Emergency management of the pregnant woman Flashcards
(33 cards)
What anatomical and physiological changes occur in pregnancy?
CV system:
Blood volume increases 40-50%
Increasd HR by 10-15bpm
SV increases
Increased CO
Decreased BP (progesterone relaxes smooth muscle around blood vessels, placenta absorbs much of the circulating volume)
Supine Postural Hypotensive Syndrome = Enlarged uterus compresses the inferior vena cava reducing volume and preload
Respiratory system:
O2 consumption increases - therefore progesterone increases minute ventilation (Vt + RR)
Decreased secreton of bicarbonate due to decreased PaCO2 from increased MV - therefore ph can be slightly alkalitic
Diaphragm lifts but chest wallcircumference increases too to assist wth breathing.
Renal:
Vasodilation increases blood flow to kidneys, therefore increased GFR
Frequency due to increased GFR and pressure on bladder from uterus.
Pressure from uterus causes occlusion of ureters, causing build up of urine towards kidneys (increasing susceptibility to pylonephritis)
Discuss the medical history taken of the pregnant woman in the Emergency Department
History:
- Expected DOB
- Current pregnancy issues/concerns
- Previous pregnancies and birth mode
(Gravida - no of pregnancies, Para - no of babies over 20 weeks) - Maternal co existing medical conditions
- Pregnancy related disorders
- Incidental pathologies
- Mental health illness in pregnancy
- Domestic violence concerns
- Drug and alcohol issues
Discuss the physical assessment of the pregnant woman in the Emergency Department
- If estemated DOB alligns with uterus size
- Vital signs - especially BP
- Pain - where, how long, what sort and severity
- Bleeding - how much, how long, where from
- Other vaginal loss - odour, colour, amount, when noted
- Abdominal palpation if gestation warrents and no contraindications of bleeding
- Oedema
- Fetal heart rate and wellbeing - growth, movements +/- CTG (cardiotocograph) - at appopriate gestation
Identify risk factors relevent to the pregnant or port partum woman presenting to ED
?
Define the parameters of HTN in a pregnant patient
SBP > 140
and/or
DBP > 90
On two occasions at least 4 hours apart
Define pre-eclampsia
Diagnosed after 20 weeks
A multi-system disorder characterised by HTN and associated involvement of one or more organ systems
(eg, heamatological, renal, hepatological, neurological, foetal/placental)
*affects 3-8% of pregnancies, can also develop or continue into the post natal period
Signs and symptoms of pre-eclampsia
- Rapidly increasing facial oedema
- Proteinuria
- Vitual disturbance
- Headache
- RUQ pain
- Hyper-reflexia/Clonus - involuntary muscle spasms
Late signs
- Reduced fetal movements
- LFT’s - skewed AST
- Seizure/Eclampsia
Risk factors for pre-eclampsia
- Previous personal or family history
- Co existing medical conditions
(diabetes, essential HTN, antiphospholipid syndrome, renal disease) - Multiple pregnancy
- Nulliparity (hasn’t given birth before)
- Obesity
*the risk of preeclampsia is increased when more than 1 risk factor is present
Maternal assessment/investigations for pre-eclampsia
Thourough history/general exam
- Vitals: manual BP, ensure correct cuff size
- Neuro exam: ?hyper reflexia
- Abdo palpation (fetal lia, presentation, size)
- UA
+/- MSU and urine protein creatinine ratio (PCR) if FWT > 1+ proteinuria - Pre-eclampsia biochem screen: FBE, UEC, LFT, UA
Fetal assessment for pre-eclampsia
- Fetal movement
- CTG (Cardiotocography: to assess fetal HR)
- U/S for AFI (Amniotic Fluid Index)
Management of pre-eclampsia
- IVC, path
- Control HTN
- Seizure prophylaxis
- *Mg sulphate** (diaz not appropriate)
- slows neuromuscular conduction and decreases CNS irritability
- fetal neuroprotective effect if anticipating pre-term birth*
- Fetal maturation
- maternal corticosteroid administration for 24 - 34+6 weeks gestation for those at risk of preterm birth within 7 days*
- Strict FBC*
- Continuous fetal monitoring (CTG)*
- Birth plan*
Define eclampsia
The development of seizures usually with pre-existing pre-eclampsia
- Life threatening
Management of eclampsia
- Control seizures with Magnesium sulphate (not diazepam)
- Control HTN with labetolol, nifedipine or hydrazazine
- Stabilising woman is primary goal over fetus
- Evaluate for stabalisation and immediate delivery
What is HELLP syndrome?
A subset of women with severe pre-eclampsia characterised bu
Haemolysis
Elevated Liver enzymes
Low Platelets
What are the 4 main hypertensive disorders in pregnancy
- *Chronic Hypertension**
- hypertension (>140/80mmHg) that predates the pregnancy or is diagnosed prior to 20 weeks gestation
- *Gestational Hypertension**
- New onset of hypertension after 20 weeks gestation.
- No assoiated signs of pre-eclampsia
- Should resolve within 6 months of birth
- *Pre-eclampsia/Eclampsia**
- >20 weeks gestation, proteinuria and evidence of end organ compromise.
- End organ compromise may manifest as CNS symptoms, hepatic dysfunction, renal insufficiency, pulmonary oedema.
- Eclampsia = new onset of seizures in the setting of pre-eclampsia
- *Pre-eclampsia superimposed in chronic hypertension**
- Pre-eclampsia in women with chronic hypertension.
- Higher risk of adverse outcomes
What are the 5 main causes of bleeding in pregnancy?
Early pregnancy
- *Ectopic pregnancy**
- *-** implantation occurs outside the uterus
- *Miscarriage**
- pregnancy loss <20weeks
- threatened (bleeding, cervix closed), inevitable (cervix open) or complete (all products expelled)
Post first trimester
- *Placenta previa**
- placenta has implanted at lower uterine segment, over the cervix or cose by
- Presents as painless bright red blood
- *Placental abruption**
- placenta prematurely becomes detached from the wall of the uterus (partially or totally)
- *Vasa previa
- ** fetal umbillical cord blood vessels run throught eh amniotic membrane near the cervix
Causes of bleeding in early pregnancy
- Implantation bleed
- Cervical lesions
- Miscarriage (spont abortion)
- Ectopic pregnancy
- Incompetent cervix
- (does not remain closed during the pregnancy)*
- Hydatiform mole
Management of miscarriage
- *Expectant Mx**
- waiting and seeing
- *Medication**
- misoprostil helps products to pass
- used in incomplete miscarriage
- not indicated with heavy bleeding/infection/>9 weeks
- *Surgical**
- Suction, dialation and curette (D&C)
- indicated for heavy bleeding/pain
S&S of ectopic pregnancy
S&S
- mild lower abdo pain
- ocasionally sharp, stabbing, increased intensity over a few days especially with bowels*
- -* Nausea
- +/- bleeding or slight brown discharge
- Pathology: decreased progesterone and bHCG
- U/S: uterus empty
Ruptured
- Sudden, severe abdo pain
- profound shock - collapse
- referred shoulder tip pain
- internal bleeding
Management of ectopic pregnancy
Dependent on presentation
Medical
- If dx early or embryo diameter <3.5cm and no severe bleeding
- IM Methotrexate stops rapid growth
- needs serial bHCG to show that it is reducing in size
- avoid pregnancy for 3 moths
Surgical
- laproscopic, may involve removing part or all of the fallopian tube to control bleeding
Define an Antipartum Heamorrhage (APH)
Bleeding from the birth canel of 10-15ml >20wks gestation
Mostly unknown cause but can be due to placenta previa, placantal abruption, vasa previa
Presentation and management of placenta previa
Presentation
- painless recurrent bleed of various amounts
- premature labout
- shock
Management
Depends on grade
- Grade 1&2 (cervix not covered)*
- repeat U/S at 32 weeks - placenta may have moved
- Grade 3&4 (cervix covered)*
- cannot have vaginal birth, must be cesarian
- will likely require hospital admit when they start bleeding
- close watch and wait to maximise fetal growth and minimise blood loss for mother
Placental abruption causes
Cause
- pre-eclampsia
- HTN
- Trauma
- Unknown
Placental abruption types
Concealed
Bleeding retained behind the placenta
- forced back into uterine muscle fibres
- extravasation causes damage to uterus
- can have hypovolaemic shock but no bleeding
- *Revealed**
- blood escapes from placental site
- seperates membrane from uterine wall
- draines out the vagina.
