Obstetrical and Gynecological Emergencies. General Strategy. Primary Survey / Resuscitation Secondary Survey. Psychological, Social, Environmental Factors. Age: consider in ages 12 years to 55 years Nationality / ethnicity Occupation Economic capabilities and resources
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General Strategy • Primary Survey / Resuscitation • Secondary Survey
Psychological, Social, Environmental Factors • Age: consider in ages 12 years to 55 years • Nationality / ethnicity • Occupation • Economic capabilities and resources • Social support system • Reproductive history • Nutritional • Genetic
Subjective Data History of present illness LNMP EDC or + pregnancy test Bleeding, discharge, pain, N&V, fever / chills Visual disturbances Fetal movement ROM ? Contractions Urinary symptoms Trauma Focused Survey
Subjective Data Medical History Reproductive Prenatal care Recent delivery ?? Abd / pelvic surgery Sexual activity Contraceptive use STD’s Substance abuse Meds, Allergies etc. Focused Survey
Focused Survey • Objective Data • Physical Exam • Diagnostic Procedures • Radiology • Other • 12 lead ECG • pH for amniotic fluid
Assessment Assumptions • Any pregnant patient should be assessed for… • EDC / LNMP • Reproductive history including complications with current and previous pregnancies • Uterine size, tone, presence of contractions • Vaginal discharge or bleeding, fluid leaking? • FHT’s
Planning and Interventions • ABC’s first • IV’s and O2 as indicated • Monitor and treat… • Hemodynamic status • Vaginal bleeding, passage of clots, products of conception • Pain • Anticipate educational and emotional needs fo patient and family. • Anticipate equipment needs
Age Related Considerations • Pediatrics • Sexual abuse • STD’s / PID • Teen preganancy • Geriatrics
Specific Obstetrical Emergencies Vaginal Bleeding in Early Pregnancy / Abortion Vaginal Bleeding in Late Pregnancy Ectopic Pregnancy PIH: preeclampsia / eclampsia Hyperemesis gravidarum Postpartum hemorrhage Emergency Delivery Neonatal Resuscitation Trauma in Pregnancy
Abortion • Termination of pregnancy before viability (20-24 weeks). • 10% to 15% of all recognized pregnancies • Etiology • Endocrine dysfunction • Chromosomal abnormalities • Maldevelopment • Trauma
Abortion • Additional factors • Maternal infections • Malnutrition • Substance abuse • Immunological incompatibility • Surgery • Structural abnormalities of the uterus
Abortion: Classification • Threatened • Incomplete • Complete • Missed • Septic
Abortion: Assessment • Subjective and Objective information same for any pregnant patient • Diagnostic procedures • Pregnancy test - ? Quantitative • CBC • Blood type and Rh • STD • Pelvic US
Abortion: Interventions • IV access • Assist with US, exam • Prep for surgery as appropriate • Drug Therapy • Rh immune globulin to all Rh negative mothers • Oxytocin • Methergine • Analgesics • Antibiotics • Conscious sedation • Supportive / Psychosocial care
Abortion : Teaching • Bedrest x 24-48 hours or until bleeding stops • Pelvic rest until bleeding / cramping cease • Pads only • Temp. four times a day, return for > 100.6 • Save clots / tissue • Follow up care with OB
Placenta Previa Abnormally implanted placenta partially or completely obstructs cervical os 45% in second trimester 1% at term Painless bright red bleeding occurs as cervix effaces / dilates Multiparity, multigestation, advanced maternal age, uterine surgery, smoking. Bleeding in Late Pregnancy
Abruptio placenta 3% of all pregnancies, 15% of all perinatal deaths Partial or complete separation of a normally implanted placenta Significant blood loss Risk for DIC Etiology: HTN, trauma, substance abuse, PROM, … Bleeding in Late Pregnancy
Ectopic Pregnancy • Implantation of fertilized ovum outside of the normal uterine cavity • 95% in the fallopian tube, frequently right • Rupture leads to severe pain, intraperitoneal hemorrhage and shock
Ectopic – Assessment • Pain: diffuse, unilateral or bilateral, tube rupture is sharp, sudden, severe • Referred shoulder pain • Vaginal bleeding irregular / mild • Fatigue, dizziness, syncope • History: LNMP, reproductive hx, PID / STD’s, IUD use, tubal surgery, infertility, meds, allergies
Ectopic Assessment • Physical Exam: • orthostatic VS • abdominal exam • pelvic • Quantitative BHcG, CBC, T&C, PT/PTT, electrolytes, U/S
Ectopic – Interventions • ABC’s • 2 large bore IV’s • Reassess hemodynamic status / pain • Prepare for OR • Methotrexate • Supportive care / pregnancy loss
PIH: Preeclampsia / Eclampsia • PIH: hypertension unique to pregnancy • Preeclampsia: HTN, proteinuria and non-dependent edema after 20 weeks • Eclampsia: includes convulsions, coma or both • HELLP: hemolysis, elevated liver enzymes, low platelets. The most severe form of preeclampsia.
PIH: Preeclampsia / Eclampsia - • Exact cause unknown • Underlying pathology is vasospasm • Complicates 5-8% of preganancies • Leading obstetric cause of maternal death
Pre-eclampsia / Eclampsia • Risk factors: • extremes of maternal age,chronic hypertension • hx of eclampsia • mother or sister with hx • multiple gestation • diabetes, SLE, vascular disease • molar pregnancy • More common in primigravida
Preeclampsia / Eclampsia: Assessment • Headache, weight gain, epigastric or RUQ tenderness, generalized edema, visual disturbances, anxiety • BP > 140/90 or 30 mmHg systolic or 15 mmHg diastolic over baseline. 2 BP readings 6 hours apart with Mom on L. side.
Preeclampsia / Eclampsia: Diagnostics • Urinalysis: proteinuria greater than 1+ • CBC • Electrolytes, creatinine, liver enzymes • PT / PTT
Preeclampsia / Eclampsia: Interventions • ABC’s • Supplemental O2 • Foley - monitor hourly UO • Magnesium sulfate for seizure prophylaxis • Seizure precautions • Benzodiazepines for seizures • Antihypertensive therapy • Reassess ABC’s, FHT’s, signs of Mg++toxicity (Ca gluconate is antidote)
Hyperemesis Gravidarum • Severe vomiting occurring before 20th week. • Lasts 4-8 weeks • Significant weight loss, dehydration, malnutrition • Metabolic acidosis, ketonuria, hypokalemic alkalosis, oliguria, hemoconcentration, constipation • Complications: G.I. Bleeding, Mallory – Weiss tears, and Boerhaave’s esophogeal disruption
Hyperemesis: Management • ABC’s • IV access, 1-2 liters NS rapidly • Antiemetics as ordered • Gradual oral rehydration as tolerated
Postpartum Hemorrhage • Blood loss exceeding 500 ml • Early – within 24 hours of delivery • Uterine atony • Retained placental fragments • Lower genital tract lacerations • Uterine inversion or rupture • Maternal coagulopathy • Late - usually 6-10 days • Retained products of conception • Infection • Episiotomy breakdown • Coital trauma
Postpartum Hemorrhage: Risk Factors • Overdistention of uterus • High parity • Prolonged difficult labor, especially after oxytocin induction • History of PPH • Preeclampsia • Placenta previa • Precipitous labor
Postpartum Hemorrhage: Management • Assessment to include: orthostatic VS, Uterine size / tone, amount / color of bleeding • Diagnostics: CBC, T&C, Coagulation profile, fibrinogen, fibrin split products, US • 2 large bore IV’s – fluids / blood as appropriate • Firm bimanual massage of uterus • Oxytocin, Methergine as ordered • Prepare for surgery
Emergency Delivery • Rapid obstetric assessment / history • Contractions: frequency, intensity, duration • Rupture of membranes: time, color, odor • Bloody show? • Rectal pressure or passage of feces • FHT’s • Pelvic Exam for effacement, dilation, station
Emergency Delivery • Position side lying or fowlers • Encourage mother to “pant” to prevent uncontrolled delivery • Allow head to emerge slowly • Once head delivered, assess for nuchal cord • Loose – slip over head • Tight – clamp in 2 places and cut between clamps • Wipe infants face, suction mouth then nose. • Support head, deliver anterior then posterior shoulder. • Body will follow rapidly….slippery, don’t drop
Emergency Delivery continued • Hold infant head down at level of perineum, suction mouth then nose again • Clamp cord 4-5 cm from infants abdomen when cord stops pulsating. Cut between clamps • Dry wrap, warm, stimulate infant • Apgar at birth and 5 minutes • Do not massage uterus until placenta is delivered
Trauma in Pregnancy • Trauma is primary cause of mortality in pregnancy causing up to 22% of maternal deaths • Maternal death is leading cause of fetal death • Management priorities for pregnant trauma patient are identical to those for any trauma patient.
Review of A&P Changes in Pregnancy • ABDOMINAL • CARDIOVASCULAR • PULMONARY
Specific Gynecological Emergencies Vaginal bleeding / Dysfunctional uterine bleeding Pelvic pain Vaginal discharge Sexually Transmitted diseases Pelvic Inflammatory Disease Sexual Assault
Vaginal Bleeding / Dysfunctional Uterine Bleeding • Vaginal bleeding: uterine fibroids, menstrual cycle irregularities, trauma, infection, malignancy or coagulopathy • DUB: hormonal imbalance • Assessment: include sexual and contraceptive history, quantity, duration, quality of bleeding • Diagnostics: BHCG, CBC, coags, T&S, UA, STD screening, Thyroid, liver function, FSH, LH as appropriate.
Pelvic Pain • Variety of causes…assess pain carefully (PQRST).
Vaginal Discharge • Variety of causes. • Bacterial 40-50% • Candida albicans 20-25% • Trichomonas 15-20% • Non-infectious processes • Retained FB • Chemicals • Hormonal changes • Alteration in vaginal flora due to pregnancy, antibiotics, diabetes, HIV infection, poor hygiene • See table 13-5
Sexually Transmitted Disease • Vaginitis, cervicitis, PID, urethritis, epididymitis, pharyngitis, proctitis, skin and mucous membrane lesions, AIDS • See table 13-6