Obstetric Emergencies & Common Issues

Preeclampsia, eclampsia, gestational diabetes, ectopic, placental abruption vs previa.

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◆Hypertensive disorders of pregnancy

•Gestational HTN: >140/90 after 20 weeks, no proteinuria, no end-organ damage
•Preeclampsia: HTN + proteinuria OR end-organ damage (renal, liver, neuro, hemato, pulm edema)
•Severe features: BP ≥160/110, ↑Cr, ↑LFTs 2×, ↓plt <100K, pulm edema, neuro symptoms, RUQ pain
•HELLP: Hemolysis + Elevated Liver + Low Platelets — variant of severe preeclampsia
•Eclampsia: seizures
•Treatment: magnesium for seizure prophylaxis; labetalol/hydralazine/nifedipine for severe BP; deliver if severe features or ≥37 weeks
•Magnesium toxicity: loss of DTRs → respiratory depression; reverse with IV calcium

•Placenta previa: painless bright red bleeding; placenta over cervical os; transvaginal US safe; CESAREAN delivery; NO digital exam
•Placental abruption: painful bleeding + tetanic uterus + DIC; risk: cocaine, HTN, trauma; emergent delivery
•Vasa previa: fetal bleeding (Apt test +); fetal demise quickly without C-section
•Uterine rupture: prior C-section + sudden severe pain + loss of fetal station; emergency

•First visit (8–10 wk): labs (CBC, blood type/Rh, antibody screen, HIV, syphilis, HBsAg, rubella, varicella, UA/culture); Pap if due
•10–13 wk: nuchal translucency + PAPP-A + β-hCG (first trimester screen)
•15–20 wk: quad screen (AFP, β-hCG, estriol, inhibin A) OR cell-free DNA
•18–20 wk: anatomy scan
•24–28 wk: 1-hr glucose challenge (GDM screen); repeat antibody screen if Rh-
•28 wk: RhoGAM if Rh-
•36 wk: GBS culture
•Tdap each pregnancy 27–36 wk; flu vaccine any trimester

•↑ AFP: NTDs (anencephaly, spina bifida), abdominal wall defects, multiple gestation, wrong dates
•↓ AFP: trisomy 21, 18 (with ↑β-hCG/inhibin in T21; ↓ all in T18)
•Cell-free DNA: highly sensitive for trisomy 13/18/21 from 10 weeks
•If anomaly: amniocentesis (after 15 wk) or CVS (10–13 wk) — diagnostic

•4 T's: Tone (atony — most common) + Trauma + Tissue (retained placenta) + Thrombin (coagulopathy)
•Atony: massage + oxytocin → tranexamic acid → methylergonovine (NOT in HTN) → carboprost (NOT in asthma) → misoprostol → tamponade (Bakri) → surgery
•Risk factors: prolonged labor, multiparity, large baby, multiples, polyhydramnios

◆Always RhoGAM at 28 weeks AND postpartum for Rh- mom with Rh+ baby (or any sensitizing event: bleeding, trauma, amniocentesis)
◆Mg toxicity → IV calcium gluconate
◆Don't do digital cervical exam in suspected placenta previa
◆Tdap each pregnancy (passive immunity to newborn)
◆Pregnant + UTI → always treat (asymptomatic bacteriuria → pyelo + preterm labor)

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