Pitfalls in the First Half of Pregnancy

Charlotte Page Wills, MDAssociate Program Director

Alameda Health System-Highland Hospital EM Residency, Oakland, CA

Associate Clinical Professor of Emergency Medicine

University of California, San Francisco School of Medicine

Financial Disclosures: None!

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10 weeks pregnantSevere abdominal pain and vaginal bleeding

BP 70/30 HR 130 RR 22 O2 98% POC glu 98ETA 3 minutes

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Ectopic

Pregnant

Bleeding Pain

Goals!

• Go beyond the basics, and highlight diagnostic challenges with uncommon types of ectopic.

• Raise awareness of when pregnancy may make common complaints and conditions more dangerous.

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Ectopic Pregnancy in 2014

• Increasing rates of EP with increasing rates of STIs.

• 1.5‐2% of pregnancies

• Mortality 0.5/1000 pregnancies.

• Remains the cause of 6% of maternal deaths.

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Ectopic

Pregnant

Bleeding Pain

Pregnant Pain

Visit 1

Pain

Visit 1 •Normal vital signs•No bleeding•Mild suprapubic      tenderness

WBC 8KHgb 11.9

WBC 10‐20+ LE

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cervical ectopic

Pregnant Pain

Visit 1

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Ectopics Hiding Near the Uterus

• More difficult to diagnose ‐ both can appear intrauterine.

• More likely to cause catastrophic bleeding.

• Higher rates in ART patients.

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Cervical Scar Ectopic

• Embryonic implantation at the site of a cesarean section scar in the lower uterine segment.

• ULS: uterine cavity and cervical canal empty.

• Complications include massive bleeding, uterine rupture, hysterectomy ‐ early in the first trimester.

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Heterotopic Pregnancy

• 1 in 4,000 pregnancies

• 1 in 100 pregnancies in patients using assisted reproductive technology

• cervical

• ovarian

• abdominal

• cornual

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Gestational Sac Pitfalls

• Pseudo‐gestational sac

• Irregular shape

• Lack of decidual reaction

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Scan Transabdominally:Free Fluid

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Avoiding Ultrasound Pitfalls

• Make sure you are oriented correctly!

• Find the uterine cavity.• Find the endocervical canal.

• Always look in the adnexa and ovaries.

• Look for free fluid.

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14 weeks pregnantHeadaches and nausea, GCS 15, no weakness

BP 146/90 HR 120 RR 22 O2 98% POC glu 80ETA 5 minutes

Pregnancy

Pregnant

Vomiting Nausea

Pregnant

Vomiting Nausea

Vital Signs

More Volume Under Less Pressure

• Blood pressure: decreases 10‐15 mm Hg

• Heart rate: increases 10‐15 bpm

• SVR: decreases by 10‐15%

• Cardiac output: increases by 30‐50%

• Blood volume: increases by 30‐50%

• Hematocrit: decreases to 32‐34%

Vital Signs

Cardiovascular Changes

Respiratory Changes

Pregnant

Vomiting Nausea

Vital Signs

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Pyelonephritis

• May complicate 2% of pregnancies.

• Asymptomatic bacteriuria occurs in a third.

• E.coli, Klebisiella, Group B strep.• Crucial to culture the specimen and know local resistance patterns.

• Treatment: avoid quinolones.

• Disposition: frequently admitted. 

Pneumonia 

• Incidence is the same but the complications are worse.

• Organisms are the same.– S. pneumo

• Tendency to avoid imaging which then delays diagnosis/treatment.

High Risk Pneumonia

• Varicella–Higher rates of morbidity and mortality; complications to the fetus

• Influenza–High rates of respiratory failure

• Coccidiomycosis–Higher rates of dissemination

Influenza and H1N1• Increased susceptibility.

• Increased complications.

Appendicitis

• Perforation rates increase with trimester

• 9% > 13% >26%

• Unreliable exam: displacement of the normal position of the appendix.

• Labs generally unhelpful.

• Associated morbidity and mortality to the fetus with rupture.

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Pregnant

Headache Nausea

Pregnant

Visit 1 •Hypertensive•Intermittent bleeding•Severe nausea and vomiting

WBC 8KHgb 11.9

trace prot

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One More Lab

βhCG: 364,356

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Pregnant

Headache Nausea

Molar Pregnancy

Gestational Trophoblastic Disease

• Hydatiform mole

• Invasive mole

• Choriocarcinoma

• Trophoblastic tumor

Moles in the ED

• One of the few causes of pre‐eclampsia occurring prior to 20 weeks.

• Should be suspected with:

• new onset hypertension

• very elevated hCG levels

• abnormal ULS

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