OB Complications: Hyperemesis Gravidarum, Rh Factor, and Cervical Insufficiency
Hyperemesis Gravidarum (Hyper E)
Definition: Characterized by severe, excessive vomiting during pregnancy.
Treatment:
Primarily involves medications, the list of which is constantly updated and will be provided separately (via study guide).
Cause:
It is hormonal in nature.
Studies suggest a higher incidence and potentially greater severity in women pregnant with girls, possibly due to higher estrogen levels.
Clinical Presentation & Assessment:
Symptoms: Patient reports frequent and severe throwing up, inability to keep down fluids.
Key Questions to Ask:
"How long has this been happening?"
"Do you have a fever?"
"Have you been able to keep down any fluids?"
Objective Findings & Interventions:
Weight Loss: A crucial indicator of severity. Patient's current weight should be compared to their last doctor's visit. A loss of pounds in a few days (e.g., from Monday to Saturday) is indicative of severe hyperemesis.
Urine Dipstick: Used to assess dehydration. A significantly pink or magenta color suggests severe dehydration.
Specific Gravity: Will be elevated due to dehydration.
Severity & Complications:
In extreme cases, a PICC line may be necessary as a last resort for hydration and medication administration (though less aggressive in its use now).
Can persist throughout the entire pregnancy; some individuals require a PICC line from as early as weeks gestation until birth.
Some women experience such severe and unbearable symptoms that they opt for termination of the pregnancy.
The condition can also resolve suddenly, with symptoms disappearing overnight.
Management & Patient Environment:
Typically occurs in early pregnancy (first trimester), although it can, less commonly, extend into the second and third trimesters.
Fetal Monitoring: For babies under weeks gestation, a Doppler is used for fetal heart rate assessment. For weeks or more, ultrasound monitors are employed.
Environment: Patients usually prefer a dark and cold room, as warmth tends to exacerbate nausea.
Hygiene: Meticulous cleaning of the patient's environment is essential due to the intense and unpleasant odor of saliva/emesis. Larger bath basins with towels in the bottom are preferred over small emesis basins for easier clean-up, which helps reduce smells that can worsen nausea.
Pharmacist Intervention: In refractory cases, pharmacists may formulate custom-mixed medications.
Rh Factor Incompatibility
Review of Basics: If both mother and father are Rh-negative, the baby is expected to be Rh-negative.
RhoGAM Administration:
Indication: Administered when an Rh-negative mother is carrying an Rh-positive baby.
Timing:
A prophylactic dose is given at weeks gestation to protect the current baby.
An additional dose may be given if there is an injury during pregnancy.
Crucially, after delivery: A dose is given to protect any subsequent Rh-positive pregnancies.
Post-Delivery Window: The most critical aspect is that RhoGAM must be administered within hours post-delivery.
However, it can be given much earlier (e.g., hours after birth) as soon as the baby's Rh-positive blood type is confirmed.
Clinical Practice Change: Hospitals now prioritize obtaining the baby's blood type immediately after birth. RhoGAM is sent quickly from the blood bank, and nurses face repercussions if administration is delayed (e.g., being written up).
Patient Compliance: Emphasizes the importance of patients returning to the hospital if discharged within the -hour window to receive their RhoGAM shot.
Note: Further discussion on Rh factor incompatibility, particularly its effects on the baby (like jaundice), will be covered in the postpartum lecture.
Bleeding Disorders: Cervical Insufficiency (Incompetent Cervix)
Context: Discussed as a cause of mid- to late-pregnancy terminations, distinct from early terminations like ectopic pregnancy.
Definition: A condition where the cervix prematurely dilates without contractions, leading to recurrent second-trimester pregnancy loss.
Timing: Primarily associated with mid-pregnancy (second trimester), though complications can occur later, especially with more viable fetuses.
Treatment: Cerclage:
Procedure: A surgical procedure to stitch the cervix closed.
Historical Diagnosis: Historically, a diagnosis and cerclage intervention were often considered only after a woman experienced three or more consecutive pregnancy losses (though this threshold may be lower now).
Surgical Details: Performed in the operating room under spinal anesthesia. The cervix is pulled into vision and then stitched using a special material (compared to a plastic braiding material with two distinct stitching methods).
Post-Procedure: Patients remain in recovery until the spinal anesthetic wears off and are typically discharged home with recommendations for bed rest. In severe cases, hospital admission to an antepartum unit may be required for prolonged monitoring.
Example Case & Ethical Implications:
A patient who had experienced eight previous losses received a cerclage and was admitted to an antepartum unit. She complied with bed rest and progressed past weeks, a milestone for her. However, her cervix thinned out, and the baby broke through the stitch at weeks.
Ethical Dilemma: A social worker, aware of the patient's repeated losses and another mother's decision to give up her baby for adoption, facilitated a meeting with the intention of the patient adopting the baby. Despite permission from the high-risk doctor, the social worker was subsequently fired by the hospital due to legalities and policy violations. This created significant emotional distress for both mothers: the patient grappled with her loss and the perceived responsibility for the social worker's job loss, while the birth mother's benevolent intentions were complicated by the hospital's actions. The patient ultimately did not receive the baby. This illustrates the complex interplay between human compassion, institutional rules, and legal frameworks in healthcare decisions.