2. Critical Care of the Obstetric Patient Shannon Carroll, M.D. Suresh Agarwal, M.D. www.peainthepodcast.com

3. Page 3 Aspects of Critical Care Specific to Obstetric Patients Anatomic Changes in Pregnancy Physiologic/Pathologic Changes in Pregnancy –Hemodynamic –Endocrinologic –Pulmonary Postpartum Hemorrhage Trauma in the Pregnant Patient

4. Page 4 Anatomic Changes in Pregnancy ajnoffthecharts.wordpress.com/2009/11/03

5. Page 5 Anatomic Changes in Pregnancy focosi.altervista.org/uterinelevels.jpg

6. Page 6 Physiologic/Pathologic Changes in Pregnancy Cardiovascular Changes Endocrinologic Changes Pulmonary Changes empracticenews.files.wordpress.co m/2008/06/0708-emp-table-2.png

7. Page 7 Cardiovascular Changes Increase Cardiac Output –Up to 50% by 24th week of gestation –CO plateaus from 24th week until term –Further increased during labor and delivery –“Autotransfusion Effect” –Increased Preload after fetus and placenta delivery www.ljmu.ac.uk/sportandexercisesciences/RISES/Health/82521.htm

8. Page 8 Cardiovascular Changes Increased Cardiac Output –Increased Contractility –Early in Pregnancy: Increased Blood Volume –Later in Pregnancy: Increased Heart Rate 15 – 20 beats faster www.biomaterials.org/SIGS/Cardiovascular/Heart.htm

9. Page 9 Cardiac Output and Stroke Volume Supine Position –Aortocaval Compression –Decreased Preload –“Supine Hypotensive Syndrome” of Pregnancy –Left Lateral Recumbent Position after 20th week Body Positioning media.photobucket.com/image/left%20and%20ivc%20and% 20gravid/JHWalker/shs1.jpg

10. Page 10 Body Positioning Cardiac Resuscitation –Left Lateral Recumbent Position Or –Left Manual Displacement of the Uterus www.the-pillow.com.au/more/lucky-7-body-pillow-more.php

11. Page 11 Cardiovascular Changes LV End-Diastolic Volume is Increased Filling Pressures Unchanged –Decreased systemic and pulmonary vascular resistance

12. Page 12 Blood Volume –30 – 50% Increase by Full Term Red Blood Cell Mass –15 – 20% Increase by Full Term -> “Physiologic Anemia” of Pregnancy Cardiovascular Changes nursingcrib.com/pregnancy-complications/

13. Page 13 Cardiovascular Changes Up to 35% Blood Volume Loss before Tachycardia and Hypotension occur

14. Page 14 Increased Blood Flow –Breasts Cardiovascular Changes www.med.yale.edu/intmed/cardio/imaging/anatom y/breast_anatomy/graphics/breast_anatomy.gif

15. Page 15 Cardiovascular Changes Increased Blood Flow –Breasts –Uterus embryology.med.unsw.edu.au/notes/images/uroge n/uterine_blood_supply.jpg

16. Page 16 Cardiovascular Changes Increased Blood Flow –Breasts –Uterus –Kidneys ↑ Renal Blood Flow by 25 – 50% ↑ Glomerular Filtration Rate up to 50% ↓ BUN and Plasma Creatinine www.physicscentral.org/explore/action/im ages/scans-img8.jpg

17. Page 17 Cardiovascular Changes Diastolic Blood Pressure Decreased –↓ by 10% in 2nd Trimester –Due to ↓ Systemic Vascular Resistance –Returns to Baseline by Full Term

18. Page 18 Cardiovascular Changes Blood Vessel Remodeling Coagulation System Changes –Most Clotting Factors Increased –Hypercoagulable www.answers.com/topic/factor-xii

19. Page 19 Cardiovascular Changes Heart Remodeling –Enlargement of All 4 Chambers Susceptible to Supraventricular and Atrial Arrhythmias myhealth.ucsd.edu/library/healthguide/en- us/support/topic.asp?hwid=zm2767

20. Page 20 Cardiovascular Changes “Normal” Changes in Heart Sounds –Systolic Ejection Murmur –Third Heart Sound Potentially Pathologic Changes in Heart Sounds –Diastolic Murmurs –Pansystolic Murmurs –Late Systolic Murmurs www.ed4nurses.com/heartsnd.aspx

21. Page 21 Cardiovascular Changes Cardiac Disease –Mild to Moderate: Pregnancy Usually Well-Tolerated –Pulmonary Hypertension and Right-to-Left Shunts: up to 50% Mortality with Pregnancy

22. Page 22 Hypertension In Pregnancy Definition: –increase of at least 30 mmHg in the SBP and –Increase of at least 15 mmHg in the DBP –Above baseline

23. Page 23 Hypertension In Pregnancy Monitoring Etiology Preeclampsia Treatment Management During Labor and Delivery

24. Page 24 Blood Pressure Monitoring Sustained Hypertension –At least 2 separate occasions Position –Upper arm in the sitting position, or –Lower arm in the lateral recumbent position

25. Page 25 Etiology of Hypertension in Pregnancy Predisposing factors –Family history –Personal history of Diabetes mellitus –Vascular or Renal Disorders –Primigravid state –Multiple gestational pregnancies

26. Page 26 Preeclampsia Pregnancy induced Multisystem Onset is after 32nd week of gestation Symptom triad: –Peripheral edema –Systemic hypertension –Significant proteinuria (> 0.3g in 24hr urine) nursingcrib.com/pregnancy-complications/

27. Page 27 Preeclampsia US Incidence = 7% Diastolic hypertension is usually more prominent than systolic hypertension Evaluate patient for underlying or coexisting disease processes Familial cases May present as late as 7 days postpartum Postpartum preeclampsia often associated with the HELLP syndrome

28. Page 28 Preeclampsia and the HELLP Syndrome Some or all of the following: –(H) microangiopathic hemolytic anemia –(EL) elevated liver enzymes –(LP) low platelets –May be present without significant blood pressure elevations

29. Page 29 Preeclampsia Increased risk with significant elevation in blood pressure in the second trimester –1/3 of patients with MAP > 90 in the second trimester will develop it –< 2% of patients with MAP < 90 in the second trimester will develop it

30. Page 30 Treatment of Hypertension In Pregnancy Uterine Blood Flow and BP Management –Increases or shows no change with BP control Avoid Overly Aggressive BP Management –Affects maternal hemodynamics –Compromises uterine blood flow Initial Agents –po α-methyldopa –po labetalol IV Agents –Labetalol –Hydralazine –Sodium Nitroprusside

31. Page 31 BP Management During L&D Antihypertensive agents Judicious use of IV fluids Postpartum monitoring for high risk patients Preeclampsia –Hypertension resolves spontaneosly within a few weeks Trace amounts of all antihypertensive agents are found in breast milk –No adverse affects on infants have been identified

32. Page 32 Endocrinologic Changes Hypothalamus Pituitary Gland Adrenal Glands www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/1093.jpg

33. Page 33 Endocrinologic Changes Increased ACTH and Cortisol Levels in Pregnancy –Cushing’s Syndrome may be exacerbated by pregnancy –Acute Adrenal Crisis may be precipitated by labor and delivery www.beliefnet.com/healthandhealing/getcontent.aspx?c id=179661

34. Page 34 Waterhouse-Friderichsen syndrome Massive adrenal hemorrhage –Usually bilateral –Meningococcemia –Hypotension/Shock –DIC with purpura –Rapidly progressive adrenocortical insufficiency Most common etiology = Neisseria meningitidis Prevention: Vaccine against meningococcus www.livestrong.com/ls_images/disease/1000-1999/1814-2938.jpg

35. Page 35 Waterhouse-Friderichsen syndrome Onset: fever, rigors, vomiting, and headache Rash quickly develops –first macular –progresses to petechiae and purpura; dusky gray color Hypotension/Septic shock Usually no Meningitis Adrenal Insufficiency (hypoglycemia, hyponatremia, hyperkalemia) DIC Acidosis ARF Meningococci –from blood or CSF –smears of cutaneous lesions library.med.utah.edu/WebPath/jpeg4/ENDO004.jpg

36. Page 36 Waterhouse-Friderichsen syndrome Treatment: –Medical emergency –Ceftriaxone –Hydrocortisone for hypoadrenal shock library.med.utah.edu/WebPath/jpeg4/ENDO006.jpg

37. Page 37 Endocrinologic Changes Prolactin Levels Increased –Preparation for lactation –Pituitary Adenomas May increase in size May become symptomatic www.biologie.uni-freiburg.de/data/bio1/varga/projects.htm

38. Page 38 Endocrinologic Changes Thyroid Hormones Increased –Thyroxine-Binding Globulin Increased –Free Levels Unchanged –No Associated Complications if Iodine Consumption is Adequate www.pyroenergen.com/articles08/thyroid- gland-hormones.htm

39. Page 39 Endocrinologic Changes Transient Diabetes Insipidus –Due to Vasopressin Resistance www.medscape.com/viewarticle/558561_3

40. Page 40 Endocrinologic Changes Fluctuations in Insulin and Glucose Levels Increased Insulin Secretion Increased Insulin Resistance Gestational Diabetes Mellitus –Obese women with insulin resistance –Women with minimal pancreatic reserve nursingcrib.com/pregnancy-complications/

41. Page 41 Endocrinologic Changes Increased Maternal Lipid Metabolism

42. Page 42 Pulmonary Complications in the Obstetric Patient Normal Pulmonary Physiology in Pregnancy Asthma Pulmonary Edema Acute Respiratory Distress Syndrome Embolism saltyandsweet.wordpress.com/2008/05/12/various-gunky-topics

43. Page 43 Pulmonary Complications in the Obstetric Patient Normal Pulmonary Physiology in Pregnancy –Tidal volume is increased –Functional residual capacity is decreased Normal ABG = compensated respiratory alkalosis Respiratory distress may progress more rapidly due to pregnancy medical- dictionary.thefreedictionary.com/functional +residual+capacity

44. Page 44 Pulmonary Complications in the Obstetric Patient Asthma in Pregnancy –Monitoring: Peak flow meter (no change in FEV1) –PaCO2 > 35 mmHg in a pregnant patient with asthma may signify respiratory distress –Treatment principles are the same for pregnant and non-pregnant patients wellness.blogs.time.com/2009/10/09 /women-with-asthma-keep-up-your- treatment-during-pregnancy

45. Page 45 Pulmonary Complications in the Obstetric Patient Acute Respiratory Distress Syndrome in Pregnancy –Need for mechanical ventilation does not mandate delivery –Therapeutic drugs NOT contraindicated in pregnancy: Sedatives Hypnotics Non-depolaring paralytics http://www.rtjournalonline.com/images.htm

46. Page 46 Pulmonary Complications in the Obstetric Patient Embolism in Pregnancy –Hypercoagulable state –Radiographic studies if indicated by respiratory distress –Warfarin contraindicated in 1st trimester –Amniotic fluid embolism 1/80,000 pregnancies significant maternal morbidity/mortality www.oxygentimerelease.com/B/Bonnie/p23.htm

47. Page 47 Postpartum Hemorrhage Definition Epidemiology Pathophysiology Diagnosis Treatment Surgical Therapy Prognosis

48. Page 48 Postpartum Hemorrhage Definition: excessive and life-threatening bleeding Normal blood loss: –Vaginal birth < 500 mL –Cesarean section = 800 – 1000 mL after 20 weeks gestation at time of delivery of baby or placenta Primary PPH: within 24 hours of delivery Secondary PPH: between 24 hours and 12 weeks of delivery

49. Page 49 Postpartum Hemorrhage Epidemiology leading world-wide cause of maternal death (> 100,000 deaths per year) one of three leading causes of maternal death in the US (with embolism and hypertensive disorders) www.thedoctorstv.com/main/show_synopsis/207?section=synopsis

50. Page 50 Pathophysiology Uterine Blood Flow at Term –10% of maternal cardiac output –Approximately 600 to 1200 mL/min Myometrial Contraction –Placental separation –Hemostasis –Myometrial fibers contract (compression) and retract (occlusion) –Increase in Circulating Clotting Factors Postpartum Hemorrhage www.bodyworlds.com/en/media/picture_ database/preview.html?id=12

51. Page 51 Postpartum Hemorrhage Pathophysiology Causes of excessive hemorrhage –Uterine Atony –Lacerations –Placental Anomalies –Trauma library.med.utah.edu/kw/human_reprod/mml/hrob_oh_5.html

52. Page 52 Postpartum Hemorrhage Diagnosis/Workup: –often obvious, w/ external bleeding –if occult: Ultrasonography –Clot –Hematoma –retained placental fragments www.3bscientific.co.th/obgyn/placenta- w10604,p_895_0_0_0_3376_image_full. html

53. Page 53 Oxytocic drugs Treatment for Postpartum Hemorrhage –First line = Oxytocin (Pitocin) –Methylergonovine (Methergine) –Carboprost tromethamine (Hemabate) Uterine packing Balloon occlusion catheters Arteriography with selective arterial embolization www.cookmedical.com/wh/featur es/bakri_en_US/index_bakri.html Treatment for Postpartum Hemorrhage

54. Page 54 www.obfocus.com/high- risk/bleeding/hemorrhagepa.htm Surgical Therapy for Postpartum Hemorrhage Temporizing measure: occlusion of aorta by manual pressure with fist just cephalad to the umbilicus Manual examination of the uterus w/ evacuation of retained placenta

55. Page 55 Surgical Therapy for Postpartum Hemorrhage Hematomas of lower genital tract: incise and drain Hematomas of broad ligament and retroperitoneum: monitor unless expanding Visible lacerations: repaired & oversewn Ligation of uterine, ovarian, internal iliac arteries –Supply 90% of uterine blood flow Definitive treatment for PPH = Hysterectomy Uterine rupture mandates Hysterectomy

56. Page 56 Postpartum Hemorrhage Complications –DIC –Dilutional Coagulopathy -when > 80% of blood volume replaced –Hemorrhagic Shock –Renal failure –Liver failure –ARDS –Sheehan’s Syndrome –Avascular necrosis of pituitary gland –Permenant hypopituitarism Prognosis -- Dependent on prompt diagnosis and treatment www.ohiohealth.com/bodymayo.cfm

57. Page 57 Trauma in the Obstetric Patient Relevant Fetal Physiology Assessment and Resuscitation Blunt Trauma Penetrating Trauma Specific Complications of Trauma in the Pregnant Patient

58. Page 58 Trauma in the Obstetric Patient “Save the mother, save the fetus”

59. Page 59 Trauma in the Obstetric Patient Trauma –#1 cause of nonobstetric death in pregnant patients –#1 traumatic cause of fetal demise with maternal survival is placental abruption Maternal injuries associated with fetal demise –Pelvic fracture = fetal skull fracture and intracranial injury –80% of patients with hemorrhagic shock experience fetal demise

60. Page 60 Trauma in the Obstetric Patient Screen all female patients of child-bearing age for β- human chorionic gonadotropin www.babydoll.ws/content/uploads/2008/05/a-baby-in-the-making-3.jpg

61. Page 61 Specific Complications of Trauma in the Pregnant Patient Fetomaternal Hemorrhage –Fetal blood crosses into maternal circulation –About 1 in 4 pregnant trauma patients –To quantify: Kleihauer-Betke test Complications –Maternal Rh sensitization –Neonatal anemia –Fetal cardiac arrhythmias –Fetal exsanguination Treatment –Rho(D) immune globulin for Rh negative mothers

62. Page 62 Specific Complications of Trauma in the Pregnant Patient Abruptio Placentae –Most frequent cause of fetal death with maternal survival in trauma –Occurs even with minor trauma –Risk increases with gestational age Presentation –Abdominal pain –Vaginal bleeding –Premature rupture of membranes –Uterine tenderness or rigidity –Expanding fundal height –Maternal shock –Fetal distress Treatment = Delivery

63. Page 63 Specific Complications of Trauma in the Pregnant Patient Amniotic Fluid Embolism www.wadsworth.org/chemheme/heme/microscope/pix/schistocyte_nw.jpg

64. Page 64 Amniotic Fluid Embolism –Leakage of amniotic fluid with fetal elements into the maternal circulation –Incidence: 1/8,000 to 1/80,000 –Most common cause of peripartum deaths Presenting symptoms: –1st through 3rd trimester –Seizures or seizure-like activity –Cardiopulmonary collapse Progress to develop a consumptive coagulopathy Specific Complications of Trauma in the Pregnant Patient ipodsuite.com/search/?cx=016304524648153656 041%3Atn7nrxq7qf4&cof=FORID%3A11&ie=UTF -8&q=amniotic%20fluid#946

65. Page 65 Specific Complications of Trauma in the Pregnant Patient Amniotic Fluid Embolism –Consumptive Coagulopathy Decreased Fibrinogen (<100mg/dL) Increased Fibrin Split Products Decreased Platelets Increased PT and aPTT

66. Page 66 Specific Complications of Trauma in the Pregnant Patient Amniotic Fluid Embolism –Diagnosis Diagnosis of exclusion Fetal elements in maternal venous blood –Not always present/identified

67. Page 67 Specific Complications of Trauma in the Pregnant Patient Amniotic Fluid Embolism –Prognosis: dismal <15% survive neurologically intact

68. Page 68 Specific Complications of Trauma in the Pregnant Patient Amniotic Fluid Embolism –Treatment Supportive –CPR with L lateral displacement of uterus –Intubation, Mechanical Ventilation with FiO2=100% –Volume resuscitation –Pressor support early; 1st –line = Epinephrine –Emergent C-section if fetus not yet delivered –? Corticosteroids Treat DIC –Red blood cells, Platelets, FFP, and Cryoprecipitate

69. Page 69 Specific Complications of Trauma in the Pregnant Patient –Treatment: Delivery of the fetus Platelets + Clotting factors (including fibrinogen)

70. Page 70 Specific Complications of Trauma in the Pregnant Patient Premature Labor –Common –Usually self-limited –May require tocolytics –Tocolytics are contraindicated in patients with placental abruption i.ehow.com/images/GlobalPhoto/Articles/5378889/351878-main_Full.jpg

71. Page 71 Specific Complications of Trauma in the Pregnant Patient Uterine Rupture –Direct trauma to the uterus –Almost all result in fetal death –Often associated with maternal death –Abdominal pain + peritoneal signs library.med.utah.edu/kw/human_reprod/mml/hrob_oh_5.jpg

72. Page 72 Specific Complications of Trauma in the Pregnant Patient Fetal Demise –Labor usually ensues within 48 hours –Induction or C-section indicated if labor does not begin –Monitor for DIC

73. Page 73 Specific Complications of Trauma in the Pregnant Patient Cesarean Section –Fetal indications: Fetal distress Placental abruption Uterine rupture Fetal malposition with premature labor –Maternal indications: Inability to control other injuries due to pregnancy DIC www.jeffersonhospital.org/obgyn/fibroi d_images/39weeks-2.jpg

74. Page 74 Cardiac Arrest –Manually displace the uterus to the left –Consider left thoracotomy and cardiac massage + emergency C-section Continue CPR until delivery Delivery may allow maternal resuscitation C-section is indicated if: –delivery within 5 to 15 minutes of maternal cardiac arrest –Fetal vital signs persist Specific Complications of Trauma in the Pregnant Patient www.ehow.com/how_5511869_heal-having- emergency-cesarean-section.html

75. Page 75 Specific Complications of Trauma in the Pregnant Patient Maternal Head Trauma –Pregnant patients diagnosed with brain death have been supported until a viable fetus could be safely delivered –Essential Consults: Obstetricians Ethicists jeffreyleow.files.wordpress.com/2009/03/the_hand_of_hope_.jpg

76. Page 76 Medications Commonly Used in Pregnancy

77. Page 77 Critical Care of Gynecologic Patients Necrotizing fasciitis Risk factors –DM –Atherosclerosis –Long-term NSAID use –Glucocorticoids –Immune Deficiency Causative organisms –Streptococcus pyogenes (group A Strep) –Staphylococcus aureus –Polymicrobial media.jaapa.com/images/2009/04/07/fournierCME1107figs23_49370.jpg

78. Page 78 Critical Care of Gynecologic Patients Necrotizing fasciitis Indications for Surgical resection –Areas of necrosis (purple discoloration early) –Anesthetic areas Treatment –Systemic support –Systemic antibiotics –Radical Excision Histology: –Vascular occlusion/thrombosis –Leukocyte infiltration –Necrosis

79. Page 79 Critical Care of Gynecologic Patients Uterine Perforation Potential Etiologies: –Endometrial biopsy –IUD Placement –Dilation and Curettage –Surgical Termination of Pregnancy –Hysteroscopy Risk factors –Pregnancy or Infection (Uterus is edematous) –Postmenopausal (Uterus is fibrotic)

80. Page 80 Critical Care of Gynecologic Patients Uterine Perforation If suspected: –Blunt instrument/No negative pressure applied Conservative management Monitor for bleeding –Sharp instrument/Negative pressure applied Exploratory laparoscopy/laparotomy Close inspection of nearby structures for damage

81. Page 81 Critical Care of Gynecologic Patients Adnexal Torsion Risk factors –Long ligaments (Infundibulopelvic, Uteroovarian) –Adnexal Mass –Absence of Uterine attachments Pain –Unilateral –Intermittent Treatment –Reduction with fixation to Psoas muscle –Resection if necrotic or postmenopausal

82. Page 82 Critical Care of Gynecologic Patients Salpingo-oophoritis/Tubo-Ovarian Abscesses Risk Factors –IUD use –History of PID Diagnosis –Radiographic (Transvaginal Ultrasound) Treatment –Antibiotics –Interventional Radiology –Surgical Bilateral Salpingo-oopherectomy Transvaginal Colpotomy Drainage 2.bp.blogspot.com/_fBQVVpFhTQs/ SsTC-TdKK3I/AAAAAAAAAy8/JeB- 86DE8qc/s320/tuboovarian- abscess.jpg

83. Page 83 Critical Care of the Obstetric Patient Complex patients Medical, Surgical, Trauma, Postpartum Physiologic Alterations Altered response to potential injuries/illness Management of specific injuries/processes travel.ciao.co.uk/Body_Worlds_4_Manchester__Review_5753139

84. Page 84 References Fink MB, Abraham E, Vincent JL, Kochanek PM. Textbook of Critical Care, Fifth Edition. Elsevier, 2005 Mulholland MW, Lillemoe KD, Doherty GM, Maier RV, Upchurch GR. Greenfield’s Surgery: Scientific Principles & Practice, Fourth Edition. Lippincott Williams & Wilkins, 2006

85. Page 85 Image Sources ajnoffthecharts.wordpress.com/2009/11/03/ anatomyforme.blogspot.com/2008/05/pathways-of 2.bp.blogspot.com/_fBQVVpFhTQs/SsTC-TdKK3I/AAAAAAAAAy8/JeB- 86DE8qc/s320/tuboovarian-abscess.jpg embryology.med.unsw.edu.au/notes/images/urogen/uterine_blood_supply.j pg empracticenews.files.wordpress.com/2008/06/0708-emp-table-2.png focosi.altervista.org/uterinelevels.jpg i.ehow.com/images/GlobalPhoto/Articles/5378889/351878-main_Full.jpg jeffreyleow.files.wordpress.com/2009/03/the_hand_of_hope_.jpg library.med.utah.edu/kw/human_reprod/mml/hrob_oh_5.html library.med.utah.edu/kw/human_reprod/mml/hrob_oh_5.jpg

86. Page 86 Image Sources library.med.utah.edu/WebPath/jpeg4/ENDO004.jpg library.med.utah.edu/WebPath/jpeg4/ENDO006.jpg media.jaapa.com/images/2009/04/07/fournierCME1107figs23_49370.jpg media.photobucket.com/image/left%20and%20ivc%20and%20gravid/JHWa lker/shs1.jpg medical-dictionary.thefreedictionary.com/functional+residual+capacity myhealth.ucsd.edu/library/healthguide/en- us/support/topic.asp?hwid=zm2767 nursingcrib.com/pregnancy-complications saltyandsweet.wordpress.com/2008/05/12/various-gunky-topics/ travel.ciao.co.uk/Body_Worlds_4_Manchester__Review_5753139 wellness.blogs.time.com/2009/10/09/women-with-asthma-keep-up-your- treatment-

87. Page 87 Image Sources www.babydoll.ws/content/uploads/2008/05/a-baby-in-the-making-3.jpg www.beliefnet.com/healthandhealing/getcontent.aspx?cid=179661 www.biologie.uni-freiburg.de/data/bio1/varga/projects.htm www.biomaterials.org/SIGS/Cardiovascular/Heart.htm www.bodyworlds.com/en/media/picture_database/preview.html?id=12 www.3bscientific.co.th/obgyn/placenta-w10604,p_895_0_0_0_3376_image_full.html www.cookmedical.com/wh/features/bakri_en_US/index_bakri.html www.thedoctorstv.com/main/show_synopsis/207?section=synopsis www.ed4nurses.com/heartsnd.aspx www.ehow.com/how_5511869_heal-having-emergency-cesarean-section.html www.jeffersonhospital.org/obgyn/fibroid_images/39weeks-2.jpg www.ljmu.ac.uk/sportandexercisesciences/RISES/Health/82521.htm

88. Page 88 Image Sources www.livestrong.com/ls_images/disease/1000-1999/1814-2938.jpg www.medscape.com/viewarticle/558561_3 www.med.yale.edu/intmed/cardio/imaging/anatomy/breast_anatomy/graphics/breast_ anatomy.gif www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/1093.jpg www.obfocus.com/high-risk/bleeding/hemorrhagepa.htm www.ohiohealth.com/bodymayo.cfm?id=6&action=thumbnail&image=/images/image_ popup/ww5rn89.jpg www.oxygentimerelease.com/B/Bonnie/p23.htm www.peainthepodcast.com www.physicscentral.org/explore/action/images/scans-img8.jpg www.the-pillow.com.au/more/lucky-7-body-pillow-more.php www.pyroenergen.com/articles08/thyroid-gland-hormones.htm www.rtjournalonline.com/images.htm www.sonosite.com/news/2008/10/advanced-new-la-county-usc-trauma-center- redefines-resuscitation-through-integrating-mounted-point-of-care-ultrasound/