OB Case, need info

[Riblett]

Last shift I had an OB case which I had never seen before. I was dispatched to "pregnancy problems" at the local college. The patient was on the third floor of the men's dorm building, which in accordance with Murphy's Laws of EMS had super narrow stairs and no elevator. I found a 16 year old girl kneeling on the floor of a dorm room. She had her hands over her vagina attempting to keep something from coming out. It looked like large portion of an intact amniotic sac. Before my EMT even made it into the room I called for back up. She said that she was 22 weeks pregnant and had just had sex with her boyfriend when this started. She denied any cramping or urge to push. There was a moderate amount of blood in the toilet but no fetus according to my partner whom I sent on an unfortunate fishing expedition.

All I could see at the vagina was (for lack of more sensitive or appropriate term) what looked like a big bubble protruding about 3 inches. There was also what appeared to be bloody semen. I could not see any identifiable fetal parts, just the amniotic membranes. While waiting for the other crew to help us get her out of the building I took vitals and started a line. I soaked an ABD pad in sterile water and covered the vagina and membranes with it, not having any idea what else to do. We took her down the stairs in the stair chair. En route to the OB hospital I started a second line, did an basic EKG, and repeated vitals. Her vitals were normal, rather good actually. We made it to the hospital without a fetus being expelled in what must have been the longest 17 miles of my career so far. More of the amniotic sac was visible when we got to the ED but still no visible fetal parts or significant bleeding . They of course told us to proceed immediately to Labor and Delivery during call-in. (As an aside, the L&D nurse had the nerve to demand why didn't I stop downstairs to register her. Yeah, I'm going to drive emergently to the hospital, then stop off in a crowded ER waiting room with my bloody sheets, IV poles, and a half naked teen trying to deliver a 22 week fetus. Might as well let her have a look round the gift shop while I am down there, huh?)

I learned nothing about this sort of situation in my education as a paramedic. I can't find much online and there is nothing in my textbooks about it. Has anyone seen this before? How would you treat this patient? What should we as field providers do in this situation?

Edited April 13, 2011 by Riblett

[FireMedic65]

It sort of sounds like an inverted uterus.

[PCP]

I feel you did everything that you could for that patient. The patient mentioned she did not feel that she needed to push, nor did she have any cramping and when you looked you said you did not see the fetus, so to me the best option was to head straight to the hospital and that was what you did. Now by putting the damp sterile dressing over the vagina, I feel that would have helped keep what ever it was that was exposed moist and possibly keep from drying out and soak up any body fluids. I feel that is the best that you could do for that patient along with starting a line which may have helped keep her blood pressure stable.

I don't have much experience in genral, and especially when it comes to dealing with OB. Hopefully some of our more experienced members can coment on this post.

Good Job!

Brian

[tcripp]

Any chance you called the receiving nurse back for follow-up? Find out what exactly had happened?

[fiznat]

YOWZA!!! LOL this is one of my nightmare calls. I deal with so few actual OB emergencies that it feels almost like a foreign planet. The fact that you (or I!) could run that entire call and still have no idea wtf was coming out of that woman's vagina is SCARY to me haha. Could it have been placenta? Did it have a sac-like quality to it? How do you know the sac wasn't a baby gremlin and putting water on it was the worst thing you could have possibly done?! Oh, man.

You didn't follow up with the OB doc or nurses?? I would not have left that hospital until I had a conversation with someone who knows wtf they are doing!!

Edited April 13, 2011 by fiznat

[Riblett]

I am pretty sure it was the amniotic sac. I have seen the placenta a couple times before and it didn't look like that. This girl was visiting her boyfriend at college and lives in another part of the state. So she had no relationship with any OB in the area. There was no doc in the ward when we got there. They paged the on-call OB when we brought her in. The nurses were really not helpful. I still don't know the outcome. The only thing I was sure of on this call was that my partner was experiencing an acute Zofran deficiency

[BAYAMedic]

YOWZA!!! LOL this is one of my nightmare calls. I deal with so few actual OB emergencies that it feels almost like a foreign planet. The fact that you (or I!) could run that entire call and still have no idea wtf was coming out of that woman's vagina is SCARY to me haha. Could it have been placenta? Did it have a sac-like quality to it? How do you know the sac wasn't a baby gremlin and putting water on it was the worst thing you could have possibly done?! Oh, man.

You didn't follow up with the OB doc or nurses?? I would not have left that hospital until I had a conversation with someone who knows wtf they are doing!!

I know this is off topic and for that I am sorry. But I wanted to take a second and congratulate Fiznat on his 1,000th post. Thanks for being such a great part of the city man.

Fireman1037

[scubanurse]

I am pretty sure it was the amniotic sac. I have seen the placenta a couple times before and it didn't look like that.

Probably not placenta previa, but rather a uteran prolapse... possible for the sac to prolapse though but I haven't seen or heard of that happening before but theoretically it is possible..

We need Ak to chime in on this one

[Just Plain Ruff]

Thsi is one of those calls that make even the best medic cringe and turn white and have his asshole pucker up to near infinitely small in size.

I am thinking the the amniotic sac had come loose and the baby was just a hare's breadth from being delivered.

This is probably a fetal demise.

When my wife miscarried at 17 weeks, the sac and the baby came out at the same time. This is exactly what we saw, the sac coming out and then the baby. It was HORRIBLE to watch and very very sad. But the baby came out nonetheless and your description sure sounds like what we went thru.

Get the girl to the hospital but at 22 weeks it's very very early and a small survivability but kidlets at that gestation have been known to survive but with many many problems. Our perinatologist told us that a 22 weeker would probably not survive regardless of lifesaving measures done.

There was a reason why this happened, I'm not one to guess.

[DartmouthDave]

Hello,

Wow.

I am at a loss here. I assume she was null-para. The cervex should be closed and I can not see how the placenta and fetus could prolapse. I will add my guess and go with Uterus Prolapse.

Time to dust off a OB text.

Cheers