Consider possibility of pregnancy in all women of child-bearing age whatever the presentation.
Always do urine B HCG test in PV bleed/abdo pain (unless known to be pregnant by US).
Always document BP in the pregnant woman.
EARLY PREGNANCY < 20 WEEKS (NB > 20/40 – See Below)
Bleeding and/or Pain.
Diagnosis
Consider miscarriage and ectopic pregnancy.
Record ectopic risk factors – PID, subfertility, tubal surgery, previous ectopic (IUCD/PCP-relative risks only). Most patients have no risk factors.
Beware lateralised sharp pain, syncope, hypotension, pain preceding bleeding, (ectopic).
Miscarriage can be threatened (no products and cervix undilated), inevitable (products passed or cervix dilated), incomplete or complete.
Vaginal examination is not normally done in the ED as it is unlikely to change ED management.
Urine pregnancy test may be negative in 10% of cases of ectopic pregnancy, consider serum.
Management
- Cannulate and refer if ectopic a possibility.
- Initiate volume resuscitate if shocked – PRIOR to transfer.
- In suspected miscarriage refer to gynae SHO for assessment.
- If significant pain and bleeding cannulate and send blood prior to transfer to Gynae.
LATE PREGNANCY > 24 WEEKS (But treat > 20 / 40 in similar way)
Bleeding
Consider placenta praevia, and abruption
Resuscitate, avoid VE and refer immediately.
Medical Problems
Have a low threshold for discussion with obstetricians. Remember the risk of hypertensive disease, thromboembolism, aortic dissection, cardiac failure, acute fatty liver, and pyelonephritis. Pregnant patients with DVT are managed by the Obstetric team.
Abdominal Trauma in Pregnancy
Take blood for Kleihauer-Betke test (which detects foetal blood cells in the maternal circulation).
Remember possible need for Anti-D.
Discuss all cases of significant trauma > 20 weeks with senior ED Doctor or Obstetricians.