Obstetric emergency lecture 3

Dr. Miada Mahmoud Rady

SPECIAL OBSTETRIC PROBLEMS

Lecture 3

Topics

1. supine hypotension syndrome .

2. Cardiac problems during pregnancy

3. Hypertension during pregnancy

4. Seizers

5. Diabetes

6. Respiratory problem during pregnancy

7. Hyperemesis gravidarum

Supine hypotension syndrome

Definition: Decrease in blood pressure when pregnant women

lies supine .

Timing : seen in third trimester when uterus is large and patient

mobility is impaired.

Etiology : pressure of the gravid uterus on inferior vena cava

Pathogenesis :

I. Gravid uterus press in inferior vena cava .

II. Decrease venous return .

III. Which decrease cardiac out put .

IV. Which decrease blood pressure .

Enlarged uterus

• pathogenesisPress on

IVC • of supine

Decrease VR

• Hypotension syndrome Decrease

COP

Decrease blood pressure

Supine hypotension syndrome

Complication : can result in significant maternal

hypotension which can lead to fetal distress .

Clinical presentation :

it usually occurs 3-7 min. after lying down.

• Early → nausea , dizziness and tachycardia.

• Later → breathing difficulty and syncope.

Supine hypotension syndrome

Management :

Placing patient in the left lateral recumbent position

Treating underlying causes

Monitoring blood pressure and other vital signs

Obtaining an ECG

Caused by position

Treated by position

Cardiac diseases

When taking history of pregnant female with possible cardiac

disease the following should be documented :

1. Cardiac medications.

2. Dysrhythmias or heart murmurs.

3. History of rheumatic fever.

4. Congenital heart defect : Could be deteriorated by

pregnancy.

5. Dizziness, light-headedness, or syncope : may be

signs of dysrhythmias that could be dangerous

during labor.

Hypertension during pregnancy

Hypertension with pregnancy can cause great morbidity and

mortality .

Border line and preexisting hypertension could be exacerbated

by pregnancy.

Types :

Chronic HTN : hypertension before pregnancy ,

or occurring before 20th week .

Pregnancy induced HTN : occurring after 20th

week of pregnancy.

Eclampsia and pre-eclampsia .

Chronic HTN Pregnancy induced HTN

Present before pregnancy Occurs before 20th gestational

week Persist postpartum

Occurs after 20th gestational week Resolves spontaneously after

labor.

Can cause stroke and cardiovascular problem

May be sign of pre-eclamspsia .

Blood pressure ≥ 140/90 . Blood pressure ≥ 140/90 .

Preeclampsia

Incidence : occurs in about 8% of all pregnancies

Risk factors:

I. First pregnancy before age of 20 (highest risk

factor).

II. Women with advanced maternal age.

III. History of multiple pregnancies.

IV. Chronic hypertension or previous preeclampsia.

V. Renal disease.

VI. Diabetes.

Clinical presentation :

Manifests after 20th week with a triad of symptoms :

1. Edema (usually of the face, ankles, and hands)

2. Gradual onset of hypertension

3. Protein in the urine

Other symptoms include:

Severe headache.

Nausea and vomiting.

Rapid weight gain.

Visual disturbances.

Preeclampsia Complication :

Cerebral hemorrhage

Placental abruption

HELLP syndrome (hemolysis, elevated liver

enzymes, low platelets)

Retard growth of the fetus.

Impair liver and renal function .

pulmonary edema .

Progress to life-threatening seizure

(eclamspia ) .

Preeclampsia Management :

1. address ABCS and supportive care.

2. emergency antihypertensive may be necessary.

3. Eclampsia :

Seizers control : magnesium sulfate is

recommended.

ICU admission in dark quiet room.

Immediate C.S may be necessary to save

mother life.

Seizures Can be caused by:

a. Hypertension

b. Toxemia

c. Preeclampsia

d. Preexisting seizure disorder

Treatment : difficult because drugs normally used for

seizures cause fetal distress.

Magnesium sulfate is recommended ,

especially with eclampsia.

High-flow oxygen is needed to prevent

hypoxia.

Diabetes Diabetes during pregnancy is either :

Preexisting before pregnancy ,or gestational diabetes mellitus.

Gestational diabetes : glucose intolerance due to effect of

pregnancy hormone.

Patient may be asymptomatic or have the same signs as

diabetes mellitus:

I. Polyuria

II. Polydipsia

III. Polyphagia

Complication :

Fetal macrosomia ( large baby ) which may lead to

obstructed labor .

prematurity and preterm labor .

May continue after delivery.

Treatment :

A. Diet control : first line .

B. Insulin .

C. Prehospital : supportive care , I.V D50 if

hypoglycemia present .

Respiratory problems

shortness of breath ( dyspnea ) :

Commonest complaint during pregnancy .

Due to the effect of hormones.

Careful history and examination is necessary to

exclude other causes.

Treatment is assurance.

Remember physiological

changes

Respiratory problems

Asthma

Asthma is common condition that usually

complicates pregnancy .

Patient may be known asthmatic or asthma

may present for the first time during pregnancy.

Acute episode of asthma can cause serious

maternal and fetal complication.

Complication of asthma

Maternal

• Premature labor

• Preeclampsia, eclampsia

• Respiratory failure

• Vaginal hemorrhage

Fetal

• Premature birth

• Low birth weight.

• Growth retardation.

• Fetal death.

Respiratory problems

Pneumonia :

One of the leading indirect causes of maternal death in

the United States.

More sever during pregnancy due to depressed immune

system of pregnant female .

Caused by :

Infectious agent : bacterial , viral or

parasitic.

Non-infectious : chemical inhalation.

Respiratory problems

complications of pneumonia :

I. Low birth weight

II. Premature labor

III. Preterm delivery

Hyperemesis gravidarum

Definition : persistent nausea and vomiting during

pregnancy which is more serious than morning sickness .

Etiology : Exact cause is unknown, but possibly from:

I. Increased hormones (estrogen, human

chorionic gonadotropin).

II. Stress.

III. Gastrointestinal system changes.

Hyperemesis gravidarum

Complication : dehydration , malnutrition and electrolyte

imbalance.

Symptoms :

Severe and persistent vomiting more than

three or four times daily.

Projectile vomiting, consisting of bile and

sometimes blood.

Severe nausea.

Pallor.

Hyperemesis gravidarum

Prehospital treatment :

Administer 100% supplemental oxygen.

Start IV line of normal saline.

If protocols allow, administer

diphenhydramine.

Check blood glucose levels.

Check orthostatic vital signs, obtain an

ECG.

Transport to a hospital.

Summary Supine hypotension syndrome could be avoided by lying

on left lateral position.

Hypertension with pregnancy causes great morbidity and

mortality

Gestational D.M could be controlled by diet .

Asthma is very common and dangerous in pregnancy.

Pregnancy can exacerbate asymptomatic congenital

heart disease .

Delivery is the only line of treatment for eclampsia .