Pregnancy and the Risk for Multiple Lawsuits

Educational Objectives

The goal of this lecture is to improve management of patients with pregnancy-related emergencies. After listening to and assimilating this lecture, the clinician will be better able to:

1. Diagram an approach for diagnosing venous thromboembolism in pregnant patients.

2. Use appropriate imaging and diagnostic testing for ectopic pregnancy and ovarian torsion.

3. Identify and treat preeclampsia and eclampsia.

Summary

Venous Thromboembolism

Incidence during pregnancy: 0.76 to 1.72/1000 pregnancies; 4 times greater than in nonpregnant women; deep venous thrombosis (DVT) — two-thirds occur antepartum (evenly distributed among trimesters); pulmonary embolism (PE) — 43% to 60% occur puerperium; leading cause of maternal death in developing countries; study by Greer et al — 50% of thromboembolic events occur ≤20 wk of pregnancy; relative risk for PE during puerperium period 20 times greater than at other points in time; risk factors — include history of thromboembolism, smoking, weight gain, and parity

D-dimer: levels rise at conception; test intended to rule out PE, but elevated levels may lead to false-positive diagnosis; retrospective chart review — among 220 D-dimer tests, 118 positive; positive predictive value 4.2%, ie, 5 patients had PE; D-dimer not useful for predicting need for further testing, particularly during pregnancy

Diagnostic approach: primary principle — limit exposure to ionizing radiation; clinical suspicion for PE — if DVT suspected, rule out using ultrasonography (US); if DVT not suspected, perform other diagnostic tests; radiation exposure — for fetus, greater with ventilation/perfusion (V/Q) scan vs computed tomography (CT); for mother, greater with CT vs V/Q scan; indeterminate results following CT — recommend higher-order test (eg, pulmonary angiography); clinical decision rules — not useful for pregnant patients; Wells criteria — well validated in general population but not in pregnant patients; include leg swelling, pain, and slow venous blood flow (all common during pregnancy)

PE rule-out criteria (PERC): D-dimer levels not included; because derivation study did not include pregnant patients, not useful in this population; registry study — in 6% of patients with PE, PERC rule results completely negative

Amniotic Fluid Embolism (AFE)

Case 1 (“SE”): 2 hr after delivery by cesarian delivery, 36-yr-old woman had episode of syncope and persistent hypotension; surgeon did not believe symptoms related to bleeding from surgery; 2 cardiologists consulted; 2 days later — patient had cardiopulmonary arrest; resuscitation successful; strategy for treatment debated among clinicians (who disagreed about whether finding of fluid in abdomen present at or increased since time of surgery); SE developed disseminated intravascular coagulation (DIC); patient died during insertion of catheter; postmortem examination — showed intraabdominal hemorrhage and AFE

Background: AFE often occurs in second or third trimester; cause — release of material, eg, amniotic fluid, into maternal circulation; usually occurs during procedure (eg, amniocentesis, delivery) or with event (eg, abruptio placentae, trauma); signs — sudden cardiovascular collapse, shock, dyspnea, hypoxemia, and DIC; mortality — 50% after 1 hr; treatment — supportive care; incidence — 1 in 40,000 deliveries

Ovarian Torsion

Ovarian torsion (OT) vs testicular torsion (TT): complications — intraabdominal sepsis and permanently impaired fertility more likely with OT than with TT

Retrospective review: incidence — similar; mean time of presentation — 36 hr for TT vs 72 hr for OT; time from request for to completion of imaging — 0.77 hr for testicular pain vs 1.86 hr for pelvic pain; median time between diagnosis and surgery — 2.3 hr for TT vs 6.3 hr for OT; salvage rate — 30% for TT vs 14% for OT

Diagnosis: pelvic examination in ED — did not change strategy for management in 94% of cases (ie, if OT suspected, do not perform pelvic examination if it delays more definitive diagnostic tests); imaging — CT not sensitive for torsion; US recommended

Ectopic Pregnancy (EP)

Transvaginal US: difficult to perform; misinterpretation common with bedside US (eg, ectopic pregnancies misdiagnosed as cysts); if clinician unsure of how to interpret findings, obtain US through radiology

Epidemiology: incidence — as common as 1 in 40 pregnancies; mortality — high; increases with age; study — among patients with positive human chorionic gonadotropin (HCG), 7.5% had EP, but only ≈50% detected on initial presentation; most common misdiagnoses — threatened or spontaneous abortion

Signs and symptoms: abdominal pain — reported in 100% of ruptured vs 30% of unruptured EP; amenorrhea — ≈50% of unruptured EP; vaginal bleeding — 39% of unruptured EP; adnexal tenderness — 28% of unruptured EP; conclusion — unruptured EP difficult to diagnose without HCG test and US

Reliability of patient reports: >10% of patients reporting “last menstrual period on time” or “no chance of pregnancy” have positive pregnancy test; perform HCG test in all patients of child-bearing age regardless of self-reported history

Assessment: patient with positive HCG, abdominal pain, and normal physical examination — transvaginal US recommended; change in HCG over 2 days — may increase as in normal pregnancy; decreases or remains stable in some patients

Study of transvaginal US in patients with low HCG: included patients with lower abdominal pain or bleeding and quantitative HCG <1000 mIU/mL; all underwent transvaginal US within 24 hr; HCG <1000 mIU/mL in ≈33% of EPs; conclusion — HCG not diagnostic for EP; obtain transvaginal US regardless of quantitative HCG result

Indeterminate findings on US: empty uterus — EP present in >25%; nonspecific fluid — EP in ≈15%; gestational sac (normal or abnormal) — EP in <5%; high discriminatory zone for HCG (>3000 mIU/mL) with negative US — study showed 35% sensitivity for detection of EP; quantitative HCG not recommended to identify or rule out EP

Methotrexate: indications — no evidence of rupture or hemoperitoneum, hemodynamic stability, <8 wk gestation, β-HCG <5000 mIU/mL, adnexal mass <4 cm, no fetal cardiac activity, and EP confirmed; surgeon should decide whether to administer and document decision

Heterotopic pregnancy: definition — simultaneous intra- and extrauterine pregnancies; incidence — 1 in 4000 overall; 1 in 100 with in vitro fertilization

Case 2: 26-yr-old woman with positive home pregnancy test; symptoms — spotting for 2 days, mild cramping, and pain in lower abdomen; physical examination — relatively normal, with “old” pelvic blood; diagnostic workup — qualitative HCG positive and urinalysis normal; patient discharged with instructions for US following morning; 2 hr after discharge — unable to sleep due to pain and presents to second hospital (returns home because of long wait time); 5 hr after discharge — patient has syncopal episode at home; transported to third hospital; emergency department (ED) physician diagnosed EP; review of care — diagnostic evaluation incomplete; patient should have been admitted for observation until US available; normal vital signs, lack of risk factors, and benign examination created “false sense of security”

Case 3: 26-yr-old pregnant woman with schizophrenia and vaginal bleeding for 2 wk presented to labor and delivery unit of hospital; US showed empty uterus; obstetrician, who knew of patient’s schizophrenia, expressed disbelief about patient being pregnant and ordered discharge; 2 days later — patient presented to different hospital with severe abdominal pain; HCG test positive; pain decreased after large bowel movement and patient discharged; 1 day later — patient found dead in apartment; postmortem assessment — 1.5-in EP in fallopian tube undetected because obstetrician did not perform US

Case 4: 30-yr-old woman with vaginal bleeding, abdominal cramping and positive HCG; US showed small amount of nonspecific endometrial fluid; obstetrician consulted with patient and prescribed methotrexate; 2 days later — patient presented to different facility; US showed 6-wk intrauterine pregnancy with fetal pole; follow-up US — showed decline in fetal heart rate; 1 wk later — decrease in HCG and fetal demise; dilatation and curettage performed; conclusion — methotrexate used inappropriately

Acute Coronary Syndrome (ACS)

Case 5: 33-yr-old pregnant woman with chest pain radiating to back; history and physical examination — no risk factors for ACS, but examination detected ST segment elevation myocardial infarction (STEMI); intervention — percutaneous coronary intervention without stenting; outcome — excellent

Background: incidence — 0.6 to 1/10,000 pregnancies; increasing as result of increase in mean age during pregnancy; mortality rate — 5% to 37%; detailed information lacking because of reporting bias (ie, no controlled studies); hypertension — odds increased 11.7-fold; location — subendocardial 37%; anterior 20%; inferior 20%; age >40 yr — increases risk 30-fold; pregnancy — increases risk for MI or ACS 3- to 4-fold

Preeclampsia and Eclampsia

Preeclampsia: criteria — for gestational age >20 wk, blood pressure ≥140/90 mm Hg, or significant increase in systolic or diastolic blood pressure from baseline, proteinuria, and edema; consider molar pregnancy if gestational age <20 wk; symptoms — headache, vision changes, edema, or abdominal pain; risk factors — primigravida status, diabetes, hypertension before pregnancy, young or older age, multiple gestation, obesity, family history, and molar pregnancy

Eclampsia: criteria — preeclampsia with seizures; symptoms — headache, central nervous system and vision changes, and hyperreflexia; treatment — decrease blood pressure; administer magnesium sulfate to prevent and treat seizures; if hypermagnesemia develops, treat with calcium gluconate; parturition — not always curative, ie, preeclampsia and eclampsia may occur ≤8 wk postpartum

Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome: clinical variant of preeclampsia; treatment — same as for preeclampsia; avoid diuretics and angiotensin-converting enzyme (ACE) inhibitors

Rh Isoimmunization

Walker v Rinck: decision of court stated “physician owes duty to future children of woman with Rh factor-negative blood who gives birth to Rh-positive child”; Rho(D) immune globulin (eg, MICRhoGAM, RhoGAM) must be administered to pregnant woman with Rh factor-negative blood within 72 hr if possible transfusion occurs between maternal blood and Rh-positive fetal blood

Rho(D) immune globulin: purpose — destroy Rh-positive fetal red blood cells in maternal circulation; dose — 50 µg for gestational ages <12 wk and 300 µg if >12 wk (or, give 300 µg in all cases); after spontaneous abortion — per Cochrane Database of Systematic Reviews (2013), has little effect on maternal sensitization or Rh alloimmunization in future pregnancies for women with Rh-negative blood

Readings

Barnhart KT: Clinical practice. Ectopic pregnancy. N Engl J Med. 2009 Jul 23;361(4):379-87; Dart RG: Role of pelvic ultrasonography in evaluation of symptomatic first-trimester pregnancy. Ann Emerg Med. 1999 Mar;33(3):310-20; El-Deeb M et al: Acute coronary syndrome in pregnant women. Expert Rev Cardiovasc Ther. 2011 Apr;9(4):505-15; Marik PE and Plante LA: Venous thromboembolic disease and pregnancy. N Engl J Med. 2008 Nov 6;359(19):2025-33; Neligan PJ and Laffey JG: Clinical review: Special populations — critical illness and pregnancy. Crit Care. 2011 Aug 12;15(4):227; Piper HG et al: Ovarian torsion: diagnosis of inclusion mandates earlier intervention. J Pediatr Surg. 2012 Nov;47(11):2071-6; Tan M and Huisman MV: The diagnostic management of acute venous thromboembolism during pregnancy: recent advancements and unresolved issues. Thromb Res. 2011 Feb;127 Suppl 3:S13-6.

Disclosures

For this lecture, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Klauer was recorded at the 25th Annual High Risk Emergency Medicine, held May 28-29, 2014, in Las Vegas, NV, and sponsored by the Center for Emergency Medical Education. For information on future CME activities from this sponsor, please visit www.ccme.org. The Audio Digest Foundation thanks the speakers and sponsors for their cooperation in the production of this lecture.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

EM322401

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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