3Psychological, Social, Environmental Factors Age: consider in ages 12 years to 55 yearsNationality / ethnicityOccupationEconomic capabilities and resourcesSocial support systemReproductive historyNutritionalGenetic
4Focused Survey Subjective Data History of present illness LNMP EDC or + pregnancy testBleeding, discharge, pain, N&V, fever / chillsVisual disturbancesFetal movementROM ?ContractionsUrinary symptomsTrauma
5Focused Survey Subjective Data Medical History Reproductive Prenatal careRecent delivery ??Abd / pelvic surgerySexual activityContraceptive useSTD’sSubstance abuseMeds, Allergies etc.
6Focused Survey Objective Data Physical Exam Diagnostic Procedures RadiologyOther12 lead ECGpH for amniotic fluid
7Assessment Assumptions Any pregnant patient should be assessed for…EDC / LNMPReproductive history including complications with current and previous pregnanciesUterine size, tone, presence of contractionsVaginal discharge or bleeding, fluid leaking?FHT’s
8Planning and Interventions ABC’s firstIV’s and O2 as indicatedMonitor and treat…Hemodynamic statusVaginal bleeding, passage of clots, products of conceptionPainAnticipate educational and emotional needs fo patient and family.Anticipate equipment needs
9Age Related Considerations PediatricsSexual abuseSTD’s / PIDTeen preganancyGeriatrics
10Specific Obstetrical Emergencies Vaginal Bleeding in Early Pregnancy / Abortion Vaginal Bleeding in Late Pregnancy Ectopic Pregnancy PIH: preeclampsia / eclampsia Hyperemesis gravidarum Postpartum hemorrhage Emergency Delivery Neonatal Resuscitation Trauma in Pregnancy
11Abortion Termination of pregnancy before viability (20-24 weeks). 10% to 15% of all recognized pregnanciesEtiologyEndocrine dysfunctionChromosomal abnormalitiesMaldevelopmentTrauma
12Abortion Additional factors Maternal infections Malnutrition Substance abuseImmunological incompatibilitySurgeryStructural abnormalities of the uterus
14Abortion: AssessmentSubjective and Objective information same for any pregnant patientDiagnostic proceduresPregnancy test - ? QuantitativeCBCBlood type and RhSTDPelvic US
15Abortion: Interventions IV accessAssist with US, examPrep for surgery as appropriateDrug TherapyRh immune globulin to all Rh negative mothersOxytocinMethergineAnalgesicsAntibioticsConscious sedationSupportive / Psychosocial care
16Abortion : Teaching Bedrest x 24-48 hours or until bleeding stops Pelvic rest until bleeding / cramping ceasePads onlyTemp. four times a day, return for > 100.6Save clots / tissueFollow up care with OB
17Bleeding in Late Pregnancy Placenta PreviaAbnormally implanted placenta partially or completely obstructs cervical os45% in second trimester1% at termPainless bright red bleeding occurs as cervix effaces / dilatesMultiparity, multigestation, advanced maternal age, uterine surgery, smoking.
18Bleeding in Late Pregnancy Abruptio placenta3% of all pregnancies, 15% of all perinatal deathsPartial or complete separation of a normally implanted placentaSignificant blood lossRisk for DICEtiology: HTN, trauma, substance abuse, PROM, …
19Ectopic PregnancyImplantation of fertilized ovum outside of the normal uterine cavity95% in the fallopian tube, frequently rightRupture leads to severe pain, intraperitoneal hemorrhage and shock
22Ectopic – Interventions ABC’s2 large bore IV’sReassess hemodynamic status / painPrepare for ORMethotrexateSupportive care / pregnancy loss
23PIH: Preeclampsia / Eclampsia PIH: hypertensionunique to pregnancyPreeclampsia: HTN, proteinuria and non-dependent edema after 20 weeksEclampsia: includes convulsions, coma or bothHELLP: hemolysis, elevated liver enzymes, low platelets. The most severe form of preeclampsia.
25PIH: Preeclampsia / Eclampsia - Exact cause unknownUnderlying pathology is vasospasmComplicates 5-8% of pregananciesLeading obstetric cause of maternal death
26Pre-eclampsia / Eclampsia Risk factors:extremes of maternal age,chronic hypertensionhx of eclampsiamother or sister with hxmultiple gestationdiabetes, SLE, vascular diseasemolar pregnancyMore common in primigravida
27Preeclampsia / Eclampsia: Assessment Headache, weight gain, epigastric or RUQ tenderness, generalized edema, visual disturbances, anxietyBP > 140/90 or 30 mmHg systolic or 15 mmHg diastolic over baseline. 2 BP readings 6 hours apart with Mom on L. side.
28Preeclampsia / Eclampsia: Diagnostics Urinalysis: proteinuria greater than 1+CBCElectrolytes, creatinine, liver enzymesPT / PTT
29Preeclampsia / Eclampsia: Interventions ABC’sSupplemental O2Foley - monitor hourly UOMagnesium sulfate for seizure prophylaxisSeizure precautionsBenzodiazepines for seizuresAntihypertensive therapyReassess ABC’s, FHT’s, signs of Mg++toxicity (Ca gluconate is antidote)
31Hyperemesis: Management ABC’sIV access, 1-2 liters NS rapidlyAntiemetics as orderedGradual oral rehydration as tolerated
32Postpartum Hemorrhage Blood loss exceeding 500 mlEarly – within 24 hours of deliveryUterine atonyRetained placental fragmentsLower genital tract lacerationsUterine inversion or ruptureMaternal coagulopathyLate - usually 6-10 daysRetained products of conceptionInfectionEpisiotomy breakdownCoital trauma
33Postpartum Hemorrhage: Risk Factors Overdistention of uterusHigh parityProlonged difficult labor, especially after oxytocin inductionHistory of PPHPreeclampsiaPlacenta previaPrecipitous labor
34Postpartum Hemorrhage: Management Assessment to include: orthostatic VS, Uterine size / tone, amount / color of bleedingDiagnostics: CBC, T&C, Coagulation profile, fibrinogen, fibrin split products, US2 large bore IV’s – fluids / blood as appropriateFirm bimanual massage of uterusOxytocin, Methergine as orderedPrepare for surgery
35Emergency Delivery Rapid obstetric assessment / history FHT’s Contractions: frequency, intensity, durationRupture of membranes: time, color, odorBloody show?Rectal pressure or passage of fecesFHT’sPelvic Exam for effacement, dilation, station
36Emergency Delivery Position side lying or fowlers Encourage mother to “pant” to prevent uncontrolled deliveryAllow head to emerge slowlyOnce head delivered, assess for nuchal cordLoose – slip over headTight – clamp in 2 places and cut between clampsWipe infants face, suction mouth then nose.Support head, deliver anterior then posterior shoulder.Body will follow rapidly….slippery, don’t drop
37Emergency Delivery continued Hold infant head down at level of perineum, suction mouth then nose againClamp cord 4-5 cm from infants abdomen when cord stops pulsating. Cut between clampsDry wrap, warm, stimulate infantApgar at birth and 5 minutesDo not massage uterus until placenta is delivered
39Trauma in PregnancyTrauma is primary cause of mortality in pregnancy causing up to 22% of maternal deathsMaternal death is leading cause of fetal deathManagement priorities for pregnant trauma patient are identical to those for any trauma patient.
40Review of A&P Changes in Pregnancy ABDOMINALCARDIOVASCULARPULMONARY