Urgent considerations
See Differentials for more details
Obstetric emergencies
Placental abruption
Associated with increased perinatal mortality and morbidity. Also a cause of significant maternal morbidity. 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, ectopic pregnancy 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.[64] 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%.[65][66] 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)
A potentially life-threatening iatrogenic complication. Severe OHSS requiring hospitalisation occurs in approximately 0.5% to 2% of women undergoing gonadotrophin stimulation.[14][15][16] Severe cases of OHSS are characterised by enlarged ovaries, ascites, increased blood viscosity, and renal or hepatic dysfunction.[18] Close monitoring and care by a physician with experience in treating OHSS is mandated.
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.[19][67] Tocolytic agents are used to suppress contractions if <34 weeks' gestation.
Incarceration of the gravid uterus
Clinical complications tend to occur after the first trimester and are mostly related to the pressure generated from anatomical structures adjacent to the entrapped uterus. Early diagnosis and intervention with reduction is required to prevent further complications (including uterine rupture, bladder rupture, sepsis, intrauterine growth retardation, premature delivery, and fetal death) as the pregnancy progresses.[68]
Adnexal masses
Blood flow impairment due to adnexal (ovarian) torsion may lead to congestion, oedema, discoloration, ischaemia, and necrosis. Adnexal damage may become irreversible if not promptly identified and managed with operative intervention.
Adnexal torsion may 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.[69] 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 affects ≤0.1% of pregnancies.[70][71] 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.[72][73] Early laparoscopic management for acute cholecystitis in pregnancy has been associated with reduced risk of fetal complications; delay in operative management with increased risk of both maternal and fetal complications.[74][75] Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines recommend laparoscopic cholecystectomy rather than non-operative management for pregnant patients presenting with acute cholecystitis.[76] 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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