Late Pregnancy EmergenciesDr Ian Turner FACEM

When and What?• After 20 weeks up to post-partum• Viable >22.5 weeks• Bleeding• Trauma• Pre-eclampsia and it’s complications• VTE• Cardiomyopathy• Maternal arrest

Changes in Pregnancy• Mucosal swelling = difficult airway• Oxygen consumption increased, FRC decreased = early hypoxia• Aortocaval compression = hypotension• Relative anaemia = more susceptible to blood loss• Increased reflux, weak LOS = aspiration risk

Risk Factors in Late Pregnancy• Maternal age• Previous pregnancy problems• Diabetes• Obesity• Hypertension• Multiple gestation• Multiparity

Delivery often, but not always, the answer• Consider gestational stage• Stable – consider steroids, evaluate over 24-48 hours• Unstable – deliver

Case 131 F G3P0, 31/40Mild hypertension last check up3/7 worsening upper abdominal pain1/7 vomitingPoor appetite

Early DifferentialViral illnessGORDCholelithiasis/cystitisPre-eclampsiaHELLP

AssessmentObstetric historyCurrent pregnancy progressROSVitals signsFocused exam findings

ExaminationLooks unwell37.1C, RR 25, SaO2 96%, BP 152/82, HR 108Dry MMSlightly jaundicedTender RUQFundus 10cm above umbilicus – nontenderMild peripheral oedema

Refined DifferentialCholelithiasis/cystitisPre-eclampsiaHELLP

InvestigationsBedside – FWT, BSLBloods – FBE, UEC, LFTs, LDH, coag, G+HImaging – U/S

InvestigationsFWTFBE FilmUECLFT

CoagsU/S

Protein 2+Hb 98, WCC 7.8, Plt 87SchistocytesNormalBili 47, ALP 128, GGT 58, ALT 101, AST 120, LDH 600, TP 45, alb 28Normal31/40, normal placenta, small subcapsular haematoma

DiagnosisHaemolysisElevated Liver EnzymesLow Platelets

1-2% mortalityCross-over with pre-eclampisa

ED InterventionsEarly obstetric involvementSeizure prophylaxisBP controlCorticosteroidsCorrect coagulopathyDelivery indications

Case 227 F G1P0, 25/40BIBA following MVA – rear-ended whilst stationary in 50kph zoneUpper right chest discomfort

ApproachUsual trauma approach2 patients

Indications for collar?Nexus or Canadian

Place ICCs higher

CTG

ApproachLook for RPH, abruption, foetal distress, labour

Blood loss may not be obvious initially

Image as needed – ALARAAnti-D

Case 335 F G3P2, 32/40PV bleeding for 3 hours with increasing abdominal pain

Early differentialPlacental abruptionPlacenta previaPlacenta accretaLabour

ExaminationIn pain36.8C, HR 110, BP 109/60, RR 22, SaO2 100%Tender uterusHeavy PV bleeding

InterventionsLarge bore IV accessFBE, coags, X-matchAnti-D – how much?Foetal monitoring – options?Deliver?

Case 436 FG2P1, 30/402/7 headache6/24 blurred vision

Early DifferentialSimple headachePre-eclampsiaComplex headache

AssessmentNever gets headachesBand-like pain for last 2 daysDifficulty focusing on objectsNauseated36.5C, RR 18, SAO2 100%, HR 95, BP 165/110DryNormal fundal heightPeripheral oedemaNo focal neurology

InvestigationsFWTBloodsImaging

Protein 1+NormalModality?

DiagnosisPre-eclampsiaCerebral sinus thrombosis

InterventionsAnalgesiaControl BP – optionsPrevent seizuresPrevent further clot formationMultiple referrals and consider delivery

Case 529 FG1P0, 33/405/7 increasing breathlessnessWorsening peripheral oedema

Early differentialNormal pregnancy!PEPre-eclampsiaCardiomyopathy

AssessmentNormal pregnancy so farHas been occasionally SOBOE last few weeks but now at rest Worse lying downAware of heart beat37.1C, RR 26, SaO2 95% R/A, 130/80, HR 110Systolic murmurBasal crepitationsModerate peripheral oedema

AssessmentFWTECGD-dimer CXRU/SEchoCTPAV/Q

normal

AssessmentFWTECGD-dimer CXRU/SEchoCTPAV/Q

normalST, RBBB, ant TWI1.12

AssessmentFWTECGD-dimer CXRU/SEchoCTPAV/Q

normal

1.12normalnormalnormal

Radiation Dose• Foetal dose minimal with

either V/Q or CT• Maternal dose is the concern

Maternal Dose (mGy)

Lung Breast

CTPA 39.5 10-60

V/Q 5.7-13.5 0.98-1.07

resus.com.au

InterventionsPE – anticoagulate, no warfarinCM – diuretics, digoxin, afterload reduction (hydralazine, nitrates, β-blockers), anticoagulate if low EFMultiple consultations

Case 630 F33/40BIBA massive PV bleedingAshen, BP 75/40, HR 160, RR 28, SaO2 89%Becomes unresponsive on transfer to resus cubicle

Actions?HelpCodeBLS and ACLSWedgeHands higherDifficult airwayLarge bore IV accessBlood productsCall / prepare for perimortem C-section