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Obstetrical and Gynecological Emergencies

Obstetrical and Gynecological Emergencies. General Strategy. Primary Survey / Resuscitation Secondary Survey. Psychological, Social, Environmental Factors. Age: consider in ages 12 years to 55 years Nationality / ethnicity Occupation Economic capabilities and resources

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Obstetrical and Gynecological Emergencies

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  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 • 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 • ABDOMINAL • CARDIOVASCULAR • PULMONARY

  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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