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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.