<23 Weeks - Early Pregnancy
This has been covered here: https://www.rcemlearning.co.uk/foamed/induction-bleeding-in-early-pregnancy/
Later Pregnancy
https://www.rcemlearning.co.uk/modules/bleeding-in-pregnancy/
Antepartum Haemorrhage
>24 weeks gestation
Placenta praevia - stage depends how much of the os is covered by the placenta. Bright red and painless bleeding.
Placental abruption - complete or partial separation of the placenta. Causes lots of bleeding which may be concealed. Normally associated with continuous abdominal pain.
Vasa praevia - the fetal blood vessels run everywhere, not protected by the placenta. They may run over the cervix. High perinatal mortality - easy to rupture the fetal blood vessels. Can cause painless bleeding.
AntiD may be needed after a potentially sensitising event.
Hopefully all of these will be identified by screening, and hopefully these patients will present to the maternity assessment unit, not the ED!
PostPartum Haemorrhage
Primary PPH - in first 24hours. Secondary PPH - up to six weeks. Again, hopefully these patients will present to MAU not ED.
In pregnancy, problems are the 4Ts
Tone, trauma, tissue, thrombin.
Tone: uterine massage, bimanual compression, catheterise, give syntrometrin
Bleeding should slowly stop after a 12 weeks. It's often significantly less after the first few hours, and should change from bright red to brown (lochia).
The commonest cause is endometritis. There may be retained products - start IVs, get an USS. If there's no RPOC, there could still be endometritis. The uterus in endometritis will remain palpable after 14days after delivery. Endometritis is a clinical diagnosis.
I think bleeding persistently after delivery needs to see O&G.
Bleeding that stops and starts again is probably "new" bleeding.
https://www.bmj.com/content/358/bmj.j3875?sso=
http://www.emdocs.net/postpartum-endometritis-ed-setting-presentation-evaluation-management/
Showing posts with label HAP27. Show all posts
Showing posts with label HAP27. Show all posts
Tuesday, 13 November 2018
Tuesday, 24 October 2017
Hyperemesis Gravidarum
We all know that nausea and vomiting in pregnancy is common affecting 50–75% of pregnant women any time from the 4th week of pregnancy, most common in the 9th and 12 week, and we probably misdiagnose some of these people with hyperemesis gravidarum which affects less than 1%. To me, I'm not sure that the precise difference matters, as I think I'd struggle to send home a ketotic pregnant lady with at least some of the hyperemesis protocol...
Hyperemesis Gravidarum
Persistent, intractable nausea and vomiting beginning in the first trimester
Associated with a weight loss of >5% of pre-pregnancy weight
Dehydration, electrolyte imbalance and ketosis
Cause
Likely multifactorial - typically higher levels of human chorionic gonadotrophin
H. pylori may have a part to play
Make sure you exclude other causes - molar pregnancy is the most serious. These patients are unlikely to improve enough to be able to go home.
Treatment
Antiemetics:
Ginger - evidence base says ginger tablets improve symptoms in four days
Other:
Small meals (6 times a day). Eat as soon as you feel hungry. Avoid likely triggers - like fatty food.
Fluids- cold, clear, and carbonated like ginger ales and lemonades as well as smoothies or slushies.
Thiamine - thiamine requirements increase in pregnancy, so give if "prolonged" vomiting. Some say if no meal in a weak, others say vomiting for more than three weeks.
Oral thiamine 100mg / day, or IV thiamine (pabrinex is OK, but does have other B vitamins). Toxbase suggests overdose of thiamine is low risk.
Antiacids- treat non ulcer dyspepsia if there are signs of it. PPIs are thought to be safe. There is some evidence that H. pylori increases vomiting, so if the patient has prolonged vomiting, consider
Corticosteroids - can be used as a third line. I'd like O&G do that bit.
Patient Advice
No proven effects on the fetus, except fetal growth restriction, pre-term delivery. The pregnancy may be complicated by triploidy, trisomy 21 and hydrops fetalis. It may be due to a molar pregnancy.
Mum can get problems from electrolyte derangement - wernickes, central pontine myelinolysis due to hyponatraemia, ATN, splenic avulsion and increased VTE risk. Peripheral neuropathies are rare. One case report of epistaxis due to vitamin K deficiency!
Results
Ketones in the urine
Hypochloremic alkalosis
Slightly elevated liver enzymes - amniotransferases elevations are 2-3 times normal, but can be 15-20 times normal. They should resolve
Electrolyte abnormalities, typically hypokalaemia
Transient hyperthyroidism
1st Line - Cyclizine
Antihistamines (Cyclizine) and phenothiazines should be prescribed.
2nd Line - Metoclopramide
Safe and effective but there is a risk of extrapyramidal side effects.
3rd Line - Ondansetron
Some mostly unproven link with ondansetron and septal defects.
Fluids
RCOG says no evidence any fluid is better than another.
Nausea apparently resolves faster with dextrose containing fluid, but you need to check the sodium and consider thiamime replacement first - with the dogma that otherwise you can precipitate Wernickes.
References and Links
http://bestbets.org/bets/bet.php?id=2923
http://pmj.bmj.com/content/postgradmedj/72/853/688.full.pdf
https://www.rcog.org.uk/globalassets/documents/guidelines/green-top-guidelines/gtg69-hyperemesis.pdf
https://wikem.org/wiki/Hyperemesis_gravidarum
http://pmj.bmj.com/content/78/916/76
http://bestpractice.bmj.com/best-practice/evidence/intervention/1405/0/sr-1405-i8.html
Hyperemesis Gravidarum
Persistent, intractable nausea and vomiting beginning in the first trimester
Associated with a weight loss of >5% of pre-pregnancy weight
Dehydration, electrolyte imbalance and ketosis
Cause
Likely multifactorial - typically higher levels of human chorionic gonadotrophin
H. pylori may have a part to play
Make sure you exclude other causes - molar pregnancy is the most serious. These patients are unlikely to improve enough to be able to go home.
Treatment
Antiemetics:
Ginger - evidence base says ginger tablets improve symptoms in four days
Other:
Small meals (6 times a day). Eat as soon as you feel hungry. Avoid likely triggers - like fatty food.
Fluids- cold, clear, and carbonated like ginger ales and lemonades as well as smoothies or slushies.
Thiamine - thiamine requirements increase in pregnancy, so give if "prolonged" vomiting. Some say if no meal in a weak, others say vomiting for more than three weeks.
Oral thiamine 100mg / day, or IV thiamine (pabrinex is OK, but does have other B vitamins). Toxbase suggests overdose of thiamine is low risk.
Antiacids- treat non ulcer dyspepsia if there are signs of it. PPIs are thought to be safe. There is some evidence that H. pylori increases vomiting, so if the patient has prolonged vomiting, consider
Corticosteroids - can be used as a third line. I'd like O&G do that bit.
Patient Advice
No proven effects on the fetus, except fetal growth restriction, pre-term delivery. The pregnancy may be complicated by triploidy, trisomy 21 and hydrops fetalis. It may be due to a molar pregnancy.
Mum can get problems from electrolyte derangement - wernickes, central pontine myelinolysis due to hyponatraemia, ATN, splenic avulsion and increased VTE risk. Peripheral neuropathies are rare. One case report of epistaxis due to vitamin K deficiency!
Results
Ketones in the urine
Hypochloremic alkalosis
Slightly elevated liver enzymes - amniotransferases elevations are 2-3 times normal, but can be 15-20 times normal. They should resolve
Electrolyte abnormalities, typically hypokalaemia
Transient hyperthyroidism
1st Line - Cyclizine
Antihistamines (Cyclizine) and phenothiazines should be prescribed.
2nd Line - Metoclopramide
Safe and effective but there is a risk of extrapyramidal side effects.
3rd Line - Ondansetron
Some mostly unproven link with ondansetron and septal defects.
Fluids
RCOG says no evidence any fluid is better than another.
Nausea apparently resolves faster with dextrose containing fluid, but you need to check the sodium and consider thiamime replacement first - with the dogma that otherwise you can precipitate Wernickes.
References and Links
http://bestbets.org/bets/bet.php?id=2923
http://pmj.bmj.com/content/postgradmedj/72/853/688.full.pdf
https://www.rcog.org.uk/globalassets/documents/guidelines/green-top-guidelines/gtg69-hyperemesis.pdf
https://wikem.org/wiki/Hyperemesis_gravidarum
http://pmj.bmj.com/content/78/916/76
http://bestpractice.bmj.com/best-practice/evidence/intervention/1405/0/sr-1405-i8.html
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