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Chapter 12: Obstetrics and Gynecology

Sabrina A. Adams

PHYSIOLOGICAL CHANGES IN PREGNANCY

Physiologic changes begin in early pregnancy and continue throughout. Major changes are listed in Table 12.1.

Table 12.1.Maternal Physiological Changes in Pregnancy
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Table 12.1. Maternal Physiological Changes in Pregnancy
Cardiovascular

↑ Cardiac output

↓ Systemic vascular resistance

↑ HR 10-15 bpm
Respiratory

↓ Functional residual capacity

↑ Tidal volume and RR

↑ Minute ventilation

Respiratory alkalosis
Hematology

↑ Blood volume > ↑ RBC volume

Physiologic anemia

Hypercoagulable state
Musculoskeletal ↑ Ligament laxity
Gastrointestinal ↓ Esophageal sphincter tone

HR, heart rate; RBC, red blood cell; RR, respiratory rate.

ECTOPIC PREGNANCY

Extrauterine pregnancy is common in the emergency department, occurring in up to 10% of patients with first trimester bleeding. The vast majority are located in the fallopian tube; other sites include the ovary, abdominal cavity, and cervix (Figures 12.1 and 12.2). A simultaneous intrauterine pregnancy (IUP) and ectopic pregnancy, or heterotopic pregnancy, is rare, occurring in only 1 in 30,000 naturally-conceived pregnancies. The incidence is much higher with assisted reproduction.

Figure 12.1.

Various sites and frequency of ectopic pregnancies. (Reproduced, with permission, from Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics. 24th ed. New York, NY: McGraw-Hill Education; 2010. Figure 19.1.)

A diagram of the cross-section of the female reproductive organs is labeled with the common locations of ectopic pregnancies and the percentage of occurrences.
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Figure 12.2.

Interstitial ectopic pregnancy. Parasagittal long-axis ultrasound imaging showing empty uterus with ectopic mass that is located cephalad and lateral to the uterine fundus in the region of the interstitium of the fallopian tube. (Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics. 24th ed. New York, NY: McGraw-Hill Education, 2010. Figure 19.9A.)

An ultrasound of the lower abdomen shows an empty uterine cavity and an abnormal mass.
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Q

A 33-year-old woman presents to the emergency department with abdominal pain. Her last menstrual period was 2 months ago. Vital signs are BP 90/60 mm Hg, HR 130 bpm, and RR 18 breaths/min. Urine pregnancy test is positive. An ultrasound is done (Figure 12.3). What is the next appropriate step?

Figure 12.3.

Ultrasound showing free fluid in Morison’s pouch (arrow).

An ultrasound of the abdomen reveals an abnormal collection of fluid.
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image KEY FACT

Heterotopic pregnancy occurs in 1-3% of patients with assisted reproduction.

RISK FACTORS

History of previous ectopic pregnancy (most common), prior tubal infection, abnormal fallopian tubes, previous tubal surgery, intrauterine device (IUD) use, smoking, advanced age, elective abortion, and fertility treatments. Over half of patients have no identifiable risk factors at time of diagnosis.

A

Emergent consultation of OB/GYN for surgical treatment of ectopic pregnancy.

image KEY FACT

All other forms of contraception besides IUD decrease the incidence of ectopic.

SYMPTOMS...

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