Transcript The Art of Obstetrical Triage

The Art of Obstetrical
Triage
Katherine Degen, MD
Black Hills Ob/Gyn
Objectives
Identify common obstetrical emergencies and immediate treatment
Hypertensive disorders
Vaginal bleeding
Preterm labor
Care of the pregnant trauma patient
Physiologic changes unique to pregnancy
Placental abruption
Maternal fetal hemorrhage and Rh disease
Basics of Triage
Sick or not sick
Appropriate location to evaluate patient
Term vs Preterm
Vitals
Medical comorbidities
Pregnancy complications
Capabilities of facility
Bread and Butter of Triage
Labor check
Term vs Preterm
Membrane rupture check
Decreased fetal movement
Vaginitis
Urinary tract complaints
Common Obstetrical Emergencies: HTN
Chronic HTN
HTN prior to 20 weeks gestation
Gestational HTN
HTN after 20 weeks gestation
Preeclampsia
With/without severe features
BP 140/90, +/- proteinuria, low plt, high LFT, renal failure, cerebral disturbances, etc
Hypertension in Pregnancy
Assess level of hypertension
Neurological symptoms?
Headache/visual changes
Stroke sx
Is it preeclampsia?
Signs and symptoms of placental abruption?
Other potential causes for hypertension?
Hypertension in Pregnancy
Initial workup
CBC
CMP
Urine dip
UDS
Spot urine protein to creatinine ratio
NST
Common Obstetrical Emergencies: Vaginal
Bleeding
Very common complaint amongst pregnant women
Sources
Vagina
Rectum
Bladder
Cervix
Uterus/Placenta/Membranes
Painful= abruption, labor, uterine rupture, vaginal laceration, UTI, anal fissure
Vaginal Bleeding in Pregnancy
Assess quantity and patient status (both of them)
Other physical signs
Uterine contractions, previous cesarean scar
What was patient doing when bleeding started?
Trauma, intercourse
Examine the perineum/vagina
Where is it really coming from?
Vaginal Bleeding in Pregnancy
Initial Workup
CBC
+/- type and screen
At least know her Rh status from records
IV access
Coags
Remember fibrinogin is normally elevated in pregnancy, a normal value is not necessarily
reassuring
Common Obstetrical Emergencies: Preterm Labor
Labor: Uterine contractions along with cervical change
Term: > 37 weeks gestation
Risks are numerable
History of PTB, short cervix, ROM, multiple gestations, drug use, UTI, smoking, eco status
50-80% of admissions are later discharged and deliver at term
Preterm Labor
How long have the contractions been present?
Increasing in frequency and strength?
Trauma?
Urinary or vaginal symptoms?
Pregnancy history?
Leakage of fluid?
Last intercourse?
Preterm Labor
Initial Workup
Sterile speculum exam vs digital exam
Fetal fibronectin
Recent intercourse/vaginal exam, vaginal bleeding= false positive
Toco pattern
CBC
UA/UDS
Preterm Labor
Optimize Fetal Outcome if delivery imminent
Antibiotics for GBS unknown or positive status
Betamethasone for lung maturity
Now up to 37 weeks!!
Think about diabetes, have they had a GTT?
Magnesium for neuroprophylaxis
Try Terb to get Time To Transfer… but no ambulance/helicopter unstable
patients
Care of the Pregnant Trauma Patient
THE LEADING CAUSE OF MATERNAL DEATH (NON-OBSTETRICAL)
20% of maternal deaths are from trauma
Trauma affects 1:12 pregnant women
Most importantly: TREAT MOTHER FIRST!!
Quickly assess gestational age by fundal height
1cm=1 week
If 18-20 weeks, left lateral tilt
Physiologic Changes in Pregnancy
Placental Abruption
Separation of placenta from uterus
5-50% of cases of obstetrical trauma
Largest risk 2-6hrs after trauma, up to 24 hours
Maintain high index of suspicion
Minor trauma
Ultrasound poor diagnostic test
PAINFUL VAGINAL BLEEDING
Maternal Fetal Hemorrhage and Rh Factor
17 % of women Rh D negative who do not receive Rhogam will become
alloimmunized
28 weeks, any bleeding, and after birth (if indicated)
12 week duration of action
SAB, TAB, abruption, trauma, amniocentesis, version
30mL of fetal blood covered by 300mcg of Rhogam
Screen for excessive fetomaternal hemorrhage with KB, or rosette
Paternity
Approach to the Patient Without Prenatal Care
Access records from outside facilities if possible
Detailed history and physical
Look for cesarean scar(s)
Treat the patient as though she will not seek care after she leaves your facility
Ob package (including RAPID HIV), fetal anatomical survey, GBS, gonorrhea and chlamydia cx,
urine cx, glucose testing (gtt or FSBG)
Healthy living education, side sleeping, hydration, seat belt use, safe medications, etc
Compassionate care!
Hypertensive Patient
16 yo G1P0 @ 37 weeks gestation
Blood pressure 140/90
No history of HTN per history or records
Headache and scotomata
Fundal height 34cm
Abdominal pain and uterine irritability on toco
Patient with Vaginal Bleeding
38 yo G3P2 @ 36 wks presents with copious bright red bleeding
Was sleeping when awakened by bleeding, no pain
Vital stable, but… FHT Category 3
Examination: bright red blood from cervical os on
SSE
CBC WNL, Rh positive
Pregnant Woman Involved in Trauma
25 yo presents to ED unconscious after MVA, gestational age unknown
Fundal height 40cm, FHT 170s
After stabilization by ED staff and your suggestion of displacing
uterus off of midline you finally get records from labor and
delivery
She is only 32 weeks, singleton
What is the diagnosis? Why is the fundal height so large? What would you
expect her labs to be?
Patient in Possible Preterm Labor
23 yo G3P2 @ 33 weeks, Q5 min uterine contractions for several hours
Some small vaginal bleeding, increased rectal pressure
Vitals stable, FHT 130s reassuring, Toco: q5 min contractions
Cervix appears closed on SSE, digitally 1cm
Send FFN?
After 2 hours continued contractions, no cervical change
Points to Remember
Keep a high index of suspicion for something being wrong
Frequent Flyers
Common things are common, but remember the zebras
Treat the mother first
Think of DV in all trauma patients
Triage is the first line
Remember the physiologic changes in pregnancy, tachycardia can be normal,