OBSTETRICAL

EMERGENCIES 1
GERILETTE P. ROSARIO, RM, RN, LPT
●Bleeding during late pregnancy (> 20
weeks gestation, but before birth) occurs
in 3 to 4 % of pregnancies
●Bleeding in later pregnancy (after 20
weeks) is usually caused by problems
with the placenta
 Cause
Risk Factors

Hypertension
Age > 35
Multiparity
Abruptio placentae Cigarette smoking
Cocaine
Previous abruptio placentae

Some Risk Trauma

Factors for Previous cesarean delivery

Multiparity
Multiple gestations

Major Causes Placenta previa Previous placenta previa

Age > 35
Cigarette smoking
In vitro fertilization

of Bleeding
Low-lying placenta

During Late Vasa previa

Bilobed or succenturiate-lobed placenta
Multiple gestations
In vitro fertilization

Pregnancy
Previous cesarean delivery
Any uterine surgery
Age > 30
History of uterine infection
Induction of labor
Uterine rupture Trauma (eg, gunshot wound)
Grand multiparity (delivery of ≥ 5 viable fetuses)
Uterine abnormalities
Multifetal pregnancies
Short interpregnancy interval
Placenta accreta spectrum (including placenta increta, and perceta)
 ●History of present illness
OB Score
Duration of bleeding
EVALUATION Amount and color of blood
●Review of systems
●Past medical History
●Physical Examination
 • Hypotension
• Tense, tender uterus
RED FLAGS • Fetal distress (loss of heart sounds,
(Warning bradycardia, variable or late
decelerations detected during
Signs)
monitoring)
• Cessation of labor and atonic uterus
 • Ultrasonography
• Complete blood count (CBC) and
type and screen
• Kleihauer-Betke testing - measure
DIAGNOSTIC the amount of fetal blood in the
maternal circulation and determine
the need for additional doses
of Rho(D) immune globulin to
prevent maternal sensitization.
 • All patients with vaginal bleeding during
late pregnancy require IV access for fluid or
blood resuscitation, as well as continuous
maternal and fetal monitoring.
• A digital cervical examination is
contraindicated in evaluation of bleeding
during late pregnancy until placenta previa
and vasa previa are excluded.
KEY POINTS • In abruptio placentae, vaginal bleeding may
be absent if blood is concealed between
the placenta and uterine wall.
• Suspect uterine rupture in women with a
history of cesarean delivery or other
uterine surgery.
• Vaginal bleeding may be mild despite
maternal hypotension.
 ●One of the most common infections
GENITAL for women who are childbearing
TRACT ●May be asymptomatic and can have
INFECTIONS serious consequences to a woman’s
fertility causing tubal ligation and
damage
 ●Caused by a fungus called Candida
albicans
VAGINAL ●These infections tend to occur during
YEAST pregnancy because of changes in the
INFECTIONS immune system, increased production of
glycogen, and higher estrogen levels.
 • Itchiness around the vagina or vulva
• A thick, white, cottage cheese-like
vaginal discharge
• An odor of bread or beer coming from
Symptoms the vagina
• Pain or burning in or around the vagina
• Pain or burning during sexual intercourse
 • 14-day cream, ointment, tablet, or suppository vaginal
treatment
• Two or three doses of fluconazole (diflucan)
• Long-term prescription of fluconazole taken once a
week for 6 weeks, or long-term use of a topical
Treatment antifungal medication
• If infection is recurring, patient may want to see if her
sexual partner has a yeast infection. Use barrier
methods, such as condoms, when having sex if you
suspect either of you has a yeast infection. Talk to your
doctor about your yeast infection treatment options.
 ●Easily treated bacterial infection in the
vagina
●Organisms: mycoplasmas, Gardenella
BACTERIAL vaginalis
VAGINOSIS ●Transmission:
A. Sexual intercourse
B. Douching
 • Itching, burning, or pain in the vagina or vulva
• A fishy odor coming from the vagina
• A bad smell that gets worse after sexual intercourse
• A large amount of thin, grey colored discharge

Symptoms ● If bacterial vaginosis is left untreated during pregnancy, it

might cause preterm labor, premature birth, and lower birth
weight babies.
 ●Syptomatic:
Metronidazole (Flagyl) 500 mg orally
twice daily for 7 days
Treatment ●Asymptomatic:
Antibiotics to prevent preterm labor
 ●Spontaneous abortion
●PROM
Effects on
Pregnancy ●Preterm labor
●Chorioamnionitis
●Neonatal Septicemia
 ● Group of bacteria that come and go in the body but often
frequent the vagina and rectum.
GROUP B ● Mothers who have gbs will pass it on to their babies in 1 to 2
percent
STREPTOCOC ● Treatment with antibiotics through a needle in a vein (IV
CUS (GBS) antibiotics) can significantly reduce the risk of a GBS infection
passing to the baby.
 ●Trichomonas. An anerobic flagellated protozoan a form
of microorganism
●Causative agent of Trichomoniasis and is the most
common pathogenic protozoan infection of humans
TRICHOMONAS ●a common, treatable, sexually transmitted disease
VAGINALIS (STD)
●Trichomoniasis (or “trich”) is a very common STD
caused by infection with Trichomonas vaginalis (a
protozoan parasite)
 ● Men with trich may notice:
• Itching or irritation inside the penis;
• Burning after peeing or ejaculating; and
• Discharge from the penis.

Symptoms
● Women with trich may notice:
• Itching, burning, redness or soreness of the genitals;
• Discomfort when peeing; and
• A clear, white, yellowish, or greenish vaginal discharge (i.e.,
thin discharge or increased volume) with a fishy smell.
 ●Symptomatic women
●Asymptomatic women at risk:
A. New partner
Who should
be tested? B. Multiple partners
C. History of STIs
D. Sex work
E. Injection drug use
 1. Relieve symptoms
Rationale for 2. Reduce risk of preterm labor and low
Treating birth weight
Trichomoniasi 3. Reduce HIV shedding in HIV infected
s women
 ●Metronidazole 500mg four tabs in a single dose
● Withhold breastfeeding during treatment and 12-24 after
dose
●Tinidazole 500 mg PO four tabs in a single dose
● Withhold breastfeeding during treatment and 3 day after
dose
Treatment
● *Partner Treatment
Partners must be treated
Metronidazole, 2g in a single dose
Abstain from sex until therapy is completed and both partners
are asymptomatic
 ●Is a Sexually transmitted disease caused
by Treponema pallidum
SYPHILIS ●Sexual/direct contact (infected lesions)
with a person who was infected with
syphilis within the preceding year
●REMEMBER: ALL pregnant women must
be assumed to be at risk
●Incubation: 10-90 days
Four Stages of
Syphilis
 ●Syphilis Serology- VDRL
a screening test for syphilis
It measures substances (proteins), called
antibodies, which your body may produce if
you have come in contact with the bacteria
Diagnosis that cause syphilis.
 ● Primary, secondary and early latent syphilis:
Benzathine penicillin G, IM, 2.4 million units in a single dose
*Additional therapy a second dose of benzathine penicillin
2.4 million units IM administered 1 week after the initial dose to
improve the likelihood of serologic response in early disease
Treatment ● Late latent or latent syphilis of unknown duration
Benzathine penicillin administered as three doses of 2.4
million units IM each at 1 week intervals
● Tertiary (late) syphilis of unknown duration
Benzathine penicillin administered as three doses of 2.4
million units IM each at 1 week intervals
●In pregnant women, missed doses are
not considered acceptable and the full
course of therapy must be repeated
●Long-term sex partners of patients who
have latent syphilis should be evaluated
clinically and serologically for syphilis and
treated on the basis of the evaluation
findings
 ●Primary Syphilis – should be
reexamined clinically and
serologically 1,3,6,12,24 months
Evaluation
●Secondary Syphilis – by 6 and 12
After
Months
Treatment
●Latent Syphilis – Should be
followed up clinically and
serologically at 6,12 and 24 months
 ●Delivery < 36 weeks
Causes of
Treatment
●Short interval between
Failure treatment and delivery
●Non penicillin regimen
CANDIDIASI
S ●Organisms: Candida albican,
Candida tropicalis
●Causes vaginal pH to be more
alkaline and high estrogen levels
causing increased production of
vaginal glycogen
 ●Vaginal and vulvar
irritation
●Pruritic, white, curd like
vaginal discharge
Symptoms ●Yeasty odor
●Dysuria
●Dyspareunia
 ●Saline of KOH wet mount
microscopically examined
Diagnostic ●Usually pH lower than 4.7
●Whiff test absent amine (fishy)
odor
 ●Use an antifungal,
intravaginal agent such as
Butoconazole, Clotirmazole,
Miconazole or terconazole
Treatment ●Sitz Baths
GONORRHEA ●Organism: Neisseria gonorrhea
●Transmission: Close sexual contact
●Incubation: 3-5 Days
 ●Vaginal discharge: profuse purulent
and yellow green
●Itching or swelling of vulva
●Dysuria
Symptoms
●Dyspareunia
●Joint and tendon pain
●Anal discharge, discomfort and pain
with rectal infection
 ●Molecular Diagnostics
●Endocervical Culture
Screening
 ●Cefixime 400mg orally or one dose of Ceftriaxone
125mg IM
●Sexual partners within the preceding
● 60 days should be identified, examined, cultured and
Treatment treated
 ●PROM
●Preterm Delivery
●IUGR
●Postpartum sepsis
●If the organism is present at the time of delivery may
Effect on cause GONOCOCCAL OPHTHALMIA
Pregnancy an infection that is transmitted by contact of the eyes with
infected genital secretions from a person with genital gonorrhea
infection
 PELVIC
INFLAMMATORY
DISEASE
Microbial
Etiology
Risk Factors
Symptoms
Complications
Diagnostic
Management
Prevention
Prevention
 ●FUNCTION OF PERITONEUM
●- Largest serous membrane of the body
PERITONITIS
●Consist of 2 Parts
a. Parietal Layer – attaches to the cavity wall
b. Visceral Layer-part that covers and attaches to
the organ inside the cavity
●Each layer consists of areolar connective tissue covered
by mesothelium (simple squamous epithelium)
●Mesothelium secretes fluid (watery lubricating fluid
that allows organ to glide easily over one another or to
slide again the wall of cavities)
 ●An inflammation (irritation) of the peritoneum, the
thin tissue that lines the inner wall of the abdomen
and covers most of the abdominal organs

PERITONITIS
 ●Medical procedures such as peritoneal dialysis
●Ruptured appendix, stomach ulcer or
Risk Factors perforated colon
●Pancreatitis
●Trauma
 ●Painful abdomen
●Abdominal distention
●Fever and chills
Symptom ●Passing few or no gas stools
●Excessive fatigue
●Passing less urine
●Nausea and vomiting
 ●Physical Exam
●Peritoneal fluid analysis (Paracentesis)
Diagnostic
●Blood test
●Imaging test (Abdominal Xray)
●PARACENTESIS
a procedure that removes fluid (peritoneal fluid) from
the abdomen through a slender needle
a procedure in which a needle or catheter is inserted
into the peritoneal cavity to obtain ascitic fluid for diagnostic or
therapeutic purposes
 ● Abdominal, pelvic pain and dyspareunia
● Mucopurulent vaginal discharge
● Pyrexia
Symptoms ● Heavy menstrual bleeding
● Pelvic tenderness
● Generalized sepsis
 ● Oral ofloxacin 400mg twice a day
● Metronidazole 400 mg twice a day x 14 days
● Ceftriaxone 250mg single IM injection plus oral doxycycline 100
mg twice a day

Treatment
 ● Monitor vital signs – Aids in evaluating degree of fluid deficit,
effectiveness of fluid replacement therapy and response to
medications
● Observe skin and mucous membrane, dryness and turgor. Note
peripheral and sacral edema – Hypovolemia, fluid shifts and
Interventions nutritional deficits contribute to poor skin turgor and taut
edematous tissue
● Change position frequently, provide frequent skin care and
maintain dry wrinkle free bedding – edematous tissue with
compromised circulation is prone to breakdown
 ● Maintain NPO status with nasogastric or intestinal aspiration –
reduces vomiting caused by hyperactivity of bowel, manages
Interventions stomach and intestinal fluids
● Measure urine specific gravity – reflects hydration status and
changes in renal function