The EMS crew of Station 4 is called to the home of a pregnant female who’s complaining of abdominal pain and vaginal bleeding that began occurring after a fall. The crew learns that she slipped on a wet floor and fell on her abdomen. She advises the lead paramedic that she’s 30 weeks pregnant and that it’s her second pregnancy. During questioning, the paramedic learns that the patient has not sought prenatal care due to severe financial difficulties and lack of insurance.
The bleeding is described as dark red and estimated at approximately 100–150 milliliters and is accompanied by significant abdominal pain. There are no visible wounds upon visual assessment of the abdomen. The blood pressure is 104/66, pulse is 108 beats per minute and respirations are 30 and shallow. Oxygen is provided through a non-rebreather mask while the crew quickly packages the patient for transport.
During the trip to the hospital, IV access is established. Additional assessment reveals that her pain began immediately after the fall, is a 9 on a 1–10 scale and is described as a constant, very sharp pain diffused across her lower abdomen. Nothing alleviates the pain. Reassessment of the vital signs reveals no significant changes. The ECG monitor shows sinus tachycardia and the pulse oximeter reads 100%.
The patient is transferred to labor and delivery staff members, who meet the patient and EMS providers in the emergency department. It’s later discovered the patient suffered a placental abruption; however, baby and mother survived the event.
Understanding Pregnancy Complications
Field providers represent a vital link in the system that provides complete care to pregnant patients. EMS personnel can be called to assess a patient suffering from a medical condition arising as a direct result of the pregnancy, or arrive to learn that the condition is wholly unrelated to the pregnancy. EMS personnel can also be called to care for a pregnant patient who has experienced a traumatic event. In either case, the patient receives the best care when EMS personnel understand how pregnancy causes changes in anatomy and physiology, know the complications that can arise in medical and trauma cases, and possess the ability to tailor the assessment and treatment to the patient’s specific needs. This article explores some of the common complications that EMS providers may experience in the out-of-hospital environment and provides insight on tailoring assessment and treatment.
General Assessment Considerations
When assessing a pregnant patient, there are a series of questions and examinations that should be standard. Begin by performing the initial assessment: airway, breathing, circulation, disability, and expose and examine (do the ABCs). Obtain a complete SAMPLE history: signs/symptoms, allergies, medications, past history, last oral intake and events preceding the incident.
Be certain to ask the patient how many times she’s been pregnant (gravida) and how many live births (parity) resulted from those pregnancies. Determine if the patient has sought prenatal care, and if so, whether her obstetrician or other medical professional has diagnosed her as having a complication. Ask if she has had any vaginal discharge, including bleeding. If the patient complains of pain, ask about the onset, provocation, quality of pain, region of pain, radiation of pain, severity and time (OPQRST) of the pain. Note any abnormalities in the EMS report and ensure that it’s included in your transfer report to the hospital staff.
Assess all vital signs including pulse, respirations, blood pressure, temperature and pulse oximetry readings. Examine the abdomen for any abnormalities, particularly if the patient complains of abdominal pain. Inspect for any obvious signs of trauma. Palpate the abdomen for tenderness, rigidity, guarding, masses or other abnormalities. Auscultation for fetal heart tones is helpful if the provider has been taught how to perform the procedure.
An ectopic pregnancy occurs when a fertilized ovum is implanted outside of the endometrial lining of the uterine wall. While the site of improper implantation can vary, it most often occurs within the fallopian tubes. As the ovum begins to develop into an embryo and eventually into a fetus, it will stretch the fallopian tube, which can result in rupture and massive hemorrhage.
Recent research demonstrates that the incidence of ectopic pregnancy has been declining over the past few decades, and that decrease is expected to continue until there are only 0.36 ectopic pregnancy deaths per 100,000 live births by 2013–2017.(1) Though this decline is favorable, it’s still a serious concern for EMS providers. For example, one study determined that almost two-thirds of all ectopic pregnancy deaths in the U.S. appear to have occurred in the emergency department, in transit to a hospital, or outside the hospital.1 It’s for this reason that any woman of child-bearing years who presents with abdominal pain is considered to have an ectopic pregnancy until proven otherwise by hospital staff.
Assessment of a patient with a possible ectopic pregnancy should focus on addressing any life threats, assessing the pain and determining the level of acuity. If a life threat is discovered, treat it rapidly. The prehospital care is generally limited to addressing the ABCs, providing oxygen, establishing IV access and providing fluids when necessary. Prompt transport is a high priority.
Placenta previa is a medical condition that occurs when the entire placenta or a portion of it covers the opening to the cervix. This condition is important for EMS professionals to recognize because it may prevent the ability for the baby to be delivered vaginally, which increases the urgency to rapidly recognize the condition and quickly transport the patient.
When assessing the history, ask the patient about common risk factors for placenta previa, such as treatments for infertility, prior caesarean section and advanced maternal age.(2) Placenta previa is relatively easy to detect during prenatal care, and the patient should be aware of the condition. If the patient hasn’t sought prenatal care, EMS providers can suspect placenta previa when the patient presents with painless bleeding during the third trimester. When present, assess the color and amount of blood, determine if there are any other associated complaints and treat for shock when indicated by patient presentation.
Placental abruption occurs when a portion or the entire placenta detaches from the uterine wall prior to birth. This condition complicates approximately 1% of all pregnancies.(3) The detachment can cause significant bleeding that can be concealed, such as when the bleeding accumulates behind the placenta. It’s also possible for the patient to experience vaginal bleeding. Because the detachment isn’t due to the natural process of birth, abdominal pain is a common presenting symptom.
Assess the patient to determine if abdominal pain is present, and use the OPQRST mnemonic as a guide to gather a complete pain profile. Check all vital signs to determine if signs of shock are present, and remember that the bleeding can be significant yet completely concealed. Ask the patient about risk factors, such as recent trauma, a short umbilical cord, multiple fetuses (i.e. twins, triplets), prior caesarean section, and pre-eclampsia/eclampsia. If placental abruption is suspected, rapid transport is indicated.
There are a variety of types of abortion ranging from those that are induced by medical intervention to those that occur due to a fetal abnormality.
Spontaneous abortion, commonly called a miscarriage, is defined as fetal death prior to 20 weeks gestation that isn’t due to medical intervention. EMS providers can expect to be called to this type of pregnancy complication because it is present in up to 20% of recognized pregnancies.(4)
In most cases, the primary focus for EMS providers is to provide psychological support to the female patient and family. The patient doesn’t often present with an acute condition. If the patient has passed fetal tissue, collect all parts for examination by a physician. Transport to the hospital is necessary because the patient will require follow-up care to ensure that no fetal parts remain.
A female who wasn’t diabetic before pregnancy can develop what is known as gestational diabetes. This condition affects approximately 18% of all pregnancies.(5) A screening test, known as a glucose screening test or glucose tolerance test, is administered to the expectant mother when she seeks prenatal care. If the test is positive, the more definitive “glucose tolerance test” is used to make the diagnosis. Since insulin doesn’t cross the placenta but glucose does, the excess glucose levels in the mother's bloodstream results in an increase in calories for the fetus. A mother seeking prenatal care will be coached on how to check and control her blood sugar level.
It’s important to ask the pregnant patient if she has been diagnosed as having gestational diabetes or has a history of diabetes. This line of questioning becomes important in the context of pregnancy because babies born to women with gestational diabetes tend to be larger (macrosomia), which can complicate delivery. Prehospital providers should perform a blood glucose test and follow local medical protocols if the level is abnormally low or high. The remaining assessment elements follow the standard line of questioning presented earlier, along with a physical examination. Remember that any acute condition requires treatment aimed at bringing the mother’s health to normal. For example, if the mother is found to be hypoglycemic and in need of glucose or dextrose, correcting the hypoglycemia will help mother and baby.
Preeclampsia and Eclampsia
Hypertension in pregnancy can be a serious concern, and a recent study found that the number of delivery hospitalizations in the U.S. with hypertensive disorders in pregnancy is increasing.(6) A blood pressure greater than 140/90 mm/Hg is considered abnormal for the pregnant patient.(7) If the patient is found to have elevated blood pressure, protein in the urine, edema and is beyond 20 weeks of gestation, she is diagnosed with preeclampsia. This condition typically takes place during the first pregnancy, and occurs more frequently and severely in women who are pregnant with more than one fetus, have chronic hypertension, previously had preeclampsia, were diabetic before the pregnancy or had thrombophilia (increased tendency to form clots).(8)
Eclampsia is defined as a seizure occurring during pregnancy when there is no other known cause (i.e. it is not epilepsy or other identifiable cause).9 Twenty-five percent of the seizures occur before labor, 50% during labor, and 25% after delivery, which can occur as much as 10 days after delivery.(9)
EMS providers must quickly recognize the seizure, protect the patient from harm and manage the seizure according to adopted medical protocols. Most agencies allow for the administration of magnesium sulfate to control eclamptic seizures. Typical dosing for eclampsia is 2–4 grams of magnesium sulfate mixed with 50–100 ml of normal saline and infused over five minutes. The overall goals are cessation of seizure activity and rapid transport to the hospital.
While many pregnancies will occur without complication, the EMS provider needs to have an understanding of the common complications that can arise. In many cases, the provider will only be able to recognize the condition and provide supportive therapies; however, EMS providers shouldn’t underemphasize the importance of being able to determine which complication is present. Knowing the condition can help the provider to select an appropriate hospital, be able to predict the complications that can occur while on scene or en route, and transfer care with a complete report.
1. Creanga AA, Shapiro-Mendoza CK, Bish CL, et al. Trends in ectopic pregnancy mortality in the United States: 1980–2007. Obstet Gynecol. 2011;117(4):837–843.
2. Rosenberg T, Pariente G, Sergienko R, et al. Critical analysis of risk factors and outcome of placenta previa. Arch Gynecol Obstet. 2011;284(1):47–51.
3. Ananth CV, Kinzler WL: Placental abruption. In Sheiner E (Ed.), Bleeding during pregnancy. New York: Springer, pp. 119–133, 2011.
4. Griebel CP, Halvorsen J, Golemon TB, et al. Management of spontaneous abortion. Am Fam Physician. 2005;72(7):1243–1250.
5. What is Gestational Diabetes? (n.d.) In American Diabetes Association: Diabetes Basics. Retrieved May 18, 2013, from www.diabetes.org/diabetes-basics/gestational/what-is-gestational-diabetes.html.
6. Kuklina EV, Ayala C, Callaghan WM. Hypertensive disorders and severe obstetric morbidity in the United States. Obstet Gynecol. 2009;113(6):1299–1306.
7. Mayo Clinic Staff. Preeclampsia: Tests and diagnosis. (April 21, 2011.) In Mayo Clinic Health Information . Retrieved May 10, 2013, from www.mayoclinic.com/health/preeclampsia/DS00583/DSECTION=tests-and-diagnosis.
8. Sibai B, Dekker G, Kupferminc M. Pre-eclampsia. Lancet. 2005;365(9461):785–799.
9. Stead LG. Seizures in pregnancy/eclampsia. Emerg Med Clin North Am. 2011;29(1):109-116.