Obstetrical and Obstetrical and Gynecological Gynecological EmergenciesEmergencies

General StrategyGeneral Strategy

Primary Survey / ResuscitationPrimary Survey / Resuscitation Secondary SurveySecondary Survey

Psychological, Social, Psychological, Social, Environmental FactorsEnvironmental Factors

Age: consider in ages 12 years to 55 yearsAge: consider in ages 12 years to 55 years Nationality / ethnicityNationality / ethnicity OccupationOccupation Economic capabilities and resourcesEconomic capabilities and resources Social support systemSocial support system Reproductive historyReproductive history NutritionalNutritional GeneticGenetic

Focused SurveyFocused Survey Subjective DataSubjective Data

• History of present illnessHistory of present illness LNMPLNMP EDC or + pregnancy testEDC or + pregnancy test Bleeding, discharge, pain, N&V, fever / chillsBleeding, discharge, pain, N&V, fever / chills Visual disturbancesVisual disturbances Fetal movementFetal movement ROM ?ROM ? ContractionsContractions Urinary symptomsUrinary symptoms TraumaTrauma

Focused SurveyFocused Survey Subjective DataSubjective Data

• Medical HistoryMedical History ReproductiveReproductive Prenatal carePrenatal care Recent delivery ??Recent delivery ?? Abd / pelvic surgeryAbd / pelvic surgery Sexual activitySexual activity Contraceptive useContraceptive use STD’sSTD’s Substance abuseSubstance abuse Meds, Allergies etc.Meds, Allergies etc.

Focused SurveyFocused Survey

Objective DataObjective Data• Physical ExamPhysical Exam• Diagnostic ProceduresDiagnostic Procedures• RadiologyRadiology• OtherOther

12 lead ECG12 lead ECG pH for amniotic fluidpH for amniotic fluid

Assessment AssumptionsAssessment Assumptions Any pregnant patient should be assessed Any pregnant patient should be assessed

for…for…• EDC / LNMPEDC / LNMP• Reproductive history including complications Reproductive history including complications

with current and previous pregnancieswith current and previous pregnancies• Uterine size, tone, presence of contractionsUterine size, tone, presence of contractions• Vaginal discharge or bleeding, Vaginal discharge or bleeding,

fluid leaking? fluid leaking?• FHT’sFHT’s

Planning and InterventionsPlanning and Interventions

ABC’s firstABC’s first IV’s and O2 as indicatedIV’s and O2 as indicated Monitor and treat…Monitor and treat…

• Hemodynamic statusHemodynamic status• Vaginal bleeding, passage of clots, products Vaginal bleeding, passage of clots, products

of conceptionof conception• PainPain

Anticipate educational and emotional Anticipate educational and emotional needs fo patient and family.needs fo patient and family.

Anticipate equipment needsAnticipate equipment needs

Age Related ConsiderationsAge Related Considerations

PediatricsPediatrics• Sexual abuseSexual abuse• STD’s / PID STD’s / PID • Teen preganancyTeen preganancy

GeriatricsGeriatrics

Specific Obstetrical Specific Obstetrical EmergenciesEmergencies

Vaginal Bleeding in Early Pregnancy / Vaginal Bleeding in Early Pregnancy / AbortionAbortion

Vaginal Bleeding in Late PregnancyVaginal Bleeding in Late PregnancyEctopic PregnancyEctopic PregnancyPIH: preeclampsia / eclampsiaPIH: preeclampsia / eclampsiaHyperemesis gravidarumHyperemesis gravidarumPostpartum hemorrhagePostpartum hemorrhageEmergency DeliveryEmergency DeliveryNeonatal ResuscitationNeonatal ResuscitationTrauma in PregnancyTrauma in Pregnancy

AbortionAbortion

Termination of pregnancy before Termination of pregnancy before viability (20-24 weeks).viability (20-24 weeks).

10% to 15% of all recognized 10% to 15% of all recognized pregnanciespregnancies

EtiologyEtiology• Endocrine dysfunctionEndocrine dysfunction• Chromosomal abnormalitiesChromosomal abnormalities• MaldevelopmentMaldevelopment• TraumaTrauma

AbortionAbortion

Additional factorsAdditional factors• Maternal infectionsMaternal infections• MalnutritionMalnutrition• Substance abuseSubstance abuse• Immunological incompatibilityImmunological incompatibility• SurgerySurgery• Structural abnormalities of the uterusStructural abnormalities of the uterus

Abortion: ClassificationAbortion: Classification

ThreatenedThreatened IncompleteIncomplete CompleteComplete MissedMissed SepticSeptic

Abortion: AssessmentAbortion: Assessment

Subjective and Objective information Subjective and Objective information same for any pregnant patientsame for any pregnant patient

Diagnostic proceduresDiagnostic procedures• Pregnancy test - ? QuantitativePregnancy test - ? Quantitative• CBCCBC• Blood type and RhBlood type and Rh• STDSTD• Pelvic USPelvic US

Abortion: InterventionsAbortion: Interventions

IV accessIV access Assist with US, exam Assist with US, exam Prep for surgery as appropriatePrep for surgery as appropriate Drug TherapyDrug Therapy

• Rh immune globulin to all Rh negative mothersRh immune globulin to all Rh negative mothers• OxytocinOxytocin• MethergineMethergine• AnalgesicsAnalgesics• AntibioticsAntibiotics• Conscious sedationConscious sedation

Supportive / Psychosocial careSupportive / Psychosocial care

Abortion : TeachingAbortion : Teaching

Bedrest x 24-48 hours or until Bedrest x 24-48 hours or until bleeding stopsbleeding stops

Pelvic rest until bleeding / cramping Pelvic rest until bleeding / cramping ceasecease

Pads onlyPads only Temp. four times a day, return for > Temp. four times a day, return for >

100.6100.6 Save clots / tissueSave clots / tissue Follow up care with OBFollow up care with OB

Bleeding in Late PregnancyBleeding in Late Pregnancy Placenta PreviaPlacenta Previa

• Abnormally implanted placenta Abnormally implanted placenta partially or completely obstructs partially or completely obstructs cervical oscervical os

• 45% in second trimester45% in second trimester• 1% at term1% at term• Painless bright red bleeding occurs Painless bright red bleeding occurs

as cervix effaces / dilatesas cervix effaces / dilates• Multiparity, multigestation, Multiparity, multigestation,

advanced maternal age, uterine advanced maternal age, uterine surgery, smoking.surgery, smoking.

Bleeding in Late PregnancyBleeding in Late Pregnancy

Abruptio placentaAbruptio placenta• 3% of all pregnancies, 15% of all perinatal 3% of all pregnancies, 15% of all perinatal

deathsdeaths

• Partial or complete separation of a Partial or complete separation of a normally implanted placentanormally implanted placenta

• Significant blood lossSignificant blood loss

• Risk for DICRisk for DIC

• Etiology: HTN, trauma, substance abuse, Etiology: HTN, trauma, substance abuse, PROM, …PROM, …

Ectopic PregnancyEctopic Pregnancy Implantation of fertilized ovum outside of Implantation of fertilized ovum outside of

the normal uterine cavitythe normal uterine cavity 95% in the fallopian tube, frequently right95% in the fallopian tube, frequently right Rupture leads to severe pain, Rupture leads to severe pain,

intraperitoneal hemorrhage and shockintraperitoneal hemorrhage and shock

Ectopic – AssessmentEctopic – Assessment Pain: diffuse, unilateral or bilateral, tube Pain: diffuse, unilateral or bilateral, tube

rupture is sharp, sudden, severerupture is sharp, sudden, severe Referred shoulder painReferred shoulder pain Vaginal bleeding irregular / mildVaginal bleeding irregular / mild Fatigue, dizziness, syncopeFatigue, dizziness, syncope History: LNMP, reproductive hx, PID / STD’s, History: LNMP, reproductive hx, PID / STD’s,

IUD use, tubal surgery, infertility, meds, IUD use, tubal surgery, infertility, meds, allergiesallergies

Ectopic AssessmentEctopic Assessment

Physical Exam: Physical Exam: • orthostatic VSorthostatic VS

• abdominal examabdominal exam

• pelvicpelvic

Quantitative BHcG, CBC, T&C, Quantitative BHcG, CBC, T&C, PT/PTT, electrolytes, U/SPT/PTT, electrolytes, U/S

Ectopic – InterventionsEctopic – Interventions

ABC’sABC’s 2 large bore IV’s2 large bore IV’s Reassess hemodynamic status / painReassess hemodynamic status / pain Prepare for ORPrepare for OR MethotrexateMethotrexate Supportive care / pregnancy lossSupportive care / pregnancy loss

PIH: Preeclampsia / PIH: Preeclampsia / EclampsiaEclampsia

PIH:PIH: hypertension hypertensionunique to pregnancyunique to pregnancy

Preeclampsia:Preeclampsia: HTN, proteinuria and HTN, proteinuria and non-dependent edema after 20 weeksnon-dependent edema after 20 weeks

Eclampsia:Eclampsia: includes convulsions, coma includes convulsions, coma or bothor both

HELLP:HELLP: hemolysis, elevated liver hemolysis, elevated liver enzymes, low platelets. The most enzymes, low platelets. The most severe form of preeclampsia.severe form of preeclampsia.

PIH: Preeclampsia / EclampsiaPIH: Preeclampsia / Eclampsia

PIH: Preeclampsia / Eclampsia -PIH: Preeclampsia / Eclampsia -

Exact cause unknownExact cause unknown Underlying pathology is vasospasmUnderlying pathology is vasospasm Complicates 5-8% of pregananciesComplicates 5-8% of preganancies Leading obstetric cause of maternal Leading obstetric cause of maternal

deathdeath

Pre-eclampsia / EclampsiaPre-eclampsia / Eclampsia Risk factors:Risk factors:

• extremes of maternal age,chronic extremes of maternal age,chronic hypertensionhypertension

• hx of eclampsiahx of eclampsia• mother or sister with hxmother or sister with hx• multiple gestationmultiple gestation• diabetes, SLE, vascular diseasediabetes, SLE, vascular disease• molar pregnancymolar pregnancy

More common in primigravidaMore common in primigravida

Preeclampsia / Eclampsia: Preeclampsia / Eclampsia: AssessmentAssessment

Headache, weight gain, epigastric or RUQ Headache, weight gain, epigastric or RUQ tenderness, generalized edema, visual tenderness, generalized edema, visual disturbances, anxietydisturbances, anxiety

BP > 140/90 or 30 mmHg systolic BP > 140/90 or 30 mmHg systolic or 15 mmHg diastolic over baseline. or 15 mmHg diastolic over baseline. 2 BP readings 6 hours apart 2 BP readings 6 hours apart with Mom on L. side. with Mom on L. side.

Preeclampsia / Eclampsia: Preeclampsia / Eclampsia: DiagnosticsDiagnostics

Urinalysis: proteinuria greater than 1+Urinalysis: proteinuria greater than 1+ CBCCBC Electrolytes, creatinine, liver enzymesElectrolytes, creatinine, liver enzymes PT / PTTPT / PTT

Preeclampsia / Eclampsia: Preeclampsia / Eclampsia: InterventionsInterventions

ABC’sABC’s Supplemental O2Supplemental O2 Foley - monitor hourly UOFoley - monitor hourly UO Magnesium sulfate for seizure prophylaxisMagnesium sulfate for seizure prophylaxis Seizure precautionsSeizure precautions Benzodiazepines for seizuresBenzodiazepines for seizures Antihypertensive therapyAntihypertensive therapy Reassess ABC’s, FHT’s, signs of Mg++toxicity Reassess ABC’s, FHT’s, signs of Mg++toxicity

(Ca gluconate is antidote)(Ca gluconate is antidote)

Hyperemesis GravidarumHyperemesis Gravidarum Severe vomiting occurring before 20Severe vomiting occurring before 20thth

week.week.• Lasts 4-8 weeksLasts 4-8 weeks

• Significant weight loss, dehydration, Significant weight loss, dehydration, malnutritionmalnutrition

• Metabolic acidosis, ketonuria, hypokalemic Metabolic acidosis, ketonuria, hypokalemic alkalosis, oliguria, hemoconcentration, alkalosis, oliguria, hemoconcentration, constipationconstipation

• Complications: G.I. Bleeding, Mallory – Weiss Complications: G.I. Bleeding, Mallory – Weiss tears, and Boerhaave’s esophogeal disruptiontears, and Boerhaave’s esophogeal disruption

Hyperemesis: ManagementHyperemesis: Management

ABC’sABC’s IV access, 1-2 liters NS rapidlyIV access, 1-2 liters NS rapidly Antiemetics as orderedAntiemetics as ordered Gradual oral rehydration as Gradual oral rehydration as

tolerated tolerated

Postpartum HemorrhagePostpartum Hemorrhage Blood loss exceeding 500 mlBlood loss exceeding 500 ml Early – within 24 hours of deliveryEarly – within 24 hours of delivery

• Uterine atonyUterine atony• Retained placental fragmentsRetained placental fragments• Lower genital tract lacerationsLower genital tract lacerations• Uterine inversion or ruptureUterine inversion or rupture• Maternal coagulopathy Maternal coagulopathy

Late - usually 6-10 daysLate - usually 6-10 days• Retained products of conceptionRetained products of conception• InfectionInfection• Episiotomy breakdownEpisiotomy breakdown• Coital traumaCoital trauma

Postpartum Hemorrhage: Postpartum Hemorrhage: Risk FactorsRisk Factors

Overdistention of uterusOverdistention of uterus High parityHigh parity Prolonged difficult labor, especially Prolonged difficult labor, especially

after oxytocin inductionafter oxytocin induction History of PPHHistory of PPH PreeclampsiaPreeclampsia Placenta previaPlacenta previa Precipitous laborPrecipitous labor

Postpartum Hemorrhage: Postpartum Hemorrhage: ManagementManagement

Assessment to include: orthostatic VS, Uterine Assessment to include: orthostatic VS, Uterine size / tone, amount / color of bleedingsize / tone, amount / color of bleeding

Diagnostics: CBC, T&C, Coagulation profile, Diagnostics: CBC, T&C, Coagulation profile, fibrinogen, fibrin split products, USfibrinogen, fibrin split products, US

2 large bore IV’s – fluids / blood as appropriate2 large bore IV’s – fluids / blood as appropriate Firm bimanual massage of uterusFirm bimanual massage of uterus Oxytocin, Methergine as orderedOxytocin, Methergine as ordered Prepare for surgeryPrepare for surgery

Emergency DeliveryEmergency Delivery

Rapid obstetric assessment / historyRapid obstetric assessment / history• Contractions: frequency, intensity, durationContractions: frequency, intensity, duration• Rupture of membranes: time, color, odorRupture of membranes: time, color, odor• Bloody show?Bloody show?• Rectal pressure or passage of fecesRectal pressure or passage of feces

FHT’sFHT’s Pelvic Exam for effacement, dilation, Pelvic Exam for effacement, dilation,

stationstation

Emergency DeliveryEmergency Delivery Position side lying or fowlersPosition side lying or fowlers Encourage mother to “pant” to prevent Encourage mother to “pant” to prevent

uncontrolled deliveryuncontrolled delivery Allow head to emerge slowlyAllow head to emerge slowly Once head delivered, assess for nuchal cordOnce head delivered, assess for nuchal cord

• Loose – slip over headLoose – slip over head• Tight – clamp in 2 places and cut between clampsTight – clamp in 2 places and cut between clamps

Wipe infants face, suction mouth then nose.Wipe infants face, suction mouth then nose. Support head, deliver anterior then posterior Support head, deliver anterior then posterior

shoulder.shoulder. Body will follow rapidly….slippery, don’t drop Body will follow rapidly….slippery, don’t drop

Emergency Delivery continuedEmergency Delivery continued Hold infant head down at level of perineum, Hold infant head down at level of perineum,

suction mouth then nose againsuction mouth then nose again Clamp cord 4-5 cm from infants abdomen Clamp cord 4-5 cm from infants abdomen

when cord stops pulsating. Cut between when cord stops pulsating. Cut between clampsclamps

Dry wrap, warm, stimulate infantDry wrap, warm, stimulate infant Apgar at birth and 5 minutesApgar at birth and 5 minutes Do not massage uterus until Do not massage uterus until

placenta is delivered placenta is delivered

Trauma in PregnancyTrauma in Pregnancy

Trauma is primary cause of mortality Trauma is primary cause of mortality in pregnancy causing up to 22% of in pregnancy causing up to 22% of maternal deathsmaternal deaths

Maternal death is leading cause of Maternal death is leading cause of fetal deathfetal death

Management priorities for pregnant Management priorities for pregnant trauma patient are identical to those trauma patient are identical to those for any trauma patient.for any trauma patient.

Review of A&P Changes in Review of A&P Changes in PregnancyPregnancy

ABDOMINALABDOMINAL CARDIOVASCULARCARDIOVASCULAR PULMONARYPULMONARY

Specific Gynecological Specific Gynecological EmergenciesEmergencies

Vaginal bleeding / Dysfunctional uterine Vaginal bleeding / Dysfunctional uterine bleedingbleeding

Pelvic painPelvic pain

Vaginal dischargeVaginal discharge

Sexually Transmitted diseasesSexually Transmitted diseases

Pelvic Inflammatory DiseasePelvic Inflammatory Disease

Sexual AssaultSexual Assault

Vaginal Bleeding / Dysfunctional Vaginal Bleeding / Dysfunctional Uterine BleedingUterine Bleeding

Vaginal bleeding: uterine fibroids, menstrual Vaginal bleeding: uterine fibroids, menstrual cycle irregularities, trauma, infection, cycle irregularities, trauma, infection, malignancy or coagulopathymalignancy or coagulopathy

DUB: hormonal imbalanceDUB: hormonal imbalance Assessment: include sexual and contraceptive Assessment: include sexual and contraceptive

history, quantity, duration, quality of bleedinghistory, quantity, duration, quality of bleeding Diagnostics: BHCG, CBC, coags, T&S, UA, Diagnostics: BHCG, CBC, coags, T&S, UA,

STD screening, Thyroid, liver function, FSH, LH STD screening, Thyroid, liver function, FSH, LH as appropriate.as appropriate.

Pelvic PainPelvic Pain

Variety of causes…assess pain Variety of causes…assess pain carefully (PQRST).carefully (PQRST).

Vaginal DischargeVaginal Discharge Variety of causes.Variety of causes. Bacterial 40-50%Bacterial 40-50% Candida albicans 20-25%Candida albicans 20-25% Trichomonas 15-20%Trichomonas 15-20% Non-infectious processesNon-infectious processes

• Retained FBRetained FB• ChemicalsChemicals• Hormonal changesHormonal changes• Alteration in vaginal flora due to pregnancy, Alteration in vaginal flora due to pregnancy,

antibiotics, diabetes, HIV infection, poor hygieneantibiotics, diabetes, HIV infection, poor hygiene See table 13-5See table 13-5

Sexually Transmitted DiseaseSexually Transmitted Disease

Vaginitis, cervicitis, PID, urethritis, Vaginitis, cervicitis, PID, urethritis, epididymitis, pharyngitis, proctitis, epididymitis, pharyngitis, proctitis, skin and mucous membrane lesions, skin and mucous membrane lesions, AIDSAIDS

See table 13-6See table 13-6

PIDPID

Sexual AssaultSexual Assault

Questions?Questions?