Author: Don Stader, M.D.
- Pulmonary embolism is one of the leading causes of maternal mortality.
- There is disagreement among different medical societies about the value of D-dimer as a screening modality. If you use it, consider the rational D-dimer approach whereby you add 250 to your cut-off for every trimester.
- A useful screening modality is an ultrasound of bilateral lower extremities looking for DVT.
- Keep in mind, both a V/Q scan and CT scan have a significant amount of radiation. CTA is probably the right diagnostic test (less radiation than CT w&w/o).
- Always use the shared decision-making model and clinical acumen to choose your tests.
Leung AN, et. al. (2011). An official American Thoracic Society/Society of Thoracic Radiology clinical practice guideline: evaluation of suspected pulmonary embolism in pregnancy. American Journal of Respiratory and Critical Care Medicine. 184(10):1200-8
Polak JF, Wilkinson DL. (1991). Ultrasonographic diagnosis of symptomatic deep venous thrombosis in pregnancy. American Journal of Obstetrics and Gynecology. 165(3):625-9.
Sachs BP, et. al. (1987). Maternal mortality in Massachusetts. Trends and prevention. New England Journal of Medicine. 316(11):667-72.
Check out this episode!
Author: Dylan Luyten, M.D.
- Rhogam is commonly used when an Rh negative woman has an Rh positive fetus. It is commonly used in the ER in the setting of a miscarriage.
- Rh(+) fetal blood can enter the Rh(-) maternal circulation, sensitizing the woman to the Rh antigen. During a subsequent pregnancy, if the fetus is Rh(+), the woman may mount an immune response to the fetus, lead to fetal demise. Rhogam is used to block this process.
- Use of Rhogam has reduced this complication from 16% of Rh(+) pregnancies in the 1960’s to less than 1% today.
- Under 10 weeks, the amount of maternal-fetal blood exchange is very small, so the use of Rhogam in a 1st trimester miscarriage is unnecessary. It should be used in patients with a miscarriage after 12 weeks, or women undergoing a surgical D&C.
- Rhogam is expensive and in limited supply, so it is important to only use it when necessary.
References: Hannafin, Blaine et al. Do Rh-negative women with first trimester spontaneous abortions need Rh immune globulin? 2006. The American Journal of Emergency Medicine, Volume 24 , Issue 4 , 487 – 489
Author: Jared Scott, M.D.
- A pessary is a device inserted into the vagina for medical purposes. Examples include birth control and mechanical support of the pelvic structures.
- In older women, collapse of the pelvic structures is common, and many may have pessaries to aid in treatment.
Author: Sam Killian, M.D.
- “The Rabbit Has Died” is a lesser used phrase to denote finding out one is pregnant.
- During a test used in the 1930s, the “Rabbit’s Test,” a rabbit was injected with a potentially pregnant woman’s urine. If the woman was pregnant, the rabbit would begin displaying signs of pregnancy itself.
- This test required killing the rabbits to visualize the ovaries, hence the term “Rabbit Done Died”.
Run Time: 6 minutes
Author: Samuel Killian M.D.
- The mechanism of preeclampsia is not well understood, but it is thought to be a widespread malfunction of vascular endothelium and inflammation.
- Clinical features include hypertension – SBP >140 and DBP > 90, proteinuria, and potential pathologic edema.
- Preeclampsia typically occurs after 20 weeks gestation up to 3-6 week postpartum. Preeclampsia occurs in 2-6% of pregnancies, and Eclampsia occurs in 1 out of 200 cases of Preeclampsia.
- More severe symptoms include a blood pressure >160/110, renal dysfunction, thrombocytopenia, and elevated LFTs with or without HELLP syndrome.
- A patient with a headache or focal neurologic deficits needs a CT scan because CVA and ICH are not uncommon.
- Studies show that people who develop Preeclampsia have 2-4 fold increase in the probability of developing chronic hypertension and heart disease.
- Some risk factors include: first pregnancy, higher BMI, family history, and African-American patients.
Link to Podcast: http://medicalminute.madewithopinion.com/preeclampsia-1/
Run Time: 3 minutes
Author: Jared Scott M.D.
- Pregnancy is a hypercoagulable state and often PE is a concern. When we work up PE in pregnancy the main consideration for harm to the fetus is radiation exposure.
- The amount of radiation to cause harm to the fetus during pregnancy is thought to be 0.1 Gray.
- If 0.1 Gray is the same as $100 of radiation then an X-ray = 1/10 of a penny of radiation, a CT PE scan = 25-50 cents of radiation, a VQ scan = 50-75 cents of radiation, and background radiation during the full pregnancy = $5 of radiation.
- It has been shown that the amount of radiation needed to increase the risk of cancer before age 20 by 1/100 = $10 of radiation – or many, many CT’s and imaging studies.
- CT scans irradiate both the breast tissue and the thyroid of females, which increases the lifetime risk of breast cancer by 1.5%, which is not an insignificant amount.
- The VQ scan is the ideal test for PE during pregnancy, but the downside to a VQ scan is that the radioisotope collects in the bladder directly over uterus before it is urinated out, therefore it is not recommended in the first trimester.
Link to Podcast: http://medicalminute.madewithopinion.com/pregnancy-and-radiation/
Run Time: 4 minutes
Author: Peter Bakes M.D.
- The American College of Obstetrics and Gynecology (ACOG) has new recommendations on the management of nausea and vomiting in pregnancy. This can present in any form along the spectrum from morning sickness to hyperemesis gravidarum.
- Conventional management of any nausea in the ED is usually Zofran. Zofran has been linked to causing prolonged QT placing a pregnant woman at risk of developing Torsades, ventricular fibrillation, or cardiac arrest. There is good data from Sweden and Denmark that the relative risk of cardiac and septal defects in the fetus increases with administration of Zofran during the first trimester!
- ACOG recommends the first line treatment against nausea in pregnancy is prescribing two pills at night of Diclegis. If that is not effective, another dose can be taken in the morning and the afternoon.
- The second line treatment is Dramamine or Benadryl and the third line of is Reglan. If this does not work, Phenergan and Zofran are rescue medications that can be used! This marks a significant change in guidelines and should change our practice!
Link to Podcast: http://medicalminute.madewithopinion.com/nausea-in-pregnancy/
Run Time: 4 minutes
Author: Dr. Nicholas Hatch
- Risk of DVT and PE does go up with pregnancy and increases in each trimester. 1 in 50,000 people develop blood clots in the first trimester with 1 in 10,000 people developing blood clots in the second trimester.
- The risk for PE or DVT in pregnancy is about 3 in every 10,000 people. Comparatively, the risk for pre-eclampsia in pregnancy is 340 in every 10,000 people.
- Two third of the blood clots found in pregnancy are DVTs.
- The D-Dimer cut off in pregnancy is 0.75 in the first trimester, 1 in the second trimester, and 1.25 in the third trimester.
- A perfusion-only VQ scan has the lowest radiation of imaging for PE.
Link to Podcast: http://medicalminute.madewithopinion.com/pulmonary-embolism-in-pregnancy-1/
Run Time: 15 minutes
Author: Dr. Donald Stader
- Trauma ABCs change in pregnancy.
- A: Progesterone dilates to blood vessels in the nose and the back of the throat changing the airway in pregnant women, causes intubation to be more difficult because of increased redundant tissue.
- B: Pregnant women desaturate very quickly because of metabolic demands and diaphragm is pushed up. Supplemental oxygen should be used liberally.
- C: Volume of fluids is increased during pregnancy. There is more blood flow to the uterus.
- D: Starting in the 2nd trimester the uterus can push on the major blood vessels. Moving the uterus away from the Vena Ceva to the left will allow blood flow – either by left lateral decubitus or physically moving the uterus to the left.
- E: Pregnant women need a complete head to toe exam and a manual vaginal exam.
- Fibrinogen, rh, Kleihauer-betke tests are additional tests to consider adding to pregnant traumas.
- The decision to perform a perimortem C-section should be made within 5 minutes of loss of pulses. Performing interestingly improves infant and mother’s chance of survival.
Link to Podcast: http://medicalminute.madewithopinion.com/trauma-in-pregnancy-perimortem-c-section/