Transcript RefresherSpecialPts

OB/GYN
Beyond the Objectives
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Pregnancies
• Most are uncomplicated
• Complications can arise from:
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Eclampsia/Pre-eclampsia
Diabetes
Hypotension/Hypertension
Cardiac disorders
Abortion
Trauma
Placenta abnormalities
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Childbirth
• Involves Labor and Delivery
• Natural process, often only requiring basic
assistance
• You have at least two patients!
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Childbirth
• Complications can occur
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Breech/limb presentation
Multiple Births
Umbilical cord problems
Disproportion
Excessive bleeding
Pulmonary embolism
Neonate requiring resuscitation
Preterm labor
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Female Reproductive System
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Anatomy/Physiology
• Placenta
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Transfer of gases
Transport of nutrients
Excretion of wastes
Hormone production
Protection
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Anatomy/Physiology
• Umbilical cord
• Connects placenta to fetus
• Two arteries
• One vein
• Amniotic Sac
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Membrane surrounding fetus
Fluid originates from feral sources
500 - 1000 cc (after 20 weeks)
Rupture produces watery discharge
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Ectopic Pregnancy
• Pathophysiology
• Outside uterine cavity
• 95% Fallopian tubes
• 1 in every 200 pregnancies
• Most are symptomatic
• Predisposing factors
• Tubal infections
• Previous tubal surgery
• IUD use
• previous ectopic pregnancy
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Ectopic Pregnancy
• History
• Missed period
• Other signs of early pregnancy
• Vaginal bleeding 6 -8 weeks after last period
• Upon rupture, bleeding may be excessive
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Ectopic Pregnancy
• History
• Lower abdominal pain
• May be:
• Sharp or dull
• Constant or intermittent
• Diffuse or localized
• May be referred to shoulder
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Ectopic Pregnancy
• Physical Exam
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S/S of hypovolemic shock
Positive tilt test
Tender lower abdomen
Palpable mass may be present
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Ectopic Pregnancy
• Management
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High concentration oxygen
IV or IV’s with LR
MAST
Immediate transport
Abdominal pain or unexplained hypovolemia +
woman of child-bearing age =
Ectopic pregnancy
Until proven otherwise!
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Abortion
• Termination of pregnancy before fetal
viability (20th week)
• Induced
• Therapeutic
• Criminal
• Elective
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Abortion
• Spontaneous
• 20 -25% of pregnancies terminate
spontaneously
• Usually due to embryo abnormalities
• May also result from infection, unfavorable
intrauterine environment, cervical
incompetence
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Abortion
• Spontaneous
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Threatened
Inevitable
Complete
Incomplete
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Abortion
• Threatened
• Vaginal bleeding, mild or absent
contractions, closed cervix
• 20% of women bleed in early pregnancy
• 50% go on to abort
• Any bleeding in early pregnancy is
dangerous and abnormal
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Abortion
• Inevitable
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Vaginal bleeding
Moderately severe contractions
Possible amniotic sac rupture
Cervix effacement and dilation
Changes are irreversible
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Abortion
• Completed
• Products of conception expelled
• fetus
• placenta
• decidual lining
• Signs, symptoms
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Profuse vaginal bleeding
Passage of tissue, clots
Continuing mild contractions
Possible hypotension
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Abortion
• Incomplete
• Products of conception retained
• Signs, symptoms
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Profuse bleeding
Passage of tissue/clots
Severe contractions
Hypotension, shock
Sepsis
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Abortion
• Missed
• Fetus dies in utero before 20th week
• Retained at least 2 months afterwards
• Signs/Symptoms
• Continued amenorrhea
• History of bleeding without cramping
• Decrease in uterine size
• Resorption of fluid
• Calcification of products of conception
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Abortion
• History
• Confirmed or suspected pregnancy
• Abdominal pain, cramping
• Bleeding, passage of tissue
• Physical Exam
• Orthostatic vital signs (tilt test)
• Examine for amount of vaginal bleeding, presence
of tissue
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Abortion
• Management
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High concentration oxygen
IV or IV’s with LR
MAST if indicated
Do NOT pack vagina
Save any tissue passed
Transport
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Medical Complications
• Diabetes
• Stable may become unstable
• Gestational
• Can not use oral medications
• Neuromuscular
• May be aggravated by pregnancy
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Medical Complications
• Hypertension
• More susceptible to complications
• CVA
• Cardiac Failure
• Renal Failure
• May be complicated by preeclampsia or eclampsia
• Cardiac Disorders
• Additional stress placed on heart
• CO increases 30% by week 34
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Pregnancy-Induced Hypertension
• Two Phases:
• Pre-eclampsia
• Eclampsia
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Pre-Eclampsia
• In about 7% of pregnancies
• Between 20th week gestation, first week
postpartum
• Hypertension, albuminuria, edema
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Pre-Eclampsia
• Risk Factors
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First pregnancies
Multiple gestations
excessive amniotic fluid
Diabetes mellitus
Renal disease
Pre-existing hypertension
Family history of pre-eclampsia
Poor nutrition
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Pre-Eclampsia
• Signs/Symptoms
• Elevated BP
• >140/90 or >30mmHg above patient normal
• Edema of face/hands
• Especially in morning
• Rapid weight gain
• >3lb/wk - 2nd trimester
• >1lb/wk - 3rd trimester
• Decreased urine output
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Pre-Eclampsia
• Signs/Symptoms (Cont.)
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Severe headache
Blurred vision
Irritability
Nausea, vomiting
Epigastric pain
Pulmonary edema
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Eclampsia
Pre-eclampsia + Seizures, Coma
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Pregnancy-Induced Hypertension
• Management
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High concentration oxygen
IV tko
Left lateral recumbent position
Quiet environment
Reduce excessive light
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Pregnancy-Induced Hypertension
• Psychological support
• Avoid lights/sirens in pre-eclampsia
• Magnesium sulfate
• 4gm bolus; 1gm/hr infusion
• Monitor pulse, BP, respiration, patellar
reflex
• Calcium will reverse toxicity
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Pregnancy-Induced Hypertension
• Assess every pregnant patient for:
• Increased BP
• Edema
• Take all reported seizures in pregnant
females seriously
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Third Trimester Bleeding
• 50% due to normal changes in cervix
• 50% due to placental catastrophe
• Dangerous if amount greater than
normal period
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Abruptio Placentae
• Premature placental separation from uterus
• 0.4 - 3.5% of pregnancies
• Risk Factors
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Older patients
Hypertensives
Multigravidas
Trauma
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Abruptio Placentae
• Mild to moderate vaginal bleeding
• Continuous, knife-like abdominal
pain
• Third trimester pain = Abruption
until proven otherwise
• Rigid tender uterus
• S/S of hypovolemia
• Out of proportion to visible
bleeding
• Alteration of contraction pattern
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Placenta Previa
• Placental implantation over cervical opening
• 0.5% of pregnancies
• Predisposing factors
• increasing age
• multiparity
• previous cesarean sections
• Can lead to
• placental insufficiency
• fetal hypoxia
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Placenta Previa
• Painless, bright-red
vaginal bleeding
• Soft, non-tender uterus
• No contractions
• S/S of hypovolemia
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Third Trimester Bleeding
• Management
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100% Oxygen
IV of LR x 2
Left lateral recumbent position
MAST, legs only
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Supine Hypotensive Syndrome
• Uterus compresses inferior vena cava
• Venous return to heart decreases
• Decreased venous return leads to decreased
cardiac output
• BP decreases
• Consider volume depletion
• Management
• Place patient on left side to restore venous return
• Transport all non-laboring patients in late pregnancy
on left side
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Ruptured Membranes
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Vaginal leakage of clear, colorless fluid
84% labor spontaneously in 24 hours, BUT
50% become infected in 12 hours
Increased time = Increased infection risk
Patient MUST come to hospital
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Fever/Dysuria
• Major medical emergency
• Suggests urinary tract or amniotic fluid
infection
• Sepsis or early labor may result
• Patient MUST come to hospital
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Uterine Rupture
• Common causes:
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Prolonged labor against obstruction
Large fetus
Old C-section
Multiple pregnancies
• Signs/Symptoms
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Sudden, intense, tearing abdominal pain
S/S of hypovolemic shock
Loss of continuity of uterine mass
Possible vaginal bleeding
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Uterine Rupture
• 50 - 75% fetal mortality
• Management
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100% Oxygen
IV of LR x 2
Left lateral recumbent position
MAST, legs only
Rapid transport
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Uterine Rupture
• History of previous C-section
• Transport immediately unless baby is
crowning
• Determine reason for C-section
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Trauma in Pregnancy
• Minor Trauma
• Common in the Obstetric Patient
• Syncopal episodes
• Diminished coordination
• Loosening of the joints
• Major Trauma
• Susceptible to a life threatening episode
• increased vascularity
• may deteriorate suddenly
• Leading cause of maternal death in pregnancy
• MVC’s = 50% of perinatal mortality
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Trauma in Pregnancy
• Trauma can lead to
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Premature separation of the placenta
Premature labor
Abortion
Rupture of the uterus
Fetal death
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Death of mother
Separation of the placenta
Maternal shock
Uterine rupture
Fetal head injury
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Trauma in Pregnancy
• Injured woman of child-bearing age,
consider pregnancy
• Priorities EXACTLY same as in any
other patient
• ABC’s first
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Trauma in Pregnancy
• Assessment
• Vital signs mimic hypovolemia
• Pulse increases 10-15/minute
• BP decreases
• Blood volume increases up to 45%
• More blood loss can occur before S/S of
hypovolemia appear
• In hypovolemia, blood is shunted from
placenta causing fetal distress
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Trauma in Pregnancy
• Assessment
• Increased fluid volume needed to treat
hypovolemia
• Penetrating abdominal trauma in second,
third trimester frequently involves uterus
• Greatest danger from uterine injury is
hypovolemia
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Trauma in Pregnancy
• Assessment
• Second, third trimester blunt abdominal
trauma may cause:
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Uterine rupture
Placental abruption
Premature labor
Hemorrhage from uterine vessels
• “Loose” joints mimic orthopedic injury
• Particularly pelvic fracture
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Trauma in Pregnancy
• Management
• Treat shock early, aggressively
• Fetus may be distressed when mother is not
• S/S of shock appear later
• More volume needed to correct hypovolemia
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Trauma in Pregnancy
• Management
• Oxygenate aggressively
• Consider assisting ventilation early
• Oxygen demand increases 10-20% in last
trimester
• High diaphragm causes decreased compliance,
tidal volume
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Trauma in Pregnancy
• Management
• MAST can be used in late-term pregnancy
• Inflate legs only
• Using abdominal compartment reduces blood flow to fetus
• After first trimester never transport patient flat
on back
• Transport on left side
• Prop up right side of spine board with blanket,
pillows
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Trauma in Pregnancy
• Most common cause of fetal death from
trauma is maternal death
• Keeping mom alive keeps baby alive
• What’s good for mom is good for baby
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Braxton-Hicks Contractions
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Usually occurs in the third trimester
Benign phenomenon that simulates labor
Contractions are generally painless
Walking may help
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Preterm labor
• Labor that begins prior to 38 weeks
gestation
• Labor results in progressive dilation and
effacement of cervix
• Causes
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Multiple gestations
Intrauterine infections
Premature rupture of the membranes
Uterine or cervical anatomical abnormalities
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Preterm labor
• Management
• Consideration of tocolysis
• Rest
• Fluids
• Sedation
• Transport for evaluation
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Obstetric Patient Assessment
• Recognition of pregnancy
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Breast tenderness
Urinary frequency
Amenorrhea
Nausea/Vomiting
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Obstetric Patient Assessment
• Obstetric History
• Gravidity and Parity
• Gravidity = Number of pregnancies
• Parity = Number of live births
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Last normal menstrual period
Estimated delivery date (-3/+7)
Previous Ob-Gyn complications
Prenatal care (by whom)
Previous Cesarean sections
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Obstetric Patient Assessment
• Obstetric Physical Exam
• Evaluation of Uterine Size
• 12 to 16 weeks: above symphysis pubis
• 20 weeks: at umbilicus
• For each week beyond 20 weeks: 1 cm above
umbilicus
• At term: near xiphoid process
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Obstetric Patient Assessment
• Obstetric Physical Exam
• Presence of fetal movements
• ~20th week
• Presence of fetal heat tones
• ~20th week
• Normal: 120 to 160/minute
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Obstetric Patient Assessment
• Presence of Pain
• Abdominal pain in last trimester suggests
abruption until proven otherwise
• Appendicitis may present with RUQ pain
• Presence of vaginal bleeding
• Always dangerous in first trimester
• Dangerous in late pregnancy if greater than
normal period
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Obstetric Patient Assessment
• General health
• Diabetes may become unstable
• Hypoglycemic episodes in early pregnancy
• Hyperglycemia as pregnancy progresses
• Hypertension complicated by PIH
• Cardiovascular disease may worsen
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Obstetric Patient Assessment
• Do tilt test if blood loss is suspected
• Do NOT tilt patient with obvious shock
Do NOT
perform
vaginal
exams!
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Obstetric Patient Assessment
• Warning signs
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Vaginal bleeding
Swelling of face, hands
Dimmed, blurred vision
Abdominal pain
Persistent vomiting
Chills, fever
Dysuria
Fluid escape from vagina
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QUESTIONS
?
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