Gastrointestinal, Genitourinary, Gynecology, and Obstetrical Emergencies Study Guide for the CEN

Obstetrical

Obstetrical emergencies are any conditions relating to pregnancy or childbirth. They can impact any patient who is able to bear children and range from very minor to severe conditions that endanger the life of both mother and child.

Placental Abruption

A placental abruption occurs when the placenta partially or completely detaches from the wall of the uterus before delivery. It occurs most commonly in the third trimester, but can happen any time after 20 weeks, and happens in about 1 percent of pregnancies. This can decrease or completely obstruct blood flow to the fetus and cause the mother to hemorrhage.

Assessment

Symptoms of placental abruption include abdominal pain, back pain, dizziness, nausea and vomiting, uterine rigidity or tenderness, and frequent contractions. Some patients experience vaginal bleeding, but others have no external bleeding because blood remains trapped in the uterus. The degree of vaginal bleeding does not always correlate with how much of the placenta has detached from the wall of the uterus. The healthcare provider will perform an exam to assess the patient’s abdomen and vagina; draw a CBC, type and match, and coagulation studies; and perform an ultrasound to visualize the uterus and placenta.

Treatment

The treatment depends on the severity or degree of the abruption and how far along the pregnancy is. If it is less than 34 weeks, the abruption appears mild, and the fetus’s heart rate is normal, the patient will be monitored in the hospital. If the bleeding stops, the patient may be able to rest at home. Either way, the patient will receive corticosteroids to help the fetus’s lungs to mature and protect their brain. If it is more than 34 weeks, the healthcare provider will likely induce the patient and deliver the infant. If the abruption is mild, a vaginal delivery may be possible, but if it is severe and jeopardizes the health of mother or infant, then a C-section will be necessary. The mother may also receive a blood transfusion, crystalloids, or fresh frozen plasma if hemorrhaging or coagulopathy occurs.

Ectopic Pregnancy

Ectopic pregnancy happens when a fertilized ovum implants outside the uterus. This can be in the fallopian tube (the most common site), peritoneal cavity, cervix, or ovary. If the ovum implants in the fallopian tube or ovary, it can cause the structure to rupture and induce major hemorrhaging. Thus, the pregnancy is not viable.

Assessment

Early symptoms of ectopic pregnancy mimic those of a typical pregnancy: breast tenderness, nausea, vomiting, fatigue, and increased urination. The patient may experience intermittent vaginal bleeding as well and will have a positive pregnancy test with hCG present in the blood and urine. Symptoms of a ruptured fallopian tube or ovary include one-sided or generalized sudden severe abdominal pain, hypotension with hemorrhage, and right shoulder pain if irritation of the phrenic nerve occurs. To diagnose an ectopic pregnancy, the healthcare provider will perform a vaginal exam and order a pregnancy test. A transvaginal ultrasound will rule out an intrauterine pregnancy. The ovum is difficult to see on an abdominal ultrasound. They will also order hCG titers for the patient because hCG increases more slowly in an ectopic pregnancy. A progesterone level that is greater than 22 will help to eliminate an ectopic pregnancy diagnosis.

Treatment

The only treatment is to stop the pregnancy. If it is unruptured and measures less than 3.5 centimeters, methotrexate IM or IV can be administered to slow growth and cause the body to expel the ovum without a surgical procedure. A surgeon can also perform a laparoscopic salpingostomy to remove only the ovum and leave the fallopian tube in place. If the ovum is ruptured, the surgeon will need to perform a laparoscopic salpingectomy to remove both the ovum and the ruptured tube to control the hemorrhage.

Emergent Delivery

An emergent delivery occurs when an emergency C-section takes place to save the life of mother and child. This can happen for a number of reasons that include placental abruption, hemorrhage, preeclampsia, uterine rupture, eclampsia, HELLP syndrome, preterm labor, or an undiagnosed placenta previa. Depending on the circumstances, it should be performed within 5 to 30 minutes depending on the condition of mother and child.

Assessment

The vital signs of mother and child are monitored throughout delivery. If the infant’s heart rate begins to fluctuate unsafely, the mother’s vitals appear unstable, or the mother is hemorrhaging, the patient’s healthcare provider may suggest an emergency C-section.

Treatment

The treatment is an emergency C-section to get the infant out as quickly and as safely possible and control any hemorrhage that occurs surgically. The mother will likely be placed under general anesthesia instead of receiving spinal anesthesia as time is of the essence. The mother may receive a blood transfusion, crystalloid fluids, or fresh frozen plasma if hemorrhage has occurred or coagulopathies are present. A neonatal resuscitation team (if available at the healthcare facility) should also be present at the delivery to care for the infant post-delivery.

Hemorrhage

Hemorrhage describes any blood loss greater than 500 mL during delivery and can occur in a vaginal or C-section delivery. The patient can also experience a postpartum hemorrhage; thus the patient will receive frequent assessments and vaginal exams even after delivery is complete.

Assessment

During delivery, the mother’s vitals are monitored regularly. If she becomes hypotensive, tachycardic, feels dizzy, or appears pale, she is becoming symptomatic from her blood loss. The blood loss is measured throughout delivery. The classes of hemorrhage severity are as follows:

• Class I—15% of total blood volume lost, asymptomatic.

• Class II—15 to 30% of total blood volume lost, tachycardia, nausea, fatigue, and pallor develop.

• Class III—30 to 40% of total blood volume loss, systolic BP <90, confusion, delayed capillary refill occurs.

• Class IV—40% or more of total blood volume lost, systolic BP <90, HR >120, decreased urine output, absent peripheral pulses, decreased level of consciousness, potential hypovolemic shock occurs.

A CBC, type and cross, and coagulation studies should all be drawn as well to diagnose acute blood loss anemia.

Treatment

Treatment includes controlling the source of the bleeding and replacing the blood that has been lost. A uterine Bakri balloon can be inserted to temporarily tamponade a relaxed hemorrhaging uterus, but should stay in place for no more than 24 hours to limit tissue damage. Fundal massage will help the uterus to contract. Any severe lacerations should be repaired to minimize blood loss. Administering tranexamic acid intravenously to temporarily stop the breakdown of blood clots will slow blood loss as well. The patient may receive a blood transfusion, crystalloid fluids for volume replacement, and fresh frozen plasma to deliver clotting factors.

Hyperemesis Gravidarum

Hyperemesis gravidarum is extremely severe nausea and vomiting during pregnancy. Up to 2 percent of women experience it, and it can cause weight loss, dehydration, hypokalemia, or ketonuria, all due to inadequate nutrition.

Assessment

The primary symptom is severe nausea and vomiting. The patient will experience weight loss, dehydration, decreased urine output, dizziness, hypoglycemia, and possible fainting. The healthcare provider will perform a physical exam to rule out other disorders involving nausea and vomiting such as hepatitis, pancreatitis, cholelithiasis, and ectopic pregnancy. Lab work ordered includes CBC, BMP, and urinalysis to check for ketones, which indicate inadequate nutrition.

Treatment

The patient will receive intravenous fluids with D5 in lactated ringers or normal saline to improve hydration and increase blood glucose. They will receive acute treatment for their nausea and vomiting with drugs including promethazine, prochlorperazine, or chlorpromazine. Maintenance antiemetic drugs include metoclopramide, ondansetron, and trimethobenzamide. After their condition has stabilized, the patient should be encouraged to increase their oral fluid intake and eat bland, easy-to-digest foods. In some severe cases of hyperemesis gravidarum, the patient will need to receive IV fluids regularly and may even needed to have a PICC line inserted and receive total parenteral nutrition to prevent malnutrition. The only “cure” for hyperemesis gravidarum is delivery.

Neonatal Resuscitation

In some instances, infants are born unresponsive. That’s where the neonatal resuscitation team comes in. The team can consist of NICU nurses, respiratory therapists, and healthcare providers (if the hospital has a NICU) or of labor and delivery nurses.

Assessment

The ABCs of resuscitation should guide the assessment: airway, breathing, and circulation. Ensure that the infant’s airway is patent, that they are breathing, and that they have circulation. The Apgar score is a clinical assessment of a neonate’s physical condition at birth that rates their appearance, pulse, respirations, grimace, and activity on a scale from 0 (the worst) to 2 (the best) with a maximum score of 10. For instance, almost all infants experience cyanotic hands and feet at birth, which would give them a score of 1, but central cyanosis on their chest or face would be a score of zero.

Treatment

The intervention should also be guided by the ABCs of resuscitation. If the infant’s airway is obstructed, then the nurse may need to suction out mucus or other secretions and/or reposition the infant’s head and neck. If they display central cyanosis or are not breathing, the nurse should stimulate them and provide oxygen, initially free-flow and then with a bag mask valve if free-flow oxygen is ineffective. The infant may need to be intubated if less invasive measures are not effective. If the infant’s circulation is not adequate, the infant should be warmed and placed in an incubator to help regulate temperature. If they are bradycardic or a pulse cannot be palpated, then chest compressions need to be initiated.

Placenta Previa

In placenta previa, the placenta completely or partially covers the cervix, increasing the risk of spontaneous rupture as the large blood vessels in the placenta cross the cervix, which can lead to a life-threatening hemorrhage. Careful precautions must be taken to ensure the health of both mother and infant.

Assessment

The primary symptom of placenta previa is bright red painless vaginal bleeding after 20 weeks of pregnancy. Occasionally the bleeding occurs in conjunction with cramping or prelabor uterine contractions. For some patients, sex or a vaginal exam can trigger the bleeding, but for many, there is no evident trigger. A few patients never experience any bleeding. A transvaginal ultrasound in the early stages of pregnancy or an abdominal ultrasound in the later stages of pregnancy will demonstrate the location of the placenta and whether it covers the cervix. A CBC and type and cross will also be drawn.

Treatment

If bleeding occurs, the patient will be admitted to the hospital for closer monitoring and instructed to remain on bed rest. If the bleeding stops, the pregnancy will be allowed to progress to 36 weeks. If the bleeding is severe, the patient will need to have an emergency C-section, as well as a possible blood transfusion. As the pregnancy progresses, the placenta will sometimes move so that it is no longer covering the cervix. A closely monitored vaginal delivery is possible in this instance. If the placenta covers the cervix through the duration of the pregnancy, the patient will need to have a C-section delivery.

Postpartum Infection

Postpartum infections are most common in patients who have had a C-section; the surgical incision can dehisce or become infected. Uterine infections can also occur in patients who have had a C-section or patients who have had a vaginal delivery.

Assessment

Symptoms of a surgical incision infection include redness, warmth and swelling around the incision; increased pain; foul-smelling discharge from the incision; chills; and fever. Symptoms of a uterine infection include foul-smelling vaginal discharge that may or may not include blood, pelvic pain, a fever, chills, and general malaise. The healthcare provider will assess the surgical incision and/or perform a vaginal exam. A CBC and culture of any discharge will be obtained. An ultrasound will determine whether the patient has retained a piece of placenta, which can cause an infection and heavy postpartum bleeding.

Treatment

The primary treatment is the administration of antibiotics. If the infection is relatively minor, oral antibiotics will suffice. If the infection is more severe, the patient will need to be admitted to the hospital to receive intravenous antibiotics. Although most antibiotics are compatible with breastfeeding, a few are not, and the patient should double check with a pharmacist to see if it’s okay to breastfeed while taking their full course of antibiotics. If the ultrasound reveals a piece of retained placenta, the patient will need to undergo a surgical dilation and curettage under general anesthesia to remove the placenta, which is usually the source of the infection.

Preeclampsia, Eclampsia, and HELLP Syndrome

Preeclampsia is hypertension that presents after 20 weeks of pregnancy accompanied by proteinuria and edema, either peripheral or central. It usually affects patients who were previously normotensive. Eclampsia is preeclampsia that has progressed to seizures. In HELLP syndrome, patients develop hemolysis, elevated liver enzymes (AST and ALT), and low platelets. The cause is currently unknown.

Assessment

The primary symptom is hypertension, which is a systolic blood pressure of 160 or greater and a diastolic blood pressure of 110 or greater. The patient will notice increased edema and a weight gain of at least 5 pounds in one week during the last 20 weeks of pregnancy. They may experience a headache, right upper quadrant pain, and vision disturbances. Preeclampsia is diagnosed based on blood pressure and the presence of proteinuria greater than 300 mg in 24 hours. A CBC, CMP, liver function tests, type and cross, and urinalysis will be drawn to establish a baseline for the patient’s lab work and be rechecked regularly. The severity of HELLP syndrome is determined by how low the patient’s platelet levels are:

• Class 1—severe thrombocytopenia, AST >70, LDH >600, platelets less than 50,000
• Class 2—moderate thrombocytopenia, AST >70, LDH >600, platelets 50,000-100,000
• Class 3—mild thrombocytopenia, AST >40, LDH >600, platelets 100,000-150,000

Treatment

The treatment for preeclampsia depends on the severity and the pregnancy stage. If it is more than 37 weeks, the patient will have an emergency induction. If it is less than 37 weeks, the healthcare provider will try to delay delivery. The only definitive treatment is delivery. Until then, the patient will receive magnesium sulfate 4 to 6 grams intravenously for the first hour and then 1 to 2 grams/hour intravenously to prevent seizures. Preeclampsia can be managed with oral antihypertensive medications like nifedipine and labetalol. HELLP is a medical emergency. The patient will frequently receive a blood transfusion, platelet transfusion, or transfusion of fresh frozen plasma. The fetus will be given corticosteroids to hasten lung and brain development in the case of preterm delivery.

Preterm Labor

Preterm labor is premature labor that occurs after 20 and before 37 weeks of pregnancy. It can occur for a variety of reasons that include a pregnancy with twins or triplets, stress, fetal abnormalities, preeclampsia/eclampsia/HELLP syndrome, premature rupture of membranes, smoking, drug use, cervical incompetence, and urinary tract infection. In most cases, the cause is unknown.

Assessment

The symptoms of preterm labor are like those of any other delivery. The patient may experience regular cramping or tightening in their abdomen, back pain, bloody show or loss of their mucus plug, vaginal bleeding, and/or rectal pressure. The healthcare provider will perform a vaginal exam to assess the patient’s cervix for dilation and effacement and perform fetal heart rate monitoring, a nonstress test, and a possible ultrasound to assess the fetus’s status.

Treatment

Precisely how far along the pregnancy is and the mother and fetus’s condition will decide whether to allow labor to progress or to stop it. Tocolytic medications like terbutaline can slow or stop labor for two to seven days, as can the administration of magnesium sulfate. Corticosteroids can be administered to hasten fetal brain and lung development. The mother will be asked to remain on bed rest.

Threatened/Spontaneous Abortion

Threatened/spontaneous abortion is a spontaneous or threatened delivery that occurs before 20 weeks of pregnancy and before fetal viability. There is no chance that the fetus will survive if the patient delivers. The most common cause is a severe fetal abnormality. This is also known as a miscarriage.

Assessment

The symptoms of threatened/spontaneous abortion are like those of any other delivery. The patient will experience vaginal bleeding, regular cramping, back pain, and vaginal/rectal pressure. The healthcare provider will perform a vaginal exam to assess the patient’s cervix and an ultrasound to assess the status of the fetus and their heart rate. If the pregnancy is so early that the embryo can’t be seen on an ultrasound, the patient will have their hCG levels checked weekly to see if they are increasing. If they decrease, it is a sign of miscarriage.

Treatment

If the pregnancy is in the first trimester (less than 12 weeks), little can be done to prevent a miscarriage. No intervention will be made to extend the pregnancy. If the fetus is healthy but the patient has an incompetent cervix that dilates and effaces too early, it can be stitched closed in a procedure called a cervical cerclage. The patient will be asked to avoid heavy lifting and minimize physical activity.

If a miscarriage occurs, the patient can wait to pass the products of conception naturally or take medications by mouth called mifepristone and misoprostol up to 10 weeks of pregnancy. Misoprostol can be used independently later in the first or second trimester. If the products of conception are still retained after two weeks or the patient displays signs of infection (fever, foul-smelling vaginal discharge, or increasing abdominal discomfort), they will need to undergo suction dilation and curettage under general anesthesia. The products of conception can be sent off for genetic testing if desired to help to determine the cause of the miscarriage.