Emergency management of the pregnant woman Flashcards
What anatomical and physiological changes occur in pregnancy?
CV system:
Blood volume increases 40-50%
Increasd HR by 10-15bpm
SV increases
Increased CO
Decreased BP (progesterone relaxes smooth muscle around blood vessels, placenta absorbs much of the circulating volume)
Supine Postural Hypotensive Syndrome = Enlarged uterus compresses the inferior vena cava reducing volume and preload
Respiratory system:
O2 consumption increases - therefore progesterone increases minute ventilation (Vt + RR)
Decreased secreton of bicarbonate due to decreased PaCO2 from increased MV - therefore ph can be slightly alkalitic
Diaphragm lifts but chest wallcircumference increases too to assist wth breathing.
Renal:
Vasodilation increases blood flow to kidneys, therefore increased GFR
Frequency due to increased GFR and pressure on bladder from uterus.
Pressure from uterus causes occlusion of ureters, causing build up of urine towards kidneys (increasing susceptibility to pylonephritis)
Discuss the medical history taken of the pregnant woman in the Emergency Department
History:
- Expected DOB
- Current pregnancy issues/concerns
- Previous pregnancies and birth mode
(Gravida - no of pregnancies, Para - no of babies over 20 weeks) - Maternal co existing medical conditions
- Pregnancy related disorders
- Incidental pathologies
- Mental health illness in pregnancy
- Domestic violence concerns
- Drug and alcohol issues
Discuss the physical assessment of the pregnant woman in the Emergency Department
- If estemated DOB alligns with uterus size
- Vital signs - especially BP
- Pain - where, how long, what sort and severity
- Bleeding - how much, how long, where from
- Other vaginal loss - odour, colour, amount, when noted
- Abdominal palpation if gestation warrents and no contraindications of bleeding
- Oedema
- Fetal heart rate and wellbeing - growth, movements +/- CTG (cardiotocograph) - at appopriate gestation
Identify risk factors relevent to the pregnant or port partum woman presenting to ED
?
Define the parameters of HTN in a pregnant patient
SBP > 140
and/or
DBP > 90
On two occasions at least 4 hours apart
Define pre-eclampsia
Diagnosed after 20 weeks
A multi-system disorder characterised by HTN and associated involvement of one or more organ systems
(eg, heamatological, renal, hepatological, neurological, foetal/placental)
*affects 3-8% of pregnancies, can also develop or continue into the post natal period
Signs and symptoms of pre-eclampsia
- Rapidly increasing facial oedema
- Proteinuria
- Vitual disturbance
- Headache
- RUQ pain
- Hyper-reflexia/Clonus - involuntary muscle spasms
Late signs
- Reduced fetal movements
- LFT’s - skewed AST
- Seizure/Eclampsia
Risk factors for pre-eclampsia
- Previous personal or family history
- Co existing medical conditions
(diabetes, essential HTN, antiphospholipid syndrome, renal disease) - Multiple pregnancy
- Nulliparity (hasn’t given birth before)
- Obesity
*the risk of preeclampsia is increased when more than 1 risk factor is present
Maternal assessment/investigations for pre-eclampsia
Thourough history/general exam
- Vitals: manual BP, ensure correct cuff size
- Neuro exam: ?hyper reflexia
- Abdo palpation (fetal lia, presentation, size)
- UA
+/- MSU and urine protein creatinine ratio (PCR) if FWT > 1+ proteinuria - Pre-eclampsia biochem screen: FBE, UEC, LFT, UA
Fetal assessment for pre-eclampsia
- Fetal movement
- CTG (Cardiotocography: to assess fetal HR)
- U/S for AFI (Amniotic Fluid Index)
Management of pre-eclampsia
- IVC, path
- Control HTN
- Seizure prophylaxis
- *Mg sulphate** (diaz not appropriate)
- slows neuromuscular conduction and decreases CNS irritability
- fetal neuroprotective effect if anticipating pre-term birth*
- Fetal maturation
- maternal corticosteroid administration for 24 - 34+6 weeks gestation for those at risk of preterm birth within 7 days*
- Strict FBC*
- Continuous fetal monitoring (CTG)*
- Birth plan*
Define eclampsia
The development of seizures usually with pre-existing pre-eclampsia
- Life threatening
Management of eclampsia
- Control seizures with Magnesium sulphate (not diazepam)
- Control HTN with labetolol, nifedipine or hydrazazine
- Stabilising woman is primary goal over fetus
- Evaluate for stabalisation and immediate delivery
What is HELLP syndrome?
A subset of women with severe pre-eclampsia characterised bu
Haemolysis
Elevated Liver enzymes
Low Platelets
What are the 4 main hypertensive disorders in pregnancy
- *Chronic Hypertension**
- hypertension (>140/80mmHg) that predates the pregnancy or is diagnosed prior to 20 weeks gestation
- *Gestational Hypertension**
- New onset of hypertension after 20 weeks gestation.
- No assoiated signs of pre-eclampsia
- Should resolve within 6 months of birth
- *Pre-eclampsia/Eclampsia**
- >20 weeks gestation, proteinuria and evidence of end organ compromise.
- End organ compromise may manifest as CNS symptoms, hepatic dysfunction, renal insufficiency, pulmonary oedema.
- Eclampsia = new onset of seizures in the setting of pre-eclampsia
- *Pre-eclampsia superimposed in chronic hypertension**
- Pre-eclampsia in women with chronic hypertension.
- Higher risk of adverse outcomes
