Emergency

FCEM

medical complications of pregnancy

Emergency

Molar Pregnancy

http://radiopaedia.org/articles/hydatidiform-mole

Emergency

useful factsgestational trophoblastic disease !

20% malignancy !

presentation • probably 2nd trimester for us • higher HCG than expected • bigger fundus than expected • more hyperemesis • preecmampsia (even <24 wks)

Emergency

amniotic fluid embolus• mixing of amniotic fuid into systemic circulation • during labour or manipulation [can be spontaneous]

looks like

sudden onset • low BP • hypoxia • coagulopathy • seizures in about 10%

anaphylactoid NOT obstructive

https://en.wikipedia.org/wiki/Allergy#mediaviewer/File:The_Allergy_Pathway.jpg

Emergency

pregnancy induced hypertension

• gestational hypertension = BP>140/90 • preeclampsia = BP>140/90 and proteinuria • eclampsia = seizures with preeclampsia

https://en.wikipedia.org/wiki/Hypertension#mediaviewer/File:Grade_1_hypertension.jpg

Emergency

why?

• “vasospastic disease” • likely endogenous pressers • high cardiac output with high resistance

Emergency

diagnosis

Systolic ≥140 mmHg or diastolic ≥90 mmHg, and •Proteinuria ≥0.3 grams in a 24-hour urine specimen or protein:creatinine ratio ≥0.3, or •Signs of end-organ dysfunction (platelet count <100,000/microliter, serum creatinine >1.1 mg/dL or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration)

http://www.nice.org.uk/guidance/cg107/resources/guidance-hypertension-in-pregnancy-pdf

Emergency

what should you examine?

• pressure [NB >160/110 considered severe] • protein • oedema • mental status • reflexes/clonus • liver tenderness • jaundice • headache/visual probs [big red flag]

Emergency

H E L L P

aemolysis

levated

iver enzymes

ow

latelet count

Emergency

what HELLP can look like

• TTP • Acute fatty liver of pregnancy • Lupus • Sepsis

Emergency

it’s pre-eclampsia so what now?

• IV access/monitor • check labs

• urine dip • FBC [anaemia and low platelets. <100 a sign of severe] • renal [often AKI] • LFTs [ALT/AST/bili] • Clotting [should be normal] • Mag [as baseline]

• ultrasound [how big is the baby?] • give magnesium • give labetalol

Emergency

magnesium

http://www.nice.org.uk/guidance/cg107/resources/guidance-hypertension-in-pregnancy-pdf

keep giving it till the reflexes disappear…

Emergency

don’t forget

http://www.nice.org.uk/guidance/cg107/resources/guidance-hypertension-in-pregnancy-pdf

Emergency

abdo pain in pregnancy

bump related • preeclampsia • miscarriage/labour

non-bump related • gallbladder • appendicitis • UTI

Emergency

appendicitis• commonest surgical emergency • difficult to diagnose (up to 50% normal appendicectomy, up to 25% perforation) • most consistent feature is right sided pain • big issues if missed

imaging • ultrasound first • CT or MRI if ultrasound equivocal

Emergency

gallbladder• similar symptoms to non pregnant • ALP normally up in pregnancy, as is amylase and WCC… • ultrasound is key

much more importantly • is this HELLP? • is this preeclampsia • is this fatty liver of pregnancy?

Emergency

UTIthe exception to the rule about asymptomatic bacteruria

http://www.sign.ac.uk/pdf/sign88.pdf

Emergency

headache in pregnancy

• migraine frequency typically becomes less • tension headaches typically no change

• is this SAH? • is this preeclampsia?

Emergencyimage credit: Jeremy Jones http://radiopaedia.org/cases/venous-sinus-thrombosis

Emergency

cerebral venous sinus thrombosis

immediately post partum !usually presents • headache • stroke • seizures • reduced LOC

CT • delta sign • venous infarction • venous bleeding

management • anticoagulation

Emergency

chest pain/SOB in pregnancy

• ACS • PE [though we probably overinvestigate] • dissection [commonest during labour] • cardiomyopathy • dyspnoea of pregnancy

Emergencyhttp://www.ncbi.nlm.nih.gov/pubmed/25269575

Emergency

“Cardiac disease is the leading cause of death in pregnancy and the puerperium in the UK, and was responsible for 20%

of the maternal deaths between 2006 and 2008. Ischaemic heart disease and

myocardial infarction (MI) are the most common pathologies, being the cause of

20% of the maternal cardiac deaths”

Heart 2012;98:10 760-761 doi:10.1136/heartjnl-2011-301564

Emergency

• usual symptoms • 75% STEMI • Most anterior

• PCI/CABG preferred • lytics up to 8% bleeding • give aspirin and your anti platelet of choice • nitrates prob fine

Emergency

meadow’s syndrome

zaria syndrome

Emergency

2010 ESC Working Group defined PPCM as an idiopathic cardiomyopathy with the following characteristics: !●Development of heart failure (HF) toward the end of pregnancy or in the months following delivery ●Absence of another identifiable cause for the HF ●Left ventricular (LV) systolic dysfunction with an LV ejection fraction (LVEF) nearly always less than 45 percent. The left ventricle may or may not be dilated.

Emergency

fin