Chapter 50. Emergencies in pregnancy
Pregnancy should be considered in any woman of reproductive age. Not every woman will admit, or even realise, that she is pregnant. There are medical conditions and emergencies specific to the pregnant state as well as general emergencies such as asthma or epilepsy that can occur in any patient.
Vaginal bleeding and abdominal pain in early pregnancy
• Consider pregnancy in any woman of childbearing age
• If the LMP was more than 4 weeks prior to the current date, then the patient should be considered to be pregnant until proven otherwise
• Measure the pulse, blood pressure and respiratory rate to assess whether the patient is clinically hypovolaemic and if so, obtain IV access and administer fluids
• The most frequent cause of vaginal bleeding, with or without abdominal pain, early in pregnancy, is miscarriage
• The most dangerous cause of vaginal bleeding and abdominal pain is ectopic pregnancy and this should be considered in any woman of reproductive age complaining of abdominal pain, especially if this is associated with collapse.
Abdominal pain and vaginal bleeding in early pregnancy: think of miscarriage and ectopic pregnancy
Miscarriage
• Approximately 10–15% of confirmed pregnancies end in miscarriage
• This occurs most often at either 8 weeks or 12 weeks from the first day of the LMP
• Miscarriage may rarely cause significant uterine bleeding, resulting in hypovolaemic shock
• Avoid the term abortion as this may be misinterpreted by the parents:
1. Threatened miscarriage – vaginal bleeding with cramping abdominal pain, however the cervix remains closed and the pregnancy may continue
2. Incomplete miscarriage – vaginal bleeding may be heavy, the cervix is open and abdominal pain is caused by uterine contractions, which have begun to expel the products of conception
3. Complete miscarriage – products are completely expelled through an open cervix.
Management
• Gentle handling and reassurance are very important during the initial assessment
• Transfer to hospital for more detailed examination and management
• Manage hypovolaemia if present
• In hospital, the patient will likely have an ultrasound arranged to check the viability of the pregnancy.
Ectopic pregnancy
• Ectopic pregnancy is the most life-threatening of the early complications of pregnancy
• The incidence of ectopic pregnancy is approximately 1% of all pregnancies and is increasing. Ruptured ectopic pregnancies account for 13% of maternal deaths
• An ectopic pregnancy normally occurs in one or other of the fallopian tubes.
Symptoms and signs
• Most tubal ectopic pregnancies present 5–8 weeks after the LMP
• Pain is typically the first symptom, occurring in up to 95% of patients, and 75% complain of abnormal vaginal bleeding (such as ‘spotting’)
• The patient may present in a state of collapse secondary to hypovolaemic shock.
Management
• Manage shock aggressively with oxygen, two large-bore IV cannulae and fluid resuscitation
• Transfer rapidly to hospital as the definitive management is surgery.
Vaginal bleeding and abdominal pain in later pregnancy
Third-trimester vaginal bleeding (antepartum haemorrhage) is bleeding that occurs after 28 weeks of pregnancy. It occurs in approximately 4% of pregnancies. All patients require assessment in hospital.
Abdominal pain and vaginal bleeding in later pregnancy: think of placental abruption and placenta praevia
Placental abruption
• Placental abruption is the separation of a normally located placenta before delivery of the fetus. Bleeding occurs and the blood is initially confined between the placenta and the uterine wall
• There may be simply abdominal pain, however severe cases can present with painful vaginal bleeding associated with a tender, contracting uterus, shock and fetal compromise
• Give oxygen and manage shock with intravenous fluid resuscitation
• If the patient has deteriorating vital signs in transit, then appropriate warning to the receiving obstetric unit should be given enabling staff to prepare for urgent delivery of the baby.
Placenta praevia
• Placenta praevia occurs when the placenta is implanted in the lower uterine segment and subsequent separation will cause blood loss into the vagina
• Patients present with vaginal bleeding, which may be heavy, but may have little or no abdominal pain. The patient should be transferred urgently to hospital for full assessment
• Give oxygen and consider the need for IV fluids.
Eclampsia
• A degree of hypertension occurs in approximately 8% of pregnancies
• The most severe manifestation is eclampsia, in which a combination of hypertension, cerebral oedema, intracerebral haemorrhage and seizures
• Eclampsia results in the death of about 1000 babies and 10 women each year in the UK
• Patients usually have a known history of hypertension earlier in their pregnancy
• On examination, the patient may be fitting, will be hypertensive and will have peripheral oedema.
• Hypertension
• Cerebral oedema and haemorrhage
• Seizures
• Headaches
• Visual disturbance
• Weight gain and peripheral oedema
• Abdominal pain.
Management
• Urgent transfer to hospital is essential, since definitive treatment requires urgent delivery of the baby
• If there is fitting, the first priority is to establish an airway and administer oxygen. In a fitting patient the most practical means of achieving an airway may be the nasopharyngeal route
• Intravenous or rectal diazepam (10–20 mg) should be given in an attempt to terminate the seizures
• Alert the receiving unit that you are arriving with a pregnant patient with seizures.
Common general medical emergencies in pregnancy
Common sense and first principles apply and these are the same whether the patient is pregnant or not.
Asthma
The effect of pregnancy on asthma is variable. The majority of patients experience less frequent attacks, but a few experience more frequent attacks. Asthma has no effect on the course of pregnancy. The management of an acute exacerbation is the same as in a non-pregnant woman, with oxygen, nebulised salbutamol and transfer to hospital for assessment.
Epilepsy
Seizures may occur in pregnancy unrelated to hypertension, simply as a manifestation of pre-existing epilepsy. Treatment regimens may have been modified prior to or early in pregnancy, in order to avoid fetal damage, and control may have been lost. Management of seizures is conventional and consists of prevention of harm to the patient during a seizure, attention to the airway, administration of oxygen, diazepam if the fit is prolonged, and transfer to hospital.
Diabetes mellitus
When a diabetic woman becomes pregnant, close attention is required to maintain good control of the disease throughout the pregnancy. Hypoglycaemic and hyperglycaemic emergencies may occur and will be rapidly identified clinically using a glucose reagent strip. Standard protocols for control of hypoglycaemia should be followed (Hypostop gel, IV glucose, IM glucagon). Patients with hyperglycaemic emergencies should receive oxygen and fluid resuscitation with normal saline, and be transferred immediately to hospital.
For further information, see Ch. 51 in Emergency Care: A Textbook for Paramedics.
