Obstetric Emergencies

Obstetric Emergencies: We will cover...

● Normal Pregnancy
● Common medical and surgical complications
of pregnancy

Normal pregnancy
● All females of childbearing age are presumed
to be pregnant until proven otherwise.
All pregnancy tests detect B-HCG which is
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●
produced at the time of implantation (8-9 days
post conception)
● B-HCG should double every day for the first
weeks, peak at week 8 and remain elevated up
to 60 days post-partum

False Negatives False Positives

Too early in pregnancy Urine:

hematuria/proteinuria
Dilute/old urine
Serum:
Ectopic T.O.A.
Incomplete Ab. Thyrotoxicosis
Molar pregnancy
Drugs (MJ, ASA,
Phenothiazines,
anticonvulsants,
antidepressants,
methadone

Some Important Physiological Changes

in Pregnancy
● Cardiac: increased heart rate, decreased blood
pressure. CO increases
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● Respiratory: rate increases, TV increases, FRV
decreases, pCO2 decreases

● Heme: Volume increases, HCT drops, WBC

increases

Drugs in Pregnancy: A, B, C, D, X
Considered Safe in pregnancy:
PCN
Cephalosporins
Azithro/Erythromycin
Acetaminophen
Narcotics
Heparin
Asthma Drugs
Reglan (Metoclopramide)
Immunizations derived from killed viruses (tetanus,
diptheria, Hep. B, Rabies)

Radiation in Pregnancy
● <5-10 rads = no significant risk of birth
defects
● Beams aimed 10cm away from fetus pose no
additional risk
● Initial trauma X-rays each deliver <1 rad
● One never withholds necessary radiography.
● Use MRI or U/S if available.

Transvaginal Ultrasound Images

Normal, non-pregnant uterus on T/V

U/S

The “Double-Ring” Sign or “Double

Decidual” Sign of normal early
pregnancy

Normal Pregnancy T/V Ultrasound

Showing Gestational and Yolk Sac. No
fetus is seen. 5w 2d

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6w 1d T/V U/S showing yolk sac

Normal T/V U/S with embryo at

10w 3d

Complications of Pregnancy – Vaginal

Bleeding
1st Trimester Causes:
1. Ectopic
2. Abortion
3. Molar Pregnancy
4. Non-pregnancy Related
a. Infectious
b. Trauma
c. Neoplasm

The work-up is the same!

● Pelvic Exam
● Beta HCG
● Transvaginal ultrasound
● Rh
● CBC, CMP
● PT/PTT/INR
● UA

Ectopic Pregnancy – A surgical

emergency of pregnancy
● The leading cause of first trimester maternal
death
● Usually 5-8 weeks after LMP
● High Risk: History of ectopic, tubal surgery or
sterilization procedure, Known tubal scarring
or pathology, Diethylstilbestrol exposure, IUD.

Signs/Symptoms
● Symptoms (in decreasing order of frequency):
Abdominal pain, amenorrhea, vaginal bleeding
(50-80%), dizziness, pregnancy symptoms,
urge to defecate, passing tissue
● Signs: Adnexal tenderness, abdominal
tenderness, adnexal mass, enlarged uterus,
orthostatic changes, fever

Testing
Beta > 6000 mIU/ml + empty uterus on
transabdominal ultrasound
OR
Beta > 1200 mIU/ml + empty uterus on
transvaginal ultrasound =
Ectopic Pregnancy = Laparoscopy

Beta <6000 + empty uterus on transabdominal

ultrasound
OR
Beta < 1200 + empty uterus on transvaginal
ultrasound = serial outpatient beta
measurements to ensure normal rise.
This only applies to stable patients and should be
done in consult with ob/gyn

A heterotopic pregnancy (to compare

normal vs. abnormal)

Ectopic Pregnancy

2nd Trimester
● Causes are abortion and non-pregnancy
causes.
● Work-up is the same
● Management of threatened AB is the same
● If complete, may be D&C candidate
● If other types of AB, patient may undergo
oxytocin induced labor as inpatient.

3rd Trimester (>28 weeks)

Placental Abruption Placenta Previa
Placenta separates from uterine Placenta implants too low
wall
Painful dark or clotted blood Painless bright red bleeding

Risks: HTN, smoking, ETOH, Risks: prior C-section, grand

cocaine, multiparity, previous
abruption, trauma, mom > 40
Management: U/S, Ob consult,
cardiac/fetal monitoring, IV,
pre-op labs, delivery if possible
multiparity, previous previa,
multiple gestations, multiple
induced abortions, mom >40.
Management: U/S, Ob consult,
pre-op labs, avoid pelvic
exam, c-section

3rd Trimester Bleeding cont’d

● Uterine Rupture: Can be seen in scarred and
unscarred uteri. (uteruses? uterata?)