Chapter 61. Emergencies after 20 Weeks of Pregnancy and the Postpartum Period

Continuous fetal monitoring is essential for the evaluation of a mother and fetus during the second half of a woman's pregnancy and should be implemented when assessing all the conditions discussed in this chapter.

Abruptio placentae, placenta previa, and preterm labor are the most common causes of vaginal bleeding during the second half of pregnancy.

Clinical Features

Abruptio Placentae

Abruptio placentae, the premature separation of the placenta from the uterine wall, must be considered in all pregnant females near term who present with painful vaginal bleeding. Clinical features include vaginal bleeding, abdominal pain, uterine tenderness, hypertonic contractions, increased uterine tone, fetal distress, and, in severe cases, disseminated intravascular coagulation (DIC), and fetal and/or maternal death. Vaginal bleeding may be mild or severe, depending on whether the area of abruption communicates to the cervical os. Abruption of greater than 50% of the placenta usually results in fetal demise.

Placenta Previa

Placenta previa is the implantation of the placenta over the cervical os. Clinical features include painless, bright red vaginal bleeding. The amount of bleeding is frequently large as opposed to normal “bloody show,” when a small amount of bright red blood and mucous are passed.

Diagnosis and Differential

Transabdominal ultrasound should be obtained to prior to performing speculum or digital pelvic examination to differentiate abruption placenta from placenta previa as it is contraindicated in previa. Ultrasound is very sensitive in detecting placenta previa but has limited sensitivity in diagnosing abruption placenta.

Emergency Department Care and Disposition

1. Hemodynamic instability is managed with IV normal saline or leukoreduced packed red blood cells.

2. Obtain emergent obstetric consultation, CBC, type and crossmatching, baseline coagulation studies, electrolyte studies on all patients.

3. Obtain a DIC profile on patients with suspected abruptio placentae.

4. Give Rh (D) immune globulin 300 micrograms IM to Rh-negative patients.

5. Patients with abruptio placentae or placenta previa may need emergent caesarean delivery.

6. Tocolytics should not be used in patients with suspected abruption.

Premature Rupture of Membranes

Premature rupture of membranes (PROM) is rupture of membranes before the onset of labor. Clinical presentation is a rush of fluid or continuous leakage of fluid from the vagina. Diagnosis is confirmed by finding a pool of fluid in the posterior fornix with pH greater than 7.0 (dark blue on Nitrazine paper) and ferning pattern on smear. Sterile speculum examination may be done; however, digital pelvic examination should be avoided because it increases the rate of infection. Tests for chlamydia, gonorrhea, bacterial vaginosis, and group B Streptococcus should be performed. Management of PROM depends on gestational age and maturity of the fetus, condition of the fetus, concern for infection, and presence of other complicating factors. An obstetrics consultation should be obtained to assist with treatment and admission decisions.

Clinical Features and Diagnosis

Preterm labor is defined as labor before 37 weeks' gestation. Clinical features include regular uterine contractions with effacement of the cervix. The diagnosis is made by fetal monitoring and sterile speculum examination. Cervical fluid should be examined for possible PROM. Only after premature rupture of membranes and placenta previa have been excluded, should digital examination be performed; use sterile gloves. Tests for chlamydia, gonorrhea, bacterial vaginosis, and group B streptococci are obtained. Ultrasound should be obtained for fetal age, weight, anatomy, amniotic fluid level, but obstetric consultation should not be delayed awaiting results.

Emergency Department Care and Disposition

1. Mother and fetus are monitored.

2. An obstetrician is consulted for admission and decision regarding tocolytics.

3. If tocolytics are initiated, the mother should receive glucocorticoids to hasten fetal lung maturity. Dexamethasone 6 milligrams IM is commonly used.

4. Tocolytics are not used if abruptio placenta is suspected.

5. Gestational age younger than 34 weeks is associated with poorer outcomes; if possible, the patient should be transferred to a tertiary care center with a high-risk intensive care unit.

Hypertension in pregnancy may be chronic due to preexisting hypertension, transient (gestational), or preeclampsia. Hypertension with pregnancy is associated with preeclampsia, eclampsia, HELLP (Hemolysis, Elevated Liver enzymes, and Low Platletes) syndrome, abruptio placenta, preterm birth, and low-birthweight infants.

Clinical Features

Hypertension in pregnancy is defined as a systolic blood pressure ≥ 140 mm Hg or diastolic ≥ 90 mm Hg based on the average of at least two measurements in a woman who was normotensive prior to 20 weeks' of gestation. Preeclampsia is characterized by hypertension (greater than 140/90 mm Hg) and proteinuria (≥ milligrams/24 h) in patients 20 weeks' gestation until 4 to 6 weeks after delivery. Edema may or may not be present. Symptoms of severe preeclampsia reflect end-organ involvement and may include headache, visual disturbances, mental status changes, edema, oliguria, dyspnea (pulmonary edema) and abdominal pain. Eclampsia is preeclampsia with seizures. HELLP syndrome is probably a clinical variant of preeclampsia. Patients usually complain of abdominal pain, especially epigastric and right upper quadrant pain. Because the blood pressure is not always elevated, HELLP syndrome should be considered in the evaluation of all pregnant women (> 20 weeks' gestation) with abdominal pain.

Diagnosis and Differential

Preeclampsia is a clinical diagnosis. The following laboratory abnormalities may be seen in severe preeclampsia: anemia, thrombocytopenia, elevated creatinine, elevated liver enzymes, elevated LDH. The HELLP variant is diagnosed by laboratory tests: schistocytes on peripheral smear, platelet count lower than 150,000/mL, elevated aspartate aminotransferase and alanine aminotransferase levels. The differential diagnosis of preeclampsia includes worsening of preexisting hypertension, transient hypertension, renal disease, fatty liver disease of pregnancy, and coagulation disorders. A CT scan of the pelvis and abdomen should be done if concerns for subcapsular hematoma exist.

Emergency Department Care and Disposition

1. Severe preeclampsia or eclampsia is treated with a magnesium sulfate loading dose of 4 to 6 grams over 20 min, followed by a maintenance infusion of 1 to 2 grams/h to prevent seizure. Serum magnesium and reflexes must be monitored.

2. Severe hypertension (> 160/110 mm Hg) is treated with labetalol 20 milligrams IV initial bolus, followed by repeat boluses of 40 to 80 milligrams, if needed, to a maximum of 300 milligrams for blood pressure control or hydralazine 5.0 milligrams initially, followed by 5 to 10 milligrams IV every 10 min.

3. Consult an obstetrician emergently for severe preeclampsia or eclampsia.

4. All patients with a sustained systolic blood pressure ≥ 140 mm Hg or diastolic ≥ 90 mm Hg plus any symptoms of preeclampsia should be hospitalized.

5. Definitive treatment requires delivery of the fetus.

The differential diagnosis of hemorrhage in the first postpartum day includes uterine atony (most common), uterine rupture, laceration of the lower genital tract, retained placental tissue, uterine inversion, and coagulopathy. After the first 24 hours, retained products of conception, uterine polyps, or coagulopathy such as von Willebrand disease are more likely causes. An enlarged and “doughy” uterus suggests uterine atony; a vaginal mass suggests an inverted uterus. Bleeding despite good uterine tone and size may indicate retained products of conception or uterine rupture. The vagina and cervix must be inspected for lacerations. The first priority of ED management is stabilization of the patient with crystalloid IV fluids and/or leukoreduced packed red blood cells, if needed. CBC, clotting studies, and type and crossmatching must be obtained. Uterine atony is treated with uterine massage and oxytocin 20 units/L NS at 200 mL/h. Minor lacerations may be repaired in the ED. Extensive lacerations, retained products of conception, uterine inversion, or uterine rupture require emergency operative treatment by the obstetrician.

Postpartum endometritis is a polymicrobial infection with symptoms that usually begin several days after delivery. Clinical features include fever, lower abdominal pain, and foul-smelling lochia. Physical examination reveals uterine or cervical motion tenderness and discharge. CBC, urinalysis, and cervical cultures should be obtained. Admission for antibiotic treatment is indicated for most patients. Antibiotic regimens include clindamycin 450 to 900 milligrams IV every 8 hours plus gentamicin 1.5 milligrams/kilogram IV every 8 hours or cefoxitin 1 to 2 gram IV every 6 hours.

Mastitis is cellulitis of the periglandular breast tissue. Clinical features include swelling, redness, and tender engorgement of the involved portion of the breast, with or without fever and chills. Milk stasis presents similarly, except it lacks erythema, fever, or chills. For cellulitis, initiate treatment with dicloxacillin 500 milligrams orally 4 times daily or cephalexin 500 milligrams orally 4 times daily. Clindamycin 300 milligrams PO every 6 hours may be used in patients with penicillin allergy or if concerns about MRSA exist. Oral analgesics may be needed. Patients should continue nursing on the affected breast, however, in cases of purulent discharge, the mother should pump and discard the milk rather than nurse. Differentiate mastitis from breast abscess using bedside ultrasound.

Amniotic fluid embolism is a sudden, catastrophic illness with mortality rates of 60% to 80%. Clinical features include sudden cardiovascular collapse with hypoxemia, seizures (often a presenting sign), and DIC. Intensive management for cardiovascular collapse and DIC is indicated.