It is important to Differential Diagnosis between Preeclampsia and SLE (systemic lupus sclerosis) in pregnancy because management is totally different.
SLE shows itself by:
- Hypertension in a pregnant woman in the setting of
o Massive proteinuria
o Malar rash
o Positive ANA titer
- Also pay attention to thse facts:I
- In SLE is especially at the point of hypertension, we would have Glomerulonephritis.
- SLE very rarely starts in pregnancy, so look for the history. (They sometimes provide you with history of positive signs and symptoms not the actual disease)
Treatment of SLE in pregnancy: Do not be aggressive, you can control it and save the baby.
Wednesday, September 19, 2007
Signs and Symptoms of Magnesium Sulfate toxicity
In order:
- Depressed DTR (deep tendon reflex) is the first sign for Magnesium Sulfate toxicity which requires stopping it and administration of Calcium Gluconate.
- Respiratory depression
- Coma
- Cardiac arrest
- Death.
- Depressed DTR (deep tendon reflex) is the first sign for Magnesium Sulfate toxicity which requires stopping it and administration of Calcium Gluconate.
- Respiratory depression
- Coma
- Cardiac arrest
- Death.
Eclampsia
Presentation: It is very easy to diagnose, as it shows itself by a generalized Tonic-Clonic seizure that manifest like grand mal, in a pregnant patient.
I know there are some other signs and symptoms, but knowing these two, you can both make the diagnosis of eclampsia and determine the management method, so do not waste time!
It occurs 25% Before Labor, 50% During Labor 25% After Delivery.
Attention: In post delivery seizure, rule out eclampsia, as well as other causes (drugs effect, …)
Attention: Most common etiology of death in Eclampsia is Hemorrhagic stroke due to Hypertension and thrombocytopenia.
I know there are some other signs and symptoms, but knowing these two, you can both make the diagnosis of eclampsia and determine the management method, so do not waste time!
It occurs 25% Before Labor, 50% During Labor 25% After Delivery.
Attention: In post delivery seizure, rule out eclampsia, as well as other causes (drugs effect, …)
Attention: Most common etiology of death in Eclampsia is Hemorrhagic stroke due to Hypertension and thrombocytopenia.
Preeclampsia
Do you really think that in the exam they provide you with a case with a pregnant woman with high blood pressure, edema and proteinuria who does not have any other problem and they want you to pick the answer, and you will happily choose Preeclampsia?
I wish the exam was like this ;)
The main point in Preeclampsia questions is to differentiate Mild Preeclapsia and Severe Preeclampsia from each other as the management is different.
This sentence is not correct but let me say it, I think in the exam it is more important to different Mild and Sever Preeclampsia form each other than differentiating Severe Preeclampsia from Eclampsia.
Criteria to diagnose Mild Preeclampsia are:
- Blood pressure of higher or equal of 140/90
- Proteinuria less than 3 gr. (and ofcourse more than 300 mg.)
Criteria to diagnose sever Preeclampsia are:
- Blood Pressure higher or equal to 190/110
- Proteinuria more than 3 gr.
- Having any of the following symptoms:
- Oligurea
- Blured Vision
- Epigastric pain
The most important complication of Preeclampsia is Eclampsia, due to cerebral vasospasm and resultant cerebral hypoxemia.
Treatment of Preeclampsia:
In Patient with Mild Preeclampsia:
The point here is to take care of the patient until she gets to 36 week of pregnancy and it would be safe to deliver at that time. So if the patient gestational age is less than 36 weeks, you need to be conservative and if it is more than 36 you need to be aggressive.
Seizure prophylaxis is performed during labor, delivery and within 24 hrs after delivery
In Patient with Severe Preeclampsia:The point here is that you need to be always aggressive. There is no room to waste the time, mom is in danger so rush and be aggressive.
I wish the exam was like this ;)
The main point in Preeclampsia questions is to differentiate Mild Preeclapsia and Severe Preeclampsia from each other as the management is different.
This sentence is not correct but let me say it, I think in the exam it is more important to different Mild and Sever Preeclampsia form each other than differentiating Severe Preeclampsia from Eclampsia.
Criteria to diagnose Mild Preeclampsia are:
- Blood pressure of higher or equal of 140/90
- Proteinuria less than 3 gr. (and ofcourse more than 300 mg.)
Criteria to diagnose sever Preeclampsia are:
- Blood Pressure higher or equal to 190/110
- Proteinuria more than 3 gr.
- Having any of the following symptoms:
- Oligurea
- Blured Vision
- Epigastric pain
The most important complication of Preeclampsia is Eclampsia, due to cerebral vasospasm and resultant cerebral hypoxemia.
Treatment of Preeclampsia:
In Patient with Mild Preeclampsia:
The point here is to take care of the patient until she gets to 36 week of pregnancy and it would be safe to deliver at that time. So if the patient gestational age is less than 36 weeks, you need to be conservative and if it is more than 36 you need to be aggressive.
Seizure prophylaxis is performed during labor, delivery and within 24 hrs after delivery
In Patient with Severe Preeclampsia:The point here is that you need to be always aggressive. There is no room to waste the time, mom is in danger so rush and be aggressive.
Main Differential Diagnosis of HELLP in USMLE Questions
I really do not have any idea what the main or the most common differential diagnosis of HELLP syndrome is, but in the USMLE questions, I always tried to rule out Hemolytic Uremic Syndrome (HUS). To me HUS was the most challenging part, as you have very short time to read the question completely and both have Hemolysis, it is kinds of challenging, isn’t it?
Is that it? No… now check this out, in HUS you have Uremia (in the question high BUN, and high Cr). In the HELLP syndrome you will see rise in BUN and Cr! Damn it!
Is that is? Still now! … In HUS you do have Low Platelet, exactly like HELLP syndrome”
So just pay attention to these facts:
- In HUS usually there is a history of gastro-enteritis or Urethritis.
- In HUS, we could have complications like thrombosis of odds vessels (Budd chiari Syndrome)
Oops! I forgot to tell you that pregnant women can eat hamburger and can get HUS! So pregnancy does not rule out HUS ;)
By the way I just checked this out, the most common differential diagnoses of HELLP syndrome are:
- DIC
- Preeclampsia
- TTP (Transient Thrombocytopenic Purpura), Don’t worry about this, you will see confusion (mental status change) in it, so you won’t miss it.
- HUS
- Acute Fatty Liver of Pregnancy
Is that it? No… now check this out, in HUS you have Uremia (in the question high BUN, and high Cr). In the HELLP syndrome you will see rise in BUN and Cr! Damn it!
Is that is? Still now! … In HUS you do have Low Platelet, exactly like HELLP syndrome”
So just pay attention to these facts:
- In HUS usually there is a history of gastro-enteritis or Urethritis.
- In HUS, we could have complications like thrombosis of odds vessels (Budd chiari Syndrome)
Oops! I forgot to tell you that pregnant women can eat hamburger and can get HUS! So pregnancy does not rule out HUS ;)
By the way I just checked this out, the most common differential diagnoses of HELLP syndrome are:
- DIC
- Preeclampsia
- TTP (Transient Thrombocytopenic Purpura), Don’t worry about this, you will see confusion (mental status change) in it, so you won’t miss it.
- HUS
- Acute Fatty Liver of Pregnancy
HELLP Syndrome
Presentation: As it is a syndrome, we need to have bunch of different unrelated signs and symptoms. So here are the criteria:
HELLP
H: Hemolysis
EL: Elevated Liver enzymesLP: Low Platelet
Treatment of HELLP Syndrome:
- Main cobblestone in treatment of HELLP syndrome, is Exchange Transfusion or Plasmapheresis with FFPDelivery is definitive treatment for HELLP in women beyond 34 weeks, give MgSO4 to reduce blood pressure and vaginally deliver the baby.
HELLP
H: Hemolysis
EL: Elevated Liver enzymesLP: Low Platelet
Treatment of HELLP Syndrome:
- Main cobblestone in treatment of HELLP syndrome, is Exchange Transfusion or Plasmapheresis with FFPDelivery is definitive treatment for HELLP in women beyond 34 weeks, give MgSO4 to reduce blood pressure and vaginally deliver the baby.
Differential Diagnosis of High Blood Pressure in Pregnancy
When a pregnant woman comes with high blood pressure, we need to think of 6 specific differential diagnoses:
- Transient Hypertension
- Chronic Hypertension
- Pre-eclampsia
- Eclampsia
- Chronic Hypertension with superimposed gestational Hypertension
- HELLP syndrome
- Transient Hypertension
- Chronic Hypertension
- Pre-eclampsia
- Eclampsia
- Chronic Hypertension with superimposed gestational Hypertension
- HELLP syndrome
Why Rh Antibody is more important than ABO in Pregnancy?
Do you really think that it is because Rh Antibody are more immunologic than ABO ones? Ofcourse not! Just think about a patient that has received a non-matched blood transfusion, and see how dangerous that could be. So ABO Antibodies are even more immunologic than Rh ones.
The reason is that Antibodies to ABO antigens belong to IgM antibody class so they do not cross placenta and hence mother and baby can have different blood type. But Anti-D antibodies (the major part of Rh Antibodies) that are responsible for Rh alloimmunization belong to IgG class and do cross placenta.
The reason is that Antibodies to ABO antigens belong to IgM antibody class so they do not cross placenta and hence mother and baby can have different blood type. But Anti-D antibodies (the major part of Rh Antibodies) that are responsible for Rh alloimmunization belong to IgG class and do cross placenta.
Differential Diagnosis of Hypertension after 20 week of pregnancy
When a pregnant woman shows up with hypertension in the third trimester or even after the 20th week of pregnancy, on the top of our list we need to think of:
- Pre-eclampsia (Proteinuria >300 mg)
- Transient Hypertension (Is not accompanied by Proteinuria or it is less than 300 mg)
Ofcourse we need to consider other causes like eclampsia, HELLP Syndrome, etc, as well, however these diagnosis need specific other criteria that should have been mentioned in the exam. (Seizure, Hemolysis, Elevated Liver Enzymes, Low Platelet, …)
- Pre-eclampsia (Proteinuria >300 mg)
- Transient Hypertension (Is not accompanied by Proteinuria or it is less than 300 mg)
Ofcourse we need to consider other causes like eclampsia, HELLP Syndrome, etc, as well, however these diagnosis need specific other criteria that should have been mentioned in the exam. (Seizure, Hemolysis, Elevated Liver Enzymes, Low Platelet, …)
Differential Diagnosis of Hypertension before 20 week of pregnancy
When a pregnant woman shows up with hypertension in the first trimester or even within the first 20 weeks, on the top of our list we need to think of:
- Molar Pregnancy
- Chronic Hypertension
Rule out Molar pregnancy and the diagnosis of chronic hypertension can be made. Lack of “Snow Storm” in ultrasound will rule out molar pregnancy.
- Molar Pregnancy
- Chronic Hypertension
Rule out Molar pregnancy and the diagnosis of chronic hypertension can be made. Lack of “Snow Storm” in ultrasound will rule out molar pregnancy.
Bilateral Lower Extremity Edema in Pregnancy
Bilateral edema of lower extremities in pregnancy is most commonly a benign problem.
Attention: Pre-eclampsia should be suspected if the edema is associated with hypertension or proteinuria
Attention: Pre-eclampsia should be suspected if the edema is associated with hypertension or proteinuria
Epridural Anesthesia and Pregnancy
Question: 27 year old patient, G1 P0, is right now in the labor, after receiving the epidural Anesthesia, gets hypotensive, what is the reason?
Answer: Blood Redistribution and venous pooling. Basically because of loss of autonomic effect, blood traps in the lower extremity and consequently patient gets hypotensive
Answer: Blood Redistribution and venous pooling. Basically because of loss of autonomic effect, blood traps in the lower extremity and consequently patient gets hypotensive
Treatment of Graves Disease in Pregnancy
As you may know the main part of treatment of Graves Disease in US in non-pregnant patients is radioactive Iodine, however in Pregnancy using radioactive Iodine is contraindicated, so surgery is considered the main part.
Attention: If Grave’s Disease is being left untreated, there is a chance of Thyrotoxoicosis due to passage of Thyroid Stimulating Immunoglobin (TSI) across the placenta.
Attention: If Grave’s Disease is being left untreated, there is a chance of Thyrotoxoicosis due to passage of Thyroid Stimulating Immunoglobin (TSI) across the placenta.
Normal Laboratory Changes in Pregnancy
In pregnancy body fluid (water) increases, so many lab tests can be predicted upon this simple fact.
Blood changes in pregnancy:
- RBC is increased during pregnancy
- Plasma volume is increased during pregnancy
- Hemoglobin and Hematocrit are decreased during pregnancy, as the plasma volume increase is much more than the RBC increase
Cardiac (Heart) changes during pregnancy:
- Stroke Volume increases during pregnancy
- Heart Rate increases during pregnancy
- Cardiac Output increases during pregnancy
Pulmonary changes during pregnancy:
- I have forgotten this, so I will write it later ???
Thyroid Changes during pregnancy:
The important part here is to know that proteins and subsequently globulins are increased during pregnancy, so:
- TBG (Thyroxine Binding Globulin) increases during pregnancy
- Total T4 and Total T3 during pregnancy (these are because of increase in TBG)
- Free T4 and overall Thyroid Function is remain the same.
Renal changes during pregnancy:
- Cr (Creatine) decreases during pregnancy
- BUN (Blood Urea Nitrogen) also decreases during pregnancy
Attention: Do not forget, as I just mentioned most of the things are based on Plasma Volume change (increase) during pregnancy.
Attention: Upon knowing this fact, never ever high BUN or Cr, is considered normal during pregnancy!
Alkaline Phosphates increases during pregnancy.
Blood changes in pregnancy:
- RBC is increased during pregnancy
- Plasma volume is increased during pregnancy
- Hemoglobin and Hematocrit are decreased during pregnancy, as the plasma volume increase is much more than the RBC increase
Cardiac (Heart) changes during pregnancy:
- Stroke Volume increases during pregnancy
- Heart Rate increases during pregnancy
- Cardiac Output increases during pregnancy
Pulmonary changes during pregnancy:
- I have forgotten this, so I will write it later ???
Thyroid Changes during pregnancy:
The important part here is to know that proteins and subsequently globulins are increased during pregnancy, so:
- TBG (Thyroxine Binding Globulin) increases during pregnancy
- Total T4 and Total T3 during pregnancy (these are because of increase in TBG)
- Free T4 and overall Thyroid Function is remain the same.
Renal changes during pregnancy:
- Cr (Creatine) decreases during pregnancy
- BUN (Blood Urea Nitrogen) also decreases during pregnancy
Attention: Do not forget, as I just mentioned most of the things are based on Plasma Volume change (increase) during pregnancy.
Attention: Upon knowing this fact, never ever high BUN or Cr, is considered normal during pregnancy!
Alkaline Phosphates increases during pregnancy.
Substance Abuse (Drugs) in Pregnancy
Please just read this once, and try to memorize keywords for example knowing the relation of Cocaine and Abruptio Placenta is fine, read it fast and if you need just take some notes.
Marijuana: Small for Gestational Age (SGA) and Intra Uterine Growth Retardation (IUGR)
Cocaine (crack): Cocaine is a highly addictive drug, and in pregnancy may cause Placental Abruption as well as preterm labor.
Heroin: If heroin is used during pregnancy, it can cause:
- Preterm birth
- Fetal death
- Addiction in the fetus
- Stunted fetal growth
PCP: Many PCP users become violent and out of control. Babies exposed to PCP during pregnancy may be smaller than normal, and have poor muscle control.
Ketamine during the pregnancy may cause behavioral or learning problems.
LSD during pregnancy: LSD users may have violent behavior and flashbacks. During pregnancy, use of LSD may lead to birth defects in the baby.
Glues and Solvents: Sniffing of Glues and solvents may cause different birth defects:
- Short height
- Low Birth weight
- Small head
- Joints problems
- Limbs problems
- Abnormal facial features
- Heart defects
Amphetamines: Amphetamines during pregnancy can prevent mom from getting enough nutrients, so it can interfere in normal growth of fetus. Also Amphetamine use can cause placental abruption or even fetal death.
Ecstasy: Using ecstasy in pregnancy may cause long-term learning and memory problems.
Marijuana: Small for Gestational Age (SGA) and Intra Uterine Growth Retardation (IUGR)
Cocaine (crack): Cocaine is a highly addictive drug, and in pregnancy may cause Placental Abruption as well as preterm labor.
Heroin: If heroin is used during pregnancy, it can cause:
- Preterm birth
- Fetal death
- Addiction in the fetus
- Stunted fetal growth
PCP: Many PCP users become violent and out of control. Babies exposed to PCP during pregnancy may be smaller than normal, and have poor muscle control.
Ketamine during the pregnancy may cause behavioral or learning problems.
LSD during pregnancy: LSD users may have violent behavior and flashbacks. During pregnancy, use of LSD may lead to birth defects in the baby.
Glues and Solvents: Sniffing of Glues and solvents may cause different birth defects:
- Short height
- Low Birth weight
- Small head
- Joints problems
- Limbs problems
- Abnormal facial features
- Heart defects
Amphetamines: Amphetamines during pregnancy can prevent mom from getting enough nutrients, so it can interfere in normal growth of fetus. Also Amphetamine use can cause placental abruption or even fetal death.
Ecstasy: Using ecstasy in pregnancy may cause long-term learning and memory problems.
Prohibited Medication in Pregnancy
The following list is a very complete list however you do not need to know all of them for USMLE, just read it once, what ever sticks your memory would be fine:
ACE inhibitors (eg, captopril, enalapril) - D
Acetohydroxamic acid (AHA) - X
Aminocaproic acid - D
Androgens (eg, Danazol) - X
Angiotensin II receptor antagonists (eg, losartan, valsartan) - D
Antineoplastics (alkylating agents) - D
Antineoplastics (antimetabolites) - X
5-Fluorouracil
Methotrexate
Methylaminopterin
Cytarabine
Aminoglycosides (eg, gentamicin, streptomycin) - D
Aspirin - D
Busulfan
Chlorambucil
Azathioprine
Cyclophosphamide
Mechlorethamine
Cisplatin
Bleomycin
Atenolol - D
Benzodiazepines - D and X
Flurazepam (X)
Temazepam (X)
Triazolam (X)
Bromides - D
Carbamazepine - D
Colchicine - D
Corticosteroids - C
Danazol - X
Diethylstilbestrol - Not on market
Ergotamine - X
Finasteride - X
Fluconazole - C
Folic acid antagonists
Phenytoin - D
Methotrexate - X
Lithium - D
Methimazole - D
Methylene blue - C
Mifepristone, RU-486 - D
Minoxidil - C
Misoprostol - X
Mysoline - D
Penicillamine - D
Phenobarbital or methylphenobarbital - D
Potassium iodine and medications that effect iodine levels (diatrizoate) - D
Progestins - X (except megestrol and norethindrone - D)
Raloxifene (Evista) - X
Retinoic acid, isotretinoin (Accutane), acitretin (Soriatane), etretinate, topical tazarotene - X
Statins (3-hydroxy-3-methylglutaryl coenzyme A [HMG-CoA] reductase inhibitors) - X
Tamoxifen - D
Tetracycline - D
Thalidomide - X
Valproic acid - D Warfarin - X
ACE inhibitors (eg, captopril, enalapril) - D
Acetohydroxamic acid (AHA) - X
Aminocaproic acid - D
Androgens (eg, Danazol) - X
Angiotensin II receptor antagonists (eg, losartan, valsartan) - D
Antineoplastics (alkylating agents) - D
Antineoplastics (antimetabolites) - X
5-Fluorouracil
Methotrexate
Methylaminopterin
Cytarabine
Aminoglycosides (eg, gentamicin, streptomycin) - D
Aspirin - D
Busulfan
Chlorambucil
Azathioprine
Cyclophosphamide
Mechlorethamine
Cisplatin
Bleomycin
Atenolol - D
Benzodiazepines - D and X
Flurazepam (X)
Temazepam (X)
Triazolam (X)
Bromides - D
Carbamazepine - D
Colchicine - D
Corticosteroids - C
Danazol - X
Diethylstilbestrol - Not on market
Ergotamine - X
Finasteride - X
Fluconazole - C
Folic acid antagonists
Phenytoin - D
Methotrexate - X
Lithium - D
Methimazole - D
Methylene blue - C
Mifepristone, RU-486 - D
Minoxidil - C
Misoprostol - X
Mysoline - D
Penicillamine - D
Phenobarbital or methylphenobarbital - D
Potassium iodine and medications that effect iodine levels (diatrizoate) - D
Progestins - X (except megestrol and norethindrone - D)
Raloxifene (Evista) - X
Retinoic acid, isotretinoin (Accutane), acitretin (Soriatane), etretinate, topical tazarotene - X
Statins (3-hydroxy-3-methylglutaryl coenzyme A [HMG-CoA] reductase inhibitors) - X
Tamoxifen - D
Tetracycline - D
Thalidomide - X
Valproic acid - D Warfarin - X
Complications of Excessive use of Oxytocin in Labor
Oxytocin acts like ADH (AntiDiuretic Hormone) so it may cause water retention, hyponatremia and even consequently seizure (it is sometimes called water intoxication)
Also uterine hyperactivity could the complications. In this case discontinuing the oxytocin and rest could be enough for most of the cases. However Ritodrine may be necessary in refractory cases. Recently it has been shown that an oxytocin antagonist named Atosiban could be used to control Uterine Hyperactivity following using excessive Oxytocin.
Also uterine hyperactivity could the complications. In this case discontinuing the oxytocin and rest could be enough for most of the cases. However Ritodrine may be necessary in refractory cases. Recently it has been shown that an oxytocin antagonist named Atosiban could be used to control Uterine Hyperactivity following using excessive Oxytocin.
Effect of Pregnancy on Different Diseases
Effect of Pregnancy on Graves Disease
- Pregnancy improves the process of Graves Disease.
Effect of Pregnancy on Migraine
- Pregnancy improves the process of Migraine.
Effect of Pregnancy on Peptic Ulcer Disease (PUD)
- Pregnancy improves the process of Peptic Ulcer Disease (PUD)
- Pregnancy improves the process of Graves Disease.
Effect of Pregnancy on Migraine
- Pregnancy improves the process of Migraine.
Effect of Pregnancy on Peptic Ulcer Disease (PUD)
- Pregnancy improves the process of Peptic Ulcer Disease (PUD)
Low Back Pain in Pregnancy
Having Low Back Pain during pregnancy is mostly common in third trimester.
Etiology of low back pain in pregnancy is considered:
- Lordosis
- Relaxation of ligaments
Etiology of low back pain in pregnancy is considered:
- Lordosis
- Relaxation of ligaments
Group B Streptococcal infection Screening in Pregnancy
Epidemiology of Group B streptococcal Infection during pregnancy: Between 10 and 30 percent of pregnant women carry GBS bacteria in the vagina or rectal area, where they may pass it to their babies during labor or birth.
There are 2 completely different methods to look for this and determine who has it and who does not.
Method 1: Screening for group B strep should be done 36-37 week gestation, using swab or urine culture.
Method 2: Any patient with history of positive group B streptococcus infection during this pregnancy and/or previous one.
Treatment of Group B Streptococcal infection during pregnancy is probably to get oral Antibiotic right away and more importantly administering IV Penicillin G during labor.
There are 2 completely different methods to look for this and determine who has it and who does not.
Method 1: Screening for group B strep should be done 36-37 week gestation, using swab or urine culture.
Method 2: Any patient with history of positive group B streptococcus infection during this pregnancy and/or previous one.
Treatment of Group B Streptococcal infection during pregnancy is probably to get oral Antibiotic right away and more importantly administering IV Penicillin G during labor.
Monday, September 17, 2007
How to Rule out Ectopic Pregnancy in Complete Abortion
If Sonogram does not show product of pregnancy neither in the uterus nor in the tubes, Ectopic Pregnancy should be ruled out.
- If Beta HCG is more than 1500 and Ultrasound is still negative, it is not EP (ectopic pregnancy)
- If Beta HCG is less than 1500 and ultrasound is negative, we can not rule out neither of those, so we need to follow-up both by sonogram and quantitative Beta HCG amounts, till Beta HCG is more than 1500 or goes down to zero.
- However if during the follow-up we see Beta HCG is rising but the doubling time is more than 48 hours (the speed of rising is less than normal), we should really challenge ectopic pregnancy (EP)
- If Beta HCG is more than 1500 and Ultrasound is still negative, it is not EP (ectopic pregnancy)
- If Beta HCG is less than 1500 and ultrasound is negative, we can not rule out neither of those, so we need to follow-up both by sonogram and quantitative Beta HCG amounts, till Beta HCG is more than 1500 or goes down to zero.
- However if during the follow-up we see Beta HCG is rising but the doubling time is more than 48 hours (the speed of rising is less than normal), we should really challenge ectopic pregnancy (EP)
Complete Abortion
Presentation of Complete Abortion:
- First trimester Bleeding
- History of passed tissue
- Cervix is Closed
- No product of pregnancy is being seen in the uterus
Management of Complete Abortion: 2 important part should be done in management of Complete Abortion:
1. Administer Rhogam if indicated (like any other Abortions)
2. Rule Out Ectopic Pregnancy
- First trimester Bleeding
- History of passed tissue
- Cervix is Closed
- No product of pregnancy is being seen in the uterus
Management of Complete Abortion: 2 important part should be done in management of Complete Abortion:
1. Administer Rhogam if indicated (like any other Abortions)
2. Rule Out Ectopic Pregnancy
Septic Abortion
Presentation of Septic Abortion: Septic Abortion is to be suspected in abortions outside of the hospital that come back with pain and vaginal discharge. Patient has fever and is ill. Usually the socioeconomic status of the patients is not high.
Management of Septic Abortion:
- Cervical and blood sampling
- IV Antibiotics
- Gentle suction Curetage
Management of Septic Abortion:
- Cervical and blood sampling
- IV Antibiotics
- Gentle suction Curetage
Missed Abortion
Presentation: it shows itself in the following ways:
- First trimester bleeding
- Disappearance of the nausea and vomiting of early pregnancy, arrest of uterine growth.
- Accidentally found dead fetus in the first trimester without any signs or symptoms
- Any complications of Missed Abortion could be the first symptom or sign
Attention: The point in Diagnosis of Missed Abortion is, the cervix is closed and the fetus is dead. So missed abortion involves a dead fetus that is still retained in the uterus
Attention: Pregnancy test (urine pregnancy test or Beta HCG test) would still be positive in most of the cases.
Treatment of Missed Abortion: Once the Diagnosis is made, surgical evacuation (dilatation & cuertagge) of the uterus has to be performed
Complications of Missed Abortion: This can become pretty serious including:
- DIC (Disseminated Intravascular Coagulopathy)
- Sepsis
- Hemorrhage
- First trimester bleeding
- Disappearance of the nausea and vomiting of early pregnancy, arrest of uterine growth.
- Accidentally found dead fetus in the first trimester without any signs or symptoms
- Any complications of Missed Abortion could be the first symptom or sign
Attention: The point in Diagnosis of Missed Abortion is, the cervix is closed and the fetus is dead. So missed abortion involves a dead fetus that is still retained in the uterus
Attention: Pregnancy test (urine pregnancy test or Beta HCG test) would still be positive in most of the cases.
Treatment of Missed Abortion: Once the Diagnosis is made, surgical evacuation (dilatation & cuertagge) of the uterus has to be performed
Complications of Missed Abortion: This can become pretty serious including:
- DIC (Disseminated Intravascular Coagulopathy)
- Sepsis
- Hemorrhage
Threatened Abortion
Prevalence of Threatened Abortion: 25% (Pretty High Huh?!)
Presentation of Threatened Abortion: Threatened abortion usually shows itself by hemorrhage before 20 week of pregnancy. On history, the patient denies any extraction of tissue. On physical exam: Cervix is closed, no fetal tissue passage is noted, no cervical or vaginal lesion is seen. Also fetal heart rate is usually normal and ultrasound shows normal product or pregnancy.
Management of Threatened Abortion: There is another posting with the topic of Management of First Trimester Bleeding, so read that first.
When the Patient comes to you first step is to make sure fetus is alive. Once that is fulfilled and the diagnosis of Threatened Abortion is made, management is reassurance and performance of Ultrasonography one week later.
Treatment of Threatened Abortion is Reassurance and outpatient follow up.
Differential Diagnosis of Threatened Abortion:
- Any other reasons of first trimester abortion can be considered as differential diagnosis of threatened abortion, including:
- Incomplete abortion: OS is open and there is no viable product of pregnancy
- Complete abortion: OS is closed, Ultrasonography shows empty uterus
- Inevitable abortion: Dilated Cervix, Sonogram shows rupture or collapsed gestational sac with absence of fetal cardiac motion, history of tissue extraction.
- Complete Abortion: OS is closed; Product of Pregnancy has come out completely.
Presentation of Threatened Abortion: Threatened abortion usually shows itself by hemorrhage before 20 week of pregnancy. On history, the patient denies any extraction of tissue. On physical exam: Cervix is closed, no fetal tissue passage is noted, no cervical or vaginal lesion is seen. Also fetal heart rate is usually normal and ultrasound shows normal product or pregnancy.
Management of Threatened Abortion: There is another posting with the topic of Management of First Trimester Bleeding, so read that first.
When the Patient comes to you first step is to make sure fetus is alive. Once that is fulfilled and the diagnosis of Threatened Abortion is made, management is reassurance and performance of Ultrasonography one week later.
Treatment of Threatened Abortion is Reassurance and outpatient follow up.
Differential Diagnosis of Threatened Abortion:
- Any other reasons of first trimester abortion can be considered as differential diagnosis of threatened abortion, including:
- Incomplete abortion: OS is open and there is no viable product of pregnancy
- Complete abortion: OS is closed, Ultrasonography shows empty uterus
- Inevitable abortion: Dilated Cervix, Sonogram shows rupture or collapsed gestational sac with absence of fetal cardiac motion, history of tissue extraction.
- Complete Abortion: OS is closed; Product of Pregnancy has come out completely.
Management of First Trimester Bleeding
First step is to stabilize the patient as sometimes the bleeding could be heavy and even life threatening.
Secondly, Vaginal Exam followed by Vaginal Ultrasound should be done.
3 questions should be answered in each patient with first trimester bleeding:
1. Has the patient passed any tissue?
2. Is the OS open or close?
3. How and where is the product of pregnancy?
After answering these 3 questions, patient can be categorized to one of these categories: Threatened Abortion, Missed Abortion, Inevitable Abortion, Complete Abortion, Septic Abortion, Ectopic Pregnancy or Molar Pregnancy.
Attention: Do not forget considering Rhogam if mom is Rh negative and the father is not.
Secondly, Vaginal Exam followed by Vaginal Ultrasound should be done.
3 questions should be answered in each patient with first trimester bleeding:
1. Has the patient passed any tissue?
2. Is the OS open or close?
3. How and where is the product of pregnancy?
After answering these 3 questions, patient can be categorized to one of these categories: Threatened Abortion, Missed Abortion, Inevitable Abortion, Complete Abortion, Septic Abortion, Ectopic Pregnancy or Molar Pregnancy.
Attention: Do not forget considering Rhogam if mom is Rh negative and the father is not.
Main Reasons of First Trimester Bleeding
- Threatened Abortion
- Missed Abortion
- Inevitable Abortion
- Complete Abortion
- Septic Abortion
- Ectopic Pregnancy
- Molar Pregnancy
- Cervical or Vaginal Lesions
- Missed Abortion
- Inevitable Abortion
- Complete Abortion
- Septic Abortion
- Ectopic Pregnancy
- Molar Pregnancy
- Cervical or Vaginal Lesions
Main Reasons of Third Trimester Bleeding
- Abruptio Placenta (Placenta Abruption)
- Placenta Previa
- Vasa Previa (Bleeding belongs to fetus not mom)
- Uterine Rupture
- Placenta Previa
- Vasa Previa (Bleeding belongs to fetus not mom)
- Uterine Rupture
Uterine Rupture
Presentation of uterine rupture: with intense abdominal pain associated with vaginal bleeding, ranging from spotting to massive hemorrhage
Attention:
- Usually is after trauma
- Or the patient has history of previous classic incision on uterus
Note:
- Risk in transverse line is 0.5%
- in Vertical its 5.0%.
Diagnosis of uterine rupture:
- Clinical Settings
- Ultrasound
Attention: In the real emergency, stabilizing the patient and rushing her to operating room without any further studies would be recommended.
Treatment of Uterine Rupture:
- If Patient does not want any more children, total hysterectomy
- If she wants more kids then Debridment and closure is indicated
Main Differential Diagnosis of Uterine Rupture is Abruptio Placenta as both present by painful third trimester bleeding. Also both can be preceded by trauma.
Attention: Any pregnant patient after Motor Vehicle Accident or any other kinds of real trauma should be watched and monitored for at least 24 hours. The monitor includes Fetal Heart Rate Monitoring.
Attention:
- Usually is after trauma
- Or the patient has history of previous classic incision on uterus
Note:
- Risk in transverse line is 0.5%
- in Vertical its 5.0%.
Diagnosis of uterine rupture:
- Clinical Settings
- Ultrasound
Attention: In the real emergency, stabilizing the patient and rushing her to operating room without any further studies would be recommended.
Treatment of Uterine Rupture:
- If Patient does not want any more children, total hysterectomy
- If she wants more kids then Debridment and closure is indicated
Main Differential Diagnosis of Uterine Rupture is Abruptio Placenta as both present by painful third trimester bleeding. Also both can be preceded by trauma.
Attention: Any pregnant patient after Motor Vehicle Accident or any other kinds of real trauma should be watched and monitored for at least 24 hours. The monitor includes Fetal Heart Rate Monitoring.
Vasa Previa
Presentation of Vasa Previa is: Hemorrhage with fetal heart rate changes, progressing from tachycardia to bradycardia to a sinusoidal pattern.
Diagnosis: Do not waste time to diagnose the Vasa Previa! When you see the following criteria just run.
- the patient in labor you did the amniotomy
- the patient start bleeding
- Fetus has bradycardia
But you can still Diagnose Vasa Previa with transvaginal ultrasound in combination with Doppler. You will kill the baby if you waste time!
Attention: "APatient" test (APT test) distinguishes maternal from fetal blood.
Treatment: Treatment of Vasa Previa Immediate Cesarean Delivery.
Mortality risk of vasa previa is 75%.
Diagnosis: Do not waste time to diagnose the Vasa Previa! When you see the following criteria just run.
- the patient in labor you did the amniotomy
- the patient start bleeding
- Fetus has bradycardia
But you can still Diagnose Vasa Previa with transvaginal ultrasound in combination with Doppler. You will kill the baby if you waste time!
Attention: "APatient" test (APT test) distinguishes maternal from fetal blood.
Treatment: Treatment of Vasa Previa Immediate Cesarean Delivery.
Mortality risk of vasa previa is 75%.
Sunday, September 16, 2007
Placenta Previa
Risk factors of Placenta Previa:
- Multi Parity
- Advanced age of Mother
- History of Multiple gestation.
Presentation: Placenta Previa presents with painless vaginal bleeding in the third trimester.
Diagnosis: Diagnosis of Placenta Previa is with ultrasound, which has accuracy of:
- 90% transabdominally
- 100% transvaginally
Attention: Pelvic exam is contraindicated as will/may increase the risk of bleeding.
Treatment of Placenta Previa:
- If the bleeding continues, C-section has to be done ASAP. Even if pregnancy is not term yet.
- If the mother is stable and fetus is at term, scheduled cesarean section is choice. However, until then Patient has to be monitored closely.
- If both mother and fetus are stable IM steroid are used to mature the lungs.
- Never do vaginal delivery, specially when it is complete placenta previa.
- If both mothe and fetus are OK and there is no more bleeding and mother has access to close hospital then she can be sent home and monitored at home until 36week, then schedule cesarean section. This is being done usually to let the fetus lungs get mature.
Attention: In cases of extended bleeding surgeon might discover A Placenta Accreta.
- Multi Parity
- Advanced age of Mother
- History of Multiple gestation.
Presentation: Placenta Previa presents with painless vaginal bleeding in the third trimester.
Diagnosis: Diagnosis of Placenta Previa is with ultrasound, which has accuracy of:
- 90% transabdominally
- 100% transvaginally
Attention: Pelvic exam is contraindicated as will/may increase the risk of bleeding.
Treatment of Placenta Previa:
- If the bleeding continues, C-section has to be done ASAP. Even if pregnancy is not term yet.
- If the mother is stable and fetus is at term, scheduled cesarean section is choice. However, until then Patient has to be monitored closely.
- If both mother and fetus are stable IM steroid are used to mature the lungs.
- Never do vaginal delivery, specially when it is complete placenta previa.
- If both mothe and fetus are OK and there is no more bleeding and mother has access to close hospital then she can be sent home and monitored at home until 36week, then schedule cesarean section. This is being done usually to let the fetus lungs get mature.
Attention: In cases of extended bleeding surgeon might discover A Placenta Accreta.
Absence Seizure
Presentation: child is referred to you by teacher telling that he has problem with dictation and has multiple word loss during writing, or mom tells you the child has several spell out that he is not aware of the around situation and comes back to normal situation abruptly.
Classic EEG: symetric 3mhtz spike and wave.
Treatment: Ethosuximide is treatment of choice. Second line is Valproate
Attention: Phenytoin and Carbamazapine are first line drug used for primary generalized tonic clonic sezure or partial seizures, both work by blocking Na channels voltage dependent, Phenytoin is a second drug line for myoclonic and tonic clonic seizure, its available in both IV and oral forms, side effects are gingivial hypertrophy, lymphadenopathy, hirsutism and rash, Both Phenytoina & Carbamazepine can cause Steven Johnson syndrome and Toxic Epidermal Necrolysis (TEN).
Classic EEG: symetric 3mhtz spike and wave.
Treatment: Ethosuximide is treatment of choice. Second line is Valproate
Attention: Phenytoin and Carbamazapine are first line drug used for primary generalized tonic clonic sezure or partial seizures, both work by blocking Na channels voltage dependent, Phenytoin is a second drug line for myoclonic and tonic clonic seizure, its available in both IV and oral forms, side effects are gingivial hypertrophy, lymphadenopathy, hirsutism and rash, Both Phenytoina & Carbamazepine can cause Steven Johnson syndrome and Toxic Epidermal Necrolysis (TEN).
ABC of Homeostasis
A for AIRWAY: We should make sure that the airways are open; also cervical spine injury should be analyzed.
Attention:
An airway is needed for all unconscious patients.
- in the ER best method is Orotracheal intubation
- in the field its needle Cricothyroidectomy.
For conscious patient the best airway is chin lift with face mask.
B for BREATHING: Patient should be able to breath normally or we need to help him/her with that.
C for CIRCULATION: It needs control of bleeding and restoring the blood pressure. In most external injuries pressure is enough to stop bleeding but in case of scalp laceration suturing is needed. Also all Patients with hypotension should receive rapid infusion of isotonic fluid like ringer lactate to prevent life threatening hypotension.
Attention: Patient can go to shock because of internal bleeding in the following
situation:
- Abdominal Bleeding
- Intra Pelvic Bleeding
- Femural Fracture (fracture of each femur can make the patient lose about 1.5 litter of blood.
Attention: If IV line is not possible:
- for adults do saphaneous vein cut down
- for children intraosseous cannulation
Attention:
An airway is needed for all unconscious patients.
- in the ER best method is Orotracheal intubation
- in the field its needle Cricothyroidectomy.
For conscious patient the best airway is chin lift with face mask.
B for BREATHING: Patient should be able to breath normally or we need to help him/her with that.
C for CIRCULATION: It needs control of bleeding and restoring the blood pressure. In most external injuries pressure is enough to stop bleeding but in case of scalp laceration suturing is needed. Also all Patients with hypotension should receive rapid infusion of isotonic fluid like ringer lactate to prevent life threatening hypotension.
Attention: Patient can go to shock because of internal bleeding in the following
situation:
- Abdominal Bleeding
- Intra Pelvic Bleeding
- Femural Fracture (fracture of each femur can make the patient lose about 1.5 litter of blood.
Attention: If IV line is not possible:
- for adults do saphaneous vein cut down
- for children intraosseous cannulation
Abruptio Placenta
Presentation: Patient presents with vaginal bleeding, abdominal pain, and uterine tenderness. Basically shows itself by painful 3rd trimester bleeding.
Note: The absence of hemorrhage does not rule out this diagnosis.
Differential Diagnosis:
- Placenta Previa: absence of bleeding rules out this Diagnosis. Also this usually shows itself by painless 3rd trimester bleeding.
Risk Factors:
- HT
- Preecclampsia,
- History of previous Abruption placenta
- Trauma
- Short umbilical cord
- Cocaine abuse.
Complications: DIC is of the most common complications of Abruptio Placenta in pregnancy, which results from a release of activated thromboplastin from the decidual hematoma in to maternal circulation. Risk factors for DIC are smoking and Folate deficiency. It can progress rapidly so careful monitoring is mandatory.
Treatment: Once Diagnosis is made, large-bore IV, as well as Foley catheter is inserted. Patients with Abruptio placenta in labor should be managed aggressively to insure rapid vaginal delivery, since this will remove the inciting cause of DIC and hemorrhage. Now if Patient is stable tocolysis with MgSO4 is considered. Again, once we Diagnosis the next step is Vaginal delivery with augmentation of labor if necessary. Now if mother and baby are not stable or if there is contraindicated, then Emergency C-section is indicated.
Note: The absence of hemorrhage does not rule out this diagnosis.
Differential Diagnosis:
- Placenta Previa: absence of bleeding rules out this Diagnosis. Also this usually shows itself by painless 3rd trimester bleeding.
Risk Factors:
- HT
- Preecclampsia,
- History of previous Abruption placenta
- Trauma
- Short umbilical cord
- Cocaine abuse.
Complications: DIC is of the most common complications of Abruptio Placenta in pregnancy, which results from a release of activated thromboplastin from the decidual hematoma in to maternal circulation. Risk factors for DIC are smoking and Folate deficiency. It can progress rapidly so careful monitoring is mandatory.
Treatment: Once Diagnosis is made, large-bore IV, as well as Foley catheter is inserted. Patients with Abruptio placenta in labor should be managed aggressively to insure rapid vaginal delivery, since this will remove the inciting cause of DIC and hemorrhage. Now if Patient is stable tocolysis with MgSO4 is considered. Again, once we Diagnosis the next step is Vaginal delivery with augmentation of labor if necessary. Now if mother and baby are not stable or if there is contraindicated, then Emergency C-section is indicated.
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