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Obstetrical and Gynecological Emergencies

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Presentation on theme: "Obstetrical and Gynecological Emergencies"— Presentation transcript:

1 Obstetrical and Gynecological Emergencies

2 General Strategy Primary Survey / Resuscitation Secondary Survey

3 Psychological, Social, Environmental Factors
Age: consider in ages 12 years to 55 years Nationality / ethnicity Occupation Economic capabilities and resources Social support system Reproductive history Nutritional Genetic

4 Focused Survey Subjective Data History of present illness LNMP
EDC or + pregnancy test Bleeding, discharge, pain, N&V, fever / chills Visual disturbances Fetal movement ROM ? Contractions Urinary symptoms Trauma

5 Focused Survey Subjective Data Medical History Reproductive
Prenatal care Recent delivery ?? Abd / pelvic surgery Sexual activity Contraceptive use STD’s Substance abuse Meds, Allergies etc.

6 Focused Survey Objective Data Physical Exam Diagnostic Procedures
Radiology Other 12 lead ECG pH for amniotic fluid

7 Assessment Assumptions
Any pregnant patient should be assessed for… EDC / LNMP Reproductive history including complications with current and previous pregnancies Uterine size, tone, presence of contractions Vaginal discharge or bleeding, fluid leaking? FHT’s

8 Planning and Interventions
ABC’s first IV’s and O2 as indicated Monitor and treat… Hemodynamic status Vaginal bleeding, passage of clots, products of conception Pain Anticipate educational and emotional needs fo patient and family. Anticipate equipment needs

9 Age Related Considerations
Pediatrics Sexual abuse STD’s / PID Teen preganancy Geriatrics

10 Specific 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

11 Abortion Termination of pregnancy before viability (20-24 weeks).
10% to 15% of all recognized pregnancies Etiology Endocrine dysfunction Chromosomal abnormalities Maldevelopment Trauma

12 Abortion Additional factors Maternal infections Malnutrition
Substance abuse Immunological incompatibility Surgery Structural abnormalities of the uterus

13 Abortion: Classification
Threatened Incomplete Complete Missed Septic

14 Abortion: Assessment Subjective and Objective information same for any pregnant patient Diagnostic procedures Pregnancy test - ? Quantitative CBC Blood type and Rh STD Pelvic US

15 Abortion: Interventions
IV access Assist with US, exam Prep for surgery as appropriate Drug Therapy Rh immune globulin to all Rh negative mothers Oxytocin Methergine Analgesics Antibiotics Conscious sedation Supportive / Psychosocial care

16 Abortion : Teaching Bedrest x 24-48 hours or until bleeding stops
Pelvic rest until bleeding / cramping cease Pads only Temp. four times a day, return for > 100.6 Save clots / tissue Follow up care with OB

17 Bleeding in Late Pregnancy
Placenta Previa Abnormally implanted placenta partially or completely obstructs cervical os 45% in second trimester 1% at term Painless bright red bleeding occurs as cervix effaces / dilates Multiparity, multigestation, advanced maternal age, uterine surgery, smoking.

18 Bleeding in Late Pregnancy
Abruptio placenta 3% of all pregnancies, 15% of all perinatal deaths Partial or complete separation of a normally implanted placenta Significant blood loss Risk for DIC Etiology: HTN, trauma, substance abuse, PROM, …

19 Ectopic Pregnancy Implantation of fertilized ovum outside of the normal uterine cavity 95% in the fallopian tube, frequently right Rupture leads to severe pain, intraperitoneal hemorrhage and shock

20 Ectopic – Assessment Pain: diffuse, unilateral or bilateral, tube rupture is sharp, sudden, severe Referred shoulder pain Vaginal bleeding irregular / mild Fatigue, dizziness, syncope History: LNMP, reproductive hx, PID / STD’s, IUD use, tubal surgery, infertility, meds, allergies

21 Ectopic Assessment Physical Exam:
orthostatic VS abdominal exam pelvic Quantitative BHcG, CBC, T&C, PT/PTT, electrolytes, U/S

22 Ectopic – Interventions
ABC’s 2 large bore IV’s Reassess hemodynamic status / pain Prepare for OR Methotrexate Supportive care / pregnancy loss

23 PIH: Preeclampsia / Eclampsia
PIH: hypertension unique to pregnancy Preeclampsia: HTN, proteinuria and non-dependent edema after 20 weeks Eclampsia: includes convulsions, coma or both HELLP: hemolysis, elevated liver enzymes, low platelets. The most severe form of preeclampsia.

24 PIH: Preeclampsia / Eclampsia

25 PIH: Preeclampsia / Eclampsia -
Exact cause unknown Underlying pathology is vasospasm Complicates 5-8% of preganancies Leading obstetric cause of maternal death

26 Pre-eclampsia / Eclampsia
Risk factors: extremes of maternal age,chronic hypertension hx of eclampsia mother or sister with hx multiple gestation diabetes, SLE, vascular disease molar pregnancy More common in primigravida

27 Preeclampsia / Eclampsia: Assessment
Headache, weight gain, epigastric or RUQ tenderness, generalized edema, visual disturbances, anxiety BP > 140/90 or 30 mmHg systolic or 15 mmHg diastolic over baseline. 2 BP readings 6 hours apart with Mom on L. side.

28 Preeclampsia / Eclampsia: Diagnostics
Urinalysis: proteinuria greater than 1+ CBC Electrolytes, creatinine, liver enzymes PT / PTT

29 Preeclampsia / Eclampsia: Interventions
ABC’s Supplemental O2 Foley - monitor hourly UO Magnesium sulfate for seizure prophylaxis Seizure precautions Benzodiazepines for seizures Antihypertensive therapy Reassess ABC’s, FHT’s, signs of Mg++toxicity (Ca gluconate is antidote)

30 Hyperemesis Gravidarum
Severe vomiting occurring before 20th week. Lasts 4-8 weeks Significant weight loss, dehydration, malnutrition Metabolic acidosis, ketonuria, hypokalemic alkalosis, oliguria, hemoconcentration, constipation Complications: G.I. Bleeding, Mallory – Weiss tears, and Boerhaave’s esophogeal disruption

31 Hyperemesis: Management
ABC’s IV access, 1-2 liters NS rapidly Antiemetics as ordered Gradual oral rehydration as tolerated

32 Postpartum Hemorrhage
Blood loss exceeding 500 ml Early – within 24 hours of delivery Uterine atony Retained placental fragments Lower genital tract lacerations Uterine inversion or rupture Maternal coagulopathy Late - usually 6-10 days Retained products of conception Infection Episiotomy breakdown Coital trauma

33 Postpartum Hemorrhage: Risk Factors
Overdistention of uterus High parity Prolonged difficult labor, especially after oxytocin induction History of PPH Preeclampsia Placenta previa Precipitous labor

34 Postpartum Hemorrhage: Management
Assessment to include: orthostatic VS, Uterine size / tone, amount / color of bleeding Diagnostics: CBC, T&C, Coagulation profile, fibrinogen, fibrin split products, US 2 large bore IV’s – fluids / blood as appropriate Firm bimanual massage of uterus Oxytocin, Methergine as ordered Prepare for surgery

35 Emergency Delivery Rapid obstetric assessment / history FHT’s
Contractions: frequency, intensity, duration Rupture of membranes: time, color, odor Bloody show? Rectal pressure or passage of feces FHT’s Pelvic Exam for effacement, dilation, station

36 Emergency Delivery Position side lying or fowlers
Encourage mother to “pant” to prevent uncontrolled delivery Allow head to emerge slowly Once head delivered, assess for nuchal cord Loose – slip over head Tight – clamp in 2 places and cut between clamps Wipe infants face, suction mouth then nose. Support head, deliver anterior then posterior shoulder. Body will follow rapidly….slippery, don’t drop 

37 Emergency Delivery continued
Hold infant head down at level of perineum, suction mouth then nose again Clamp cord 4-5 cm from infants abdomen when cord stops pulsating. Cut between clamps Dry wrap, warm, stimulate infant Apgar at birth and 5 minutes Do not massage uterus until placenta is delivered

38 Neonatal Resuscitation

39 Trauma in Pregnancy Trauma is primary cause of mortality in pregnancy causing up to 22% of maternal deaths Maternal death is leading cause of fetal death Management priorities for pregnant trauma patient are identical to those for any trauma patient.

40 Review of A&P Changes in Pregnancy

41 Specific Gynecological Emergencies
Vaginal bleeding / Dysfunctional uterine bleeding Pelvic pain Vaginal discharge Sexually Transmitted diseases Pelvic Inflammatory Disease Sexual Assault

42 Vaginal Bleeding / Dysfunctional Uterine Bleeding
Vaginal bleeding: uterine fibroids, menstrual cycle irregularities, trauma, infection, malignancy or coagulopathy DUB: hormonal imbalance Assessment: include sexual and contraceptive history, quantity, duration, quality of bleeding Diagnostics: BHCG, CBC, coags, T&S, UA, STD screening, Thyroid, liver function, FSH, LH as appropriate.

43 Pelvic Pain Variety of causes…assess pain carefully (PQRST).

44 Vaginal Discharge Variety of causes. Bacterial 40-50%
Candida albicans 20-25% Trichomonas 15-20% Non-infectious processes Retained FB Chemicals Hormonal changes Alteration in vaginal flora due to pregnancy, antibiotics, diabetes, HIV infection, poor hygiene See table 13-5

45 Sexually Transmitted Disease
Vaginitis, cervicitis, PID, urethritis, epididymitis, pharyngitis, proctitis, skin and mucous membrane lesions, AIDS See table 13-6

46 Sexual Assault One RN will triage, assess, provide care, perform the sexual assault kit, provide referrals as needed, and discharge this patient. There is to be no more than one RN giving care

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