Urgent considerations

See Differentials for more details

Obstetric emergencies

Placental abruption

  • The danger to the mother depends on the severity of the abruption, whereas the risk to the fetus is related to both the severity of the abruption and the gestational age at which the abruption occurs. As well as causing haemorrhage, it may lead to disseminated intravascular coagulation (DIC). In cases where the abruption is severe and both maternal and fetal wellbeing are compromised, urgent delivery of the fetus is indicated, usually by caesarean section.

Uterine rupture

  • An obstetric catastrophe that can lead to massive intra-abdominal haemorrhage, maternal mortality, and fetal death. The initial signs and symptoms may be non-specific, making diagnosis difficult and delaying vital life-saving surgery. As timing is critical, the diagnosis of a ruptured uterus is usually based on clinical findings. An urgent caesarean section is required to deliver the fetus and repair the uterus. A hysterectomy may be considered in cases of severe intractable uterine bleeding or extensive uterine damage.

Ectopic pregnancy

  • If undiagnosed or incorrectly managed, may lead to maternal death due to rupture of the implantation site and intraperitoneal haemorrhage. Patients with a positive urine pregnancy test and the absence of an intrauterine pregnancy on transvaginal ultrasound are considered to have an ectopic pregnancy until proved otherwise. Urgent laparoscopy with salpingectomy or salpingotomy is performed for a ruptured ectopic pregnancy.

Haemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome

  • In cases of HELLP syndrome, maternal mortality rates vary from 0% to 24%, with the most common causes being cerebral haemorrhage, cardiopulmonary arrest, and DIC.[15] In addition, mothers with HELLP syndrome are at increased risk for pre-term delivery, placental abruption, and sub-capsular hepatic haematoma. Perinatal mortality ranges from 11% to 37%.[34][35] Most of the neonatal complications seem to be the result of prematurity and placental insufficiency. Treatment includes delivery of the fetus as soon as possible.

Acute fatty liver of pregnancy

  • If left untreated, the prodromal phase is often followed by jaundice, which may progress to fulminant hepatic failure. Treatment involves immediate delivery of the fetus and correction of hepatic failure.

Ovarian hyper-stimulation syndrome (OHSS)

  • The most life-threatening iatrogenic complication, occurring in 2% of women undergoing gonadotrophin stimulation. In its severe form (0.2%), OHSS is characterised by enlarged ovaries, ascites, increased blood viscosity, and renal or hepatic dysfunction.[9] Severe cases require hospitalisation, with close monitoring and care by a physician with experience in treating OHSS.

Premature labour

  • Uterine contractions, leading to possible premature labour and pre-term rupture of membranes, can be triggered by nephrolithiasis, urinary tract infections (UTIs) (particularly pyelonephritis), HELLP syndrome, placental abruption (implicated in up to 10% of premature deliveries), chorioamnionitis, and appendicitis, thus endangering survival of the fetus.[10] Tocolytic agents are used to suppress contractions if <34 weeks' gestation.

Adnexal masses

Blood flow impairment due to adnexal (ovarian) torsion may lead to congestion, oedema, discoloration, ischaemia, and necrosis. If not promptly identified and managed with operative intervention, the adnexal damage may become irreversible.

Adnexal torsion may also complicate OHSS due to the presence of enlarged cystic ovaries. If a large adnexal cyst ruptures, there may be severe pain with vomiting and a degree of shock. A ruptured haemorrhagic corpus luteum cyst can cause free bleeding into the peritoneal cavity. Urgent surgery to control the bleeding is indicated in the haemodynamically unstable patient.

Urological emergencies

Pyelonephritis can be a life-threatening illness as it may cause sepsis, adult respiratory distress syndrome, and acute renal failure. It may also lead to pre-term delivery. Hospitalisation and treatment with intravenous antibiotics is required.

Gastrointestinal emergencies

Pancreatitis is an unusual and potentially devastating event in pregnancy. There may be a rapid progression from a phase of mild oedema to necrotising pancreatitis. In fulminating cases, the pancreas is replaced by black pus. Death may be from shock, renal failure, sepsis, or respiratory failure. Hyperlipidaemic pancreatitis has been reported to result in a high rate of fetal mortality.[36] Urgent surgical consultation is indicated.

Maternal morbidity and mortality due to acute appendicitis is usually associated with advanced gestational age, significant delay in the diagnosis, and appendiceal perforation. The premature delivery rate is greatest during the first week after surgery. Fetal loss increases when perforation is present. A swift surgical consultation should be obtained if there is a possibility of appendicitis.

Acute cholecystitis is the second most common general surgical condition affecting pregnancy (appendicitis being the first).[37] Non-operative management has been associated with higher incidence of adverse pregnancy outcomes including poor fetal growth, pregnancy loss, pre-term labour, and pre-term delivery.[38][39]​​​​ Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines recommend laparoscopic cholecystectomy rather than non-operative management for pregnant patients presenting with acute cholecystitis.[40]​ Urgent surgical opinion should be sought if acute biliary symptoms are present in a pregnant patient.

Trauma

Pressure transmission to the uterus from blunt trauma may cause placental abruption and uterine rupture. Direct fetal injury, commonly involving fetal skull and brain damage, is caused by pelvic fracture in association with an engaged cephalic presentation.

If splenic rupture occurs in pregnancy, most cases are associated with high maternal mortality largely due to intra-abdominal haemorrhage. Domestic abuse is the most common cause, so patients tend to present late, resulting in delayed diagnosis.

In cases of severe traumatic injury, fetal monitoring should be implemented immediately and the relevant specialist consulted.

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