Abnormal Pregnancy

CAPT Mike Hughey, MC, USNR

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 1
Incidence of Miscarriage

• 1 in every 6 pregnancies
• Risk of subsequent
miscarriage 1/6
• Bedrest will not prevent
miscarriage but may
postpone it

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 2
Causes of Miscarriage
• 60% chromosome abnormalities
• 30% placental malformation
• 10% miscellaneous, but not:
-trauma
-climbing mountains
-intercourse
-medication
-too much activity, etc.

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 3
Threatened Abortion
• 1 in every 4 pregnancies
• 1st TM bleeding/cramping
• Half will abort, Half will be OK
• Bedrest will not prevent abortion
but may postpone it.

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 4
 Complete Abortion
• Passage of all tissue
• Rest for a day or two
• Ergotrate, Oxytocin
• Antibiotics
• Rhogam

9-week spontaneous complete abortion

• D&C?

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 5
Incomplete Abortion: Diagnosis

• Some tissue remains behind

• Continuing bleeding/cramping
• Tissue in cervical os
• Uterus tender
• Fever if infection present
• Ultrasound helpful if available

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 6
Incomplete Abortion: Treatment
• Convert it to a Complete
Abortion
• If tissue visible in the os,
remove it

Tissue removed from os • Ergotrate, Oxytocin

• Antibiotics
• Rhogam
• D&C

Tissue still inside uterus

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 7
Inevitable Abortion
• No tissue has been passed
• Cervix dilated or hemorrhage
• Ergotrate, Oxytocin
• Antibiotics
• Rhogam
• D&C

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 8
 Septic Abortion
• Any abortion complicated by
infection
• Fever, Tenderness
• Ergotrate, Oxytocin
• Antibiotics
• MEDEVAC
• D&C

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 9
Septic Abortion: Antibiotics

• Clindamycin & Gentamicin IV

• Flagyl & Gentamicin IV
• Cefoxitin IV

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 10
Unruptured Ectopic Pregnancy
• + HCG
• Unilateral pelvic pain
and tenderness
• ±Pelvic mass?
• DD: CL cyst, Appy,
PID
• Lie still
• MEDEVAC

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 11
Ruptured Ectopic: Diagnosis
• Pelvic & right shoulder pain
• Sudden onset
• Shock
• Positive pregnancy test
• Rebound & Rigidity late
• Ultrasound
• Culdocentesis

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 12
Ruptured Ectopic: Treatment

• Surgery
• MEDEVAC
• IVs, oxygen, lie still
• Maintain urine output
(Foley)
• MAST suit?

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 13
Blood Transfusion
• O Negative blood
• Blood collection bags
• Direct Donor to Patient
#16 needle
3-4 feet gravity feed
10 minutes
• Have a plan before you need it

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 14
Placental Abruption
• >20 weeks
• Uterine pain, tenderness,
and contractions
• ±Bleeding
• Coagulopathy
• Lie still, IV Fluids
• MEDEVAC, Cesarean
Section

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 15
 Placenta Previa
• >20 weeks
• Painless vaginal bleeding
• No pelvic exam unless
instructed by an OB-
GYN
• Pelvic exam may cause
torrential hemorrhage,
exsanguination and death
within minutes
• Rest, IVs, MEDEVAC

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 16
Toxemia of Pregnancy
• Elevated BP (>140/90)
• Proteinuria (>300 mg in 24 hours)
• Weight Gain (>2 pounds/week)
• Swelling (?)
• Increased reflexes (Clonus)

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 17
 Pre-Eclampsia

• BP, Protein
• Stable and unstable
• Risk of IUGR
• Risk of Abruption
• Risk of maternal seizures
• Risk of HELLP syndrome
• Hemolysis
• Elevated Liver Enzymes
• Low Platelets
Naval Hospital Jacksonville

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 18
 Eclampsia

• Siezures
• Risk of maternal death
• Risk of HELLP syndrome
• Hemolysis
• Elevated Liver Enzymes
• Low Platelets

Naval Hospital Guam

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 19
Treatment of Toxemia of Pregnancy

• Delivery is definitive treatment

• If delivery is to be postponed
(prematurity), then consider
hospitalization for unstable patients

• Magnesium sulfate

• Watch for HELLP syndrome

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 20
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