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OB/GYNOB/GYNBeyond the ObjectivesBeyond the Objectives

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Pregnancies

• Most are uncomplicated• Complications can arise from:

• 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• 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• 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• 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• S/S of hypovolemic shock• Positive tilt test• Tender lower abdomen • Palpable mass may be present

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Ectopic Pregnancy

• Management• 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• 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• 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• Profuse vaginal bleeding

• Passage of tissue, clots

• Continuing mild contractions

• Possible hypotension

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Abortion

• Incomplete• Products of conception retained• Signs, symptoms

• 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• 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• 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.)• 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• 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• 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• 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

• 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:• Prolonged labor against obstruction• Large fetus• Old C-section• Multiple pregnancies

• Signs/Symptoms• 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• 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 • Premature separation of the placenta• Premature labor• Abortion• Rupture of the uterus• Fetal death

• 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: • 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

• 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• 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• 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

• 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 performvaginalexams!

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Obstetric Patient Assessment

• Warning signs• Vaginal bleeding

• Swelling of face, hands

• Dimmed, blurred vision

• Abdominal pain

• Persistent vomiting

• Chills, fever

• Dysuria

• Fluid escape from vagina

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QUESTIONSQUESTIONS

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