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Obstetrical Emergencies

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Multiple sex partners, Hx of STD's. Substance abuse. Use of IUD. Sequelae. Tubo-ovarian abscess ... Previous EP, STD, surgery, etc. Lower quadrant pain/tenderness ... – PowerPoint PPT presentation

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Title: Obstetrical Emergencies


1
Obstetrical Emergencies
  • Lynn K. Wittwer, MD, MPD
  • Clark County EMS

2
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

3
Anatomy Physiology
Netter Atlas of Human Anatomy
4
(No Transcript)
5
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

6
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

7
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

8
Etiology
9
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.

10
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

11
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.

12
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.

13
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

14
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

15
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

16
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

17
Pathophysiology/Management
  • Toxic Shock Syndrome
  • Prehospital Management
  • Treat for Shock
  • O2 aggressive airway management prn
  • Iv w/ BSS
  • Pressors may be necessary

18
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

19
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

20
Complications of Pregnancy
21
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

22
Complications of Pregnancy
  • Ectopic Pregnancy (EP)
  • Clinical Presentation
  • Amenorrhea
  • Bleeding/Spotting Abdominal Pain

23
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

24
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

25
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

26
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

27
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

28
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

29
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

30
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

31
Management of the Vaginal Breech Delivery
32
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

33
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

34
Postpartum Complications
35
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)

36
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

37
Postpartum Complications
38
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
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