PREGNANCY EMERGENCIES AFTER 20 WEEKS GESTATION AGE

Question 1

MANAGEMENT

Answer 1

GENERAL MEASURMENTS

Maternal Resuscitation takes precedence

Treat hypotension in normal fashion: 1-2 L bolus of crystalloid

Place patient in LATERAL TILT POSITION or manually displace the uterus to the left

Initiate a massive transfusion protocol if hemodynamic stability is not achieved with 2-4 units of packed red blood cells (PRBC)

If 23+0 and 36+6 weeks GA give (Previa):
Betamethasone 12 mg IM q 24 h x 2 doses
Dexamethasone 6 mg IM q 12 h x 4 doses

If 23-32 weeks GA (PROM):
MgSO4 4 g IV x 1 over 30 minutes

If systolic BP ≥160 mm Hg or diastolic BP ≥110 mm Hg:

Labetalol 20 mg IV
OR
Hydralazine 5-10 mg IV OR
Immediate-release nifedipine 10-20 mg PO

RhoGAM 300 μg as a one-time IM to Rh-negative women

Seizure Prophylaxis:
4-6 g IV given over 10-20 minutes followed by continuous infusion of 2 g/h.
If the patient seizes, give an additional 2 g IV bolus.
Assess Fetal Heart Rate

Immediately notify Obstetrics or Neonatology / Pediatrics

Definitive Treatment for the unstable pregnant patient after 20 weeks is Delivery (usually C-Section)

INVESTIGATIONS
Blood Pressure
BP ≥140 mm Hg or diastolic BP ≥90 mm Hg warrants further investigation in the ED, even if the patient is asymptomatic.

Significantly elevated BP (systolic ≥160 or diastolic ≥110 mm Hg) must be controlled quickly to reduce the risk of stroke.

Creatinine

LFT’s

CBC

Type and Cross

Coags

Fibrinogen Level

Beta HCG

Urinalysis:
Urine protein or
urine protein:creatinine ratio

Transabdominal Ultrasound

Question 2

CRITICAL DDx

Answer 2

Preeclampsia/Eclampsia
Placental Abruption
Placentia Previa
Vasa Previa
Prelabour Rupture of Membranes

Question 3

DOCUMENTATION

Answer 3

Trauma

Vaginal Bleeding
Fluid Loss
Pelvic Pain
Contractions

RUQ / Epigastric Pain
Headaches
Blurred Vision
Shortness of Breath
Sudden Onset leg swelling
New onset petichial rash
Seizures

OBGYN History
BP History