THE PREGNANT PATIENT
Educational Objectives
| The goal of this program is to improve diagnosis and management of pregnant patients in the emergency department
(ED). After hearing and assimilating this program, the clinician will be better able to:
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 | 1. Describe the classification system that categorizes drugs according to their safety in pregnant patients.
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| 2. Recognize levels of radiation that pose a risk to the fetus and levels associated with various diagnostic tests.
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| 3. Indentify common nonpregnancy-related problems seen in pregnant patients in the ED and the recommended
treatment options.
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| 4. Discuss the approach to treatment of a pregnant patient involved in major trauma.
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| 5. List the key points in the evaluation of a pregnant patient with minor trauma.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a
proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.
Acknowledgments
Dr. Sacchetti was recorded at PaACEP Scientific Assembly 2008, Advances, Controversies and Technology, held
April 6-9, 2008, in Harrisburg, PA, and sponsored by The American College of Emergency Physicians (ACEP) and
the Pennsylvania Chapter of ACEP. Dr. Manko was recorded at Contemporary Concepts in Clinical Emergency Medicine:
A Literature-Based Approach, held June 6-8, 2007, in New York, NY, and sponsored by New York University
School of Medicine, Department of Emergency Medicine. The Audio-Digest Foundation thanks the speakers and the
sponsors for their cooperation in the production of this program.
| FROM ANTIEMETICS TO X-RAYS: DIFFICULT DECISIONS IN THE PREGNANT PATIENT— Alfred Sacchetti,
MD, Chief, Emergency Services, Our Lady of Lourdes Medical Center, Camden, NJ
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| Introduction: 1 in 28 neonates has birth defect (most minor); ≈30% have identifiable cause; 1 in 164 women take
known teratogenic agent sometime during pregnancy
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| Case: 20-yr-old (gravida 2, para 1; 10-wk gestation) with sudden onset of shortness of breath; tachycardic; hypoxic;
physical examination unremarkable; fetal heart tones fine; chest clear; worry about pulmonary embolism (PE)
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| Venous thromboembolic disease: accounts for 33% of all maternal deaths and 50% of first-trimester deaths; seen in
1 in 2000 pregnancies in United States; interventions—oxygen; heparin safe for anticoagulation empirically or after
work-up; diagnostic studies—chest x-ray; echocardiography (dilated right ventricle); PE-specific work-up: ultrasonography
(US) of legs to look for deep venous thrombosis (DVT; not seen if in iliac vein); computed tomography
(CT) pulmonary angiography; ventilation-perfusion (V/Q) scan
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| Radiation risk: gray (Gy) represents absorption of one joule of energy per kilogram of mass in target material; 1 Gy
equals 100 rads; sievert (Sv) represents amount of radiation delivered from that energy source; threshold for deterministic
effect (minimum amount of radiation needed to affect biologic system), 50 milliseivert (mSv; 5000 mrem);
difficult to get up to 50 mSv (chest x-ray = 0.2 mSv, hip x-ray = 0.8 mSv, and hand x-ray = 0.005 mSv to fetus)
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| Diagnostic modalities: chest x-ray— if pneumothorax or other finding seen, diagnosis made; D-dimer—not useful
in pregnant patient because baseline values not known; compression US—97% sensitive for proximal DVT
in leg; does not work for pelvis; V/Q scan—normal scan rules out PE; minimal risk for radiation to fetus; hydrate
patient to reduce bladder paradox (tracer excreted in urine and concentrates in bladder); dose of radiation to fetus
= 0.2 to 0.6 mSv; CT pulmonary angiography—accuracy 90%; may alert physician to alternative diagnosis
(breath holding difficult for pregnant patient); single-section 0.03 to 0.06 mSv exposure to fetus; multisection
has higher exposure; formal pulmonary angiography 0.5 mSv; study of choice (75% of radiologists); increased
breast cancer risk (questionable); magnetic resonance imaging (MRI)—not as helpful as CT because of motion
artifact
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| Treatment: heparin; warfarin contraindicated in pregnancy
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| Cold: woman 28 yr of age, 8-wk gestation; fever, chills, cough, sore throat, nasal congestion, vomiting, and malaise;
history of asthma; vital signs unremarkable; diagnosis common cold
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| Safety classifications for medications in pregnancy: category A—randomized controlled trials (RCTs) in
pregnant humans found no problems; category B—animal studies and observational studies in humans (not RCTs)
showing relative safety; category C—animal studies show relative safety, but little information on humans; category
D—medication causes problems, but no other therapeutic options available; category X—other options for
treatment available, and drug unsafe
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| Considerations when prescribing medications for pregnant patients: topical medications good; nonabsorbable
medications good; give lowest dose that will treat symptoms; look at maternal (primary) effect and fetal (secondary)
effect, eg, penicillin has minimal fetal effect, but epinephrine has fetal effect due to vasoconstriction in uterus;
avoid absolutely teratogenic medications and those that lead to fetal demise, eg, methotrexate, angiotensin-converting
enzyme (ACE) inhibitors in third trimester; decongestants—nasal sprays (category C, but speaker feels they should
be category B); pseudoephedrine, phenylpropanolamine, and ephedrine all considered category C because of vasoconstrictor
effect; antipyretics—acetaminophen category B; aspirin category C because of antiprostaglandin effect
(prostaglandins maintain patency of ductus arteriosus); antiemetics—most safe in pregnancy; ondansetron category
B; metoclopramide also category B; drugs for asthma—albuterol and terbutaline safe; leukotriene inhibitors and
prednisone safe; antibiotics—penicillin and cephalosporins fine; stay away from quinolones and tetracyclines;
azithromycin safest macrolide; analgesics—oxycodone and hydrocodone safe; codeine (category C)
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| Right-sided abdominal pain: case—woman 24 yr of age, 24-wk gestation; right-sided abdominal pain; vital
signs unremarkable; nontender gravid uterus; urine dipstick shows trace of blood, few “specks” of leukocyte esterase;
initial treatment—pain medication
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| Differential diagnosis and diagnostic studies: biliary colic—US; renal colic—US to look for distention of ureter,
hydronephrosis, and markedly dilated collecting system; minimal-dose CT (5 mSv); appendicitis—try US; difficult
to do with large uterus; appendix protocol 13 to 14 mSv; still below 50 mSv threshold; MRI not usual
choice; ovarian torsion— US; pyelonephritis—clinical examination; summary—start with abdominal US; if
normal and clinical suspicion of another diagnosis, move to CT; do not withhold usual diagnostic studies in pregnant
patients
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| Sedation: case—18-yr-old patient, 6-wk gestation; falls on left shoulder; vital signs unremarkable; tender shoulder;
given pain medication; shoulder x-ray (0.8 mSv) shows anterior dislocation; sedation—propofol safest drug for
procedural sedation; benzodiazepine (category D; teratogenic effects when taken long term); pentobarbital (category
B); ketamine (category B); etomidate (do not use; shuts down adrenal glands); remifentanil (no data)
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| Chemical restraint: case—intoxicated (cocaine [category C] and ethanol [category D]) woman; 27 yr of age with
scalp laceration and abscess on leg (methicillin-resistant Staphylococcus aureus [MRSA]); loud and uncooperative;
claims to be pregnant (gestational age unknown)
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| Management: US shows pregnancy 10-wk gestation; order CT of head (2 mSv); chemical restraints—droperidol
or haloperidol (category C); lorazepam (eg, Ativan; category D); ziprasidone (Geodon; category C); lidocaine
(category B); tetanus toxoid—category C; intravenous drug abuse leading cause of tetanus in United States;
antibiotics—for leg ulcer; trimethoprim-sulfamethoxazole (eg, Bactrim; category C); vancomycin (category C)
but cannot give orally; doxycycline (eg, Vibramycin; category D); clindamycin (category C); use if MRSA sensitive
to it in local area
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| Puncture wound and body fluid exposure: case—35-yr-old nurse (gravida 3; 12-wk gestation) with needle
stick while working in emergency department; no hepatitis prophylaxis; vital signs significant for hypertension;
postexposure prophylaxis—antiviral agents (category C), except for acyclovir (category B); ribavirin (category
X); immunoglobulins (category C); treat as if patient not pregnant; hypertension— β blockers generally safe, with
exception of atenolol (category D; due to lack of data); avoid ACE inhibitors and angiotensin-receptor blockers
(ARBs); calcium channel blockers (category C); hypertensive crisis—patient not eclamptic; nitroprusside (category
C); fenoldopam (category B); other drugs for hypertensive crisis category D
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| Supraventricular tachycardia: case—woman, 40 yr of age, with palpitations and supraventricular tachycardia
(SVT); adenosine (category C; preferred drug because probably metabolized before reaching fetus); verapamil
(category C); esmolol (category B); cardioversion safest
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| Acute management of seizure: case—pregnant women (10-wk gestation) has grand mal seizure; acute
management—noneclamptic patient; benzodiazepines (category D with long-term use; fine for immediate management);
propofol (category B); long-term management—lamotrigine (Lamictal) category C (if patient can afford);
other medications (ie, benzodiazepines, eg, carbamazepine) more affordable but category D (inform patient)
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| Resuscitation: case—28-yr-old pregnant patient (36-wk gestation); extreme shortness of breath; hypoxic; anxious;
extreme dyspnea, rales to apices, wheezing, pulmonary edema (confirmed on chest x-ray); probably has cardiomyopathy
of pregnancy; heart sounds inaudible; nontender uterus; when doing major resuscitation, treat patient same
as if not pregnant (saving mother only way to save fetus); manage with bilevel positive airway pressure (BiPAP; no
data); intubating agents—propofol (category B); midazolam (category D); pentobarbital (category B); ketamine
(category C); do not use etomidate; remifentanil excellent drug and short-acting; paralytic agents—rocuronium
(category B); succinylcholine (category C; long duration of action in pregnant patient); pressors—shunt blood
away from splanchnic circulation, including uterus; if patient put on pressor, must monitor fetal heart tones; no
good data on pregnancy category; summary—any diagnostic study used for nonpregnant patient fine for pregnant
patient; most of drugs not studied extensively in humans in pregnancy but probably fine for short-term use; take-
home message— good maternal care good fetal care
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| MANAGEMENT OF TRAUMA DURING PREGNANCY —Jeffrey Manko, MD, Assistant Professor of Emergency
Medicine, and Associate Program Director, Emergency Medicine Residency, New York University School of
Medicine/Bellevue Medical Center, New York, NY
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| General approach: 2 patients (mother and fetus); viability of fetus important, eg, 6-wk gestation or 6-mo gestation?
mother treated first; epidemiology—car accidents; falls; domestic violence; trauma considered leading nonobstetric
cause of death of pregnant mother
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| Fetal mortality: maternal death; abruptio placentae; preterm labor and delivery; fetal-maternal hemorrhage; direct
penetrating trauma
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| Stratification based on gestation: unknown pregnancy—test for pregnancy not important before treatment of
major trauma; <23-wk gestation—fetus not necessarily considered viable; >23-wk gestation—considered viable;
important in deciding whether to monitor fetus or do perimortem caesarean delivery if maternal arrest occurs
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| Physiologic changes of pregnancy:plasma volume increases >50% and red blood cell volume increases 18% to
30% (de facto dilutional physiologic anemia; decreased hematocrit); increased white blood cell count; diaphragm
elevated up to 4 cm (consider when putting in chest tube); decreased gastrointestinal motility and delayed emptying
results in increased risk for aspiration; increased ventilation early in pregnancy; decreased residual volume; heart
rate (HR) increases 10 to 15 bpm; blood pressure falls slightly; cardiac output increases, but as uterus becomes
more gravid, if patient lying supine, cardiac output decreases (place all pregnant women >20-wk gestation on left
side)
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| Major trauma: treat mother first; airway, breathing, circulation (ABCs); turn patient onto left side; put all pregnant
patients on oxygen (even if mother’s oxygen saturation within normal limits; physiologic changes occur in fetus
first and mother second); volume resuscitate (pregnant patients must lose 2 L of blood before becoming hypotensive,
but fetus becomes hypotensive much sooner); monitor fetus early; assessing fetus early probably key vital
sign in pregnant trauma patient because distress in fetus often indication of problem in mother; do all usual procedures
and tests
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| Radiographs: irradiation does cause anomalies, but mostly in fetus in first trimester; shield and take necessary precautions
to lessen radiation exposure; do not think twice about doing procedure or getting study mother needs for
her survival; in emergency, do not wait for pregnancy test
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| Ultrasonography: noninvasive; user-dependent; screening tool for intra-abdominal hemorrhage and pericardial
fluid; use in looking for abruptio placentae, but sensitivity poor, so abruption not ruled out by negative US); use to
assess fetal viability (HR, size, and number of fetuses)
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| Procedures: diagnostic peritoneal lavage (not used much) performed supraumbilically; chest tubes need higher
placement; thoracotomy and cesarean delivery in setting of maternal arrest; perimortem cesarean delivery—assess
viability of fetus (>23-wk gestation); determine duration of arrest; make cut in uterus, put hands in and separate
baby from uterus; enlarge opening, remove fetus, and begin neonatal resuscitation; no points for style or cosmesis;
continue resuscitative efforts on mother
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| Minor trauma: studies show that no matter how minor trauma considered, risk for abruptio placentae still present;
fetal monitoring necessary; obtain type and screen for all patients; fetal monitoring—to look for changes in fetal
HR (tachycardia or bradycardia) and uterine contractions; minimum of 4 to 6 hr, no matter how minor trauma considered;
check for late decelerations; monitoring mother—abdominal pain and uterine tenderness; vaginal bleeding;
decreased fetal movement; assess frequency of contractions; study—showed if mother has no symptoms and
fetal monitoring shows no problems after 4 to 6 hr, both can be discharged safely; if contractions and/or decelerations
present, look further to find source of distress and monitor for 24 to 48 hr
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| Abruptio placentae: occurs in 0.57% of pregnancies; occurs in 1% to 5% of patients with minor trauma, 40% to
60% of patients with major trauma; difficult to pick up by US; can have delayed presentation; no signs or symptoms
that predict delayed abruption
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| Fetomaternal hemorrhage: Kleihauer-Betke (KB) test (testing for mixing of fetal blood with maternal blood);
add acid to blood, fetal cells keep color and maternal cells lose color; count ratio of fetal cells to maternal cells;
there should be no fetal cells; any fetomaternal hemorrhage problematic (especially in Rh-negative patient); all female
patients need blood type and Rh status checked; all Rh-negative patients get RhoGAM; KB test potentially
used to determine dose of RhoGAM; study showed all patients in preterm labor had positive KB test (no one in preterm
labor with negative KB test), raising question whether test predicts risk for preterm labor
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| Disposition: if at any time during monitoring any signs or symptoms of fetal distress or abdominal pain or tenderness occur,
consider delayed abruptio placentae, requiring 1 to 2 days of monitoring; if 4 to 6 hr of monitoring uneventful, send
home
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| Trauma prevention: wear seat belt across hips, not uterine dome
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| Key points: major trauma—treat mother first; aggressive resuscitation; left side down; oxygen; diagnostic and therapeutic
interventions as usual; cesarean delivery quickly if mother arrests; minor trauma—everyone gets monitoring
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Suggested Reading
Andrade SE et al: Use of prescription medications with a potential for fetal harm among pregnant women. Pharmacoepidemiol
Drug Saf 15:546, 2006; Archer T: The pregnant trauma patient. J Trauma 62S110, 2007; Constanty
PM, Cruz DA: Trauma and the obstetric patient: collaboration in care. Crit Care Nurs Clin North Am 18:273, 2006;
Cusick SS, Tibbles CD: Trauma in pregnancy. Emerg Med Clin North Am 25:861, 2007; Dresang LT et al:
Venous thromboembolism during pregnancy. Am Fam Physician 77:1709, 2008; Hull SB, Bennett S: The pregnant
trauma patient: assessment and anesthetic management. Int Anesthesiol Clin 45:1, 2007; Ladavac AS et al: Emergency
management of agitation in pregnancy. Gen Hosp Psychiatry 29:39, 2007; Patel SJ et al: Imaging the pregnant
patient for nonobstetric conditions: algorithms and radiation dose considerations. Radiographics 27:1705, 2007; Singh
A et al: MR imaging of the acute abdomen and pelvis: acute appendicitis and beyond. Radiographics 27:1419, 2007;
Sperry JL et al: Long-term fetal outcomes in pregnant trauma patients. Am J Surg 192:715, 2006; Thomas J et al:
Emergency department imaging: current practice. J am Coll Radiol 5:811, 2008; Watkins S et al: validation of emergency
physician ultrasound diagnosing hydronephrosis in ureteric colic. Emerg Med Australas 19:188, 2007; Pregnant
patient at risk for unnecessary appendectomy. Hosp Case Manag 16:46, 2008.
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