Para-pregnancy Emergencies

Question 1

What are the differentials for Dyspnoea in pregnancy?

Answer 1

PE!
Severe anaemia
- Iron deficiency
- HELLP syndrome
APO
- pre-eclampsia
- Peri-partum cardiomyopathy
- Worsening of underlying cardiac/lung diseases
Pneumonia
Influenza/viral pneumonia
Overwhelming sepsis
Aortic Dissection

Question 2

What are the different modalities for CONFIRMING PE in pregnancy?

Answer 2

CTPA
- Gold standard
- 10mGy of radiation to the mother directly through the breasts
- Lower radiation to the foetus
- Contrast risks to mother and foetus (very low thyroid risk to foetus)

V/Q scan
- Lower radiation to mum but more to the foetus
- Less diagnostic accuracy to CTPA
- Still uses contrast

Echo
- Unless frank clot seen cannot truly confirm a PE
- Can use to risk stratify and treat empirically, also rule out other causes ie peri-partum cardiomyopathy
- No radiation to mum or foetus

Contrast enhanced pulmonary artery angiography
- Old technique for diagnosis
- Can diagnose and then also treat with catheter directed thrombolysis
- Variable radiation dose, may be higher
- Higher complication rate (5%)

MRPA
- Not validated
- Needs patient to remain very still for extended period
- Contrast risks
- No radiation

Question 3

When is an IVC filter indicated in pregnant patients with VTE?

Answer 3

• Allergy to Heparin/LMWH
• High bleeding risk

IVC filters are well tolerated in younger pregnant patients
Placed under flouroscopic guidance so some radiation involved, usually 2mGy

Question 4

What is the radiation dose that in pregnancy that is considered too high for the foetus?

Answer 4

• Cumulatively >50 milliGray (mGy)
• At this point adverse effects from radiation are likely to be observed (foetal death and abnormalities)
• Most vulnerable times are at the beginning during the 1st trimester

Question 5

What is the recommended treatment of intrapartum PE?

Answer 5

Enoxaparin 1mg/kg BD
- At least 3 months
- At least until 6 weeks post the end of the pregnancy

Warfarin is relatively contraindicated in pregnancy due to the risk of warfarin embryopathy
- This occurs in 5% of those exposed in the first 5-14 weeks
- facial flattening and dwarfism

NOAC’s also contraindicated due to foetal abnormalities

Question 6

What are the differentials for post partum Sepsis?

Answer 6

Puerperal sepsis (endometritis)
Wound infection
Influenza/covid/viral infection
CAP
Aspiration pneumonia
Staph TSS
C. diff colitis
Severe mastitis
Pyelonephritis
PE

Question 7

What is the usual cause of post partum endometritis and how is it treated?

Answer 7

Streptococcus species (A, B, C and G)
- May cause toxic shock syndrome

Broad spectrum antibiotics
ie Benzylpenicillin 1.8gm +/- Tazocin
Clindamycin 600mg
Vancomycin 30mg/kg +/- Gentamicin 5mg/kg

Question 8

What are the symptoms/signs of magnesium toxicity?

Answer 8

Respiratory depression
Loss of deep tendon (ie patellar) reflexes
Muscle weakness > paralysis
N/V
CNS depression
Arrhytmias

Toxicity with Mg+ >4mmolL, severe when >10

Question 9

What are the causes of hypermagnesaemia?

Answer 9

Iatrogenic (ie eclampsia Mx)
Anatacid intake
Laxatives
Tumour lysis syndrome
Rhabdomyolysis
Renal failure

Question 10

What are the ECG changes in hypermagnesaemia and what is the treatment?

Answer 10

Similar to Hyper K

Wide QRS
Peaked T waves
P wave flattening/loss
PR prolongation
High grade AV block

Treat with IV calcium

Question 11

What is the definition of hyperemesis gravidarum?

Answer 11

Persistent, severe N/V that commences before 20 weeks of gestation
AND
results in dehydration, electrolyte imbalance, ketosis and weight loss of at least 5% of pre-pregnancy weight

Question 12

What are the stats and treatment of hyperemesis gravidarum?

Answer 12

• 1-2% of all pregnancies
• Risks include previous HG, mutli pregnancy and molar prengnacy
• Peaks around 8-12 weeks and resolves by 20 weeks (90%)
• A diagnosis of exclusion

1st line Metoclopramide
2nd line
- Ondansetron, Pyridoxine, ginger, prednisolone, doxylamine

Question 13

What are the admission criteria for hyperemesis gravidarum?

Answer 13

• Severe dehydration
• Not tolerating oral intake
• Electrolyte abnormalities
• Ketosis
• Associated infection

Question 14

What are the risk factors and complications of Ovarian hyperstimulation syndrome (OHSS)?

Answer 14

Risks
- Previous OHSS
- Pre-existing PCOS
- Number of follicles (>20)
- More Oocytes retrieved
- hCG use instead of progesterone use for the luteal phase
- younger age
- Low body weight
- Becoming pregnant
- Using non-GnRH agonists for final oocyte maturation

Complications
- Thromboembolism
- Hypovolaemic shock
- Ascites, pleural and pericardial effusions
- Ovarian torsion
- Abdominal compartment syndrome
- AKI
- Fluid and electrolyte shifts (hyponatraemia, hyperkalaemia)
- Hypertension
- Respiratory failure
- Death

Question 15

What is the severity classification of OHSS?

Answer 15

Mild
- No biochemical abnormalities
- Mild GI symptoms and distention

Moderate
- U/S evidence of ascites
- Hct >41%, WBC >15, low protein
- Ovaries >12cm
- Worse GI symptoms and distention

Severe
- Ascites + pleural effusions
- Severe abdominal pain
- 15-20kg weight gain
- Hypoxia + respiratory compromise
- Deranaged electrolytes
- Hepatorenal failure, oliguria
- Hct >55%
- Abdominal compartment syndrome

Critical
- Massive ascites/hydrothorax with associated pericardial effusion
- Multiorgan failure
- DIC
- ARDS/Pneumonia/Massive PE

Question 16

What are the ultrasound findings in OHSS? What is the essentials of management?

Answer 16

Ultrasound
- Enlarged ovaries
- Multiple ovarian cysts
- Ascites
- Pleural/pericardial effusions
- Pulmonary oedema

Treatment
- Analgesia
- IV fluids, potentially albumin
- DVT prophylaxis/treatment
- Daily weights and strict fluid balance
- Paracentesis as needed for ascities, pericardial and pleural effusions
- Airway and respiratory support
- Electrolyte management
- Abdominal compartment pressure monitoring and management
- Potentially RRT

Question 17

What are the features of Rhesus isoimmunisation?

Answer 17

• Rh antigens grouped into 3 pairs, Dd, Cc and Ee
• 85% of caucasians are Rh+ve
• 90% of sensitisation occurs during delivery
• Anti-D decreases overall risk from 1% to 0.3%
• Overall risk for an Rh positive foetus with an Rh negative mother is 15%
• Anti-D should be given for all sensitising events, even if the Kleihauer-Betke test is negative
• 250IU in 1st trimester unless multiple pregnancy, after that 625IU
• KH test suggest the need for >625IU if large bleed

Question 18

What is the grading system for HELLP syndrome and what are the biggest complications?

Answer 18

Missisipi Grading System
- Class III Mild = platelets >100 with AST >40
- Class II Moderate is 50-100
- Class I Severe is <50

The most common causes of death are liver rupture, cerebral haemorrhage and cerebral oedema

Question 19

What are some of the features of examining and treating a rape victim?

Answer 19

• Test for all STI’s including HIV and syphilis
• Offer pregnancy prophylaxis
• Obtain a baseline pregnancy test
• Give antibiotics to prevent venereal disease occurring
• Assessment >72hrs post incident inhibits some evidence collection as sperm is often negative
• Vaginal aspirate for acid phosphatase and PSA can be detected up to 48hrs post

Question 20

What are the 3 main emergency contraceptives in Australia and how effective are they?

Answer 20

Levonorgestrel
- PO 1.5mg
- Up to 72hrs post coitus
- reduces to 2.3% risk of pregnancy if taken within 24hrs

Ulipristal acetate
- PO 30mg
- Up to 120hrs
- Reduces to 0.9% if taken within 24hrs

Copper IUD
- Up to 120hrs
- 0.1% effective

Question 21

What are the perinatal factors that predict the need for neonatal resuscitation post delivery?

Answer 21