Dr. Jesus Seda MD PGY-3 A 24-year-old woman presents in cardiac arrest after being hit by a car as she crossed a street. She is pregnant; the uterine fundus is 8 cm above the umbilicus. Paramedics performed CPR en-route With no return of pulses. Fetal heart tones are still present. The decision is made to perform a perimortem cesarean delivery in an attempt to save the fetus. Which of the following statements regarding this procedure is correct? A. A low, horizontal incision should be made with careful attention to avoid injuring the bladder B. CPR should be discontinued C. If present, the anterior placenta should be incised to improve access D. The height of the uterine fundus is not related to predicted outcome 2 A 24-year-old woman presents in cardiac arrest after being hit by a car as she crossed a street. She is pregnant; the uterine fundus is 8 cm above the umbilicus. Paramedics performed CPR en-route With no return of pulses. Fetal heart tones are still present. The decision is made to perform a perimortem cesarean delivery in an attempt to save the fetus. Which of the following statements regarding this procedure is correct? A. A low, horizontal incision should be made with careful attention to avoid injuring the bladder B. CPR should be discontinued C. If present, the anterior placenta should be incised to improve access D. The height of the uterine fundus is not related to predicted outcome 3 4 A 33-year-old woman at 30 weeks' gestation is brought in by ambulance for severe chest pain. While in the emergency department, she becomes pulseless, and ventricular fibrillation is noted on the cardiac monitor. Chest compressions are started, and defibrillation is attempted twice without success. After 5 minutes of resuscitation efforts, there is still no maternal pulse. What is the next best step in management? A. Administer magnesium B. Intubate the patient C. Perform perimortem cesarean delivery D. Perform thoracotomy 5 A 33-year-old woman at 30 weeks' gestation is brought in by ambulance for severe chest pain. While in the emergency department, she becomes pulseless, and ventricular fibrillation is noted on the cardiac monitor. Chest compressions are started, and defibrillation is attempted twice without success. After 5 minutes of resuscitation efforts, there is still no maternal pulse. What is the next best step in management? A. Administer magnesium B. Intubate the patient C. Perform perimortem cesarean delivery D. Perform thoracotomy 6 7 CPR is essential for optimal fetal flow Positioning: Left lateral decubitus is not practical, so put towels under the patients right side in order to tilt the patient 20 30 towards the left Have a dedicated team member manually displace the uterus to the left side and superior Defibrillation is safe for the fetus and should be used for witnessed arrest Epinephrine (although it decreases uteroplacental circulation) can be used Thrombolysis has only been reported in case reports so decision must be individualized Emergency C section (during cardiac arrest) must considered early and completed within 5 min of arrest; 4 minute rule Procedure: While CPR is ongoing, do vertical incision through all the abdominal wall layers from epigastrium to pubic symphysis Perforate uterus at fundus and extend incision vertically down with scissors by inserting 2 fingers in the uterine cavity to separate it from the fetus Deliver the fetus, then hold the baby below the mother, clamp the cord and cut it. 8 A 26-year-old woman who is 6 months pregnant presents with diffuse abdominal pain and mild vaginal bleeding of 2 days duration. She says that she is lightheaded and fatigued; she reports decreased fetal movement but no chest pain or shortness of breath. Vital signs reveal hypotension and tachycardia. What diagnosis should be considered in the workup? A. Early labor B. Placental abruption C. Pre-eclampsia D. Urinary tract infection 9 A 26-year-old woman who is 6 months pregnant presents with diffuse abdominal pain and mild vaginal bleeding of 2 days duration. She says that she is lightheaded and fatigued; she reports decreased fetal movement but no chest pain or shortness of breath. Vital signs reveal hypotension and tachycardia. What diagnosis should be considered in the workup? A. Early labor B. Placental abruption C. Pre-eclampsia D. Urinary tract infection 10 11 A 25-year-old woman at 34 weeks gestation presents with vaginal bleeding. Physical examination reveals no uterine tenderness and normal vital signs. The primary focus of ordering a transabdominal ultrasound examination is to rule out: A. Cervical effacement B. Placenta previa C. Placental abruption D. Uterine rupture 12 A 25-year-old woman at 34 weeks gestation presents with vaginal bleeding. Physical examination reveals no uterine tenderness and normal vital signs. The primary focus of ordering a transabdominal ultrasound examination is to rule out: A. Cervical effacement B. Placenta previa C. Placental abruption D. Uterine rupture 13 14 Placenta Previa Placenta partially or completely covering cervical os Painless vaginal bleeding in the late second or third trimester, often after sexual intercourse Initial sentinel bleed usually is not sufficient to produce hemodynamic instability or to threaten the fetus in the absence of cervical instrumentation or cervical digital examination Placenta Abruptia Premature separation of the placenta Painful vaginal bleeding and evidence of fetal distress in the third trimester 15 Placenta PreviaPlacenta Abruptia 16 17 A 30-year-old woman who is 7 months pregnant presents with right leg pain and swelling of 4 days duration. Which of the following studies should be used to evaluate the iliac veins in the right leg for suspected deep vein thrombosis? A. Compression ultrasonography B. CT C. D-dimer assay D. MRI 18 A 30-year-old woman who is 7 months pregnant presents with right leg pain and swelling of 4 days duration. Which of the following studies should be used to evaluate the iliac veins in the right leg for suspected deep vein thrombosis? A. Compression ultrasonography B. CT C. D-dimer assay D. MRI 19 CT scan: Delivers less ionizing radiation to fetus (1 to 2 3rad, which is below the teratogenic cutoff of 5 10rad) Delivers a significant radiation dose to the Mothers breast tissue Less accurate in pregnant patients than in non pregnant patients V/Q Scan: Delivers more radiation to fetus (difference even greater earlier in the pregnancy) Can result in non conclusive scan for which a CT scan needs to be performed subsequently Radiation dose can be minimized in pregnancy by using a 1/2 dose perfusion scan Doppler Ultrasound: 70% of pregnant patients with PE have a DVT, and 85% of them in the left leg In one study, in FIRST TRIMESTER pregnant patients with LEFT leg symptoms and calf CIRCUMFERENCE >2cm more in affected leg, 70% have a DVT. If positive, investigations are stopped and patient treated If negative further imaging must be undergone Iliac vein DVTs are frequent in pregnancy, but not seen on Doppler examination 20 A 23-year-old woman at 34 weeks gestation presents with new-onset headache for the past 3 days and blurry vision for 1 day. Blood pressure is182/115. Physical examination reveals generalized nonpitting edema and a nontender gravid abdomen. Laboratory test results include the following: platelets, 80,000/mcL; AST, 321 units/1.; ALT, 280 units/L; normal coagulation studies; and significant proteinuria on urinalysis. This patient is at increased risk of developing: A. Cholecystitis B. lntracranial bleeding C. Pancreatitis D. Placenta previa 21 A 23-year-old woman at 34 weeks gestation presents with new-onset headache for the past 3 days and blurry vision for 1 day. Blood pressure is182/115. Physical examination reveals generalized non-pitting edema and a nontender gravid abdomen. Laboratory test results include the following: platelets, 80,000/mcL; AST, 321 units/1.; ALT, 280 units/L; normal coagulation studies; and significant proteinuria on urinalysis. This patient is at increased risk of developing: A. Cholecystitis B. lntracranial bleeding C. Pancreatitis D. Placenta previa 22 Classic triad: HTN, proteinuria, Edema Magnesium administered as a loading of dose of 4 to 6 g IV followed by 2 g IV/ hour Can occur up to 6 weeks postpartum HELLP Syndrome Preeclampsia variant Dx: Hemolysis, Elevated Liver enzymes, Low Platelets 23 TestComments CBC with differentialMay see hemoconcentration or falling hematocrit. Thrombocytopenia suggests severe disease. CreatinineElevation suggests severe disease. Alanine and aspartate aminotransferase concentrations Elevation suggests severe disease. Lactate dehydrogenase levelElevation suggests microangiopathic hemolysis. Protein in urine3+ proteinuria; 24-h collection may be done by obstetric service. >5 grams/24 h suggests severe disease. Protein/creatinine ratio0.10.3 indicates need for 24-h collection Uric acid levelLevel 5.5 milligrams/dL may suggest superimposed preeclampsia on chronic hypertension 25 26 A 24-year-old woman at 14 weeks' gestation presents with 2 days of epigastric abdominal pain now radiating to the right lower quadrant. The appendix cannot be visualized using ultrasonography. What is the appropriate next step? A. Admit for treatment with parenteral antibiotics B. Obtain surgery or obstetrics consultation C. Order abdominal and pelvic CT scanning D. Perform serial abdominal examinations in the observation unit 27 A 24-year-old woman at 14 weeks' gestation presents with 2 days of epigastric abdominal pain now radiating to the right lower quadrant. The appendix cannot be visualized using ultrasonography. What is the appropriate next step? A. Admit for treatment with parenteral antibiotics B. Obtain surgery or obstetrics consultation C. Order abdominal and pelvic CT scanning D. Perform serial abdominal examinations in the observation unit 28 Peritoneal signs may be delayed or absent due to the desensitization of the abdominal wall caused by stretching Appendix is located in the RLQ in the majority of patients, and most still present with RLQ pain and tenderness Same proportion of pregnant as non pregnant patients present with an atypical location (15%) Non perforated appendicitis carries a 5% fetal loss rate, and this jumps to 30% for ruptured appendicitis, as well as increased rates of pre term labour 29 30 A 30-year-old woman who is 29 weeks pregnant presents after she slipped on a patch of ice and fell on her front steps. She has had a normal pregnancy with no complications. She denies abdominal pain, vaginal discharge, and bleeding and can feel movement of the fetus. Vital signs include blood pressure 108/76 and pulse 88; fetal heart rate is 130. Physical examination reveals a small area of ecchymosis on the left side of the abdomen with no other abdominal or uterine tenderness. What is the appropriate management? A. Abdominal and fetal ultrasonography and discharge if negative B. Admission and cardiotocographic monitoring for 24 hours C. Discharge home with next-day follow-up with obstetrician D. Observation and cardiotocographic monitoring for 6 hours 31 A 30-year-old woman who is 29 weeks pregnant presents after she slipped on a patch of ice and fell on her front steps. She has had a normal pregnancy with no complications. She denies abdominal pain, vaginal discharge, and bleeding and can feel movement of the fetus. Vital signs include blood pressure 108/76 and pulse 88; fetal heart rate is 130. Physical examination reveals a small area of ecchymosis on the left side of the abdomen with no other abdominal or uterine tenderness. What is the appropriate management? A. Abdominal and fetal ultrasonography and discharge if negative B. Admission and Cardiotocographic monitoring for 24 hours C. Discharge home with next-day follow- up with obstetrician D. Observation and Cardiotocographic monitoring for 6 hours 32 2%-4% of women involved in seemingly minor trauma suffer abruption All patients should undergo a minimum of four hours of cardiotocographic monitoring Patients with obstetric signs (e.g. vaginal bleeding, premature contractions, uterine tenderness, or rupture of membranes) or with major trauma require 24 hours of cardiotocographic monitoring 33 34 26-year-old woman presents to the emergency department (ED) complaining of vaginal bleeding and abdominal pain. She states that the pain began today and has been getting progressively worse. Her last menstrual period was 7 weeks ago. Abdomen is soft with mild diffuse tenderness. Pelvic examination reveals a small amount of blood oozing from the cervical os. The uterus is slightly enlarged but nontender with no adnexal masses. Vitals signs WNL, Beta-HCG is 500 Pelvic Ultrasound is obtained with the following image: 35 What is the appropriate next step for this patient: A. Consult OB-GYN for D&C B. Administer Methotrexate C. Repeat HCG within 48 hours D. CT What other lab test is indicated?: A. CBC B. Chem C. Coags D. Type and Screen 36 What is the appropriate next step for this patient: A. Consult OB-GYN for D&C B. Administer Methotrexate C. Repeat HCG within 48 hours D. CT What other lab test is indicated?: A. CBC B. Chem C. Coags D. Type and Screen 37 What is the appropriate next step for this patient: A. Consult OB-GYN for D&C B. Administer Methotrexate C. Repeat HCG within 48 hours D. CT What other lab test is indicated?: A. CBC B. Chem C. Coags D. Type and Screen 38 39 NOTES: Pseudosacs: False sacs that can be confused with gestational sacs Can occur in 10 20% of ectopic pregnancies Rhogam dose: < 12 week: 50 g > 12 week: 300 g