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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.