mmuh reg teaching pregnancy
DESCRIPTION
This is a talk I gave recently for our registrar teaching morning. Not the sexiest presentation (forgive the bullets) but hopefully will give you the basic, textbook level info a al foamcast styleTRANSCRIPT
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