Tasty Morsels of EM 090 – #FRCEM Medical Complications of Pregancy

28 Jul

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here.

What is hyperemesis?

(From the RCOG 2016 Guideline)

  • Distinguishes nausea and vomiting of pregnancy from hyperemesis gravidarum
  • hyperemesis defined as
    • >5% pre pregnancy weight loss
    • dehydration
    • electrolyte imbalance

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how should it be treated?

  • antiemetics in the community is first line treatment
    • prochlorperazine, promethiazine and cyclizine are first line
    • metoclopramide is second line due to the extra pyramidal effects
    • ondansetron only when others have failed (less safety data)
    • pyridoxine (vit B6) not recommended
Who should be admitted?
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  • indications for admission
    • inability to keep down anti emetics
    • ketonuria or weight loss (>5%) despite antiemetics
    • comorbidity and vomiting (eg UTI…)
  • steroids can be used (but not by us!)
  • both ginger and acupressure are suggested as reasonable to try if patient wish to avoid drugs
  • remember thiamine supplementaion

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What are risk factors and signs of Pre-eclampsia?

(NICE 2011)

  • Risk factors for pre eclampsia
    • prior pre-eclampsia
    • multiple gestation
    • history of high BP
    • first pregnancy
    • obesity
    • age <18, >40
  • Symptoms of pre-eclampsia
    • severe headache
    • blurring or flashing vision
    • pain below ribs
    • vomiting
    • swelling of face, hands or feet

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How do you treat it?

  • Treatment of hypertension and pre eclampsia
    • admission for all!
    • oral labetalol first line
  • Severe pre-ecamplsia (various ways to define but involves BP>160)
    • usual symptoms plus addition of possible clonus, pailloedema and signs of HELLP
    • if seizing or imminent risk of eclampsia give magnesium
      • loading dose 4g over 5 mins
      • followed by infusion 1g/hour for 24hrs
      • recurrent seizures treated with further 2g boluses over 5 mins
      • resp depression (muscle weakness) and loss of deep tendon reflexes as signs of toxicity
      • do not use standard antiepileptic drugs as an alternative to magnesium
    • labetalol, hydralaizine or oral nifedipine are the antihypertensives to use
    • remember the steroids for the bubba
    • restrict fluids to 80ml/hr (risk of pulm oedema)

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What is HELLP syndrome

(LITFL)

  • haemolysis (MAHA), elevated LFTs (LDH>600, AST>70), low platelets (<100)
  • a variant presentation fo pre-eclampsia
  • can have jaundice and RUQ pain and might just get referred to the surgeons as cholecystitis so don’t do that!!

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Urinary tract infection in pregnancy

  • unique in that recommendation is to treat asymptomatic bateriuria
  • these asymptomatic UTIs have been associated with poor foetal outcomes

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VTE in pregnancy

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