1 OB/GYN Beyond the Objectives

2 Pregnancies Most are uncomplicated Complications can arise from: Eclampsia/Pre-eclampsia Diabetes Hypotension/Hypertension Cardiac disorders Abortion Trauma Placenta abnormalities

3 Childbirth Involves Labor and Delivery Natural process, often only requiring basic assistance You have at least two patients!

4 Childbirth Complications can occur Breech/limb presentation Multiple Births Umbilical cord problems Disproportion Excessive bleeding Pulmonary embolism Neonate requiring resuscitation Preterm labor

5 Female Reproductive System

6 Anatomy/Physiology Placenta Transfer of gases Transport of nutrients Excretion of wastes Hormone production Protection

7 Anatomy/Physiology Umbilical cord Connects placenta to fetus Two arteries One vein Amniotic Sac Membrane surrounding fetus Fluid originates from feral sources cc (after 20 weeks) Rupture produces watery discharge

8 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

9 Ectopic Pregnancy History Missed period Other signs of early pregnancy Vaginal bleeding 6 -8 weeks after last period Upon rupture, bleeding may be excessive

10 Ectopic Pregnancy History Lower abdominal pain May be: Sharp or dull Constant or intermittent Diffuse or localized May be referred to shoulder

11 Ectopic Pregnancy Physical Exam S/S of hypovolemic shock Positive tilt test Tender lower abdomen Palpable mass may be present

12 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!

13 Abortion Termination of pregnancy before fetal viability (20th week) Induced Therapeutic Criminal Elective

14 Abortion Spontaneous % of pregnancies terminate spontaneously Usually due to embryo abnormalities May also result from infection, unfavorable intrauterine environment, cervical incompetence

15 Abortion Spontaneous Threatened Inevitable Complete Incomplete

16 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

17 Abortion Inevitable Vaginal bleeding Moderately severe contractions Possible amniotic sac rupture Cervix effacement and dilation Changes are irreversible

18 Abortion Completed Products of conception expelled fetus placenta decidual lining Signs, symptoms Profuse vaginal bleeding Passage of tissue, clots Continuing mild contractions Possible hypotension

19 Abortion Incomplete Products of conception retained Signs, symptoms Profuse bleeding Passage of tissue/clots Severe contractions Hypotension, shock Sepsis

20 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

21 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

22 Abortion Management High concentration oxygen IV or IV’s with LR MAST if indicated Do NOT pack vagina Save any tissue passed Transport

23 Medical Complications Diabetes Stable may become unstable Gestational Can not use oral medications Neuromuscular May be aggravated by pregnancy

24 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

25 Pregnancy-Induced Hypertension Two Phases: Pre-eclampsia Eclampsia

26 Pre-Eclampsia In about 7% of pregnancies Between 20th week gestation, first week postpartum Hypertension, albuminuria, edema

27 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

28 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

29 Pre-Eclampsia Signs/Symptoms (Cont.) Severe headache Blurred vision Irritability Nausea, vomiting Epigastric pain Pulmonary edema

30 Eclampsia Pre-eclampsia + Seizures, Coma

31 Pregnancy-Induced Hypertension Management High concentration oxygen IV tko Left lateral recumbent position Quiet environment Reduce excessive light

32 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

33 Pregnancy-Induced Hypertension Assess every pregnant patient for: Increased BP Edema Take all reported seizures in pregnant females seriously

34 Third Trimester Bleeding 50% due to normal changes in cervix 50% due to placental catastrophe Dangerous if amount greater than normal period

35 Abruptio Placentae Premature placental separation from uterus % of pregnancies Risk Factors Older patients Hypertensives Multigravidas Trauma

36 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

37 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

38 Placenta Previa Painless, bright-red vaginal bleeding Soft, non-tender uterus No contractions S/S of hypovolemia

39 Third Trimester Bleeding Management 100% Oxygen IV of LR x 2 Left lateral recumbent position MAST, legs only

40 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

41 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

42 Fever/Dysuria Major medical emergency Suggests urinary tract or amniotic fluid infection Sepsis or early labor may result Patient MUST come to hospital

43 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

44 Uterine Rupture % fetal mortality Management 100% Oxygen IV of LR x 2 Left lateral recumbent position MAST, legs only Rapid transport

45 Uterine Rupture History of previous C-section Transport immediately unless baby is crowning Determine reason for C-section

46 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

47 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

48 Trauma in Pregnancy Injured woman of child-bearing age, consider pregnancy Priorities EXACTLY same as in any other patient ABC’s first

49 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

50 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

51 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

52 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

53 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

54 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

55 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

56 Braxton-Hicks Contractions Usually occurs in the third trimester Benign phenomenon that simulates labor Contractions are generally painless Walking may help

57 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

58 Preterm labor Management Consideration of tocolysis Rest Fluids Sedation Transport for evaluation

59 Obstetric Patient Assessment Recognition of pregnancy Breast tenderness Urinary frequency Amenorrhea Nausea/Vomiting

60 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

61 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

62 Obstetric Patient Assessment Obstetric Physical Exam Presence of fetal movements ~20th week Presence of fetal heat tones ~20th week Normal: 120 to 160/minute

63 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

64 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

65 Obstetric Patient Assessment Do tilt test if blood loss is suspected Do NOT tilt patient with obvious shock Do NOT perform vaginal exams!

66 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

67 QUESTIONS ?