenderness with
mild vaginal bleeding in a patient with
hypertension (HTN) indicates placental
abruption

Difficult to identify on ultrasound

Can help differentiate from other causes of
bleeding (i.e placenta previa)
Abruptio Placentae (Class 0-3)
Class 0


Asymptomatic
Diagnosis is made retrospectively

organized blood clot or a depressed area on
a delivered placenta
Abruptio Placentae (Class 0-3)
Class 1



Mild
~48% of all cases
Characteristics :





No vaginal bleeding to mild vaginal bleeding
Slightly tender uterus
Normal maternal BP and heart rate
No coagulopathy
No fetal distress
Abruptio Placentae (Class 0-3)
Class 2



Moderate
~27% of all cases
Characteristics:





Vaginal bleeding: none to moderate
Moderate-to-severe uterine tenderness with
possible tetanic contractions
Maternal tachycardia with orthostatic changes in
BP and heart rate
Fetal distress
Hypofibrinogenemia (ie, 50-250 mg/dL)
Abruptio Placentae (Class 0-3)
Class 3



Severe
~24% of all cases
Characteristics:






vaginal bleeding: none to heavy
Very painful tetanic uterus
Maternal shock
Hypofibrinogenemia (ie, <150 mg/dL)
Coagulopathy
Fetal death
Abruptio Placentae
Causes


Maternal hypertension (44%)
Maternal trauma (1.5-9.4%)









MVA, assaults, falls
Cigarette smoking
Alcohol consumption
Cocaine use
Short umbilical cord
Advanced maternal age
Retroplacental fibromyoma
Sudden decompression of
the uterus

Retroplacental bleeding
from needle puncture


premature rupture of
membranes, delivery of
first twin
postamniocentesis
Idiopathic

probable abnormalities of
uterine blood vessels and
decidua
Abruptio Placentae
Maternal complications





Hemorrhagic shock
Coagulopathy/DIC
Uterine rupture
Renal failure
Ischemic necrosis of
distal organs
(eg, hepatic, adrenal,
pituitary)
Fetal complications





Hypoxia
Anemia
Growth retardation
CNS anomalies
Fetal death
Preeclampsia - Eclampsia
Morrison EH. Common Peripartum Emergencies. Am
Fam Physician 1998; 58(7). Retrieved 16 November
2005 from www.aafp.org/afp/981101ap/morrison.html.
Wagner LK. Diagnosis and Management of
Preeclampsia. Am Fam Physician 2004; 70(12):231724.
Preeclampsia
Defined as a “pregnancy-specific
multisystem disorder of unknown
etiology.”

New onset of elevated blood pressure
and proteinuria after 20 weeks’
gestation
Preeclampsia

Affects 5-7% of pregnancies
Increased risk of:
 Placental abruption
 Acute renal failure
 Cerebrovascular/cardiovascular complications
 Disseminated intravascular coagulation
 Maternal death
Preeclampsia

3rd leading cause of pregnancy-related
deaths
Maternal death due to:
 Cerebrovascular events
 Renal or hepatic failure
 HELLP syndrome
 Complications of hypertension
Preeclampsia
Risk Factors
1. Pregnancy-associated
2. Maternal-specific
3. Paternal-specific
Preeclampsia Risk Factors
1. Pregnancy-associated
 Chromosomal abnormalities
 Hydatidiform mole
 Hydrops fetalis
 Multifetal pregnancy
 Structural congenital anomalies
 Urinary tract infection
Preeclampsia Risk Factors
2. Maternal-specific
 Age >35 years
 Age <20 years
 Black
 Family history of
preeclampsia
 Nulliparity
 Preeclampsia in a
previous pregnancy

Medical conditions:






Gestational diabetes
Type I diabetes
Obesity
Chronic hypertension
Renal disease
Stress
Preeclampsia Risk Factors
3. Paternal-specific
 First-time father
 Previously fathered a preeclamptic
pregnancy (in another woman)
Preeclampsia
Diagnosis
 Blood pressure: 140 mmHg or higher
systolic or 90 mmHg or higher diastolic
*Previously normal blood pressure

Proteinuria: 0.3 g or more of protein in
a 24 hr urine collection
Severe Preeclampsia
Diagnosis
 Blood pressure: 160 mmHg or higher systolic or
110 mmHg or higher diastolic

Proteinuria: 5g or more of protein in a 24 hr urine
collection

Other:



Oliguria
Cerebral or visual
disturbances
Pulmonary edema
or cyanosis




Epigastric or R upper
quadrant pain
Impaired liver function
Thrombocytopenia
Intrauterine growth
restriction
Hypertensive Disorders of
Pregnancy
Pregnant woman with blood pressure
higher than 140/90 mmHG
Before 20 weeks’ gestation
After 20 weeks’ gestation
No or stable proteinuria
New or increased proteinuria,
development of increasing BP,
or HELLP syndrome
Proteinuria
No proteinuria
Chronic hypertension
Preeclampsia superimposed
on chronic hypertension
Preeclampsia
Gestational hypertension
Wagner LK. Diagnosis and Management of
Preeclampsia. Am Fam Physician 2004; 70(12):2317-24.
25%
Preeclampsia
Clinical Presentation
Asymptomatic
Severe Preeclampsia
 Visual disturbances
 Severe headache
 Upper abdominal
pain
HELLP
Preeclampsia – HELLP Syndrome





Hemolysis
Elevated Liver enzymes
Low Platelet count
4-14% of women with preeclampsia
Mortality or serious morbidity: 25%
Preeclampsia
History
“Pregnant women should be asked about
specific symptoms, including visual
disturbances, persistent headaches,
epigastric or R upper quadrant pain, and
increased edema.”
Preeclampsia
Examination
 Blood pressure
 Fundal height

Growth retardation? Oligohydramnios?
NOTE
 Increasing maternal
facial edema
 Rapid weight gain
Fluid retention is
often associated
with preeclampsia
Preeclampsia
Medical Management
 Antihypertensive drug therapy*


160-180/105-110 or higher
*many are contraindicated for use during
pregnancy…
Magnesium sulfate

During labor to prevent seizures
Preeclampsia
Treatment
If preterm…



Observed on an outpatient basis
Hospitalized
Delivery

Vaginal delivery is preferred

Avoid added physiological stress of C-section
Indications for Delivery
Fetus
 Severe intrauterine
growth retardation
 Nonreassuring fetal
surveillance
 Oligohydramnios
Mother
 Gestational age 38
weeks or greater
 Low platelet count
Mother (cont’d)
 Deterioration of
hepatic or renal
function
 Suspected placental
abruption
 Persistent severe HA,
visual changes
 Persistent severe
epigastric pain,
nausea, or vomiting
 Eclamspia
Preeclampsia
Risk of recurrence
Nulliparous
Multiparous
may be as high as 40%
even higher
Eclampsia
Severe complication of preeclampsia
 New onset of seizures in a woman with
preeclampsia

Affects .05 to .3% of pregnancies
(developed countries)


Mortality rate: 2%
Serious complications: up to 35%
Eclampsia
Clinical course is usually gradual BUT…

20% do not have classic preeclamptic
triad (or only mild)
Eclampsia
Treatment
 Magnesium sulfate


Antihypertensive agents


Controls seizures
Decrease risk of maternal intracranial
hemorrhage without jeopardizing uterine blood
flow
As soon as the mother is stable…deliver the
baby
Preterm Labor
Von Der Pool BA. Preterm labor: diagnosis and
treatment. Am Fam Physician. 1998 May
15;57(10):2457-64.
Weismiller DG. Preterm Labor. Am Fam Physician.
1999 Feb 1;59(3):593-602.
Preterm Labor

Cervical effacement and/or dilatation and
increased uterine irritability before 37 weeks
of gestation

Affects 8-10% of births in the US


Rate may be worsening but survival rates have
increased and morbidity has decreased
Still remains a leading cause of perinatal
morbidity and mortality in the US
Risk Factors







Previous preterm delivery (greatest risk)
Low socioeconomic status
Non-white race
Maternal age <18 years or >40 years
Preterm premature rupture of the
membranes (PPROM)
Multiple gestation
Maternal history of one or more
spontaneous second-trimester abortions
Risk Factors (cont’d)


Maternal complications

Smoking

Illicit drug use

Alcohol use

Lack of prenatal care
Uterine causes

Myomata

Uterine septum

Bicornuate uterus

Cervical
incompetence

Exposure to
diethylstilbestrol




Infectious causes

Chorioamnionitis

Bacterial vaginosis

Acute pyelonephritis
Fetal causes

Intrauterine fetal
death

Intrauterine growth
retardation

Congenital
anomalies
Abnormal placentation
Presence of a retained
intrauterine device
Preterm Labor
Predicting preterm labor…
 Monitor cervical change, uterine
contractions, bleeding, and changes in
fetal behavioral states ?


High false positive rate
Unnecessary and potentially hazardous
treatment
Preterm Labor
Management

Tocolytic therapy



Corticosteroid therapy



Enhance pulmonary maturity
Reduce severity of fetal RDS and intraventricular
hemorrhage
Antibiotic Therapy


Inhibit labor, slow down or halt the contractions of the
uterus
Delay delivery; time to administer corticosteroid therapy
Women with PPROM sustain the pregnancy longer
Bed rest(?)

No conclusive studies documenting its benefit
Higher-risk Pregnancies*


Gestational diabetes
Hypertension
*Cannot be managed the same way as
low-risk post-term pregnancies
Mcq

The definition of bleeding in early
pregnancy include
A.
Any bleeding at any duration of pregnancy
Bleeding after 20 wks
Bleeding before 20 wks
All of the above
B.
C.
D.
Young patient newly married came in
with lower abdominal pain , the first
step in ED?
A.
B.
C.
D.
To do abdominal xray
To do urinary pregnancy test to R/O
possibility of ectopic pregnancy
To discharge patient with the pain
killer
To do ultrasound
Which of the following statements best
describes pregnancy-induced hypertension
(PIH)?
A.
B.
C.
D.
E.
Defined by blood pressure greater than
120/80
Eclamptic seizures do not occur postpartum
Greatest risk in women older than 20 years
of age
Proteinuria is always present
Severe form is characterized by hemolysis,
elevated liver enzymes and low platelets
Which of the following statements is the
most accurate regarding placenta previa?
A.
B.
C.
D.
E.
Most cases identified in the second trimester go on
to spontaneous miscarriage.
Uterine contractions and pain are hallmarks of
placenta previa.
Prolonged passage of dark vaginal blood is
characteristic of placenta previa.
Sonography is not a sensitive diagnostic procedure.
Digital probing of the cervix should be avoided in
the second half of pregnancy.