Obstetric Emergencies PDF

Obstetric emergencies Nicole Wa s, Allison Cummins Essentials Modiﬁcations to basic and advanced basic life support approaches are appropriate for the pregnant woman in cardiac arrest because of the physiological changes that are present in pregnancy and the early postpartum period. One important modiﬁcation is the necessity to tilt or wedge a pregnant woman from a supine position during ambulance transfer and cardiopulmonary resuscitation. Maternal collapse may be caused by thromboembolism, haemorrhage, amniotic ﬂuid embolism, genital tract sepsis or preexisting cardiac disease. Breathlessness and tachycardia are keys to the diagnosis of pulmonary embolism. Ectopic pregnancy should be considered in all women of childbearing age who present to the emergency department with abdominal pain. Women with a headache severe enough to seek medical advice or with new epigastric pain should have their blood pressure taken and urine checked for protein. Sepsis is often insidious in onset with a fulminating course. The severity of illness should not be underestimated. Trauma in pregnancy can occur as a result of domestic violence. Domestic violence has immediate and long-term eﬀects on the woman and her baby. Amniotic ﬂuid embolism is a rare emergency, but carries a high risk of mortality. The usual scenario is that the woman experiences acute respiratory distress, then collapses, often after pushing in the second stage of labour or immediately after the birth of the baby. A perimortem caesarean section can save the life of both the mother and baby if undertaken in the ﬁrst 5 minutes after a cardiac arrest in the acute se ing. The collapse and resuscitation of a pregnant woman is very stressful and diﬃcult for the woman's family. They need accurate and timely information conveyed sensitively. Debrieﬁng for all staﬀ involved in obstetric emergencies should occur as soon as possible. Introduction For most women, pregnancy is a normal life event and most babies are born healthy without complications. Obstetric emergencies are fortunately rare; however, they can occur at home or in hospital se ings. In hospital, most of these women will be in maternity units (often a birthing unit); however, some women will present through the emergency department (ED) or be seen ﬁrst by paramedical personnel. Knowledge of the normal reproductive system and functions is necessary to care for women who have an obstetric emergency. This chapter will initially review the relevant anatomy and physiology in relation to the changes that occur during pregnancy and how these impact on emergency situations. This is followed by a description of the most acute of all obstetric emergencies, that is, a maternal collapse or cardiac arrest requiring cardiopulmonary resuscitation (CPR). This includes a discussion of the modiﬁcations that need to be made to CPR in pregnant or newly postpartum women and the requirements for a perimortem caesarean section. Caring for the family and the staﬀ and investigating and learning from critical events such as these are also addressed. Integral to providing care is obtaining informed consent from the woman where possible and the next of kin where the woman is unconscious. A description of caring for a woman and baby where birth is imminent precedes a description of the major obstetric emergencies that may be seen in women who are a ended to by paramedics, present to EDs or who are admi ed to intensive care units. Obstetric emergencies is a large topic and this chapter cannot cover them all in detail. Readers are advised to access other resources, including the midwifery textbook: Midwifery: Preparation for Practice, which has a chapter on life-threatening emergencies and covers a number of other obstetric emergencies in more depth.1 Obstetric emergencies The most recent UK Conﬁdential Enquiry into Maternal Deaths2 reported that early intervention by clinical staﬀ to immediately recognise and act on the signs and symptoms of life-threatening conditions for pregnant women saves lives. A recommendation from the previous conﬁdential enquiries into maternal deaths in the United Kingdom3 is the use of a modiﬁed early obstetric warning system. Observation and response charts for deteriorating patients have been introduced in Australia, with some states and territories having modiﬁed the charts for pregnant women.4 The UK Conﬁdential Enquiry into Maternal Deaths in 2011 found that 52 of the 350 women who died from direct, indirect or coincidental causes died in the ED.3 The majority of these women had either collapsed in the community and were already undergoing CPR on arrival or collapsed shortly afterwards. Of the women whose care was assessed in relation to ED practice, the main causes were: pulmonary embolism ectopic pregnancy intracerebral bleed sepsis road traﬃc accidents. The other signiﬁcant maternal conditions that may be seen in the prehospital, ED or other critical care se ings are newborn resuscitation, postpartum haemorrhage, eclampsia and amniotic ﬂuid embolism. As there are no similar data for Australian women who present through EDs, and many of the issues will be similar to the UK context, this information has been drawn upon throughout this chapter. In the most recent report on maternal deaths in Australia, there were 63 maternal deaths between 2012 and 2014, with the three most common causes being cardiovascular events, sepsis and obstetric haemorrhage.5 Anatomy and physiology From the onset of conception and throughout pregnancy, a woman's body undergoes many changes to allow her to accommodate and support her baby as it grows, and to prepare for birth and the postnatal period. These changes occur under the inﬂuences of the hormones of pregnancy and aim to maintain and develop the woman's pregnancy and the growing baby. These changes may also increase the risk factors for some women in emergency situations. A brief description of the main changes is presented in the next section. The section is based on a number of textbooks and reference material.6,7 In addition, the textbook Physiology in Childbearing8 provides a detailed description of the speciﬁc physiology and physiological changes. Influence of pregnancy hormones Oestrogen, progesterone, human chorionic gonadotrophin (hCG), human placental lactogen and relaxin are the main hormones of pregnancy, and they produce signiﬁcant physiological and anatomical changes during pregnancy. Progesterone and oestrogen, produced early in pregnancy by the corpus luteum, then by the placenta, work closely together for the maintenance of the pregnancy and adaptation of the mother's body in preparation for birth and breastfeeding. Human chorionic gonadotrophin is produced early in pregnancy as the placenta is developing and the chorionic villi embed into the uterine wall. Its main function is to maintain the corpus luteum during early pregnancy, allowing for continued secretion of oestrogen and progesterone to maintain the pregnancy, and to prevent the shedding of the endometrium, as usually occurs during the menstrual cycle. Human chorionic gonadotrophin also suppresses the maternal lymphocyte response to prevent the maternal immune system from rejecting the placenta. The hCG levels present in either urine or blood are used as indicators of pregnancy. The placenta produces human placental lactogen (also known as human chorionic somatomammotrophin). This hormone has the primary function of promoting fetal growth. It produces a degree of maternal insulin resistance, which then alters the maternal metabolism and use of protein, carbohydrate and fat. This process changes the availability of glucose, which may be metabolised by the growing baby. Relaxin is produced by the corpus luteum and then the placenta. It has some eﬀects—working with progesterone—in relaxing the uterus to inhibit uterine activity during pregnancy. It also aids in the relaxation of the ligaments within the woman's pelvis and softens the cervix during labour. Uterus Under the inﬂuence of oestrogen and progesterone the woman's uterus relaxes and grows to accommodate the growing baby. The non-pregnant uterus weighs approximately 70 g and has a volume capacity of approximately 10 mL. As a result of growth of the muscle ﬁbres and increased vascular supply, the uterus increases to a weight of 1000 g and a volume capacity of approximately 5000 mL by term. The increase in the size of the uterus and the growth of the baby produce changes in the anatomical location of the uterus. During early pregnancy, a woman's uterus is a pelvic organ; however, by the 12th week of pregnancy the uterus becomes an abdominal organ. At 20 weeks’ gestation, the top of the uterus (fundus) is at the umbilical region, and by 36 to 40 weeks is at the level of the xiphisternum. The blood supply to the uterus is approximately 500 to 700 mL each minute at term, which is a signiﬁcant contributing factor for haemorrhage being a leading cause of maternal death. The pregnant, or gravid, uterus poses the risk of compression of the inferior vena cava when the woman is lying supine. The inferior vena cava is compressed in the majority of pregnant women in the second trimester, and the compression may aﬀect the uterine artery blood ﬂow but not the fetal circulation. As pregnancy progresses into the third trimester the uterus grows and develops an upper and lower segment. The upper segment is the ideal region for the placenta to be located as it has three layers of muscle ﬁbres to anchor the placenta during pregnancy and to act as ligatures to the vessels of the placental site when the placenta separates at birth. The lower segment has two layers of muscle ﬁbres. If the placenta embeds in the lower region of the uterus it may ultimately be anchored in the lower segment closer to the cervix. Low-lying placentas have a risk of premature separation leading to an antepartum haemorrhage. There is also a greater chance of a postpartum haemorrhage because of reduced ligature eﬀects of the muscle layers of the lower segment. Cervix Under the eﬀects of oestrogen and progesterone the cervix has increased vascularity and secretory eﬀects. Early in pregnancy a mucous plug, called the operculum, develops in the cervix, which helps guard against ascending infection. Later in pregnancy there is a softening eﬀect to allow for dilation and subsequent birth of the baby. There is a change to the cervical cells, which leads to a risk of bleeding directly from the cervix if the cells are disrupted, for example, during sexual intercourse or a vaginal examination. Vagina Under the inﬂuence of oestrogen and progesterone, vaginal changes include increased vascularity, hypertrophy of the muscle and changes to the connective tissue, which allows for the passage of the baby at birth. Secretory changes create a more acid environment as a protective mechanism against infection; this may also lead to a white discharge called leucorrhoea, which is a normal discharge during pregnancy. Breasts During pregnancy, oestrogen and progesterone stimulate changes to the breasts by increasing blood supply and developing the glandular tissue and the duct system in preparation for lactation. The overall hormone eﬀects cause enlargement of the breasts, up to 5 cm and 1400 g in weight by term. Respiratory As the uterus enlarges and pushes up against the diaphragm and the unborn baby's need for oxygen supply and removal of carbon dioxide increases, respiratory changes occur to accommodate these demands. In addition, there is a slight ﬂaring of the ribs to cater for the physical changes within the abdomen and thoracic cavity. The woman's residual volume decreases because of the enlarging uterus. There is decreased airway resistance, an increase in tidal volume, the arterial partial y p pressure of oxygen increases up to 105 mmHg and the maternal sensitivity to CO2 is decreased to approximately 32 mmHg. The increased consumption of oxygen by the pregnant woman is necessary for the needs of the unborn baby. Cardiovascular and haematological changes As pregnancy progresses the vascular changes taking place within the uterus, cervix, vagina and breast tissue require an increase in circulating blood volume. Oestrogen and progesterone both have the eﬀect of promoting ﬂuid and electrolyte retention throughout pregnancy to meet these needs. Antidiuretic hormone and aldosterone also play a role in maintaining plasma volume. Physiological eﬀects include: an increase in plasma volume of approximately 45% by 32 weeks of pregnancy. The increase in blood volume predominantly supplies the uterus and helps to compensate for blood loss at birth through an auto-transfusion eﬀect as uterine blood ﬂow decreases and is shunted to the main circulation. vascular changes, which occur to allow for the increased blood volume. Metabolites of progesterone alter the response to the pressor action of angiotensin II, which leads to a vasodilatory eﬀect and is evident in normal pregnancy by a drop in blood pressure. The peak eﬀect is usually by 28 to 34 weeks of pregnancy. an increase in cardiac output by 30–40%. This is achieved through a slight increase in heart rate, an increase in stroke volume and a decrease in systemic vascular resistance. The heart muscle increases in size to meet the increasing workload and is also slightly displaced (turned to the left) as the uterus pushes up against the diaphragm. This may be represented by a left axis deviation on a 12-lead ECG. The woman's red blood cell count increases by approximately 25% to meet the increased metabolic demands; however, since the plasma volume increases at a greater rate the woman typically experiences a physiological anaemia. a decrease in anticoagulation components, and an increase in coagulation factors VII, VIII, IX and X; there is a slight increase in platelet numbers and an increased tendency for platelets to aggregate. The purpose is protective, to guard against haemorrhage; however, this does increase the risk of thromboembolism and pulmonary embolism, which is a leading cause of maternal mortality. Gastrointestinal tract The gastrointestinal tract plays a role in maintaining intravascular ﬂuid volume by decreasing motility and increasing absorption. This leads to a risk of constipation and the potential for mechanical obstruction. The woman's enlarging uterus also impinges on the gastrointestinal tract because her abdomen has to accommodate the bowel and gravid uterus. The stomach is displaced and emptying may be slowed due to increased intragastric pressures, which also increases the incidence of reﬂux. The growth of the uterus displaces the bowel and can aﬀect how a physical assessment is performed. Hepatic system The increased metabolic demands of pregnancy increase the woman's hepatic workload. There is an increase in the viscosity of bile and the residual volume in the gallbladder, which increases the incidence of gallstone formation. The delayed bile ﬂow can also result in mild jaundice and pruritus related to the deposits of bile salts in subcutaneous tissue—known as cholestasis of pregnancy. Renal system The increase in circulating volume leads to an increase in renal blood ﬂow and glomerular ﬁltration rate. The increase in glomerular ﬁltration rate reduces the ability of the renal tubules to reabsorb substances such as glucose, amino acids, folic acid and some minerals. Endocrine system During pregnancy the woman enters into a mild hyperthyroid state which increases her basal metabolic rate to meet the increased demands of pregnancy. The increase in cardiac output and heart rate, combined with the eﬀects of progesterone, causes vasodilation which accommodates the increased blood volume. The adrenal gland has some increase in function, in particular, increasing blood cortisol levels to meet the stressors of pregnancy and aldosterone to support the increased circulating volume. The pancreas increases the production of insulin; however, under the inﬂuence of human placental lactogen there is a decreased sensitivity to insulin, to allow for greater availability of glucose for the baby. The decreased sensitivity to insulin may also result in pregnancy-induced diabetes (gestational diabetes), which may pose risks to the woman and her unborn baby. Immune system During pregnancy there is a general depression of maternal immunity due to lymphocyte depressant factor and increased adrenal cortex activity. This is designed to prevent an immune response rejecting the baby which contains the father's ‘foreign’ DNA. Women who are Rhesusnegative and have a baby with Rhesus-positive blood are at risk of isoimmunisation, which occurs when fetal blood mixes with the maternal circulation and the mother develops antibodies to the positive Rhesus factor. Exposure may occur during miscarriage, amniotic ﬂuid sampling and placental abruption, or at delivery. Isoimmunisation is a complication for any subsequent pregnancies where the baby has a positive blood group as the mother's immune response is triggered to act against the fetal blood. Women who are Rhesus-negative should be given anti-D immunoglobulin within 72 hours of an actual or suspected exposure, to prevent isoimmunisation. Recognition of the sick woman One of the core skills of being a clinician is the recognition of a patient who is unwell. This is not the same as making a diagnosis. In fact, the two skills are often independent of each other. Recognition of the seriously ill pregnant or postpartum woman relies on taking a complete history (listening to the cues given by her or her family) and measurement and understanding of vital signs such as heart rate, respiratory rate, temperature and pulse oximetry. It is important to reﬂect on the stages of shock in recognising a woman who is unwell, as these basic skills will provide valuable information. It is also important to remember that pregnant women who are sick often remain looking well for longer than they would if they were not pregnant due to the physiological compensatory changes of pregnancy. Recognition of the sick woman does not depend on complex and timeconsuming tests. Recognition of illness needs to be taught to all clinicians who a end to pregnant women on a regular basis. It is also important to make this teaching multidisciplinary.9 In recognising the sick woman, Hulbert,9 an emergency doctor writing in the UK Conﬁdential Enquiry into Maternal Deaths, stated that: Tachycardia is without doubt the most significant clinical feature of an unwell patient and is regularly ignored or misunderstood. Measurements of respiratory rate and heart rate are infinitely more important than measurements of blood pressure. A normotensive patient may all too often be unwell and compensating. A tachycardic patient is hypovolaemic until proved otherwise. A patient with tachypnoea has a cardiorespiratory cause until proved otherwise. Attributing tachycardia and tachypnoea to anxiety is naïve and dangerous (p. 234).9 Maternal collapse The cardiorespiratory collapse of a pregnant or postpartum woman (known as a maternal collapse) is the most dramatic of the obstetric emergencies. Cardiac arrest complicates about 1 in 20,000 pregnancies, with a maternal survival rate of 58.9%.10 Women are more likely to survive such an event if it happens in an acute care se ing than in the community. All maternity care providers need to be adequately trained, with access to in-service education, such as emergency drill simulations to increase the survival rate for women suﬀering from maternal collapse.11,12 Fortunately, maternal collapse and/or cardiac arrest are rare events, but they have catastrophic consequences for mother and baby. The leading cause of direct maternal deaths for the triennium 2012–14 in Australia was thromboembolism, haemorrhage, followed by hypertensive disorders and sepsis.5 Unfortunately, the early warning signs of impending maternal collapse often go unrecognised and the early detection of severe illness in pregnant women remains a challenge to all involved in their care. The relative rarity of such events, combined with the normal changes in physiology associated with pregnancy and childbirth, compounds the problem.11 Practice tip The cardiovascular, respiratory and gastrointestinal changes that most aﬀect resuscitation include:6,7 Increased: plasma volume by 40 to 50% erythrocyte volume by only 20% cardiac output by 40% heart rate by 15–20 bpm clo ing factors sequestration of blood to the uterus—30% of cardiac output ﬂows to the uterus oxygen consumption by 20% tidal volume (progesterone-mediated) laryngeal angle and pharyngeal oedema Decreased: arterial blood pressure by 10–15 mmHg systemic vascular resistance colloid oncotic pressure (COP) and pulmonary capillary wedge pressure functional residual capacity by 25% gastric peristalsis and motility eﬀectiveness of the gastro-oesophageal (cardiac) sphincter of the stomach. The physiological changes of pregnancy alter the resuscitation of women who have a maternal collapse. These alterations need to be considered whether maternal collapse occurs in or out of hospital. The main physiological changes to consider are related to the respiratory and cardiovascular systems.13,14 In addition, in the supine position the pregnant uterus compresses the descending aorta and the inferior vena cava, reducing cardiac output, blood pressure and venous return. This explains the rationale for tilting the woman towards her left side during resuscitation. In pregnancy there is also a dilutional anaemia, which results in decreased oxygen-carrying capacity and increased CPR circulation demands. Pregnant women are also susceptible to thromboembolism. The respiratory changes mean that women are susceptible to a rapid decrease of PaO2 with respiratory alkalosis and there are often diﬃculties with intubation related to larangeal oedema which can occur in pregnancy. The gastrointestinal changes mean women have an increased risk of regurgitation and aspiration. Modifications of basic life support in maternal collapse Several modiﬁcations to basic life support (BLS) and advanced life support (ALS) approaches are appropriate for the pregnant woman in cardiac arrest because of the physiological changes that are present in pregnancy and the early postpartum period.14–16 Table 34.1 describes the modiﬁcations required. TABLE 34.1 Maternal cardiac arrest algorithm16 MATERNAL CARDIAC ARREST First responder Activate maternal cardiac arrest team Document time of onset of maternal cardiac arrest Place the patient supine Start chest compressions as per BLS, place hands slightly higher than usual Subsequent responders Maternal interventions Obstetric interventions for patient Treat per BLS and ACLS algorithm with an obvious gravid uterus* Do not delay deﬁbrillation Perform manual uterine displacement Give typical ACLS drugs and doses —displace uterus to the patient's left to Ventilate with 100% oxygen relieve aortocaval compression Monitor waveform capnography and CPR quality Remove both internal and external fetal Provide post-cardiac arrest care as appropriate monitors if present Maternal modiﬁcations Obstetric and neonatal teams should Start IV therapy with wide bore cannula above the level immediately prepare for possible emergency of the diaphragm caesarean section Assess for hypovolaemia and give ﬂuid bolus when If no return of spontaneous circulation required by 4 minutes of resuscitative eﬀorts, Anticipate diﬃcult airway; experienced staﬀ member consider performing emergency preferred for advanced airway placement caesarean section If patient receiving IV/intraosseous (IO) magnesium pre- Aim for delivery within 5 minutes of arrest, stop magnesium and give IV/IO calcium chloride onset of resuscitative eﬀorts 10 mL in 10% solution or calcium gluconate 30 mL in 10% solution Continue all maternal resuscitative interventions (CPR, positioning, deﬁbrillation, drugs, and ﬂuids) during and after caesarean section Search for and treat possible contributing factors Bleeding Embolism: coronary/pulmonary/amniotic ﬂuid embolism Anaesthetic complications Uterine atony Cardiac disease (myocardial infarction/ischaemia/aortic dissection/cardiomyopathy) Hypertension/pre-eclampsia/eclampsia Other: diﬀerential diagnosis of standard ACLS guidelines Placenta abruption/praevia Sepsis * An obvious gravid uterus is a uterus that is deemed clinically to be sufficiently large to cause aortocaval compression. The primary survey/assessment of a collapsed woman can be undertaken whether the woman is in hospital or in the community. Paramedics are often the front-line health professionals in these situations and need to consider the modiﬁcations of BLS required. It is essential that the pregnant woman is tilted using a wedge or IV ﬂuid bag under her right hip during ambulance transfer and CPR. Life-saving surgery—caesarean section A caesarean section is not only a last a empt to save the life of the baby, it is also an important intervention in the resuscitation of the woman in the acute care se ing.17–19 A caesarean section (known in this instance as a perimortem caesarean section) improves outcomes for both mother and baby where no possibility of survival would exist in a non-perfused uterus.14 It is recommended that perimortem caesarean section be undertaken early in the resuscitation a empt (within 4 minutes of maternal collapse if there is no response to CPR), and that equipment to facilitate this should be available on the emergency trolleys, especially in labour wards and EDs (Box 34.1).17,20 Box 34.1 Equipment for perimortem caesarean 2 0 Antiseptic solution Sterile gloves No. 10 scalpel blade Bandage (blunt end) scissors Absorbable suture Haemostats Cord clamps Towels Sterile sponges Laryngoscope with straight blades, no. 0 (preterm) and no. 1 (term) Suction catheters (5F to 14F) Neonatal endotracheal tubes (2.5-, 3.0-, 3.5- and 4.0-mm internal diameter) CO2 detector Neonatal Ambu bag Newborn and premature-size face masks Oxygen source Neonatal incubator/warmer Cardiorespiratory monitor for mother and neonate, including pulse oximetry Delivery should be achieved within 5 minutes of collapse Practice tip Perimortem caesarean section is indicated when: personnel with appropriate skill and equipment to perform the procedure are available the woman fails to respond with a return of spontaneous circulation within 4 minutes the fundus is palpable above the umbilicus, as the main aim is maternal survival appropriate facilities and personnel are available to care for the woman and baby after the procedure. It would be unusual for a perimortem caesarean section to be conducted in the community by paramedic staﬀ as it is unlikely that they would have the appropriate skill and/or equipment or have on hand the facilities and personnel to care for the woman and baby after the procedure. Survival rates for the woman and her baby are improved when perimortem caesarean section is performed within 5 minutes of ineﬀective maternal circulation. It may still be worthwhile to undertake a caesarean section after this period as fetal mortality is 100% if no action is taken. Some infants have survived perimortem caesarean section up to 20 minutes after maternal death.21 Perimortem caesarean section also increases the chance of the woman's survival. Without caesarean section, fewer than 10% of women suﬀering in-hospital cardiac arrest will survive to hospital discharge. With a caesarean section, maternal survival increases because removal of the baby results in an improvement in maternal circulation during CPR.14,20 A study from the Netherlands reported a maternal case fatality rate of 83% and a neonatal case fatality rate of 58% in 55 women over a 15-year period.18 The authors highlighted that none of the women had the caesarean section undertaken within the recommended 5 minutes after starting resuscitation and if this had been done the outcomes may have improved. Caring for the family The collapse and subsequent resuscitation of a pregnant woman is likely to be a very stressful and diﬃcult time for the woman's family. Serious illness or death during pregnancy or early in the postnatal period is usually the furthest thing from any family's mind. They are likely to be shocked and express disbelief at what is happening. Particular a ention needs to be paid to the woman's partner or support people who may be with her. It is likely that they will be very distressed with the situation and the resuscitation eﬀorts that are occurring. One of the healthcare team needs to take responsibility to care for the partner and any other family or support people who are present. This may include staying with them in the room while the resuscitation takes place, but it may be that not being present is best. The partner and support people need accurate and timely information and this needs to be conveyed sensitively. Caring for the staff A cardiac arrest or a major collapse of a pregnant woman can also be distressing for health professionals. Pregnancy is usually surrounded with positive feelings and happiness. The collapse of a pregnant woman, which may result in one or two deaths (mother and/or baby), is one of the hardest things that health staﬀ will have to cope with. Debrieﬁng for all staﬀ involved in the event should occur as soon as possible. Often a group discussion works well in these situations where each person has a chance to talk about their experience. Often a person who was not directly involved in the event should facilitate such a group meeting as they will be more objective and can ensure the discussion remains safe and supportive. It is essential that this is undertaken in a safe and supported environment and elements of blame and recriminations are not part of this process. It is important to ensure that staﬀ members are supported in their own shock and sadness and have the opportunity to reﬂect upon the event and the care provided. This is also an opportunity to reﬂect on the systems and assess which ones worked well and how things could be improved in the future if such an event happened again. Investigating and reflecting A maternal collapse, and certainly a cardiac arrest in a pregnant or postpartum woman, would be considered a serious adverse event. If the woman dies, it would be classiﬁed as a maternal death. Maternal deaths are deﬁned as: … the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.22 Maternal deaths are a sentinel event.23 In most jurisdictions in Australia and in New Zealand, maternal deaths require statutory reporting to the relevant health department. Such an event would also be classiﬁed in the risk management systems as one of the most severe adverse events, for example, given a Severity Assessment Code of 1 (SAC 1). Events assessed as being a SAC 1 will usually be subject to a Root Cause Analysis to determine what the root causes of the event were and whether any changes need to be made, particularly to the systems and processes, to reduce the chance of this recurring in the future.24–28 Summary of management A number of key points should be remembered when confronted with a pregnant woman who has a cardiorespiratory collapse and requires resuscitation. These are summarised in the box below. The immediate modiﬁcations to BLS are relevant to paramedic and hospital-based staﬀ. Practice tips Key points if a pregnant woman has a cardiorespiratory collapse and requires resuscitation: Particular a ention should be paid to minimising vascular compression caused by the pregnant uterus and to early advanced airway intervention. Early involvement of an obstetrician, midwife, neo-natologist and neonatal nurse is crucial when dealing with a pregnant woman who collapses or has a cardiopulmonary arrest. Perimortem caesarean section may have to be undertaken early ( 95%) and intravenous heparin, and should be transferred to a hospital that has a maternal–fetal, neonatal and cardiothoracic unit for high-risk patients. In women with complicated venous thromboembolus, who are haemodynamically stable, a temporary vena caval ﬁlter can be placed once the diagnosis has been conﬁrmed. As soon as the woman goes into active labour or a caesarean section is considered, the heparin should be stopped (and eﬀect reversed with protamine if necessary). A caesarean section should not be performed while the woman is in a fully anticoagulated state; this can lead to uncontrolled bleeding and an increased risk of severe morbidity or mortality.56 Ectopic pregnancy Many of the women who come into the ED with symptoms from ectopic pregnancy do not know or volunteer that they are pregnant and may not have a pregnancy test done as a routine test. Ectopic pregnancy should be considered in all women of childbearing age who present with these symptoms, regardless of contraceptive usage. Symptoms of an ectopic pregnancy include lower abdominal unilateral pain, light vaginal bleeding following a period of amenorrhoea, shoulder tip pain and, ﬁnally, shock.57 Women may also present with less speciﬁc symptoms, including generalised abdominal pain and sometimes diarrhoea and vomiting. A negative pregnancy test can exclude ectopic pregnancy as a potential diagnosis in 99% of presentations; there have been reports of negative beta-hCG and ectopic pregnancy.58 Early and accurate diagnosis of ectopic pregnancy can be challenging, partly because cases present infrequently (1 in 100 pregnancies), but mainly because their presentation may not be classical. The triad of symptoms described in textbooks of emergency medicine are bleeding, abdominal pain and dysmenorrhoea, but many of the women who died, as well as some who survived, presented with non-speciﬁc symptoms and did not undergo a pregnancy test in the ED.51 Diagnosis As explained above, women may present to paramedics or EDs with atypical signs of ectopic pregnancy. Ectopic pregnancy is often associated with diarrhoea and vomiting and may mimic gastrointestinal disease. Fainting in early pregnancy may also indicate an ectopic pregnancy. There must be a low threshold for beta-hCG testing in women of reproductive age a ending the ED with abdominal symptoms. A common practice in many departments is to undertake blood (serum) beta-hCG testing in all women of reproductive age who a end an ED with abdominal symptoms. In addition, it is recommended that pregnant women with abdominal pain should be reviewed by obstetrics and gynaecology staﬀ, if available, or at least discussed with a specialist doctor by telephone.51 Practice tip Ectopic pregnancy should be considered in all women of childbearing age who present with abdominal pain to paramedics or EDs. Undertake serum beta-hCG testing in all women of reproductive age who a end an ED with abdominal symptoms. The diagnosis is made using beta-hCG measurements and transvaginal ultrasound.59 Consultation and referral with an obstetrician and gynaecologist should occur as soon as possible to discuss ongoing management. For women who are suspected of a ruptured ectopic the following should occur:60 IV access Full blood count, blood type and Rhesus factor Group and hold or crossmatch. As best practice, women with a diagnosed ectopic or ruptured ectopic who are Rhesus-negative should be given anti-D immunoglobulin, to prevent isoimmunisation.59,61 Management The most critical step in beginning the management is to have a high clinical suspicion for ectopic pregnancy (for example, in any woman of childbearing age). After a positive blood pregnancy test, any necessary initial resuscitation and physical examination (including pelvic examination to rule out an open cervical os or completed miscarriage), a transabdominal pelvic ultrasonography, followed by a transvaginal ultrasonography if needed, should be performed to identify a deﬁnitive intrauterine pregnancy (yolk sac or fetal pole) or deﬁnitive ectopic pregnancy (extra-uterine yolk sac or fetal pole).59,60 Consultation with, and referral to, an obstetric specialist is essential in the eﬀective management of women with a suspected ectopic pregnancy. Management options include surgical and medical approaches depending on the gestation of the pregnancy and the haemodynamic status of the woman. The current standard medical treatment of an unruptured ectopic pregnancy is methotrexate therapy.62 The decision for the type of management should be case-speciﬁc and should be made in conjunction with, if not by, a consulting obstetrician because there are a number of contraindications and cautions.63 Practice tip A ruptured ectopic pregnancy is a medical emergency and needs to be managed urgently. Women may present with hypovolaemic shock secondary to blood loss and require urgent management to address their haemodynamic status. The insertion of two large bore intravenous cannulas and vigorous ﬂuid resuscitation is essential. It is important to remember that women with an ectopic pregnancy are essentially losing their pregnancy, much like a miscarriage.64 Losing a pregnancy may be seen as actually losing a baby, with all the hopes and dreams that come with this to the great majority of women, and it is likely that this will be accompanied by emotional shock, sadness and questions about this pregnancy and the future options. It is essential that the loss of this pregnancy is acknowledged and women are cared for in a sensitive manner and provided with emotional support and the amount of information they feel ready to take in at the time. Private space and time and ensuring the woman can be with her partner are also important considerations and strategies. Intracerebral haemorrhage Intracerebral haemorrhage (also known as intracranial haemorrhage) in pregnancy is associated with pre-eclampsia and hypertension.65 In the UK's 2016 report on maternal mortality,2 intracerebral haemorrhage related to inadequate surveillance and failure of eﬀective antihypertensive therapy were a common source of substandard care. In the report, seven women died from intracerebral haemorrhage. In addition, it is recommended that all pregnant women presenting with new and potentially serious neurological symptoms be seen promptly by a specialist doctor. Neurological symptoms late in pregnancy mandate an urgent review and cerebral imaging.2 Diagnosis Clinicians who work in EDs will be familiar with the means of diagnosis of an intracerebral haemorrhage and the subsequent management of people with this condition. Intracerebral haemorrhage is covered in Chapter 23. Paramedics may also see women with severe headaches in pregnancy or in the early postpartum period and may be the ﬁrst healthcare professionals to be aware of possible diagnoses. It is important to remember that severe headaches in pregnancy or in the early postpartum period can be indicative of intracerebral bleeding, despite it being a rare event. The following is a typical case that has direct relevance to paramedics and nurses in ED se ings: After a normal pregnancy and birth, a woman developed a severe headache with new onset hypertension early in her postnatal period. Her headache was not relieved by analgesics and was described as very severe. The midwife reassured the mother but she still had a very painful headache 2 days later: no action was taken. Her midwife had planned to review her again 4 days later but, before that, she was admitted to the Emergency Department (ED) with a fatal subarachnoid haemorrhage.66 Management Women with a headache severe enough to seek medical advice or with new epigastric pain should have their blood pressure taken and urine checked for protein as a minimum. For the most part, this will occur in the acute care se ing. Women with severe, incapacitating headaches described as the worst they have ever had should have an emergency neurological referral for brain imaging in the absence of other signs of pre-eclampsia. The threshold for same-day referral to an obstetrician is hypertension ≥ 140 y yp mmHg systolic and/or ≥ 90 mmHg diastolic and/or proteinuria ≥ 1+ on dipstick. The systolic blood pressure is as signiﬁcant as the diastolic. It is important to note that automated blood-pressure machines can seriously underestimate blood pressure in pre-eclampsia. Blood-pressure values should be compared with those obtained by manual auscultation.67 Eclampsia Eclampsia (seizures) complicates 1 in 1200 cases of pre-eclampsia in Australia.67 Eclampsia and pre-eclampsia are two of the leading causes of maternal death in the UK and in Australia.2,5,66 Seizures may occur antenatally, intrapartum or postnatally, usually within 24 hours of the birth of the baby, but occasionally later. Hypertension and proteinuria may be absent prior to the seizure and not all women will have warning symptoms such as headache, visual disturbances or epigastric pain. There are no reliable clinical markers to predict eclampsia. In fact, the presence of neurological symptoms and/or signs is rarely associated with seizures.2,67 Pre-eclampsia generally occurs before eclampsia. Pre-eclampsia is a multi-system disorder unique to human pregnancy and characterised by hypertension and involvement of one or more other organ systems and/or the unborn baby. Raised blood pressure is commonly, but not always, the ﬁrst manifestation. Proteinuria is the most commonly recognised additional feature after hypertension, but should not be considered mandatory to make the clinical diagnosis. Practice tip Hypertension in pregnancy is deﬁned as:67 systolic blood pressure greater than or equal to 140 mmHg and/or diastolic blood pressure greater than or equal to 90 mmHg (Korotkoﬀ 5). These measurements should be conﬁrmed by repeated readings over several hours in the acute care se ing. Severe hypertension in pregnancy is deﬁned as a systolic blood pressure greater than or equal to 170 mmHg and/or diastolic blood pressure greater than or equal to 110 mmHg.67 A diagnosis of pre-eclampsia can be made when hypertension occurs after 20 weeks gestation and is accompanied by one or more of the following: 1. Renal involvement Signiﬁcant proteinuria—dipstick proteinuria subsequently conﬁrmed by spot urine protein/creatinine ratio ≥ 30 mg/mmol Serum or plasma creatinine > 90 micromol/L Oliguria 2. Haematological involvement Thrombocytopenia Haemolysis Disseminated intravascular coagulation 3. Liver involvement Raised serum transaminases Severe epigastric or right upper quadrant pain 4. Neurological involvement Convulsions (eclampsia) Hyperreﬂexia with sustained clonus Severe headache Persistent visual disturbances (photopsia, scotomata, cortical blindness, retinal vasospasm) Stroke 5. Pulmonary oedema 6. Fetal growth restriction 7. Placental abruption.67 The HELLP syndrome (Haemolysis, Elevated Liver enzymes and a Low Platelet count) represents a particular presentation of severe preeclampsia, and separating it as a distinct disorder is not helpful. The guidelines from the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) provide more detail on the diagnosis of women with severe pre-eclampsia.67 Diagnosis The diagnosis of pre-eclampsia is made on the basis of the level of hypertension in pregnancy and the presence of the other factors outlined above. Most commonly, women present with hypertension and proteinuria, although other renal, haematological, hepatic or neurological manifestations may occur. Consistency in the terminology used to describe and deﬁne hypertension in pregnancy, pre-eclampsia and eclampsia is part of making a correct diagnosis. In the past, many diﬀerent terms have been used to describe the condition, which has at times made consistent diagnosis and management more diﬃcult. Diagnosing a seizure as eclampsia is often a process of exclusion of other diagnoses. Most often, the diagnosis of eclampsia is made in the acute care se ing, even if women have the seizure outside of hospital. The further from the birth of the baby that the seizure occurs, the more carefully other diagnoses should be considered. For example, cerebral venous thrombosis may occur in the ﬁrst few days of the postpartum period and can present with seizure activity. It should be remembered that eclampsia is not the most common cause of seizures in pregnancy and the diﬀerential diagnosis includes epilepsy and other medical problems that must be considered carefully, particularly when typical features of severe pre-eclampsia are lacking.67 Practice tip The diﬀerential diagnoses of seizures in pregnancy include: primary generalised epilepsy subarachnoid haemorrhage hypoglycaemia thrombotic thrombocytopenic purpura amniotic ﬂuid embolism central venous sinus thrombosis water intoxication phaeochromocytoma local anaesthetic toxicity (e.g. epidural) overdose (e.g. tricyclic antidepressants).66 Management Guidelines from SOMANZ67 and the National Institute of Clinical Excellence (NICE)68 provide comprehensive information to guide the management of women with hypertensive disorders of pregnancy. It is recommended that these are used to guide eﬀective management and interventions. In particular, prompt treatment of severe hypertension (systolic blood pressure of 170 mmHg or higher, or a diastolic blood pressure of 110 mmHg or higher) or seizures is mandatory. The presence of severe hypertension, headache, epigastric pain or nausea and vomiting are ominous signs which should lead to urgent admission and management according to the SOMANZ Guidelines,67 as should any concern about fetal wellbeing. The emergency management of eclampsia is outlined in Box 34.2. In the out-of-hospital se ing the important management strategies include the ﬁrst aid management of a seizure.69 These include keeping the woman in a safe environment, removed from danger; avoiding restraining her; placing her in the left lateral position as soon as possible; and supporting her in the immediate postictal phase. Most eclamptic seizures are self-limiting and once they are over the woman can be transported to an acute care se ing. Box 34.2 Management of eclampsia 6 7 Comprehensive protocols for the management of eclampsia (and severe hypertension) should be available in all appropriate areas. There are four main aspects to care of the woman who sustains eclampsia. Resuscitation These seizures are usually self-limiting. Resuscitation requires assuring a patent airway, oxygen by mask and institution of intravenous access. Intravenous diazepam (2 mg/min to maximum of 10 mg) or clonazepam (1–2 mg over 2–5 minutes) may be given while the magnesium sulphate is being prepared if the seizure is prolonged. Prevention of further seizures Following appropriate resuscitation, treatment should be commenced with magnesium sulphate given as a 4 g loading dose (diluted in normal saline over 1–20 minutes), followed by an infusion of 1–2 g/hr, diluted in normal saline. Pre-diluted magnesium sulphate should be available in all appropriate areas for this purpose (4 g/100 mL normal saline). In the event of a further seizure, a further 2–4 g of magnesium sulphate is given IV over 10 minutes. Magnesium sulphate is usually given as an intravenous loading dose, although the intramuscular route is equally eﬀective. Monitoring should include blood pressure, respiratory rate, urine output, oxygen saturation and deep tendon reﬂexes. Magnesium sulphate by infusion should continue for 24 hours after the last ﬁt. Serum magnesium levels do not need to be measured routinely unless renal function is compromised. Magnesium sulphate is excreted via the kidneys and extreme caution should be used in women with oliguria or renal impairment. Serum magnesium concentration should be closely monitored in this situation. Magnesium is not universally successful and the recurrence rate of seizures despite appropriate magnesium therapy is 10–15%. Control of hypertension Control of severe hypertension to levels below 160/100 mmHg is essential as the threshold for further seizures is lowered after eclampsia, likely in association with vasogenic brain edema. In addition, the danger of cerebral haemorrhage is real. Delivery Arrangements for delivery should be decided once the woman's condition is stable. In the meantime, close fetal monitoring should be maintained. There is no role, with currently available treatment, for continuation of pregnancy once eclampsia has occurred, even though many women may appear to be stable after control of the situation has been achieved. Prevention of eclampsia in the woman with preeclampsia The drug of choice for the prevention of eclampsia is magnesium sulphate, given as a 4 g loading dose (diluted in normal saline), followed by an infusion of 1 g/hour. Although there is good evidence for the eﬃcacy of this therapy, the case for its routine administration in women with preeclampsia in countries with low maternal and perinatal mortality rates is less than compelling. In some units, the presence of symptoms or signs, such as persistent headache, hypereﬂexia with clonus, evidence of liver involvement or severe hypertension, are considered indications for prophylaxis with magnesium sulphate, although these symptoms have poor positive and negative predictability for eclampsia. It is appropriate for individual units to determine their own protocols and monitor outcomes. Sepsis Genital tract sepsis is a major cause of morbidity and mortality in pregnant and postpartum women.2,70 Severe sepsis with acute organ dysfunction has a 20–40% mortality rate.71 Sepsis can occur in early and late pregnancy and is also commonly seen in the postpartum period. There have been reported deaths in early pregnancy often related to miscarriage or a termination of pregnancy and in later pregnancy related to the presence of a cervical suture. Infection should be suspected for women who present with pyrexia, persistent bleeding or abdominal pain, following recent miscarriage or termination of pregnancy.3 An example of sepsis in early pregnancy in Box 34.3 is taken from the report into maternal deaths from the United Kingdom. This case has speciﬁc resonance for those who work in EDs. Box 34.3 A case of a woman with sepsis in pregnancy who presented to an ED 3 A woman in mid-pregnancy called an out-of-hours general practitioner (GP) as she was feverish, shivery and unwell and had a sore throat, but was diagnosed as having a probable viral infection. A few hours later the GP visited again as she had developed constant abdominal pain associated with vomiting, greenish black diarrhoea and reduced fetal movements, but no vaginal bleeding. The GP suspected placental abruption, and, although she was rapidly transferred to hospital, on admission she was critically ill with marked tachycardia, breathlessness, cyanosis and confusion. The correct diagnosis of septic shock was quickly recognised, ﬂuid resuscitation was started, senior consultants were called, advice was sought from haematology and microbiology consultants and appropriate intravenous antibiotics were commenced immediately. Despite intensive life support she died a few hours after admission to hospital. Sepsis after the birth of the baby is often related to retained products of conception (fragments of placenta or membranes retained after the birth) or postoperative infections following caesarean section. As the caesarean section (CS) rate in many countries continues to rise (in 2015, the CS rate in Australia was 33%, with wide variations across states and territories and between public and private services, while in New Zealand it was 25.5%),72,73 more women may potentially be at risk of infection postcaesarean section. In addition, as the hospital length-of-stay decreases in many places, more women will develop their infections outside of hospital and therefore present more readily to EDs. Genital tract sepsis related to pregnancy or childbirth can occur up to 6 weeks after the birth of the baby. Sepsis can result in septic shock, which is addressed in Chapter 27. Pregnant women who present with a sore throat should have a throat swab collected as the cause may be community-acquired Streptococcal group A and there should be a low threshold for antibiotics.3 Deaths from sepsis, including group A Streptococcus, have increased over the last 10 years. Women who have died have had children with sore throats, suggesting the infection was contracted from family members.70 Practice tip Other risk factors for genital tract sepsis include: obesity; impaired glucose tolerance/diabetes; impaired immunity; anaemia; vaginal discharge; history of pelvic infection; history of Group B Streptococcal infection; amniocentesis, and other invasive intrauterine procedures; insertion of a cervical suture; prolonged ruptured membranes (during pregnancy); vaginal trauma during birth; caesarean section; wound haematoma; and retained products of conception, either after a miscarriage or after the birth.70 Diagnosis Sepsis is often insidious in onset with a fulminating course. The severity of illness should not be underestimated.70,74 Many pregnant women will maintain their haemodynamic status, often appearing deceptively well until they suddenly deteriorate and collapse. In later pregnancy, sepsis should be considered as a diﬀerential diagnosis when a woman presents with symptoms suggestive of placental abruption. Disseminated intravascular coagulation and uterine atony are common in genital tract sepsis and often cause life-threatening postpartum haemorrhage. Treatment, including facilitating the birth of the baby, should not be delayed once septicaemia has developed, because deterioration into septic shock can be extremely rapid.70 The most common pathogens found to cause severe maternal morbidity or mortality are Group A-beta-haemolytic Streptococcus (GAS) pyogenes, Escherichia coli and Group B streptococcus.70 The signs and symptoms of genital tract sepsis are often non-speciﬁc and unless genital tract sepsis is speciﬁcally considered in the diﬀerential diagnosis it may be missed until too late. The signs and symptoms are detailed in Box 34.4. Box 34.4 Back to basics—sepsis 5 3 Associated red ﬂag signs and symptoms that should prompt urgent referral for hospital assessment, and, if the woman appears seriously unwell, by emergency ambulance: Pyrexia >38°C Sustained tachycardia >100 bpm Breathlessness (RR > 20; a serious symptom) Abdominal or chest pain Diarrhoea and/or vomiting Reduced or absent fetal movements, or absent fetal heartbeat Spontaneous rupture of membranes or signiﬁcant vaginal discharge Uterine or renal angle pain and tenderness The woman is generally unwell or seems unduly anxious, distressed or panicky. A normal temperature does not exclude sepsis; paracetamol and other analgesics may mask pyrexia, and this should be taken into account when assessing women who are unwell. Infection must also be suspected and actively ruled out when a woman who has recently given birth has persistent vaginal bleeding and abdominal pain. If there is any concern, the woman must be referred back to the maternity unit as soon as possible, certainly within 24 hours. Management In many cases of maternal mortality due to genital tract sepsis, there is a failure or delay in diagnosing sepsis, a failure to appreciate the severity of the woman's condition with resultant delays in referral to hospital, delays in administration of appropriate antibiotic treatment and late or no involvement of senior medical staﬀ. It is essential that treatment is instigated promptly, within the ‘golden hour’, as once septicaemia develops the woman's clinical condition may deteriorate very rapidly,70 resulting in her death. The woman's risk of death can increase by 8% for each hour delay in commencing IV antibiotics.75 Women who present to out-of-hospital care providers with signs indicative of sepsis should be assessed and emergency management commenced before transfer to an acute care se ing. Usual measures in the management of sepsis or septic shock should be commenced by paramedics, including intravenous cannulation, intravenous ﬂuid replacement to maintain pulse and BP and transport to an appropriate centre. If pelvic sepsis is suspected, prompt early treatment with a combination of high-dose broad-spectrum intravenous antibiotics is required. Time may be lost by waiting for microbiology results, although these results should be obtained as soon as possible. Figure 34.9 details immediate management of a woman who presents with suspected sepsis; this can be enacted by both paramedics and nurses in the ED. FIGURE 34.9 Assessment and management of sepsis in pregnancy.75 Practice tip The expert advice of a consultant microbiologist and an obstetrician should be sought at an early stage. The source of sepsis should be sought and dealt with if possible and appropriate. Amniotic fluid embolism Amniotic ﬂuid embolism (AFE) is a rare obstetric emergency that carries a high risk of mortality, with reported mortality rates ranging from 11% to 44%.76 The best available evidence for the overall mortality rate of women with an AFE is 1 in 5.76 AFE is unpredictable, often occurring without warning and it is rapidly progressive. It occurs in about 1.9 : 100,000 to 7.7: 100,000 pregnancies.77 Amniotic ﬂuid embolism as the cause of maternal death in the most recent maternal death reports for Australia, NZ and the UK show varying rates. In New Zealand AFE was the leading cause of deaths directly related to pregnancy,78 while in the UK it was the second leading cause.2 In Australia, it accounted for 3.2% of deaths directly related to pregnancy,5 signiﬁcantly less than in the previous report of 2015 when AFE was the leading cause.79 The reason for this is not clearly known, but the reduced mortality may be due to improved approaches in recognition and resuscitation when the collapse occurs.3 The pathophysiology and initiating event is unclear; however, usually during labour or other procedure, amniotic ﬂuid and debris, or some as yet unidentiﬁed substance, enters the maternal circulation. This seems to trigger either a massive anaphylactic reaction, or an activation of the complement system cascade, or both. Progression usually occurs in two phases. Initially, pulmonary artery vasospasm with pulmonary hypertension and elevated right ventricular pressure cause hypoxia. Hypoxia causes myocardial capillary damage and pulmonary capillary damage, left heart failure and acute respiratory distress syndrome. Women who survive these events may enter the next phase. This is a haemorrhagic phase characterised by massive haemorrhage with uterine atony and disseminated intravascular coagulation (DIC). In some cases, fatal consumptive coagulopathy may be the initial presentation. The usual clinical scenario is that the woman experiences acute respiratory distress, then collapses often after pushing or immediately after the birth of the baby.80 Prodromal symptoms include breathlessness, chest pain, agitation, anxiety, confusion, seizures, chills and hypotension.81 The presentation of amniotic ﬂuid embolism can often be confused with other presentations; nevertheless, prompt eﬀective resuscitation is essential despite the underlying cause.2 Diagnosis Currently no deﬁnitive diagnostic test exists for amniotic ﬂuid embolism and often the diagnosis is only made at post-mortem examination. The diagnosis is often made by exclusion and any pregnant or newly postpartum woman who shows signs associated with pulmonary embolus, septic shock, acute myocardial infarction, cardiomyopathy, anaphylaxis, cardiorespiratory collapse or intractable haemorrhage must be systematically evaluated to exclude a diagnosis of amniotic ﬂuid embolism. The common features of AFE are: 1. acute hypotension, dysrhythmia or cardiac arrest 2. acute hypoxia and respiratory failure 3. coagulopathy or severe haemorrhage in the absence of other explanations 4. all of the above occurring during labour, caesarean section, dilation and evacuation of the uterus, or within 30 minutes postpartum with no other explanation of ﬁndings.82 Practice tip The laboratory investigations to exclude amniotic ﬂuid embolism in the acute care se ing include:83 full blood count with platelets coagulation parameters (prothrombin time, activated partial thromboplastin time, ﬁbrinogen) arterial blood gases chest X-ray ECG echocardiogram. Management The management of a woman with suspected amniotic ﬂuid embolism depends on her signs and symptoms. The primary goals of management are to provide oxygen, maintain cardiac output and organ perfusion, correct coagulopathy and provide supportive therapies.83 In the out-ofhospital se ing, supportive management should occur, including oxygen therapy and intravenous ﬂuids with urgent transport to hospital. The management in the acute care se ing is essentially: administer oxygen to maintain normal saturation; intubate and ventilate if necessary. initiate CPR if the woman arrests. If she does not respond to resuscitation, perform a perimortem caesarean section. treat hypotension with crystalloid ﬂuids, blood products and inotropes. consider pulmonary artery catheterisation in women who are haemodynamically unstable. continuously monitor the fetus. treat coagulopathy and thrombocytopenia using fresh frozen plasma, cryoprecipitate and platelet or whole-blood transfusion as appropriate.82 Women with symptoms suspicious of amniotic ﬂuid embolism should be transferred to an intensive care unit as soon possible. Major trauma from motor vehicle crashes or violence Although serious trauma during pregnancy is uncommon, it remains a major cause of maternal and fetal death and presents a variety of challenges because of the physiological changes due to pregnancy and because there are two people involved—mother and unborn baby.84 Major trauma in pregnancy has the potential for signiﬁcant maternal and fetal morbidity and mortality.83–86 Trauma in pregnancy is the leading non-obstetric cause of maternal and fetal injury and death.3,87 A study in the United States found that motor vehicle crashes (MVC) during pregnancy was a signiﬁcant cause of maternal morbidity, preterm birth and stillbirth.88,89 A study looking at the use of restraints for pregnant women involved in motor vehicle crashes found that unrestrained women were more likely to need non-obstetric surgery, suﬀer an abruption or fetal death.90 Women should be advised to wear a threepoint seat belt, adjusted to ﬁt well, with the lap strap placed beneath the pregnant abdomen and the diagonal strap above the abdomen and between the breasts.3,91 Unfortunately, Australian and New Zealand data on major trauma from MVC or violence during pregnancy is diﬃcult to obtain. The most recent Australian Maternal Mortality Report (2012–15)5 reported two deaths from MVC and 1 homicide. The New Zealand Maternal Mortality Report (2006–15) does not report trauma and mortality.78 The Australian deaths were classiﬁed as ‘incidental’ and, as such, were seen as being outside the scope of the report and not discussed further. Trauma in pregnancy can also occur as a result of domestic violence. Domestic violence in pregnancy is a signiﬁcant issue, as there are immediate and long-term eﬀects on both the woman and her baby.72,73 The prevalence of domestic violence varies depending on the context, population and measurement instruments. Reports vary regarding incidence, but the rates of women who experience domestic violence in pregnancy are generally reported as 3%–9%.92–94 A study conducted in antenatal clinics in the UK reported prevalence rates of 2% at booking, 6% at 34 weeks of pregnancy and 5% at 10 days postpartum.95 Domestic violence in pregnancy can have catastrophic eﬀects in relation to major trauma and death.3,96 Studies report that women who sustained a physical assault during pregnancy experienced both immediate (placental abruption, increased fetal and maternal mortality) and long-term sequelae (prematurity and low birth-weight infants).92,93 The Australian Bureau of Statistics97 reports that 60% of women who had experienced violence were pregnant at some time during their relationship, 36% experienced it during their pregnancy and 17% experienced it for the ﬁrst time when they were pregnant. Women are at risk of experiencing domestic violence with greater severity while they are pregnant.98,99 Major trauma in pregnancy, from whatever cause, has particular deleterious eﬀects on the unborn baby. The unborn baby is more likely to die after traumatic injury than is the woman. Fetal and neonatal death is a signiﬁcant outcome of trauma. It is reported that there is more than an eight-fold increase in fetal death and more than six-fold increase in neonatal death for women who experience domestic violence.93 Practice tip Major trauma in pregnancy can be as a result of a motor vehicle crash or from a physical assault, for example, in domestic violence. It is important to consider domestic violence as a cause when women present with trauma in pregnancy. Diagnosis The diagnosis of trauma in pregnancy is similar to that in non-pregnant women. The additional aspects are related to consideration of the eﬀects of the trauma on the pregnancy, particularly on the baby. One of the major complicating factors is a placental abruption, where the placenta separates from the uterine wall. This is the most likely cause of preterm labour in a trauma patient. The diagnosis of the cause of other trauma or domestic violence may be diﬃcult. Pregnant women who have experienced an assault might be reluctant to talk about it. For example, a woman presenting with vaginal bleeding might not mention that it started after she had sustained a blow to the abdomen.95 Sensitive and careful questioning in a private and safe space is important to enable women to tell their story.98,100 It is important that women have time alone with a clinician, as often their partner will have accompanied her to the ED. Paramedics will often be in an ideal position to assess a pregnant woman who has sustained trauma. Assessment will often take place outside the acute care se ing and may be challenging in terms of determining the cause if family members are present. Sensitive questioning in a private environment in the home may be necessary to be able to fully understand the nature of the trauma and the possible cause. Practice tip Compression and displacement of the pelvic, abdominal and thoracic organs occur as pregnancy advances. This makes some injuries more likely and others harder to detect. The physiological changes due to pregnancy must be considered when assessing pregnant women with trauma. Management As with non-pregnant trauma patients, the focus of initial interventions remains the ABCs: airway, breathing and circulation.84,101 Usual trauma care priorities do not change when the patient is pregnant; indeed, the baby's best chance for survival is eﬀective resuscitation of the woman. An explanation of the physiological changes due to pregnancy and how these aﬀect maternal resuscitation was discussed earlier in this chapter. Identiﬁcation that the woman is pregnant is the ﬁrst step in eﬀective resuscitation. In the primary survey by paramedics or assessment in the ED, every woman of childbearing age who presents with trauma should be asked when she last menstruated, whether she could be pregnant (if conscious) and a blood test performed for conﬁrmation of pregnancy status.84,101 Pregnant women with positive mechanism of injury according to time-critical guidelines should be transported to a major trauma centre. This applies even if the woman does not have evidence of physiological distress. Early consultation with an obstetrician, midwife and neonatologist is essential in the case of these women. If the baby is likely to be born preterm, decisions need to be made about the most appropriate location for this to occur. Preterm babies are likely to require specialist care and it is generally easier to transfer the baby in utero rather than ex utero. This, of course, depends on the condition of the woman. The pregnant woman who has experienced major trauma requires early, vigorous ﬂuid replacement to support herself and her baby. The unborn baby will be extremely sensitive to maternal hypovolaemia: fetal hypoxia and bradycardia can develop quickly. Fetal death can occur at any gestational age and usually results from fetal hypoxia. As highlighted earlier, the changes of pregnancy can mask the signs of decompensation normally present in patients going into shock, and so vigorous ﬂuid resuscitation is necessary. Pregnant women generally require two or more large-bore (14- to -16-gauge) intravenous catheters for ﬂuid replacement,84,87 as with most trauma patients. Resuscitation measures, including the volume of ﬂuid replacement, should follow usual guidelines for patients who have experienced trauma (see Chapter 14 for more detailed information on resuscitation in trauma situations). Practice tip It is important to obtain an obstetric and general medical history from the woman and/or her partner. She may also have her antenatal record with her, which will contain relevant information. This will include the woman's estimated date of birth of her baby, the numbers of previous pregnancies and births and any complications of this or previous pregnancies. The admi ing nurse should also establish whether she is currently experiencing contractions, vaginal bleeding or increased vaginal discharge (this could be amniotic ﬂuid from around the baby), or backache or contractions, any of which could indicate that she is in preterm labour. Abdominal pain, contractions or vaginal bleeding might also indicate placental abruption where the placenta has separated from the uterine wall.85 Pregnant women who present with major trauma require the same diagnostic studies and interventions as non-pregnant patients. This is detailed in Chapter 46. This includes ultrasound in the ﬁrst instance, all indicated on radiographic studies such as plain ﬁlm X-ray, and computed tomography. The uterus should be shielded during radiographic procedures, except during abdominal or pelvic imaging.84,102 As part of the primary physical assessment of an injured pregnant women, it is important to assess whether there is seatbelt bruising, as this will indicate whether the seatbelt was worn across or above the abdomen. Seatbelt bruising has been reported to signiﬁcantly predict placental abruption after MVC in pregnant trauma patients. This warrants prompt stabilisation of the woman and fetal assessment.103 In addition, all Rhesus-negative women should receive full dose Rhesus immune globulin (more if indicated by Kleihauer-Betke test, the blood test used to measure the amount of fetal haemoglobin transferred from a fetus to the mother's bloodstream). Fetal monitoring is an important aspect of the care of these women. Pregnant women who experience trauma beyond 23 weeks gestation should be monitored using an electronic fetal monitor continuously for a minimum of 4 hours.104 Electronic fetal monitoring is usually available only in the labour ward se ing, but a monitoring machine could be brought to the ED with a midwife to apply it and interpret the readings. It is likely that women who experience trauma in pregnancy will be very anxious and concerned for the welfare of their baby. Their partner may also be present and will require support and information in a timely manner. It is important to provide as much information as possible in a caring and sensitive way. In some cases, the baby will have died before arriving at, or while in, the ED. A midwife can advise the staﬀ about addressing this diﬃcult and sad issue with the parents. Practice tip The anatomical and physiological changes of pregnancy can mask the signs of decompensation normally present in patients going into shock. Therefore, pregnant women with major trauma may not look like they are experiencing severe hypovolaemia until they collapse. Consider lower acceptable limits of vital signs as being signiﬁcant in pregnant women.

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