Ob Lecture

PREGNANCY COMPLICATIONS
SFC WARD
Joint Special Operations Medical Training Center
Premature Labor
10 - 15% of all pregnancies 20 - 30% follow premature rupture of membranes Maternal medical problems Placental or fetal abnormalities Assessment-regular contractions every 10 min X 30 min with cervical dilation Prevention is key to management
Abnormal Labor (Dystocia)

Passage through the pelvis Presentation of passenger Power of uterine contraction
Pelvic Adequacy-basic shapes

Gynecoid - easiest for delivery Platypelloid - wide hipped female Android - normal male shape Anthropoid - prevalent in blacks; difficult delivery
Pelvic Adequacy
Small portals lead to dystocia
Pelvic Adequacy
Determined by pelvic exam Managed by surgical delivery (Cesarean Section)
Abnormal Presentation
Occiput posterior - 4.9% of births
70% of time will rotate into OA
Transverse - fatal
Must be rotated manually or surgically delivered
Face - 1 in 500 births

Assess by vaginal exam Carefully monitor cord position and fetal respiration
Abnormal Presentation
Breech - buttocks or feet presented instead of head
5.5 times greater infant mortality due to cord prolapse Types
Frank (knees extended, feet near head Complete (knees bent, feet near buttocks Incomplete (knees bent, foot presenting before buttocks
Breech Presentation
Assessed by vaginal/abdominal exam Management:
Prevention is preferred. Attempt external version with extreme caution Delivery is slow process of clearing one extremity at a time Keep constantly aware of status of umbilical cord
Abnormal Uterine Action

Inadequate contractions Reassure patient, maintain fluids, have patient walk if possible, enema, nipple stimulation If uterus is atonic try to correct with massage, Oxytocin IV under physicians supervision
Cord Accident
Prolapsed cord
Assessed by vaginal exam Management:
Reposition fetus and cord if possible Keep airway open Meconium staining shows fetal distress
Multiple Pregnancies
Normal delivery of one fetus followed by delivery of second no later than 20 minutes afterwards
Uterine rupture
1 in 1500 deliveries Usually occurs during labor Contributing factors are high parity, obstructed labor, intrauterine maneuvers, previous surgery, MVA with lap seat belt Sudden lower abdominal pain and shock Manage shock
Vaginal and Perineal Lacerations

1st Degree
Slight laceration No need for suturing

2nd Degree
Into perineum without entering into anal sphincter or rectal mucosa Mange with simple suture repair

3rd Degree
Into anal sphincter and/or rectal mucosa Mange with carefully placed sutures (layers)
Uterine Inversion (prolapse)

Profuse bleeding after delivery Abdominal pain Uterus descended into vagina
Possibly as a result of traction placed on cord during 3rd stage of labor
Manually reposition with fist or fingers Carefully monitor for shock and blood loss
Abortion (Miscarriage)-Termination of pregnancy before viability

Incidence--15% of all pregnancies abort spontaneously. These abortions seem to be a natural rejection of mal-developing fetus; 85% occur in the first trimester and are related to fetal causes Categories: threatened, inevitable, incomplete, complete, or induced abortions
Threatened Abortion--any vaginal bleeding in the first 20 weeks of pregnancy - 20 -30% of pregnant women have some bleeding in early months.
Threatened Abortion--Signs and symptoms

Vaginal bleeding--varies from brownish to bright red, may occur repeatedly for many days Mild cramps Tenderness over the uterus, low back pain, sense of pelvic pressure
Threatened Abortion--Signs and symptoms

Cervix closed or slightly dilated, no tissue loss Symptoms subside or it becomes an inevitable abortion
Threatened Abortion Management--conservative

Vaginal exam, make sure cervix is closed Pad count, to monitor bleeding Bed rest
Inevitable Abortion-Intolerable pain or bleeding that threatens the mother's well being
Inevitable Abortion-- Signs and symptoms

Bleeding more profuse; threatens mother Cervix dilated Membrane rupture Painful uterine contractions
Inevitable Abortion-Treatment
Embryo delivered D & C after delivery
Incomplete Abortion--some products of conception partially passed from uterine cavity
Incomplete Abortion--Signs and symptoms

Vaginal bleeding--varies from brownish to bright red, may occur repeatedly for many days Mild cramps Tenderness over the uterus, low back pain, sense of pelvic pressure Cervix closed or slightly dilated, no tissue loss
Incomplete Abortion-Management
Complete the abortion promptly with suction Monitor vital signs and amount of bleeding, treat symptomatically (IVs, blood, bedrest) Psychological assistance/reduce anxiety Pain meds PRN, vitamin and iron supplement Watch for infection Joint Special Operations Medical Training Center
Complete Abortion--all products of conception are expelled
Complete Abortion--Signs and symptoms

Same as incomplete except all POC are passed Positive pregnancy test prior to abortion Symptoms of pregnancy no longer exist (cervix closes, uterus contracts to normal size).
Complete Abortion--Management
Bedrest for three days Monitor vital signs and bleeding, replace blood PRN, keep pad count Vitamin and iron supplements D&C if bleeding continues Follow up visit to ensure return to proper menstruation and no evidence of infection for approximately 6 weeks Pain meds PRN
Missed abortion--Fetus has died but has been retained in utero 4 weeks or longer
Missed abortion--Signs and symptoms

Uterus fails to grow Fetal heart sound is not heard at appropriate time with doppler Fetal heart sound was present previously and now is absent Ultrasound no longer shows cardiac activity
Missed abortion--Treatment
If the fetus is not passed oxytoxin induction may be used D&C may be used to remove fragments of the placenta
Ectopic Pregnancies-implantation of fertilized egg in any site other than the uterine cavity
Ectopic Pregnancies--Incidence
One in 150 pregnancies Incidence is rising and higher in non whites Increases with prior tubal diseases, ectopic pregnancies and induced abortions
Ectopic Pregnancies
95% occur in fallopian tube ("tubal pregnancy"), more than half are on the right side; ectopic pregnancy may also occur in ovary, abdomen, or cervix Most common cause of maternal mortality in first trimester.
Ectopic Pregnancies--Causes-delayed passage of eggs due to decreased lumen size

PID; chandelier sign Congenital deformities in mother Use of IUD (4 x greater in IUD users) Adhesions of the tube Anything leading to tubal sterilization.
Ectopic Pregnancies--Signs and symptoms

Abdominal/pelvic pain early in pregnancy "tearing" type of pain. (Abdominal pain occurs in 90%) Amenorrhea, spotty or irregular vaginal bleeding is present in 75% Positive pregnancy test--50% Abdominal tenderness Pelvic exam may or may not reveal tender adnexal mass.
Ectopic Pregnancies-Management
If left untreated usually results in death Culdocentesis to confirm diagnosis-aspirate blood from cul-de-sac. (blood indicates intraperitoneal bleeding.) Surgery for definitive management--even if diagnosed before rupture
Ectopic Pregnancies-Management
Principles guiding management include:
Preserve maternal life Terminate the pregnancy with surgery Supportive care of mother (blood, fluid, monitor vital signs, psychological support)
Ectopic Pregnancies-Complications--catastrophic sequence

Tubal rupture Severe internal hemorrhage Shock Death
Differential assessment--history very important

PID Spontaneous abortions--miscarriage Ruptured ovarian cyst Torsion of the ovarian cyst Appendicitis Pyelonephritis Pancreatitis
Abruptio Placentae--premature separation of the normally implanted placenta after 20 weeks gestation
Abruptio Placentae
External hemorrhage--retroplacental bleeding occurs and the blood may pass behind the membranes and through the cervix Internal hemorrhage--the placenta separates centrally and the blood accumulates under the placenta.
Abruptio Placentae--Incidence
1/90 pregnancies
Abruptio Placentae-contributing factors

Hypertension Trauma Alcoholism Cocaine use Previous history of same problem.
Abruptio Placentae--Signs and symptoms--depends on degree of separation

Concealed hemorrhage
Sharp pain Change in vital signs--no external bleeding Tender uterus--can progress to board-like Evidence of fetal heart rate drop, fetal distress, or death
External: same signs and symptoms except bleeding occurs

Abruptio Placentae-Management
NO VAGINAL EXAM if even suspect, as it may precipitate hemorrhage IV fluids and oxygen Type and crossmatch blood for possible transfusion Prepare for possible immediate delivery of the fetus Frequent fetal monitoring Psychological support for the mother
Placenta Previa--implantation of the placenta in the lower uterine segment such that at least a portion of a fully dilated cervix would be covered
Placenta Previa
Incidence
One in two hundred pregnancies Multiparous greater than primiparous More common in patients with abnormalities of uterus (e.g., fibroids)
Perinatal mortality is 20%
Placenta Previa--Signs and symptoms

Sudden painless vaginal bleeding Lower abdominal cramps are possible Uterus is soft Fetal exam is usually normal--depends on the amount of bleeding when it occurs Usually not shocky as in abruptio placenta
Placenta Previa-- Management

NO VAGINAL EXAM if suspect, as it may precipitate hemorrhage IV fluids and oxygen Type and crossmatch blood Bed rest

Monitor maternal and fetal V/S Monitor amount of bleeding Position for comfort and provide psychological support When bleeding stops, the patient can ambulate

Prepare for possible delivery of the fetus-dependent upon the fetus size and the amount of bleeding; once delivery is decided on, a C-section is usually preferred
Toxemia of Pregnancy
Preeclampsia--development of hypertension with proteinuria, edema, or both due to pregnancy between 20 weeks of pregnancy and first postpartum day
Preeclampsia--Incidence
5% of all pregnancies Increased in primapara Increased in women with hypertension or other vascular disorders.
Preeclampsia--Signs and symptoms

Rise in BP over 140/90 or a 30/15 increase during pregnancy Edema--face, hands and feet, peripheral that can cause possible headache, diplopia. It is important to note that edema persists even during bedrest. Proteinuria 0.3g/liter in 24 hr sample Weight exceeds normal for patient
Preeclampsia--Management
Bedrest--preferably on the left side as this enhances tissue perfusion Frequent weight and BP measurements; UA for protein Correct dietary deficiencies; manage underlying medical conditions
Preeclampsia--Management
Ensure proper fluid and electrolyte intake--encourage fluids but avoid high sodium fluids Delivery of baby is the cure.
Toxemia of Pregnancy
Eclampsia--occurrence of one or more convulsions not attributed to other cerebral conditions in a patient with preeclampsia.
Eclampsia --Signs and symptoms

Same as preeclampsia with progression to seizures.
Eclampsia
Perinatal mortality with eclampsia = 15% Eclampsia develops in 1/200 preeclamptic patients and usually total if untreated.
Eclampsia--Management
Oxygen and airway management Monitor BP, pulse and respirations every 15 min. and urinary output and input recorded hourly. This should stabilize 46 hours when delivery must be accomplished. Magnesium sulfate--used to prevent and treat convulsions
Eclampsia--Management
Constant fetal monitoring Quiet, dark environment Hydration, balanced salt solution IV, usually 3-4 liters over 24 hours Delivery of baby is the cure. Monitor post delivery closely as eclampsia can occur up to a week postpartum.
Common Medical Complications Which Affect Pregnancy

Diabetes Mellitus Anemia Urinary tract infections Constipation Medication use/abuse Infections
Diabetes Mellitus--pregnancy increases need for glucose, Metabolic changes during pregnancy can increase diabetes mellitus signs and symptoms, and may cause problems.
Diabetes Mellitus
In most third world countries, the majority of such women will be sterile. Where signs of polyuria, polyphagia, and polydipsia appear--check the mother's blood glucose. Insulin replacement is critical along with the management of weight and diet. Type II diabetics along with type I always require insulin.
Complications associated with diabetes mellitus

Primary fetal hazard is anoxia as a result of maternal toxemia or ketoacidosis Toxemia appears in 20% of the cases Excessive weight gain, hydramnios, and fetal death are complications of the fetus Preeclampsia is also a common occurrence Pregnancy induced hypertension--25% Premature labor.
Anemia--follow the maternal hematocrit and give only crossmatched blood if absolutely needed, otherwise increase iron intake as RBC indicates.
Urinary tract infections

Always evaluate urine in prenatal care-there is a higher incidence of premature births and perinatal mortality in pregnant women with an unmanaged UTI.

Asymptomatic bacteriuria indicates UTI-always manage despite being asymptomatic since 25% of these patients will develop acute pyelonephritis later in pregnancy.

Assessment by visualizing WBCs/RBCs in urine. Almost always the result of gramnegative organisms--always gram-stain the urine to identify bacteria. Nearly all will respond well to ampicillin
Constipation--single most common problem in pregnancy

Increase fiber in diet Add some mineral oil or stool softener Enema if unresolved Common reason for hemorrhoids--iron supplements compound the problem by increasing the firmness of the stool which causes constipation
Medication use/abuse
Careful dispensing of any medication to childbearing women must be exercised The use of drugs during the first trimester can result in teratogenic effects to the fetus; therefore, education plays the most important part
Medication use/abuse
Each medication must be individually evaluated Stop all use of tobacco, alcohol, hallucinogens Review all pharmacologic substances before administering during pregnancy
Immunizations
Only tetanus and rabies should be given whenever there is an indication Smallpox and typhoid should only be given in the case of maternal exposure Never give mumps, measles, rubella
Infections
Malaria--manage mother with chloroquine Vaginal infections--venereal diseases must be managed prior to delivery to avoid fetal contraction of the disease. Some infections such as herpes merit delivery by C-section
SUMMARY
Premature Labor Abnormal Labor Cord Accidents Tears Abortion Ectopic Pregnancy Abruptio Placentae Placenta Previa Toxemia Medical Conditions
?

Ob Lecture

Uploaded by

Copyright:

Available Formats

You might also like

Ob Lecture

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ob Lecture

Uploaded by

Copyright:

Available Formats

PREGNANCY COMPLICATIONS

Joint Special Operations Medical Training Center

Abnormal Labor (Dystocia)

Joint Special Operations Medical Training Center

Pelvic Adequacy-basic shapes

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center

Face - 1 in 500 births

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center

Abnormal Uterine Action

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center

Vaginal and Perineal Lacerations

Joint Special Operations Medical Training Center

Vaginal and Perineal Lacerations

Vaginal and Perineal Lacerations

Uterine Inversion (prolapse)

Abortion (Miscarriage)-Termination of pregnancy before viability

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center

Threatened Abortion--Signs and symptoms

Joint Special Operations Medical Training Center

Threatened Abortion--Signs and symptoms

Joint Special Operations Medical Training Center

Threatened Abortion Management--conservative

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center

Inevitable Abortion-- Signs and symptoms

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center

Incomplete Abortion--some products of conception partially passed from uterine cavity

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center

Incomplete Abortion--Signs and symptoms

Complete Abortion--all products of conception are expelled

Joint Special Operations Medical Training Center

Complete Abortion--Signs and symptoms

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center

Missed abortion--Signs and symptoms

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center

Ectopic Pregnancies--Causes-delayed passage of eggs due to decreased lumen size

Joint Special Operations Medical Training Center

Ectopic Pregnancies--Signs and symptoms

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center

Ectopic Pregnancies-Complications--catastrophic sequence

Joint Special Operations Medical Training Center

Differential assessment--history very important

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center