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Transcript
OB/GYN Beyond the Objectives 1 Pregnancies • Most are uncomplicated • Complications can arise from: • • • • • • • Eclampsia/Pre-eclampsia Diabetes Hypotension/Hypertension Cardiac disorders Abortion Trauma Placenta abnormalities 2 Childbirth • Involves Labor and Delivery • Natural process, often only requiring basic assistance • You have at least two patients! 3 Childbirth • Complications can occur • • • • • • • • Breech/limb presentation Multiple Births Umbilical cord problems Disproportion Excessive bleeding Pulmonary embolism Neonate requiring resuscitation Preterm labor 4 Female Reproductive System 5 Anatomy/Physiology • Placenta • • • • • Transfer of gases Transport of nutrients Excretion of wastes Hormone production Protection 6 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 7 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 8 Ectopic Pregnancy • History • Missed period • Other signs of early pregnancy • Vaginal bleeding 6 -8 weeks after last period • Upon rupture, bleeding may be excessive 9 Ectopic Pregnancy • History • Lower abdominal pain • May be: • Sharp or dull • Constant or intermittent • Diffuse or localized • May be referred to shoulder 10 Ectopic Pregnancy • Physical Exam • • • • S/S of hypovolemic shock Positive tilt test Tender lower abdomen Palpable mass may be present 11 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! 12 Abortion • Termination of pregnancy before fetal viability (20th week) • Induced • Therapeutic • Criminal • Elective 13 Abortion • Spontaneous • 20 -25% of pregnancies terminate spontaneously • Usually due to embryo abnormalities • May also result from infection, unfavorable intrauterine environment, cervical incompetence 14 Abortion • Spontaneous • • • • Threatened Inevitable Complete Incomplete 15 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 16 Abortion • Inevitable • • • • • Vaginal bleeding Moderately severe contractions Possible amniotic sac rupture Cervix effacement and dilation Changes are irreversible 17 Abortion • Completed • Products of conception expelled • fetus • placenta • decidual lining • Signs, symptoms • • • • Profuse vaginal bleeding Passage of tissue, clots Continuing mild contractions Possible hypotension 18 Abortion • Incomplete • Products of conception retained • Signs, symptoms • • • • • Profuse bleeding Passage of tissue/clots Severe contractions Hypotension, shock Sepsis 19 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 20 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 21 Abortion • Management • • • • • • High concentration oxygen IV or IV’s with LR MAST if indicated Do NOT pack vagina Save any tissue passed Transport 22 Medical Complications • Diabetes • Stable may become unstable • Gestational • Can not use oral medications • Neuromuscular • May be aggravated by pregnancy 23 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 24 Pregnancy-Induced Hypertension • Two Phases: • Pre-eclampsia • Eclampsia 25 Pre-Eclampsia • In about 7% of pregnancies • Between 20th week gestation, first week postpartum • Hypertension, albuminuria, edema 26 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 27 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 28 Pre-Eclampsia • Signs/Symptoms (Cont.) • • • • • • Severe headache Blurred vision Irritability Nausea, vomiting Epigastric pain Pulmonary edema 29 Eclampsia Pre-eclampsia + Seizures, Coma 30 Pregnancy-Induced Hypertension • Management • • • • • High concentration oxygen IV tko Left lateral recumbent position Quiet environment Reduce excessive light 31 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 32 Pregnancy-Induced Hypertension • Assess every pregnant patient for: • Increased BP • Edema • Take all reported seizures in pregnant females seriously 33 Third Trimester Bleeding • 50% due to normal changes in cervix • 50% due to placental catastrophe • Dangerous if amount greater than normal period 34 Abruptio Placentae • Premature placental separation from uterus • 0.4 - 3.5% of pregnancies • Risk Factors • • • • Older patients Hypertensives Multigravidas Trauma 35 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 36 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 37 Placenta Previa • Painless, bright-red vaginal bleeding • Soft, non-tender uterus • No contractions • S/S of hypovolemia 38 Third Trimester Bleeding • Management • • • • 100% Oxygen IV of LR x 2 Left lateral recumbent position MAST, legs only 39 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 40 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 41 Fever/Dysuria • Major medical emergency • Suggests urinary tract or amniotic fluid infection • Sepsis or early labor may result • Patient MUST come to hospital 42 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 43 Uterine Rupture • 50 - 75% fetal mortality • Management • • • • • 100% Oxygen IV of LR x 2 Left lateral recumbent position MAST, legs only Rapid transport 44 Uterine Rupture • History of previous C-section • Transport immediately unless baby is crowning • Determine reason for C-section 45 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 46 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 47 Trauma in Pregnancy • Injured woman of child-bearing age, consider pregnancy • Priorities EXACTLY same as in any other patient • ABC’s first 48 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 49 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 50 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 51 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 52 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 53 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 54 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 55 Braxton-Hicks Contractions • • • • Usually occurs in the third trimester Benign phenomenon that simulates labor Contractions are generally painless Walking may help 56 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 57 Preterm labor • Management • Consideration of tocolysis • Rest • Fluids • Sedation • Transport for evaluation 58 Obstetric Patient Assessment • Recognition of pregnancy • • • • Breast tenderness Urinary frequency Amenorrhea Nausea/Vomiting 59 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 60 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 61 Obstetric Patient Assessment • Obstetric Physical Exam • Presence of fetal movements • ~20th week • Presence of fetal heat tones • ~20th week • Normal: 120 to 160/minute 62 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 63 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 64 Obstetric Patient Assessment • Do tilt test if blood loss is suspected • Do NOT tilt patient with obvious shock Do NOT perform vaginal exams! 65 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 66 QUESTIONS ? 67