Ectopic Pregnancy

  • Transvaginal ultrasound is the diagnostic tool of choice for tubal ectopic pregnancy.
  • Tubal ectopic pregnancies should be positively identified, if possible, by visualising an adnexal mass that moves separate to the ovary.
  • A serum beta-human chorionic gonadotrophin (β-hCG) level is useful for planning the management of an ultrasound visualised ectopic pregnancy.
  • Expectant management is an option for clinically stable women with an ultrasound diagnosis of ectopic pregnancy and a decreasing β-hCG level initially less than 1500 iu/l.
  • Systemic methotrexate may be offered to suitable women with a tubal ectopic pregnancy. It should never be given at the first visit, unless the diagnosis of ectopic pregnancy is absolutely clear and a viable intrauterine pregnancy has been excluded.
  • Surgical methods of management are associated with a high failure rate and should be reserved for those women suffering life-threatening bleeding.
  • Offer anti-D prophylaxis as per national protocol to all RhD-negative women who have surgical removal of an ectopic pregnancy, or where bleeding is repeated, heavy or associated with abdominal pain.

 

The Pregnant Peritonitis

appendix-in-pregnancy

  • The gravid uterus can mask the signs of peritoneal irritation (guarding, rigidity and rebound tenderness) by preventing the inflamed organ from contacting the peritoneum.
  • Due to increased white blood cells that naturally occur during pregnancy, leukocytosis is not helpful in identifying acute pathology.
  • A relative increase in blood volume can delay the development of tachycardia and hypotension in the truly ill patient.
  • Consider appendicitis in the patient complaining of typical signs and symptoms of appendicitis even if confounded by right middle and upper quadrant abdominal pain, pyuria, urinary symptoms and subtle signs of peritonitis.
  • HELLP syndrome is managed with blood pressure control, prevention of seizures, correction of coagulopathy, and delivery of the fetus.
  • Radiological investigations, including abdominal plain films, can be safely undertaken during pregnancy and should always be considered so as to avoid delays and failures in diagnosing potentially life-threatening conditions.

 

read-more

Peri-Mortem C-Section

perimortem-cs

How to perform a PCS:

  • Make a vertical incision from xiphoid to the pubis using a scalpel (ideally #10 Blade)
  • Cut through subcutaneous tissue to get to peritoneal wall
  • Use fingers to bluntly dissect to the peritoneum
  • Cut through peritoneum vertically (ideally with scissors or use a scalpel to initiate an opening inferiorly)
  • Deliver the uterus, then cut into the lower half of the uterus vertically to avoid the placenta and then use scissors to extend the incision upwards until you reach the baby
  • Deliver the baby (neonate will likely need resuscitation)
  • Clamp and cut the umbilical cord
  • Place packing/towels in the opened uterus and abdomen

read-more

Third trimester bleeding…

vaginal-bleeding

The most concerning causes of third trimester bleeding include placental abruption, placenta previa, and vasa previa. Any pregnant woman presenting with a loss of 500cc of bright red blood should be taken to the operating room immediately, as this can be indicative of placental abruption.

read-more

Trauma in the 3rd Trimester

Trauma in the 3rd Trimestre

  • Any resuscitative efforts geared toward optimizing the medical management of the pregnant mother will optimize the fetal well-being.
  • Provide high oxygen flow to compensate for the pregnancy-based predisposition toward hypoxia.
  • Aggressive IV fluids administration, since blood pressure and pulse are not a reliable indicator of impending cardiovascular collapse during pregnancy.
  • Avoid having the gravid uterus compressing the inferior vena cava with left-sided upward tilt, wedge displacement, or manual displacement.
  • Avoid femoral lines that could be impeded by a gravid uterus.
  • Administer prophylactic dose of Rhogam to all Rh-negative mothers with abdominal trauma.
  • Peri-mortem C-section should be considered within 5 minutes of witnessed cardiac arrest.

Ovarian Torsion

Abdominal pain

The most common presenting symptom is pelvic pain followed by the history of or a palpable adnexal mass on physical exam. Patients typically present 1 to 3 days after onset, although patients with intermittent torsion can present at any time. Abdominal pain can be characterized as sharp, stabbing, and colicky, and it can possibly radiate to the flank, back, or into the pelvis and upper thigh.

HELLP Syndrome

hellp-syndrome-3-638

  • Any pregnant lady in late second or third trimester C/O malaise – Think HELLP (BP may be normal)
  • Treatment of HELLP syndrome is seizure prevention with MgSO4 and controlling BP
  • Getting OBGYN involved early is important to decide on the definitive treatment
  • HELLP by itself is not an indication for LSCS unless there are co-existing materal/fetal indications/distress

The Pregnant Patient

Teenage-Pregnancies-in-Kenya1-321x214

Modifications of assessment of trauma patients in presence (or suspect) of pregnancy

  1. When indicated a thoracostomy tube should be inserted 1 or 2 intercostal spaces upper than usual.
  2. Vasopressors has to be avoided in pregnancy.
  3. Perform L.U.D (Lateral Uterus Displacement) to relieve Inferior Vena Cava compression.
  4. Transport the severely injuried pregnant patient to an hospital with maternal facility if fetus is viable (≥ 23 weeks).

Resuscitation of the pregnant trauma patient

  1. The utilization of mechanical chest compressors is not recommended.
  2. Continuous LUD should be performed during resuscitation.
  3. No modification in energy level when electrical therapy is needed.
  4. No modification in timing and doses of ACLS drugs.
  5. Fetal assessment is not indicated during resuscitation.
  6. Peri Mortem Cesarean Delivery (PMCD) has to be performed without delay and at the site of cardiac arrest (no transport is indicated), after 4 minutes of ineffective resuscitation attempts.