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
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