Obstetrical Emergencies

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Obstetrical Emergencies

• Lynn K. Wittwer, MD, MPD
• Clark County EMS

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Obstetrical Emergencies

• Anatomy and Physiology
• Assessment
• Pathophysiology and Management
• Vaginal Pain/Bleeding/PID
• Endometriosis/Toxic Shock
• Uterine Prolapse
• Sexual Assault
• Ectopic Pregnancy
• Spontaneous Abortion/Preeclampsia/Eclampsia
• Prolapsed/Nuchal Cord
• Puerperal Hemorrhage/Amniotic Fluid Embolus
• QA
• Quiz

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Anatomy Physiology
Netter Atlas of Human Anatomy
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(No Transcript)
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Patient Assessment

• History
• PMH
• UTI, Pain, hemorrhage, etc.
• Gravidity/Parity
• LMP
• Other Reproductive Disorders
• HPI
• Use of Oral Contraception/IUD
• Bleeding/Discharge Frequency and Amount
• Pain PQRST
• Physical Exam
• Limited to visual exam to note hemorrhage
• Witness

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Etiology

• Vaginal Pain/Bleeding (non-pregnant patient)
• Normal Menstruation
• 28 days
• Follicular 1st 14 days
• Oocyte matures, Estrogen produced, Endometrium
  thickens.
• Ovulation
• Release of the mature oocyte due to secretion of
  FSH and LH from pituitary.
• Luteal phase
• Corpus luteum secretes estrogen and progesterone
  to enhance implantation.
• Fertilized embryo secretes hCG
• Menses
• Occurs in the absence of hCG, estrogen, and
  progesterone.
• Usual blood loss is 25-60 ml

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Etiology

• Vaginal Pain/Bleeding (non-pregnant patient)
• Menopause
• Ovarian burnout (Occurs on average at age 51)
• Lengthening or variation in intramenstrual
  intervals
• Decreased Estrogen production
• Pituitary still produces quantities of FSH and LH

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Etiology
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Etiology

• Vaginal Pain/Bleeding (non-pregnant patient)
• Pelvic Pain
• Visceral
• Colicky pain due to distention of a hollow viscus
  or ligamentous stretching
• i.e. ectopic pregnancy, dysmenorrhea, and round
  ligament stretch during pregnancy.
• Peritoneal/Somatic
• Sharp and localized to inflamed tissue
• i.e. salpingitis, appendicitis, endometriosis
• Generalized Peritonitis
• Large degree of inflammation
• i.e. internal hemorrhage, leak of GI contents/Pus
  into the peritoneal cavity.

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Etiology

• Vaginal Pain/Bleeding
• Prepubertal Children
• Vaginitis
• Due to lack of estrogen and immature anatomy
• Trauma
• Always be alert to possibility of abuse
• Foreign Body
• Present with bloody foul d/c and/or pain
• Congenital Obstruction
• May manifest as abdominal and/or pelvic pain
• Precocious Puberty
• Early Menarche and/or accelerated growth (may be
  due to underlying disease)
• Urethral Prolapse
• Cause unknown, more common among black children

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Etiology

• Vaginal Pain/Bleeding
• Adolescents
• Abnormal Uterine Bleeding
• Most commonly due to anovulation
• Vaginal Obstruction
• Present as cyclical pain, amenorrhea, and
  occasional urinary symptoms.
• Dysmenorrhea
• Painful ovulation, most severe in young,
  nulliparous pt.
• Caused by muscular contraction and vasospasm
• Mittelschmerz
• Transient pain caused by pressure prior to
  follicular rupture.
• Genital Trauma
• Most commonly caused by aggressive coitus.

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Etiology

• Vaginal Pain/Bleeding
• Reproductive Age
• Ovarian Cysts
• Torsion of Adnexa
• Endometriosis
• Adenomyosis
• Abnormal uterine contractility
• Leiomyomas
• Benign tumors (fibroids)
• Blood Dyscrasias
• Any bleeding disorder may result in excessive
  menstruation
• Polycystic ovary syndrome
• Endocrine disorder (triad of obesity, hirsutism,
  oligomenorrhea)
• Other Causes
• Stress, illness, malnutrition, weight
  fluctuation, exercise, obesity, liver and renal
  disease.

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Pathophysiology/Management

• Pelvic Inflammatory Disease (PID)
• Infection of the female upper reproductive tract
• Most commonly caused by chlamydial/gonorrhea
  infections
• Generally caused by ascending STD
• Pathology/Risk Factors
• Multiple sex partners, Hx of STDs
• Substance abuse
• Use of IUD
• Sequelae
• Tubo-ovarian abscess
• Tubal lesions/adhesions
• Rate of fatal ectopic pregnancy higher

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Pathophysiology/Management

• Pelvic Inflammatory Disease (PID)
• Prehospital Management Considerations
• Pt. often present w/ lower abdominal pain
• Intensified w/ walking
• May experience rebound tenderness
• May have fever
• Report vaginal discharge
• Treatment
• Generally supportive
• Allow patient POC
• Treat for shock prn

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Pathophysiology/Management

• Endometriosis
• Extrauterine occurrence of endometrium
• Can involve the uterus, ovaries, fallopian tubes,
  rectum, bladder and appendix.
• Epidemiology
• Thought to be caused by menstrual blood flow
  escaping into the peritoneum
• ¾ of patients are gt30 years old
• More common among nulliparous white women
• Presentation
• Pain increasing during menses
• Usually specific to involved area

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Pathophysiology/Management

• Toxic Shock Syndrome
• Staphylococcus Aureus
• Characterized by profound hypotension, fever,
  multiorgan involvement, and erythroderma
• Epidemiology
• Prominent in early 80s in women using
  superabsorbent tampons
• Can occur in any patient with the above infection
• Presentation
• Hyperpyrexia w/ multiorgan involvement
• CNS sx range from HA to ALOC
• Seizures
• Hypotension
• Erythroderma
• Usually involves lower torso and spreads outward

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Pathophysiology/Management

• Toxic Shock Syndrome
• Prehospital Management
• Treat for Shock
• O2 aggressive airway management prn
• Iv w/ BSS
• Pressors may be necessary

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Pathophysiology/Management

• Uterine Prolapse
• Etiology
• Herniation of the uterus through the pelvic floor
  into/through the vagina
• Most common in postmenopausal, multiparous pt.
• Ascites, obesity, and asthma/COPD can accelerate
  prolapse.
• Presentation
• Low back, pelvic, inguinal pain
• Abnormal bleeding
• Mass may be visible at the introitus with
  complete prolapse
• Management
• Supportive

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Pathophysiology/Management

• Sexual Assault
• Epidemiology
• 1 in 5 women will be raped in their lifetime
• Estimated that as few as 1 in 3 cases are
  reported
• Recent study showed of 372 victims, only 7 had
  genital injuries. Majority had facial/extremity
  injuries
• Rape is a crime of power
• Management
• Provide for patients physical and psychological
  well being first
• Non-judgmental
• Encourage preservation of evidence
• Provide supportive care as necessary

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Complications of Pregnancy
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Complications of Pregnancy

• Ectopic Pregnancy (EP)
• Epidemiology
• Implantation of zygote outside the uterus
• 95 occur in the fallopian tube
• Tubal rupture may occur due to
• Coital trauma
• Manipulation during exam
• Gestational age (9-16 wks)
• Spontaneous
• Represents 2 of pregnancies
• Alterations in the tubal transport system
• i.e. PID, surgery, previous EP, IUDs, etc.
• Functional/hormonal alterations in the ovum
• i.e. chemical ovulation induction, altered
  motility from hormonal therapy, and inherent
  defects of the ovum

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Complications of Pregnancy

• Ectopic Pregnancy (EP)
• Clinical Presentation
• Amenorrhea
• Bleeding/Spotting Abdominal Pain

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Complications of Pregnancy

• Ectopic Pregnancy (EP)
• Clinical Presentation (cont.)
• Pain w/ rupture usually lateralized, sudden and
  severe
• May be referred
• Other atypical pain patterns may occur
• Bleeding occurs in 80 of cases
• Often scanty
• Usually precedes pain
• Hypovolemia may be present
• Bradycardia due to vagal stimulation

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Complications of Pregnancy

• Ectopic Pregnancy (EP)
• Management
• Pertinent hx
• Missed menses
• Sexually active
• Previous EP, STD, surgery, etc.
• Lower quadrant pain/tenderness
• Avoid aggressive palpation/repeated exam
• Vital signs
• Orthostatic as appropriate
• High flow O2
• Treat for shock
• Position
• IV access
• Surgical intervention usually required

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Complications of Pregnancy

• Spontaneous Abortion
• Etiology
• Defined as loss of fetus lt20 wks or lt500gm
• 75 occur before 8 wks
• Most common cause is chromosomal abnormality
• Other causes
• Advanced age
• Poor obstetric hx
• Medical hx
• Syphilis/HIV
• Certain anesthetic agents
• Tobacco use
• Exposure to heavy metals
• Management
• Physio/Psycho logic support

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Complications of Pregnancy

• Preeclampsia/Eclampsia
• Etiology
• HTN, edema, proteinuria
• Cause unknown
• Eclampsia is above plus seizures
• Occur from 20th week to 7 days post partum
• Have been reported up to 26 days
• Predisposed by chronic HTN
• Clinical Presentation
• Preeclampsia
• HA, Visual disturbances
• Edema, weight gain
• All gravid pts w/ HTN should be evaluated

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Complications of Pregnancy

• Preeclampsia/Eclampsia
• Management
• Supportive for preeclampsia
• If Eclamptic
• Versed 2.5-5 mg IV/IM
• Magnesium 2 gm IV over 5-10 min
• Rapid trnx for delivery
• Complications of Preeclampsia/Eclampsia
• Spontaneous hepatic/splenic hemorrhage
• End-organ failure
• Abruptio
• IC bleed
• Fetal compromise

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Complications of Pregnancy

• Prolapsed Cord
• Etiology
• Presentation of cord at vaginal opening
• Caused by abnormal birth, i.e. twins, breech,
  etc..
• Complications occur if cord is compressed.
• Management
• Pt. in knee/chest position or elevate buttocks
• Relieve pressure on cord
• Supportive

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Complications of Pregnancy

• Nuchal Cord
• Etiology
• Cord wrapped around neck (may be multiple times)
• Will cause hypoxic injury if not removed
• Be aware of twins!!!!
• Management
• Unwrap cord
• If unable, clamp
• and cut cord

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Complications of Pregnancy

• Breech Presentation
• Etiology
• Occur in 3-4 of term pregnancies
• Result in 3-4 times greater morbidity
• More frequent in prematurity
• Distress due to Head/Cord entrapment
• Clinical presentation
• Frank, complete, incomplete, footling
• Footling/incomplete not safe for vag. Delivery
• Management
• Supportive

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Management of the Vaginal Breech Delivery
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Postpartum Complications

• APGAR SCORING
• A Appearance
• pale, blue color - 0
• pink body, blue extremities - 1
• completely pink newborn - 2
• P Pulse
• absent - 0
• rate lt 100 bpm - 1
• rate gt 100 bpm - 2

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Postpartum Complications

• APGAR SCORING
• G Grimace
• unresponsive - 0
• responds with facial grimace only - 1
• responds by coughing, sneezing, or crying 2
• A Activity
• newborn limp - 0
• newborn exhibits some flexion - 1
• newborn actively moving - 2
• R Respirations
• absent - 0
• slow or irregular - 1
• good or newborn crying - 2

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Postpartum Complications
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Postpartum Complications

• Puerperal Hemorrhage
• Etiology
• Cause of 28 pregnancy related deaths
• May be delayed days to weeks
• DDx immediately after delivery
• Uterine atony/rupture
• Laceration
• Retained placental tissue
• Uterine inversion
• Coagulopathy
• DDx delayed hemorrhage
• Retained placental tissue
• Uterine polyps
• Coagulopathy (von Willebrands)

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Postpartum Complications

• Puerperal Hemorrhage
• Clinical Presentation/Hx
• Hx of difficult placental delivery
• Manual delivery increases risk of hemorrhage
• Uterine inversion
• Doughy uterus
• Palpable above umbilicus w/ poor tone
• Prior C-section, multiparity or uterine surgery
• Risk factors for rupture
• Management
• Supportive
• O2 IV w/ volume support

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Postpartum Complications
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Postpartum Complications

• Amniotic Fluid Embolus
• Etiology
• Mortality rates as high as 60-80
• Higher if meconium stained
• Cause unknown
• Only relationship is fetal male sex
• Clinical Presentation
• Sudden onset
• Cardiovascular collapse
• Seizures
• DIC
• Death usually sudden (lt1hr.)
• Management
• Supportive