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Critical Care of the Obstetric
Patient
Shannon Carroll, M.D.
Suresh Agarwal, M.D.
www.peainthepodcast.com
Aspects of Critical Care Specific to
Obstetric Patients
• Anatomic Changes in Pregnancy
• Physiologic/Pathologic Changes in Pregnancy
– Hemodynamic
– Endocrinologic
– Pulmonary
• Postpartum Hemorrhage
• Trauma in the Pregnant Patient
Page 3
Anatomic Changes in Pregnancy
ajnoffthecharts.wordpress.com/2009/11/03
Page 4
Anatomic Changes in Pregnancy
focosi.altervista.org/uterinelevels.jpg
Page 5
Physiologic/Pathologic Changes in
Pregnancy
• Cardiovascular Changes
• Endocrinologic Changes
• Pulmonary Changes
empracticenews.files.wordpress.co
m/2008/06/0708-emp-table-2.png
Page 6
Cardiovascular Changes
• Increase Cardiac Output
– Up to 50% by 24th week
of gestation
– CO plateaus from 24th
week until term
– Further increased during
labor and delivery
– “Autotransfusion Effect”
– Increased Preload after fetus and placenta delivery
Page 7
www.ljmu.ac.uk/sportandexercisesciences/RISES/Health/82521.htm
Cardiovascular Changes
• Increased Cardiac Output
– Increased Contractility
– Early in Pregnancy:
Increased Blood Volume
– Later in Pregnancy:
Increased Heart Rate
• 15 – 20 beats faster
www.biomaterials.org/SIGS/Cardiovascular/Heart.htm
Page 8
Body Positioning
• Cardiac Output and
Stroke Volume
• Supine Position
– Aortocaval Compression
– Decreased Preload
– “Supine Hypotensive Syndrome” of Pregnancy
– Left Lateral Recumbent Position after 20th week
Page 9
media.photobucket.com/image/left%20and%20ivc%20and%
20gravid/JHWalker/shs1.jpg
Body Positioning
• Cardiac Resuscitation
– Left Lateral Recumbent Position
Or
– Left Manual Displacement of the Uterus
Page 10
www.the-pillow.com.au/more/lucky-7-body-pillow-more.php
Cardiovascular Changes
• LV End-Diastolic Volume is Increased
• Filling Pressures Unchanged
– Decreased systemic and pulmonary vascular
resistance
Page 11
Cardiovascular Changes
• Blood Volume
– 30 – 50% Increase by Full Term
• Red Blood Cell Mass
– 15 – 20% Increase by Full Term
• -> “Physiologic Anemia” of Pregnancy
Page 12
nursingcrib.com/pregnancy-complications/
Cardiovascular Changes
• Up to 35% Blood Volume Loss before Tachycardia and
Hypotension occur
Page 13
Cardiovascular Changes
• Increased Blood Flow
– Breasts
www.med.yale.edu/intmed/cardio/imaging/anatom
y/breast_anatomy/graphics/breast_anatomy.gif
Page 14
Cardiovascular Changes
• Increased Blood Flow
– Breasts
– Uterus
embryology.med.unsw.edu.au/notes/images/urog
en/uterine_blood_supply.jpg
Page 15
Cardiovascular Changes
• Increased Blood Flow
– Breasts
– Uterus
– Kidneys
• ↑ Renal Blood Flow by 25 – 50%
• ↑ Glomerular Filtration Rate up to 50%
• ↓ BUN and Plasma Creatinine
www.physicscentral.org/explore/action/im
ages/scans-img8.jpg
Page 16
Cardiovascular Changes
• Diastolic Blood Pressure Decreased
– ↓ by 10% in 2nd Trimester
– Due to ↓ Systemic Vascular Resistance
– Returns to Baseline by Full Term
Page 17
Cardiovascular Changes
• Blood Vessel
Remodeling
• Coagulation
System Changes
– Most Clotting
Factors Increased
– Hypercoagulable
www.answers.com/topic/factor-xii
Page 18
Cardiovascular Changes
• Heart Remodeling
– Enlargement of
All 4 Chambers
• Susceptible to Supraventricular
and Atrial Arrhythmias
myhealth.ucsd.edu/library/healthguide/enus/support/topic.asp?hwid=zm2767
Page 19
Cardiovascular Changes
• “Normal” Changes in Heart Sounds
– Systolic Ejection Murmur
– Third Heart Sound
• Potentially Pathologic
Changes in Heart Sounds
– Diastolic Murmurs
– Pansystolic Murmurs
– Late Systolic Murmurs
Page 20
www.ed4nurses.com/heartsnd.aspx
Cardiovascular Changes
• Cardiac Disease
– Mild to Moderate: Pregnancy Usually Well-Tolerated
– Pulmonary Hypertension and Right-to-Left Shunts: up
to 50% Mortality with Pregnancy
Page 21
Hypertension In Pregnancy
• Definition:
– increase of at least 30 mmHg in the SBP and
– Increase of at least 15 mmHg in the DBP
– Above baseline
Page 22
Hypertension In Pregnancy
• Monitoring
• Etiology
• Preeclampsia
• Treatment
• Management During Labor and Delivery
Page 23
Blood Pressure Monitoring
• Sustained Hypertension
– At least 2 separate occasions
• Position
– Upper arm in the sitting position, or
– Lower arm in the lateral recumbent position
Page 24
Etiology of Hypertension in
Pregnancy
• Predisposing factors
– Family history
– Personal history of Diabetes mellitus
– Vascular or Renal Disorders
– Primigravid state
– Multiple gestational pregnancies
Page 25
Preeclampsia
• Pregnancy induced
• Multisystem
• Onset is after 32nd week
of gestation
• Symptom triad:
– Peripheral edema
– Systemic hypertension
– Significant proteinuria (> 0.3g in 24hr urine)
nursingcrib.com/pregnancy-complications/
Page 26
Preeclampsia
• US Incidence = 7%
• Diastolic hypertension is usually more prominent than
systolic hypertension
• Evaluate patient for underlying or coexisting disease
processes
• Familial cases
• May present as late as 7 days postpartum
• Postpartum preeclampsia often associated with the
HELLP syndrome
Page 27
Preeclampsia and the HELLP
Syndrome
• Some or all of the following:
– (H) microangiopathic hemolytic anemia
– (EL) elevated liver enzymes
– (LP) low platelets
– May be present without significant blood pressure
elevations
Page 28
Preeclampsia
• Increased risk with significant elevation in blood pressure
in the second trimester
– 1/3 of patients with MAP > 90 in the second trimester
will develop it
– < 2% of patients with MAP < 90 in the second
trimester will develop it
Page 29
Treatment of Hypertension In
Pregnancy
• Uterine Blood Flow and BP Management
– Increases or shows no change with BP control
• Avoid Overly Aggressive BP Management
– Affects maternal hemodynamics
– Compromises uterine blood flow
• Initial Agents
– po α-methyldopa
– po labetalol
• IV Agents
– Labetalol
– Hydralazine
– Sodium Nitroprusside
Page 30
BP Management During L&D
• Antihypertensive agents
• Judicious use of IV fluids
• Postpartum monitoring for high risk patients
• Preeclampsia
– Hypertension resolves spontaneosly within a few
weeks
• Trace amounts of all antihypertensive agents are found
in breast milk
– No adverse affects on infants have been identified
Page 31
Endocrinologic Changes
• Hypothalamus
• Pituitary Gland
• Adrenal Glands
Page 32
www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/1093.jpg
Endocrinologic Changes
• Increased ACTH and Cortisol Levels in Pregnancy
– Cushing’s Syndrome
may be exacerbated
by pregnancy
– Acute Adrenal Crisis
may be precipitated by
labor and delivery
www.beliefnet.com/healthandhealing/getcontent.aspx?c
id=179661
Page 33
Waterhouse-Friderichsen syndrome
• Massive adrenal hemorrhage
– Usually bilateral
– Meningococcemia
– Hypotension/Shock
– DIC with purpura
– Rapidly progressive
adrenocortical insufficiency
• Most common etiology = Neisseria meningitidis
• Prevention: Vaccine against meningococcus
Page 34
www.livestrong.com/ls_images/disease/1000-1999/1814-2938.jpg
Waterhouse-Friderichsen syndrome
•
•
•
•
•
•
•
•
•
Onset: fever, rigors, vomiting, and headache
Rash quickly develops
– first macular
– progresses to petechiae and purpura; dusky gray color
Hypotension/Septic shock
Usually no Meningitis
Adrenal Insufficiency (hypoglycemia, hyponatremia, hyperkalemia)
DIC
Acidosis
ARF
Meningococci
– from blood or CSF
– smears of cutaneous lesions
Page 35
library.med.utah.edu/WebPath/jpeg4/ENDO004.jpg
Waterhouse-Friderichsen syndrome
• Treatment:
– Medical emergency
– Ceftriaxone
– Hydrocortisone for
hypoadrenal shock
library.med.utah.edu/WebPath/jpeg4/ENDO006.jpg
Page 36
Endocrinologic Changes
• Prolactin Levels Increased
– Preparation for lactation
– Pituitary Adenomas
• May increase in size
• May become symptomatic
Page 37
www.biologie.uni-freiburg.de/data/bio1/varga/projects.htm
Endocrinologic Changes
• Thyroid Hormones Increased
– Thyroxine-Binding Globulin
Increased
– Free Levels Unchanged
– No Associated Complications
if Iodine Consumption is
Adequate
www.pyroenergen.com/articles08/thyroidgland-hormones.htm
Page 38
Endocrinologic Changes
• Transient Diabetes
Insipidus
– Due to Vasopressin
Resistance
Page 39
www.medscape.com/viewarticle/558561_3
Endocrinologic Changes
• Fluctuations in Insulin and Glucose Levels
• Increased Insulin Secretion
• Increased Insulin Resistance
• Gestational Diabetes Mellitus
– Obese women with
insulin resistance
– Women with minimal
pancreatic reserve
Page 40
nursingcrib.com/pregnancy-complications/
Endocrinologic Changes
• Increased Maternal Lipid Metabolism
Page 41
Pulmonary Complications in the
Obstetric Patient
• Normal Pulmonary
Physiology in Pregnancy
• Asthma
• Pulmonary Edema
• Acute Respiratory
Distress Syndrome
• Embolism
Page 42
saltyandsweet.wordpress.com/2008/05/12/various-gunky-topics
Pulmonary Complications in the
Obstetric Patient
• Normal Pulmonary Physiology in Pregnancy
– Tidal volume is increased
– Functional residual capacity
is decreased
• Normal ABG = compensated
respiratory alkalosis
• Respiratory distress may
progress more rapidly
due to pregnancy
medicaldictionary.thefreedictionary.com/functional
+residual+capacity
Page 43
Pulmonary Complications in the
Obstetric Patient
• Asthma in Pregnancy
– Monitoring: Peak flow meter (no change in FEV1)
– PaCO2 > 35 mmHg in a pregnant patient with asthma
may signify respiratory distress
– Treatment principles are the same for
pregnant and non-pregnant patients
Page 44
wellness.blogs.time.com/2009/10/09
/women-with-asthma-keep-up-yourtreatment-during-pregnancy
Pulmonary Complications in the
Obstetric Patient
• Acute Respiratory Distress Syndrome in Pregnancy
– Need for mechanical ventilation does not mandate
delivery
– Therapeutic drugs NOT
contraindicated in
pregnancy:
• Sedatives
• Hypnotics
• Non-depolaring paralytics
http://www.rtjournalonline.com/images.htm
Page 45
Pulmonary Complications in the
Obstetric Patient
• Embolism in Pregnancy
– Hypercoagulable state
– Radiographic studies if
indicated by respiratory
distress
– Warfarin contraindicated
in 1st trimester
– Amniotic fluid embolism
• 1/80,000 pregnancies
• significant maternal
morbidity/mortality
www.oxygentimerelease.com/B/Bonnie/p23.htm
Page 46
Postpartum Hemorrhage
• Definition
• Epidemiology
• Pathophysiology
• Diagnosis
• Treatment
• Surgical Therapy
• Prognosis
Page 47
Postpartum Hemorrhage
• Definition: excessive and life-threatening bleeding
• Normal blood loss:
– Vaginal birth < 500 mL
– Cesarean section = 800 – 1000 mL
• after 20 weeks gestation
• at time of delivery of baby or placenta
• Primary PPH: within 24 hours of delivery
• Secondary PPH: between 24 hours and 12 weeks of
delivery
Page 48
Postpartum Hemorrhage
• Epidemiology leading world-wide cause of maternal death (>
100,000 deaths per year)
• one of three leading causes of maternal death in the US
(with embolism and hypertensive disorders)
Page 49
www.thedoctorstv.com/main/show_synopsis/207?section=synopsis
Postpartum Hemorrhage
Pathophysiology
• Uterine Blood Flow at Term
– 10% of maternal cardiac output
– Approximately 600 to 1200 mL/min
• Myometrial Contraction
– Placental separation
– Hemostasis
– Myometrial fibers contract (compression)
and retract (occlusion)
– Increase in Circulating Clotting Factors
www.bodyworlds.com/en/media/picture
_database/preview.html?id=12
Page 50
Postpartum Hemorrhage
Pathophysiology
• Causes of excessive hemorrhage
– Uterine Atony
– Lacerations
– Placental Anomalies
– Trauma
Page 51
library.med.utah.edu/kw/human_reprod/mml/hrob_oh_5.html
Postpartum Hemorrhage
• Diagnosis/Workup:
– often obvious, w/ external bleeding
– if occult:
• Ultrasonography
– Clot
– Hematoma
– retained placental fragments
Page 52
www.3bscientific.co.th/obgyn/placentaw10604,p_895_0_0_0_3376_image_full.
html
Treatment for Postpartum
Hemorrhage
• Oxytocic drugs Treatment for Postpartum Hemorrhage
– First line = Oxytocin (Pitocin)
– Methylergonovine
(Methergine)
– Carboprost tromethamine
(Hemabate)
• Uterine packing
• Balloon occlusion catheters
www.cookmedical.com/wh/featur
es/bakri_en_US/index_bakri.html
• Arteriography with selective arterial embolization
Page 53
Surgical Therapy for Postpartum
Hemorrhage
• Temporizing measure: occlusion of aorta by manual
pressure with fist just cephalad to the umbilicus
• Manual examination of the uterus w/ evacuation of
retained placenta
www.obfocus.com/highrisk/bleeding/hemorrhagepa.htm
Page 54
Surgical Therapy for Postpartum
Hemorrhage
• Hematomas of lower genital tract: incise and drain
• Hematomas of broad ligament and retroperitoneum:
monitor unless expanding
• Visible lacerations: repaired & oversewn
• Ligation of uterine, ovarian, internal iliac
arteries
– Supply 90% of uterine blood flow
• Definitive treatment for PPH = Hysterectomy
• Uterine rupture mandates Hysterectomy
Page 55
Postpartum Hemorrhage
• Complications
– DIC
– Dilutional Coagulopathy -when > 80% of blood volume replaced
– Hemorrhagic Shock
– Renal failure
– Liver failure
– ARDS
– Sheehan’s Syndrome
– Avascular necrosis of pituitary gland
– Permenant hypopituitarism
• Prognosis -- Dependent on prompt diagnosis and treatment
Page 56
www.ohiohealth.com/bodymayo.cfm
Trauma in the Obstetric Patient
• Relevant Fetal Physiology
• Assessment and Resuscitation
• Blunt Trauma
• Penetrating Trauma
• Specific Complications of Trauma in the Pregnant
Patient
Page 57
Trauma in the Obstetric Patient
• “Save the mother, save the fetus”
Page 58
Trauma in the Obstetric Patient
• Trauma
– #1 cause of nonobstetric death in pregnant patients
– #1 traumatic cause of fetal demise with maternal
survival is placental abruption
• Maternal injuries associated with fetal demise
– Pelvic fracture = fetal skull fracture and intracranial
injury
– 80% of patients with hemorrhagic shock experience
fetal demise
Page 59
Trauma in the Obstetric Patient
• Screen all female patients of child-bearing age for βhuman chorionic gonadotropin
Page 60
www.babydoll.ws/content/uploads/2008/05/a-baby-in-the-making-3.jpg
Specific Complications of
Trauma in the Pregnant Patient
• Fetomaternal Hemorrhage
– Fetal blood crosses into maternal circulation
– About 1 in 4 pregnant trauma patients
– To quantify: Kleihauer-Betke test
• Complications
– Maternal Rh sensitization
– Neonatal anemia
– Fetal cardiac arrhythmias
– Fetal exsanguination
• Treatment
– Rho(D) immune globulin for Rh negative mothers
Page 61
Specific Complications of
Trauma in the Pregnant Patient
•
•
•
Abruptio Placentae
– Most frequent cause of fetal death with maternal survival in trauma
– Occurs even with minor trauma
– Risk increases with gestational age
Presentation
– Abdominal pain
– Vaginal bleeding
– Premature rupture of membranes
– Uterine tenderness or rigidity
– Expanding fundal height
– Maternal shock
– Fetal distress
Treatment = Delivery
Page 62
Specific Complications of
Trauma in the Pregnant Patient
• Amniotic Fluid Embolism
Page 63
www.wadsworth.org/chemheme/heme/microscope/pix/schistocyte_nw.jpg
Specific Complications of
Trauma in the Pregnant Patient
• Amniotic Fluid Embolism
– Leakage of amniotic fluid with fetal elements into the maternal
circulation
– Incidence: 1/8,000 to 1/80,000
– Most common cause of
peripartum deaths
• Presenting symptoms:
– 1st through 3rd trimester
– Seizures or seizure-like activity
– Cardiopulmonary collapse
• Progress to develop a
consumptive coagulopathy
ipodsuite.com/search/?cx=016304524648153656
041%3Atn7nrxq7qf4&cof=FORID%3A11&ie=UTF
-8&q=amniotic%20fluid#946
Page 64
Specific Complications of
Trauma in the Pregnant Patient
• Amniotic Fluid Embolism
– Consumptive Coagulopathy
• Decreased Fibrinogen (<100mg/dL)
• Increased Fibrin Split Products
• Decreased Platelets
• Increased PT and aPTT
Page 65
Specific Complications of
Trauma in the Pregnant Patient
• Amniotic Fluid Embolism
– Diagnosis
• Diagnosis of exclusion
• Fetal elements in maternal venous blood
– Not always present/identified
Page 66
Specific Complications of
Trauma in the Pregnant Patient
• Amniotic Fluid Embolism
– Prognosis: dismal
• <15% survive neurologically intact
Page 67
Specific Complications of
Trauma in the Pregnant Patient
• Amniotic Fluid Embolism
– Treatment
• Supportive
– CPR with L lateral displacement of uterus
– Intubation, Mechanical Ventilation with FiO2=100%
– Volume resuscitation
– Pressor support early; 1st –line = Epinephrine
– Emergent C-section if fetus not yet delivered
– ? Corticosteroids
• Treat DIC
– Red blood cells, Platelets, FFP, and Cryoprecipitate
Page 68
Specific Complications of
Trauma in the Pregnant Patient
– Treatment:
• Delivery of the fetus
• Platelets + Clotting factors (including fibrinogen)
Page 69
Specific Complications of
Trauma in the Pregnant Patient
• Premature Labor
– Common
– Usually self-limited
– May require tocolytics
– Tocolytics are contraindicated
in patients with placental
abruption
Page 70
i.ehow.com/images/GlobalPhoto/Articles/5378889/351878-main_Full.jpg
Specific Complications of
Trauma in the Pregnant Patient
• Uterine Rupture
– Direct trauma to the
uterus
– Almost all result in
fetal death
– Often associated with
maternal death
– Abdominal pain +
peritoneal signs
library.med.utah.edu/kw/human_reprod/mml/hrob_oh_5.jpg
Page 71
Specific Complications of
Trauma in the Pregnant Patient
• Fetal Demise
– Labor usually ensues within 48 hours
– Induction or C-section indicated if labor does not
begin
– Monitor for DIC
Page 72
Specific Complications of
Trauma in the Pregnant Patient
• Cesarean Section
– Fetal indications:
• Fetal distress
• Placental abruption
• Uterine rupture
• Fetal malposition with
premature labor
– Maternal indications:
• Inability to control other injuries due to pregnancy
www.jeffersonhospital.org/obgyn/fibroi
d_images/39weeks-2.jpg
• DIC
Page 73
Specific Complications of
Trauma in the Pregnant Patient
• Cardiac Arrest
– Manually displace the uterus to the left
– Consider left thoracotomy and cardiac massage +
emergency C-section
• Continue CPR until delivery
• Delivery may allow maternal
resuscitation
• C-section is indicated if:
– delivery within 5 to 15 minutes of maternal cardiac
arrest
– Fetal vital signs persist
Page 74
www.ehow.com/how_5511869_heal-havingemergency-cesarean-section.html
Specific Complications of
Trauma in the Pregnant Patient
• Maternal Head Trauma
– Pregnant patients diagnosed with brain death have
been supported until a viable fetus could be safely
delivered
– Essential Consults:
• Obstetricians
• Ethicists
Page 75
jeffreyleow.files.wordpress.com/2009/03/the_hand_of_hope_.jpg
Medications Commonly Used in
Pregnancy
Page 76
Critical Care of Gynecologic
Patients
• Necrotizing fasciitis
• Risk factors
– DM
– Atherosclerosis
– Long-term NSAID use
– Glucocorticoids
– Immune Deficiency
• Causative organisms
media.jaapa.com/images/2009/04/07/fournierCME1107figs23_49370.jpg
– Streptococcus pyogenes (group A Strep)
– Staphylococcus aureus
– Polymicrobial
Page 77
Critical Care of Gynecologic
Patients
• Necrotizing fasciitis
• Indications for Surgical resection
– Areas of necrosis (purple discoloration early)
– Anesthetic areas
• Treatment
– Systemic support
– Systemic antibiotics
– Radical Excision
• Histology:
– Vascular occlusion/thrombosis
– Leukocyte infiltration
– Necrosis
Page 78
Critical Care of Gynecologic
Patients
• Uterine Perforation
• Potential Etiologies:
– Endometrial biopsy
– IUD Placement
– Dilation and Curettage
– Surgical Termination of Pregnancy
– Hysteroscopy
• Risk factors
– Pregnancy or Infection (Uterus is edematous)
– Postmenopausal (Uterus is fibrotic)
Page 79
Critical Care of Gynecologic
Patients
• Uterine Perforation
• If suspected:
– Blunt instrument/No negative pressure applied
• Conservative management
• Monitor for bleeding
– Sharp instrument/Negative pressure applied
• Exploratory laparoscopy/laparotomy
• Close inspection of nearby structures for damage
Page 80
Critical Care of Gynecologic
Patients
• Adnexal Torsion
• Risk factors
– Long ligaments (Infundibulopelvic, Uteroovarian)
– Adnexal Mass
– Absence of Uterine attachments
• Pain
– Unilateral
– Intermittent
• Treatment
– Reduction with fixation to Psoas muscle
– Resection if necrotic or postmenopausal
Page 81
Critical Care of Gynecologic
Patients
• Salpingo-oophoritis/Tubo-Ovarian Abscesses
• Risk Factors
– IUD use
– History of PID
• Diagnosis
– Radiographic (Transvaginal Ultrasound)
• Treatment
– Antibiotics
– Interventional Radiology
2.bp.blogspot.com/_fBQVVpFhTQs/
SsTC-TdKK3I/AAAAAAAAAy8/JeB– Surgical
• Bilateral Salpingo-oopherectomy
• Transvaginal Colpotomy Drainage
86DE8qc/s320/tuboovarianabscess.jpg
Page 82
Critical Care of the Obstetric Patient
• Complex patients
• Medical, Surgical, Trauma, Postpartum
• Physiologic Alterations
• Altered response to potential injuries/illness
• Management of specific injuries/processes
Page 83
travel.ciao.co.uk/Body_Worlds_4_Manchester__Review_5753139
References
• Fink MB, Abraham E, Vincent JL, Kochanek PM.
Textbook of Critical Care , Fifth Edition. Elsevier, 2005
• Mulholland MW, Lillemoe KD, Doherty GM, Maier RV,
Upchurch GR. Greenfield’s Surgery: Scientific
Principles & Practice, Fourth Edition. Lippincott Williams
& Wilkins, 2006
Page 84
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ajnoffthecharts.wordpress.com/2009/11/03/
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Page 85
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lker/shs1.jpg
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myhealth.ucsd.edu/library/healthguide/enus/support/topic.asp?hwid=zm2767
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•
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•
•
•
•
•
•
•
•
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www.beliefnet.com/healthandhealing/getcontent.aspx?cid=179661
www.biologie.uni-freiburg.de/data/bio1/varga/projects.htm
www.biomaterials.org/SIGS/Cardiovascular/Heart.htm
www.bodyworlds.com/en/media/picture_database/preview.html?id=12
www.3bscientific.co.th/obgyn/placenta-w10604,p_895_0_0_0_3376_image_full.html
www.cookmedical.com/wh/features/bakri_en_US/index_bakri.html
www.thedoctorstv.com/main/show_synopsis/207?section=synopsis
www.ed4nurses.com/heartsnd.aspx
www.ehow.com/how_5511869_heal-having-emergency-cesarean-section.html
www.jeffersonhospital.org/obgyn/fibroid_images/39weeks-2.jpg
www.ljmu.ac.uk/sportandexercisesciences/RISES/Health/82521.htm
Page 87
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•
•
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•
•
•
•
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