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 hemorrhage, 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 cesarean section.

Uterine rupture

  • An obstetric catastrophe that can lead to massive intra-abdominal hemorrhage, maternal mortality, and fetal death. The initial signs and symptoms may be nonspecific, 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 cesarean 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 hemorrhage. 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 proven otherwise. Urgent laparoscopy with salpingectomy or salpingotomy is performed for a ruptured ectopic pregnancy.

Hemolysis, 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 hemorrhage, cardiopulmonary arrest, and DIC.[15] In addition, mothers with HELLP syndrome are at increased risk for preterm delivery, placental abruption, and subcapsular hepatic hematoma. 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 hyperstimulation syndrome (OHSS)

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

Premature labor

  • Uterine contractions, leading to possible premature labor and preterm 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, edema, discoloration, ischemia, 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 hemorrhagic corpus luteum cyst can cause free bleeding into the peritoneal cavity. Urgent surgery to control the bleeding is indicated in the hemodynamically unstable patient.

Urologic 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 preterm delivery. Hospitalization 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 edema to necrotizing pancreatitis. In fulminating cases, the pancreas is replaced by black pus. Death may be from shock, renal failure, sepsis, or respiratory failure. Hyperlipidemic 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 consult 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] Nonoperative management has been associated with higher incidence of adverse pregnancy outcomes including poor fetal growth, pregnancy loss, preterm labor, and preterm delivery.[38][39]​​​​ Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines recommend laparoscopic cholecystectomy rather than nonoperative 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 hemorrhage. 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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