Obstetric and gynecological issues are a common reason for patients to seek urgent and emergent care. The most significant of these for the prehospital provider involve some component of vaginal bleeding. When assessing the patient with vaginal bleeding, determining certain key factors are important such as duration of bleeding as well as quantity. Oftentimes, significant or brisk vaginal bleeding is defined by the patient changing one or more pads per hour. A family or personal history of a bleeding disorder may also provide key information as to the etiology of the bleed. Associated symptoms such as weakness, lightheadedness, and shortness of breath should be noted.

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  Describe the initial prehospital evaluation and management of vaginal bleeding.

  
  
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  Describe the initial prehospital evaluation and management of patients in active labor (delivery procedure covered in Chapter 64).

  
  
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  Describe the initial prehospital evaluation and management of pregnant patients with trauma.

  
  
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  Discuss the indications for prehospital perimortem C-section (procedure covered in Chapter 64).

  
  
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  Discuss the criteria for determining stability when evaluating for interfacility transport of an obstetrical patient (also discussed in Chapter 16).

Physical examination of the patient with vaginal bleeding should initially focus on careful assessment of vital signs. Tachycardia and/or hypotension can indicate significant hypovolemia secondary to blood loss. Marked pallor or delayed capillary refill may indicate associated hypoperfusion. Signs and symptoms of shock must be recognized and addressed. An associated tender abdomen on examination may indicate a significant intra-abdominal hemorrhage and must be communicated to ED staff. Conversely, a patient who is normotensive without an elevated heart rate and a soft benign abdomen most likely has less significant pathology.

DYSFUNCTIONAL UTERINE BLEEDING

One of the more common reasons for vaginal bleeding or spotting in the nonpregnant patient is dysfunctional uterine bleeding (DUB). DUB is excessive noncyclic endometrial bleeding also described as anovulatory bleeding and most common in peri- and postmenopausal patients. DUB commonly presents as a slow persistent bleed, but excessive bleeding can occur.

ECTOPIC PREGNANCY

A more acute life-threatening cause of vaginal bleeding the prehospital provider must be familiar with is ectopic pregnancy. The incidence of ectopic pregnancy is as high as 19.7 per 1000 reported pregnancies.¹ Normally, implantation of a fertilized egg takes place within the endometrium of the uterus and is therefore referred to as an intrauterine pregnancy or IUP. Implantation in an ectopic pregnancy is inappropriately outside the uterus, most commonly within the fallopian tubes. Other possible locations for an ectopic pregnancy include the cervix, an ovary, and the abdomen. As the ectopic pregnancy progresses, the risk is organ rupture increases and can cause rapid, life-threatening interabdominal hemorrhage. Early consideration and recognition are imperative.

Ectopic pregnancy must be considered with a report of abdominal pain, missed or late menses, and vaginal spotting or bleeding. This history combined with signs of tachycardia, hypotension, or hypoperfusion can herald a potentially devastating intraabdominal bleed. Vagal stimulation from the abdominal bleeding may cause a relative bradycardia. IV access, preferably with two large bore IVs, should be established as soon as possible and fluid0esuscitation with normal saline begun. Supplemental oxygen should be provided. Rapid transport and notification of the patient’s condition and possible diagnosis should be provided to the receiving facility to prepare the appropriate resources as soon as possible as this patient will most likely need an emergent obstetrics consultation and surgery.

MISCARRIAGE

A more common reason for a patient to present with abdominal pain, vaginal spotting or bleeding, and a missed or late period is a miscarriage or a spontaneous abortion (versus elective abortion through either pharmaceuticals or a planned procedure). The World Health Organization defines spontaneous abortion as loss of pregnancy before 20 weeks or loss of a fetus weighing less than 500 g. Different types of spontaneous abortion exist: threatened, inevitable, incomplete, complete, and missed. The particulars of each are not necessarily relevant in the prehospital setting and therefore do not need to be explored in detail. A thorough history includes determining last menstrual period, knowledge of pregnancy status, amount and duration of bleeding, passage of clots or potential fetal materials, and past obstetrics history (such as prior miscarriage). A detailed physical examination should take into account vital signs, signs and symptoms of hypoperfusion, and abdominal tenderness if present. Establishing an IV, providing supplemental O₂ and close monitoring of vital signs are prudent during transport. The prehospital provider should recognize this as a very emotional and upsetting time for the patient and take steps whenever possible to minimize her stress or discomfort.

Prehospital care of the pregnant patient during the second half of pregnancy can be a challenging and anxiety provoking experience for the EMS physicians and providers. First and foremost, two patients are involved: the mother and the viable fetus. Secondly, this situation is not frequently encountered and therefore familiarity with the situation, potential complications, and treatment options may not be at the forefront of the provider’s mind. The assessment and treatment of the pregnant patient should therefore be regularly reviewed. The goal of this section is to provide a review of the assessment and treatment of the most common issues of this unique patient population when they seek emergent care.

Prior to a discussion of the emergent conditions the gravid patient may face, an understanding of the basic physiological changes encountered in pregnancy is necessary. A number of changes involving the cardiovascular system take place in pregnancy. A pregnant woman can have 50% more blood volume than that of the nonpregnant women,² equating a volume of approximately 1500 mL. Also, heart rate and stroke volume increase, causing a physiologic tachycardia of pregnancy. The pregnant patient can have a heart rate 10 to 15 beats per minute above normal. While cardiac output increases, a decreased peripheral vascular resistance actually lowers the pregnant women’s blood pressure. Lastly, venous return to heart in the supine position during the third trimester of pregnancy is compromised due to the gravid uterus resting on the inferior vena cava and decreasing cardiac preload, a phenomenon known as supine hypotensive syndrome. Pregnant patients must be placed on their left side to alleviate this syndrome. If immobilized after a trauma, the backboard should elevated on the right to allow the fetus to move to the left and improve venous return. All of these common physiological changes should be considered when assessing the pregnant patient.

Assessment of blood pressure, particularly hypertension, is of particular importance. Hypertension affects approximately 12% of pregnancies and contributes to approximately 18% of maternal deaths in the United States annually.³ Hypertension during pregnancy is defined as a blood pressure of 140/90 mm Hg, a 20 mm Hg rise in systolic blood pressure or a 10 mm Hg rise in the diastolic pressure. Different categories of hypertension affect pregnancy. Patients with an established history of hypertension prior to the pregnancy have chronic hypertension. Hypertension that is mild develops in the third trimester and does not adversely affect the pregnancy is transient hypertension. Preeclampsia is the combination of hypertension and proteinuria with or without associated edema that occurs during the second half of pregnancy. Those with chronic hypertension may progress to preeclampsia or it may develop independently. Preeclampsia is a serious condition affecting 5% to 10% of pregnancies with signs and symptoms that include headache, visual disturbances, abdominal pain, confusion, and decreased urination. Patients with these signs and symptoms of preeclampsia or an elevated blood pressure require prompt ED evaluation. Notification prior to arrival to the receiving ED of the patient’s diagnosis, signs and symptoms, or pertinent vital signs is extremely helpful.

ECLAMPSIA

Eclampsia involves the signs and symptoms of preeclampsia along with seizures. The seizing pregnant patient in the second trimester of pregnancy requires immediate treatment with 4 to 6 mg of magnesium over 15 minutes. Prehospital providers should notify medical control immediately for assistance in managing this complicated patient in extremis. Communication to the medical control physician should include pertinent information such as age, pregnancy status (37 weeks, etc), vital signs if attainable, and any other pertinent diagnosis (for example, an established history of preeclampsia or hypertension). Prompt transport must take place as the definitive treatment for preeclampsia and eclampsia is delivery of the fetus. Early notification to the receiving facility is essential as obstetrical consultation and emergent deliver may be required. Seizure management and administration of magnesium are immediate concerns in the prehospital environment. Management of hypertension is a secondary concern in the prehospital setting.

VAGINAL BLEEDING

Vaginal bleeding during the second half of pregnancy is particularly dangerous and is associated with fetal death in one-third of cases.⁴ Two significant causes of late term bleeding include placenta previa and abruptio placentae.

Placenta Previa

Placenta previa occurs when the placenta implants over the cervical os and is responsible for one-fifth of bleeding episodes during the second half of pregnancy (Figure 45-1). There are three categories of placenta previa: marginal (where the placenta implants next to but not over the cervix), partial (where the placenta covers a portion of the cervix), and complete (where the placenta covers the entire cervix). Placenta previa should be suspected with the onset of painless bright red bleeding during the late second and early third trimester.