Pregnancy Complications… DR.WASEEM AHMED ABUJAMEA ER CONSULTANT SBEM,ABEM Program director SBEM ED...

Pregnancy Complications…

DR.WASEEM AHMED ABUJAMEAER CONSULTANTSBEM ,ABEM

Program director SBEMED 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 withintermittent 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 beconsidered

ON

A

Any vaginal bleeding before 20 wks period of gestation is defined as early pregnancy bleeding

Definition

Related to pregnant state

Abortion

Ectopic pregnancy

Molar pregnancy

Related to pregnant stateRelated to pregnant state

Ectopic Pregnancy

Ectopic Pregnancy

Any pregnancy that occurs outside of the uterine cavity

Tubal Ampulla (55%) Isthmus (25%) Fimbria (17%)

Cervical Ovarian Abdominal

3%

97%

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)

No intrauterine gestational sac bHCG

Do not increase appropriately Urine pregnancy test

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

All products of conception have been passed without need for surgical or medical intervention

Incomplete abortion 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

Sexual activityDo NOT increase risk

Spontaneous Abortion

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

Risk Factors

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

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

labs

Abortion? or not?

Progesterone HCG Ultrasound Abortion?

>25 ng per mLIncreases (48 hours)

Normal No

<5 ng per mLPlateau or decrease

Nonviable pregnancy

Yes

Spontaneous AbortionManagement Surgical evacuation (D&C)

Patient is unstable Heavy bleeding Septic abortion

Patient choice Medical therapy

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

due to elevated HCG Hyperthyroidism (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

self-correct? uterus enlarges, placental site moves cephalad

Marginal placenta previa 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 premature rupture of

membranes, delivery of first twin

Retroplacental bleeding from needle puncture 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):2317-24.

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 proteinuriaNew or increased proteinuria,

development of increasing BP, or HELLP syndrome

Proteinuria No proteinuria

Chronic hypertensionPreeclampsia superimposed

on chronic hypertensionPreeclampsia Gestational hypertension

25%Wagner LK. Diagnosis and Management of Preeclampsia. Am Fam Physician 2004; 70(12):2317-24.

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 may be as high as 40%

Multiparous 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

Controls seizures Antihypertensive agents

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

Inhibit labor, slow down or halt the contractions of the uterus

Delay delivery; time to administer corticosteroid therapy Corticosteroid therapy

Enhance pulmonary maturity Reduce severity of fetal RDS and intraventricular

hemorrhage Antibiotic 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

B. Bleeding after 20 wks

C. Bleeding before 20 wks

D. All of the above

Young patient newly married came in with lower abdominal pain , the first step in ED?

A. To do abdominal xray

B. To do urinary pregnancy test to R/O possibility of ectopic pregnancy

C. To discharge patient with the pain killer

D. To do ultrasound

Which of the following statements best describes pregnancy-induced hypertension (PIH)?

A. Defined by blood pressure greater than 120/80

B. Eclamptic seizures do not occur postpartum

C. Greatest risk in women older than 20 years of age

D. Proteinuria is always present

E. 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. Most cases identified in the second trimester go on to spontaneous miscarriage.

B. Uterine contractions and pain are hallmarks of placenta previa.

C. Prolonged passage of dark vaginal blood is characteristic of placenta previa.

D. Sonography is not a sensitive diagnostic procedure.

E. Digital probing of the cervix should be avoided in the second half of pregnancy.