1. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 1 Abnormal Pregnancy CAPT Mike Hughey, MC, USNR

2. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 2 Incidence of Miscarriage 1 in every 6 pregnancies Risk of subsequent miscarriage 1/6 Bedrest will not prevent miscarriage but may postpone it

3. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 3 Causes of Miscarriage 60% chromosome abnormalities 30% placental malformation 10% miscellaneous, but not: -trauma -climbing mountains -intercourse -medication -too much activity, etc.

4. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 4 Threatened Abortion 1 in every 4 pregnancies 1st TM bleeding/cramping Half will abort, Half will be OK Bedrest will not prevent abortion but may postpone it.

5. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 5 Complete Abortion Passage of all tissue Rest for a day or two Ergotrate, Oxytocin Antibiotics Rhogam D&C? 9-week spontaneous complete abortion

6. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 6 Incomplete Abortion: Diagnosis Some tissue remains behind Continuing bleeding/cramping Tissue in cervical os Uterus tender Fever if infection present Ultrasound helpful if available

7. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 7 Incomplete Abortion: Treatment Convert it to a Complete Abortion If tissue visible in the os, remove it Ergotrate, Oxytocin Antibiotics Rhogam D&C Tissue removed from os Tissue still inside uterus

8. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 8 Inevitable Abortion No tissue has been passed Cervix dilated or hemorrhage Ergotrate, Oxytocin Antibiotics Rhogam D&C

9. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 9 Septic Abortion Any abortion complicated by infection Fever, Tenderness Ergotrate, Oxytocin Antibiotics MEDEVAC D&C

10. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 10 Septic Abortion: Antibiotics Clindamycin & Gentamicin IV Flagyl & Gentamicin IV Cefoxitin IV

11. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 11 Unruptured Ectopic Pregnancy + HCG Unilateral pelvic pain and tenderness ±Pelvic mass? DD: CL cyst, Appy, PID Lie still MEDEVAC

12. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 12 Ruptured Ectopic: Diagnosis Pelvic & right shoulder pain Sudden onset Shock Positive pregnancy test Rebound & Rigidity late Ultrasound Culdocentesis

13. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 13 Ruptured Ectopic: Treatment Surgery MEDEVAC IVs, oxygen, lie still Maintain urine output (Foley) MAST suit?

14. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 14 Blood Transfusion O Negative blood Blood collection bags Direct Donor to Patient #16 needle 3-4 feet gravity feed 10 minutes Have a plan before you need it

15. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 15 Placental Abruption >20 weeks Uterine pain, tenderness, and contractions ±Bleeding Coagulopathy Lie still, IV Fluids MEDEVAC, Cesarean Section

16. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 16 Placenta Previa >20 weeks Painless vaginal bleeding No pelvic exam unless instructed by an OB- GYN Pelvic exam may cause torrential hemorrhage, exsanguination and death within minutes Rest, IVs, MEDEVAC

17. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 17 Toxemia of Pregnancy Elevated BP (>140/90) Proteinuria (>300 mg in 24 hours) Weight Gain (>2 pounds/week) Swelling (?) Increased reflexes (Clonus)

18. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 18 Pre-Eclampsia BP, Protein Stable and unstable Risk of IUGR Risk of Abruption Risk of maternal seizures Risk of HELLP syndrome Hemolysis Elevated Liver Enzymes Low Platelets Naval Hospital Jacksonville

19. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 19 Eclampsia Siezures Risk of maternal death Risk of HELLP syndrome Hemolysis Elevated Liver Enzymes Low Platelets Naval Hospital Guam

20. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 20 Treatment of Toxemia of Pregnancy Delivery is definitive treatment If delivery is to be postponed (prematurity), then consider hospitalization for unstable patients Magnesium sulfate Watch for HELLP syndrome

21. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 21