Balancing Brain Chemistry to Treat Depression By Liz Butler This article first appeared in CAM magazine Introduction It is taking a long time for the scientific community to fully accept that what a person eats can influence their mental state but in the last few decades progress in this area has been rapid. Taking a very basic view of the subject there can be no doubt that nutrition is intimately involved with mental health as the brain and its chemical messengers are ultimately derived from food. Convincing doctors used to the traditional approach of treating mental disturbance and depression (drugs or psychotherapy) to consider the nutritional treatment approach is more difficult than simply pointing out this fact. Fortunately there is now a large amount of research supporting the view that nutrition has a role to play in promoting mental health, this article will review some of this research. It is well established that neurotransmitter imbalances can lead to mental dysfunction and depression and in fact most drugs currently being used in this area of disease aim to restore chemical balance within the nervous system (1). As some of the research mentioned in this review shows, certain nutritional factors may be able to promote chemical normality in the same way as current pharmaceutical treatments but without the side effects associated with drug therapy. Within a discussion about depression there must be some mention of genetic factors as there is no denying that the risk of developing depression, particularly a severe form, is influenced by genetics (2). It is likely that certain people are born with a predisposition to biochemical imbalances within the brain and then an inadequate nutrient intake compounds the problem. Eventually the situation deteriorates until there is expression of disease. What this means however, is that even disease with a genetic component may possibly be reversed given the correct nutrients to balance brain chemistry. Brain chemistry The brain is composed of about 100 billion neurones, the cells of the nervous system that communicate messages to each other, making up what is termed grey matter. The processes that extend from the cells to meet up with other cells constitute the white matter of the brain. Amongst the neurones are cells called neuroglia. Their role is to support, protect, and repair the neurones. Neurotransmitters are chemical substances that pass between neurones relaying messages. Examples include acetylcholine, histamine, adrenaline, noradrenaline, dopamine, and serotonin. All of these are well-studied neurotransmitters, and the effects of too much, or too little on the mental state are well observed. In addition neuromodulators and neurohormones are further classes of chemicals that affect nervous function. Neuromodulators modulate signal transmission either pre- or post-synaptically and neurohormones behave like neurotransmitters but act at a site distant
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Urqumc03_0131199900.qxdURQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 67 By the end of this chapter you should be able to Implement treatment for vaginal bleeding duringpregnancy Assess and treat the patient with suspected ectopicpregnancy Understand the causes of disseminated intravascularcoagulation in pregnancy Understand common etiologies of pelvic and abdominalpain in pregnancy Understand how to assess and transport the patientwith hyperemesis gravidarum Recognize signs and symptoms of preeclampsia Michael and Kayla arrived at the maternity unit to transport a preg- nant woman with a life-threatening condition 300 miles to a hos- pital nearer her home. Because it was likely that her infant would requiremonths of intensive care, delivery at a distant hospital would limit thetime she could spend with the baby during his stay in the NICU.
Estella Alces had presented to the emergency department the night before and was discharged after evaluation. Estella was a 23-year-oldprimigravida at 30 weeks' gestation who had recently immigrated toWest Virginia from Argentina. She had driven 5 hours to go campingwith friends when she developed substernal chest pain radiating to the URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 68 back. She had a history of symptomatic mitral valve prolapse and wason propranolol, a beta blocker. Upon arrival at the hospital, the EDevaluated her heart, lungs, and vital signs and found no pathology.
She was normotensive and well oxygenated. The staff evaluated thewell-being of her fetus and saw no abnormalities on the fetal hearttracing or sonogram. Her CBC was unremarkable except for moderate thrombocytopenia—her platelet count was 75,000 (normal is 150,000–450,000).
Dr. Presque, the on-call obstetrician, had been informed when the patient arrived, but after evaluating her symptoms the ED dischargedthe apparently healthy and now asymptomatic woman without furtherword to the obstetrician. The ED attending physician noted the throm-bocytopenia and discharged her with a copy of her labs, advising her toshare them with her own physician when she returned from vacation.
He assumed that her blood work indicated gestational thrombocytope-nia, a common and usually benign condition of pregnancy.
When Dr. Presque looked over her blood work the next morning, she was alarmed to see the low platelet count. She called the lab to askwhether it still had Estella's blood sample and whether enough blood re-mained to perform a hepatic function panel. A few hours later, the re-port showed that Estella had severely elevated liver enzymes. Dr.
Presque and staff immediately began to make phone calls in hope of lo-cating Estella so that she might return to the hospital.
What was Estella's diagnosis? 2. What are the signs and symptoms of this condition?
3. What could happen to Estella if she were not treated for
4. What should Michael and Kayla consider when
transporting this patient? Most pregnancies proceed with only minor discomforts and con- cerns, but when serious complications do arise, it is often the EMS provider who is summoned. Prehospital care of the woman with a high-risk pregnancy involves requires rapid assessment, judicious manage-ment, and prompt transport to an appropriate health care institution. Toachieve optimal outcomes for mother and fetus, the EMS professionalmust become familiar with the etiology, diagnosis, consequences, andmanagement of the most common pregnancy complications.
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 69 KEY TERMS
abortion, p. 71
hyperreflexia, p. 92
products of conception
(conceptus), p. 72
cerclage, p. 87
proteinuria, p. 92
lordosis, p. 88
pyelonephritis, p. 85
gravidarum, p. 89
Antepartal Bleeding—First Half of
Bleeding in early pregnancy does not always herald a miscarriage. Some-times the bleeding proves to originate from the rectum or urinary tractrather than the vagina. Causes of vaginal bleeding in pregnancy includevaginal or cervical infection, cervical polyps, cervical cancer, cervical orvaginal trauma, ectopic pregnancy, and hydatidiform mole. A womanmay spot after intercourse or after an office vaginal exam because evengentle cervical manipulation may rupture small blood vessels. A womanwho fails to produce sufficient progesterone may experience vaginalbleeding—treatment with supplemental progesterone sustains the preg-nancy until the placenta has matured and can manufacture adequateamounts. Implantation bleeding results from vascular disruption as theembryo burrows into the endometrial tissue. Implantation bleeding canbe scanty or profuse; it often occurs 5–6 weeks after the last menstrualperiod and lasts a day or two.
Spontaneous Abortion Spontaneous abortion is the clinical term for what is commonly termeda miscarriage. The usual definition is the loss of a pregnancy before thefetus reaches 20 weeks or 500 g. This boundary can blur in practice. Itis common for dates to prove incorrect, and occasionally a baby weigh-ing less than 500 g will survive.
It is difficult to determine what percentage of pregnancies end in spontaneous abortion. In about 30% of miscarriages, the woman is un-aware that she is pregnant and experiences simply a delayed, heavymenstrual period. Ten to 17% of pregnancies spontaneously terminatebetween 4 and 20 weeks of gestation. Twenty-five to 50% of conceivedembryos never implant. Forty-year-old women lose twice as many preg-nancies as 20-year-old women.
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 70 Most women who suffer spontaneous abortion wonder whether they did something to cause it. In most situations, this is not the caseunless they have exposed their fetuses to damaging drugs or toxins.
About half of spontaneous abortions are due to chromosomal errors.
Others are related to problems with maternal anatomy or hormones, orto maternal diseases such as diabetes, infections, placental abnormali-ties, uterine scarring, or immune dysfunction. Often the cause of a preg-nancy loss will remain unknown.
Threatened Abortion About one-third to one-half of women who experience vaginal bleedingin the first trimester will lose the pregnancy. Bleeding may be red (fresh)or brown (old), scanty or profuse. The patient may complain of cramp-ing in the back or abdomen. Many women say that the accompanyingpain equals or surpasses the contractions of labor. Always consider ectopicpregnancy a possibility unless the conceptus has been sonographically con-firmed in the uterus. Field treatment usually involves basic care and transport, but it is important to be vigilant for a decline in the patient's condition. Most lo-cal protocols support the following management strategies: • Get a complete history, including a history of the present prob-
The OLDCART checklist works well for this purpose (see chap- ter 2). Could this be an ectopic pregnancy? If the patient is certain ofher blood type, document this information and relay it to the hospitalstaff. If she is Rh-negative, she will need a shot of anti-D immunoglobu-lin (RhoGam); without it her body may manufacture antibodies thatcould attack the next fetus she conceives. Because the blood type of thefetus is usually unknown, RhoGam is given to all bleeding or miscarry-ing pregnant women with a negative Rh blood type.
• Monitor vital signs carefully. If the patient is bleeding significantly,
frequent vital signs are necessary. If you suspect hypovolemia, take ortho-
static vital signs by measuring her pulse and blood pressure in left lateral
position, then in a high Fowler's position or, better yet, standing. A 15-
mmHg drop in the blood pressure and 20-beat-per-minute increase in the
heart rate indicate that blood volume is significantly low. If your patient is
volume-depleted, she may faint in an upright position, so keep her safety
in mind at all times. If she shows signs of shock, orthostatic vital signs
should not be obtained, and she should be kept flat and on her left side.
• Watch for signs of shock.
If the patient is pale, clammy, and rest- less, treat her like any other patient in hypovolemic shock. Position herflat on her side, apply high-flow oxygen, and start at least one large-bore Chapter 3
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 71 IV of a crystalloid solution such as lactated Ringer's or normal saline in asizable vein—two if she is actively hemorrhaging. Second-trimesterpregnancy losses carry a significant risk of severe hemorrhage.
• Draw blood.
A blood draw in the field can expedite the processing of the patient's lab work after she arrives at the hospital. Check yourlocal protocols to determine whether it will be accepted by the lab.
• Count pads to measure bleeding.
Blood loss may vary. To meas- ure blood loss, look at the pads the patient has been discarding and de-termine their thickness and how saturated they are. If she is notwearing a pad, note whether blood has soaked through her underpantsor outer clothing, whether it has soaked through the sheet or into themattress, or whether it is enough to puddle on the floor. Often much ofthe evidence will have been flushed away before your arrival, so try toquantify any amount she lost in the toilet. Remember to consider othersources of blood in the toilet, such as hemorrhoids or rectal fissures. Ifshe passed any clots or tissue, bring them along to the hospital.
If she is passing large amounts of blood that does not clot, or if she is bleeding from other bodily orifices or her intravenous access sites,consider DIC (see later). DIC is most likely to occur with septicemia orwith second-trimester abortion.
• Fetal heart tones.
If you carry a Doppler on the ambulance, you can obtain fetal heart tones if the patient is beyond 12 weeks' gestation.
Heart tones can be difficult to find in the field, especially in the firsthalf of pregnancy. The decision to auscultate heart tones in a patientless than 18–20 weeks should be weighed carefully. The presence orabsence of fetal heart tones will not change your plan of care; if you failto hear a heartbeat you will increase maternal anxiety.
• Provide emotional support.
Losing a pregnancy can be frighten- ing or heartbreaking, not only for the pregnant woman but also for herfamily and friends. Statements that acknowledge their feelings andshow genuine concern are generally the most comforting. Explain pro-cedures clearly and honestly, give the patient your focused attention,and listen to her concerns. Reassure her that bleeding and cramping donot necessarily mean that she is losing the pregnancy and that there isnothing that she could have done to prevent miscarriage.
Inevitable Abortion The spontaneousor induced termi- When abortion is certain to occur, it is termed inevitable. The woman
reports abdominal or back pain and bleeding, and sometimes a gush of nancy before fetal fluid from the vagina. This condition progresses to either complete abor- tion or incomplete abortion.
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 72 Complete Abortion products of
Complete abortion is the spontaneous loss of all of the products of
conception, as evidenced by an empty uterus upon ultrasound exam.
After the uterus is empty, bleeding should diminish. Most cases of com- The results of con- plete abortion occur very early in pregnancy, and nature completes the ception—not only process without incident.
the embryo orfetus, but also theplacenta, mem- Incomplete Abortion branes, amnioticfluid, and other In incomplete abortion, part of the products of conception is not ex- pelled. Usually it is the placenta or part of the placenta that is retained.
Bleeding can be profuse because the uterus is unable to clamp down andmaintain hemostasis if placental fragments remain. The woman musthave a dilation and curettage (D&C) operation to complete the processand stop the bleeding. See Figure 3-1.
In a missed abortion, the products of conception are retained in utero af-ter the fetus has died. Expulsion occurs days or weeks later. The intro-duction of ultrasound has revealed that almost all spontaneousabortions present this way, making this term obsolete. A blighted ovumis a condition in which the gestational sac and placenta develop with noembryo.
In septic abortion, infection invades the uterine cavity during the abor-tion process. Septic abortion may occur after conception with an in-trauterine device (IUD) in place; with prolonged, undiagnosed ruptureof membranes; or after attempts by unqualified individuals to end apregnancy. The woman presents with pain, fever, and foul-smellingvaginal discharge.
Elective Abortion Elective abortion occurs when the woman chooses to end her pregnancyfor nonmedical reasons. This is often documented as voluntary inter-ruption of pregnancy (VIP). The EMS provider may encounter women Chapter 3
URQUMC03_0131199900.QXD 8/22/05 7:49 AM Page 73 FIGURE 3-1
Types of spontaneous abortion.
(a) Threatened. (b) Inevitable.
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 74 experiencing complications of this procedure. About 88% of VIPs in theUnited States are performed during the first trimester, and nearly all areperformed before 15 weeks of gestation, most by surgical suction. Theprocedure has a low rate of complications. When abortion is performedby a qualified provider, the mortality and morbidity risk to the motheris significantly less than her risk would be if she carried the pregnancyto term. There are currently several legal methods of abortion in theUnited States, and in 2000, the FDA approved a pharmacologicalmeans.
Surgical abortion is accomplished by opening the cervix and ex- tracting the products of conception—fetus, amniotic sac, placenta, andother structures—with suction or curettage. Less commonly, abortion isaccomplished by inducing labor later in gestation, but before viability.
Abortion performed very early in pregnancy confers a much lower riskof complications than at later stages of gestation.
By FDA guidelines, medical (nonsurgical) abortion can be induced by a clinician with mifepristone (RU 486, or Mifeprex) orally no laterthan 49 days after the LMP. Mifepristone blocks the action of proges-terone, a hormone necessary to maintain pregnancy. One to 3 days later,a dose of misoprostol (Cytotec, a prostaglandin) is administered. Abor-tion usually occurs within 4 hours, but may take 24 hours or longer.
Medical abortion is 97% effective, is considered very safe to the mother'shealth, and allows the loss to take place in the privacy of the woman'sown home.
All around the world, individuals without medical training induce abortion. Complications frequently follow and may be life threatening.
Some procedures involve the insertion of a foreign body through thecervix, often a urinary catheter, which may cause hemorrhage or sepsisalong with the loss of the pregnancy. If a rigid object is used, the uterus,bowel, or bladder may be perforated or otherwise damaged. Tablets ofpotassium permanganate have been inserted vaginally to produce abor-tion, resulting in deep vaginal ulcerations that bleed copiously. Chemi-cals or soap solutions have been forced into the uterus, sometimescausing emboli, hemolysis, and death.
Women who attempt to terminate a pregnancy by themselves or with unlicensed personnel are at great risk for serious complications.
With the surge of interest in botanical medicines, herbal preparationssuch as pennyroyal, oil of juniper, and black and blue cohosh are widelyavailable and hold some appeal for women seeking a "natural" means ofabortion. Herbal abortifacients can cause incomplete abortion or bleed-ing and cramping without loss of pregnancy. Misoprostol is widely usedas a gastrointestinal drug, and some women dose themselves to abortpregnancy without medical supervision. In most cases this practicecauses incomplete abortion or failed abortion.
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 75 PEARLS Despite the wide availability of elective abortion by various
means, some women ask their partners or other parties to kickor punch their abdomens in an attempt (usually unsuccessful)to end an unwanted pregnancy. The resulting injuries are indis- tinguishable at first glance from those of unsolicited domestic vio-lence. Of course in many cases these crude attempts at inducingabortion are by no definition consensual.
Vaginal bleeding and cramping, often with passage of blood clots and small bits of tissue, are the anticipated effects of medical abortion.
The patient's bleeding will resemble a heavy period for about 2 days,then will subside to a lighter flow or spotting until 3–10 days after theprocedure. One in 100 women, however, will experience prolonged orheavy bleeding that may necessitate an emergency response, and infec-tion may occur. The woman with complications will likely need a surgi-cal abortion to complete the process.
Treat the hemorrhaging elective abortion patient similarly to the woman with a profusely bleeding spontaneous abortion (see earlier).
The patient may be reluctant to discuss her abortion with family mem-bers present and when questioned may not disclose the true reason forbleeding. She also may withhold information if her abortion was per-formed by nonmedical personnel or if she thinks that her caregivers donot approve of abortion.
The topic of abortion inspires strong emotions and judgments in many caregivers. As always, EMS professionals must remain supportiveand act in the patient's best interests regardless of the choices she hasmade.
Therapeutic Abortion Therapeutic abortion is the termination of pregnancy when carrying toterm would endanger the woman's health or result in an infant with pro-found anomalies. Therapeutic abortion may also end a pregnancy inwhich the fetus is not viable, such as one with severe deformities ormetabolic defects incompatible with life. In the case of a woman whoconceives a large number of embryos, the parents and physician may de-cide to abort several of the embryos to improve viability for those thatremain, a procedure called selective reduction. Some authorities con-sider rape or incest grounds for therapeutic abortion.
Certain maternal conditions can prompt some women to consider therapeutic abortion, from severe hypertension and cardiac disease to URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 76 endocrine disorders, HIV, and coagulopathies. Invasive cervical cancer istreated with surgery or radiation, both of which will kill a previable fe-tus; but delaying treatment until the fetus is viable may result in thedeath of the mother. Therapeutic abortion is performed in the samemanner as elective abortion and carries the same risks.
Hydatidiform Mole Hydatidiform mole, known as a molar pregnancy or gestational tro-phoblastic disease, occurs with 1 in every 1,000 conceptions in theUnited States. Some parts of Asia have a rate that is significantly greater.
In a complete molar pregnancy, conception involves a defective egg thathas no nucleus, which is fertilized by two sperm or by a sperm that du-plicates its own chromosomes. Consequently, there is no maternal ge-netic input and no embryo, only a malformed placenta that proliferatesas rapidly growing, grapelike fluid-filled vesicles. See Figure 3-2.
A partial molar pregnancy usually begins when two sperm fertilize a normal egg. An embryo begins to develop, but soon dies, and the ab-normal placental tissue fills and distends the uterus as with a completemole.
In both kinds of molar pregnancy, the uterus becomes larger than expected for gestational dates. The molar tissue produces the pregnancyhormone hCG at a rate much greater than the placenta of a normal preg-nancy, often triggering severe nausea and vomiting in the woman. Thewoman begins to experience vaginal bleeding, which is often the colorof prune juice, but may be bright red. Sometimes the woman will show FIGURE 3-2
The hydatidiform mole distends the
uterus with thousands of fluid-filled
Illustration by Bonnie U. Gruenberg
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 77 signs of preeclampsia before 24 weeks. (In viable pregnancies, preeclampsia typically develops after this time.) A history of severe nau- sea and vomiting is common. About 10% show signs of hyperthy- roidism—hypertension, warm skin, tremors, and tachycardia.
Treat the woman with suspected hydatidiform mole like any other of ectopic pregnancy in woman in early pregnancy with vaginal bleeding. Diagnosis is made by any woman of child- ultrasound, and the mole is removed by surgical evacuation. Women bearing age presenting who have had a molar pregnancy run a slight risk of later developing with lower abdominal choriocarcinoma, an aggressive cancer of the uterus.
pain or shoulder pain,shock, syncope, or vagi-nal bleeding.
Ectopic Pregnancy In a normal pregnancy, conception occurs in the fallopian tubes. Propelledby cilia, the dividing cell mass reaches the uterus within about a week.
There it implants in thick, hormonally primed, vascular uterine tissue, theendometrium, and taps into the mother's bloodstream for life support.
Ectopic pregnancy occurs when the embryo embeds somewhere outside the uterus (ectopic meaning "out of place"). The most commonsite is the fallopian tube (95%), but occasionally the embryo will im-plant on the ovary (4%), on the cervix (1%), or even in the abdominalcavity (<1%). See Figure 3-3. None of these structures is suitable forsupporting a growing embryo, and the fragile, vascular fallopian tube isespecially vulnerable. An embryo implanted in the thin wall of the tubeoutgrows the available space at about 6–8 weeks' gestation, often caus-ing the tube to rupture and creating the hemodynamic equivalent of ashotgun blast to the abdomen. Tubal rupture can initially present as asmall tear in the tube with minimal pain and bleeding that grows grad-ually worse, or as massive hemorrhage into the woman's abdominal cav-ity. Immediate surgery is usually indicated for ectopic pregnancy, FIGURE 3-3
The most common site of implanta-
tion for an ectopic pregnancy is in
the fallopian tube. A tubal pregnancy
is not viable and will endanger the
mother's life and future fertility if the
fallopian tube ruptures.
Illustration by Bonnie U. Gruenberg
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 78 although early unruptured ectopics are often managed with embryo-killing medications such as methotrexate.
The incidence of ectopic pregnancy in the United States has tripled since 1970 to 1 in every 44 live births. It is the leading cause of first-trimester maternal death.
Some women are more susceptible to ectopic pregnancy. Scarred tubes with damaged cilia are less effective in moving an embryo to the uterus.
Chlamydia, the most common sexually transmitted infection in the UnitedStates, and gonorrhea, another common STI, can scar the fallopian tubes.
Other risk factors are previous pelvic or tubal surgery, prior ectopic preg-nancy, history of infertility, smoking, maternal age over 35, the presence ofan intrauterine device (IUD) for contraception, altered hormone levels, andcongenital anomalies of the fallopian tubes. Only about half of women withectopic pregnancy have one or more of the risk factors.
Tubal ligation is also a risk factor for ectopic pregnancy. Sterilization is the most popular method of contraception in the United States andaround the world. Almost 50% of American women choose tubal ligationby the age of 44. Tubal ligation involves destruction of the fallopian tubesin some fashion. Sometimes an opening remains in the scarred tube, wideenough to let sperm through to fertilize the egg, but not large enough letthe zygote pass to the uterus. The embryo implants in the tube, and ec-topic pregnancy results. EMS providers should also be aware that womenmay experience ectopic pregnancy 10 years or more after tubal ligation.
The woman may insist that she cannot be pregnant. Women who haveundergone tubal reanastomosis (reversal of tubal ligation to achieve preg-nancy) are also at greater risk for ectopic pregnancies.
Ectopic pregnancy is so potentially life threatening that the EMS provider should suspect this condition in any woman whose symptomsand history even remotely fit the clinical picture. To further complicatematters, the clinical picture is variable, and diagnosis may be difficult.
Emergency room physicians fail to correctly diagnose ectopic pregnancymore than 40% of the time on the patient's first visit, and missed ectopicpregnancy is one of the leading causes of emergency physician malprac-tice lawsuits.
The woman with an ectopic pregnancy may not know that she is pregnant and may not show signs or symptoms of pregnancy. Ectopicpregnancy usually becomes symptomatic by 6–8 weeks of gestation, butcan cause symptoms as early as 5 weeks' gestation or (rarely) as late as14–16 weeks.
The classic presentation is a woman of childbearing age with a history of amenorrhea (cessation of menses) presenting with diffuse abdominalpain that later localizes as severe, knife-like pain on one side of the lowerabdomen. A ruptured ectopic pregnancy rapidly progresses to hypov-olemic shock with rapid, weak pulse; confusion and restlessness; pale,clammy skin; collapsed neck veins; and low blood pressure, sometimes Chapter 3
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 79 even syncope. Her abdomen is tender to palpation and may be rigid ordistended. Rebound tenderness, nausea and vomiting, and diarrhea areoften present. Free blood in the abdomen often irritates the phrenicnerve (which runs under the diaphragm) causing referred pain to theright shoulder. Sometimes (but not always) she may have vaginal bleed-ing with or preceding the other symptoms, but the degree of shock usu-ally exceeds that accounted for by visible blood loss.
Many women with ectopic pregnancy, however, do not fit the clas- sic picture. Some present with only syncope. Some experience littlemore than nausea and vomiting. Many look and feel fine except for uni-lateral pelvic pain. Some display only profound shock. Vital signs maybe normal if rupture has not yet occurred. In most cases, pain onset isabrupt and severe; but in some cases, the woman may have chronic dis-comfort with irregular spotting for days before becoming acutely symp-tomatic. A rare finding is Cullen's sign, a blue tint beneath the umbilicusindicating free blood in the abdomen. There may be few available cluesto support a clinical impression of ectopic pregnancy, but any woman ofchildbearing age with the symptoms described should be presumed tohave an ectopic pregnancy until proven otherwise.
Other problems can present similarly. Differential diagnoses include spontaneous abortion, ruptured ovarian cyst, appendicitis, salpingitis(infection of the fallopian tube), torsion (twisting) of the ovary, round-ligament pain, torsion or degeneration of a uterine fibroid, kidney stone,abscess, and urinary tract infection.
Field treatment for a suspected ectopic pregnancy must be swift and efficient. Rapid transport to a hospital with the capacity for immediatesurgery is essential. Bilateral intravenous lines should be established andisotonic crystalloid solution such as lactated Ringer's or normal salinerun at a rate consistent with the patient's level of shock. Hospital labora-tory studies may be expedited if the EMS crew draws blood while estab-lishing intravenous access. The EMS provider should administeroxygen, initiate cardiac monitoring, and treat for shock.
Antepartal Bleeding—Second Half
Placental Abruption Also known as abruptio placentae, this condition occurs when the pla-centa prematurely separates partially or entirely from the uterine wall af-ter 20 weeks of gestation. Abruption complicates 1 in 75–90 births andcan be catastrophic. The ensuing hemorrhage carries a 20–35% mortal-ity rate for the fetus (up to 100% if the placenta separates completely) URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 80 and can cause significant harm to the mother. Abruption may or maynot present with vaginal bleeding—the blood may remain trapped be-hind the placenta and never leave the body.
Hypertension strongly predisposes pregnant women to placental abruption. Other risk factors include multiparity, age over 35, smoking,poor nutrition, cocaine use, and chorioamnionitis. Abruption is associatedwith overdistention of the uterus, as in the case of multiple pregnancy orpolyhydramnios (increased amniotic fluid volume). Blunt external trauma,especially from motor vehicle accidents and maternal battering, is also animportant cause of abruption. (See Trauma in Pregnancy, chapter 4.) Presentation varies with degree and location: • Marginal abruption.
The edge of the placenta separates, causing bleeding that flows between the fetal membranes and the uterine walland exits through the vagina. This presentation is called a revealedhemorrhage. The placenta may or may not continue to separate.
• Central abruption.
The center of the placenta separates, but the margins remain intact. Free blood accumulates between the placentaand uterine wall, but none escapes to exit the vagina. This presentationis known as a concealed hemorrhage. Signs and symptoms usually in-clude sharp, tearing pain; rigid, board-like abdomen; and change inuterine size and shape. See Figure 3-4.
• Combined abruption.
This condition has features of both mar- ginal and central abruptions; some of the blood escapes, and some re-mains hidden behind the placenta.
A marginal placental abruption may result in
vaginal bleeding. A central abruption may
conceal blood loss within the uterus.
Illustration by Bonnie U. Gruenberg
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 81 • Complete abruption.
Complete separation of the placenta causes profuse vaginal bleeding and shock while depriving the fetus of oxy-gen. Immediate surgery is necessary to save the life of the fetus.
Signs and symptoms can vary from subtle to dramatic. Vaginal bleeding may be profuse, scanty, or nonexistent and may be dark orbright red. Abruption may be excruciating, uncomfortable, or painless.
The patient may have contractions. With a concealed hemorrhage it iscommon for the uterus to remain very tender, rigid, and board-like be-tween contractions; but if the placenta is on the posterior wall of theuterus, these signs may not be present. Sometimes with a concealedhemorrhage, the uterus may enlarge and change shape. Shock may be disproportionate to visible blood loss.
Fetal movements often become less frequent or stop up to 12 hours TARGET for a pla-
before any obvious signs of abruption, but in a large, sudden abruption the woman may report violent fetal movement followed by stillness. Fe- tal heart tones may be faster than usual (above 160), bradycardic (under volves treatment for 120), generally within normal ranges with periodic decelerations, or ab- hypovolemic shock and sent. In a large abruption, only immediate surgery can save the baby rapid transport to a from severe neurological damage or death. Chief risks to the mother are hospital with the ca- shock and disseminated intravascular coagulation (DIC).
pacity for immediatecesarean section.
EMS field treatment for placental abruption consists of treatment for hypovolemic shock and rapid transport to a hospital with the capac-ity for immediate cesarean section. If the fetus is preterm, transport to ahospital with a neonatal intensive care unit if possible. Vital signs, fetalheart tones, and assessments of uterine tone, contractions, and vaginalbleeding should be performed frequently. Some providers mark the fun-dal height on the maternal abdomen with a pen in order to monitorchanges caused by trapped blood.
Bilateral large-bore intravenous lines should be established and blood drawn in accordance with local protocols to expedite hospital laboratorystudies. The patient will need type and cross matching for blood productsat the hospital and may require transfusion. Infuse normal saline or lac-tated Ringer's at a rate consistent with her condition. If shock is develop-ing, aggressive fluid therapy is indicated. High-flow oxygen and left lateralpositioning may improve the delivery of oxygen to the fetus.
Disseminated IntravascularCoagulation (DIC) DIC is a life-threatening derangement of the clotting cascade triggeredby underlying disease or trauma. Obstetrical causes include abruptioplacentae, eclampsia, intrauterine fetal demise, amniotic fluid embolism,septic shock, and trauma. Serious infections are the most common cause URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 82 of DIC. During DIC, the body forms and dissolves fibrin clots through-out the circulation, causing simultaneous uncontrolled bleeding andclotting. DIC begins when an event triggers the formation of innumer-able microscopic clots throughout the body, which use up the clottingfactors. The body responds by attempting to dissolve the unneededclots. The by-products created by this widespread clot forming and clotdissolving interfere with the ability of the blood to coagulate, and thepatient begins to hemorrhage.
The woman with DIC will present with bleeding from body orifices and breaks in the skin including venipuncture sites, nose, mouth, GI tract,and vagina. Bruising, purpura, and petechiae are commonly noted on theskin. DIC may lead to stroke, myocardial infarction, end-organ dysfunc-tion, shock, and death. Definitive treatment in a hospital setting includesremoving the cause, if possible, and transfusion of blood products. In somecircumstances, DIC is treated with heparin to interrupt the clotting cascade.
Field treatment includes rapid transport with an advanced life sup- port (ALS) crew to a hospital with the capacity to deal with a critically illobstetrical patient. If the fetus is preterm, a hospital with a capableneonatal intensive care unit will give the baby a better chance of survival.
EMS personnel should establish bilateral large-bore intravenous lines,draw blood for rapid laboratory tests upon arrival, administer high-flowoxygen, begin cardiac monitoring, and implement left lateral flat posi-tioning. The crew member with the greatest skill in venipuncture shouldestablish venous access to minimize skin punctures that may bleed pro-fusely as DIC progresses, and isotonic crystalloid intravenous solutionshould be infused at a brisk rate as permitted by local protocols. Vitalsigns should be reassessed frequently along with fetal heart tones, uterinetone (Is it soft or rigid? Are contractions regular?), and vaginal bleeding.
Placenta previa is a condition in which the embryo implants in the loweruterine segment instead of the uterine fundus. At or near term, the pla-centa partially or completely covers the cervical os (cervical opening).
When the cervix begins to thin and dilate in preparation for labor, pla-cental villi are torn from the uterine wall, and bleeding results. There arethree variations of this condition: • Marginal placenta previa.
The placenta encroaches on the edge of the cervical os. Marginal previa may resolve as the pregnancyprogresses. See Figure 3-5.
• Partial placenta previa. The placenta partially covers the cervical os.
• Total placenta previa.
The placenta occludes the cervical os. See Chapter 3
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 83 FIGURE 3-5
Marginal Placenta Previa.
A marginal placenta previa occurs when
the edge of a low-lying placenta
encroaches on the cervical os.
Illustration by Bonnie U. Gruenberg
Complete Placenta Previa.
A complete placenta previa is im-
planted directly over the cervical os.
Illustration by Bonnie U. Gruenberg
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 84 Placenta previa most commonly presents with painless bleeding that may be scanty or profuse. Sometimes it accompanies or is precededby contractions. Typically, the first bleeding episode is slight, and eachsubsequent hemorrhage is more copious.
Even in the hospital, vaginal exams are not performed on women who present with third-trimester vaginal bleeding unless the placentallocation has been confirmed on ultrasound; if an examiner were to puta finger through the placenta, uncontrolled hemorrhage would result.
The woman with placenta previa will probably undergo a cesarean de-livery if she is near term. If the fetus is still immature and her bleedingis slight, her provider may admit her and observe for further bleedingwhile the fetus continues development. Occasionally the woman is dis-charged home and instructed to call if further bleeding occurs.
Field treatment for any vaginal bleeding in the second half of preg- nancy calls for history and assessment (including serial vital signs andfetal heart tones), rapid transport, at least one large-bore intravenousline with isotonic crystalloid intravenous solution hanging (flow rate de-pendent on her condition and vital signs), transport in left lateral posi-tion, oxygen as indicated, and frequent reassessment.
PEARLS Positive diagnosis of the source of vaginal bleeding can be made
only by an obstetrical provider, usually in a hospital setting. Inprehospital care, it is not necessary to distinguish between pla-cental abruption and placenta previa. Field treatment is the same for either condition.
Pelvic and Abdominal Pain
The presence of pelvic pain does not necessarily herald loss of the preg- nancy. Most pregnant women feel discomfort at various points in the pregnancy, and usually these aches and pains are inconsequential. In most cases, field care will consist of taking a good history, positioning always con- for comfort, giving nothing by mouth, and perhaps establishing IV ac- siders preterm cess and drawing blood. If a patient is hypovolemic, consider a fluid bo- labor as a possible lus. As always, follow local protocols. cause of abdominal A few of the most common etiologies follow.
discomfort in womenbetween 20 and 37weeks' gestation.
Round ligaments are like stretchy guy wires that hold the uterus in po-sition. They run from the lateral aspect of the uterus to the pubic bonebilaterally. During the second trimester, the uterus outgrows the pelvis Chapter 3
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 85 and falls forward, putting stress on these ligaments and causingcrampy spasms on one side or the other of the pubic bone, along ei-ther or both sides of the uterus, and up to the level of the umbilicus.
The right side is more commonly affected because the uterus rotates tothe right as it grows. As the uterus continues to expand and have ton-ing contractions, the ligaments continue to stretch. Round-ligamentpain is one of the most common discomforts in pregnancy. The pain issharp and can be severe, but it does not indicate any pathologicalprocess. It is often triggered by coughing or sudden movement. Awoman can avoid triggering spasms by splinting the area with herhand when she moves suddenly. Sometimes she will find relief if shecurls toward the pain and flexes her thigh on the painful side. Warmbaths, application of heat, and wearing a maternity belt can improvesymptoms.
During pregnancy, the growing uterus displaces the appendix, and atterm the appendix is located above the right iliac crest in most women.
Appendicitis presents initially as epigastric or periumbilical pain inpregnant and nonpregnant women, but can later localize to either theright upper or lower quadrant. The patient with appendicitis may alsocomplain of fever, chills, nausea and vomiting, rebound tenderness (testfor increased pain with cough), and rigid abdomen.
Urinary Tract Infection Pregnancy predisposes women to urinary tract infections, which canrange from inconvenient to life threatening. Pregnancy hormones relaxsmooth muscle in the ureters, which can kink and allow urine to pooland support bacterial growth. Sometimes urinary tract infection mimicsor triggers preterm labor.
Cystitis, or bladder infection, presents with frequent urination, lower pelvic cramping (especially while voiding), a burning sensationwith urination, and sometimes a low-grade fever. Urine may be cloudy,bloody, or bad smelling.
Pyelonephritis, or kidney infection, is often preceded by a bladder
infection and occurs in about 2% of pregnancies. Symptoms include sudden onset of high fever, shaking chills, hematuria, nausea, vomiting, renal pelvis, usu- urinary pain and urgency, flank or low back pain, costovertebral angle ally from infection.
(CVA) tenderness, and malaise. During pregnancy the right side is mostlikely to be affected because the intestines push the uterus to the rightand compress the right ureters and kidney.
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 86 PEARLS Check for costovertebral angle (CVA) tenderness by firmly tap-
ping down the back from scapula to pelvis with a closed fist. Ifthe patient winces upon percussion of where her lower ribs meetthe spine, she has CVA tenderness.
Sometimes the woman with pyelonephritis will experience swelling of the kidney and ureter that can reduce urine output and cause severepain and even small bowel ileus. Pyelonephritis can also lead to pretermlabor and life-threatening maternal sepsis. It is treated by intravenousantibiotics and bed rest in the hospital.
Hydronephrosis and Renal Calculi
Most cases of renal colic present in the second or third trimester of preg-
nancy. Hydronephrosis is fluid buildup in the kidneys when urine flow
is obstructed in the urinary tract. Hydroureter is distention of the ureter
with urine. During pregnancy, these conditions most commonly result
from smooth muscle relaxation of the ureter due to progesterone and
HCG, coupled with compression of the ureter at the pelvic brim by the
heavy uterus, obstructing urine flow. Physiologic hydronephrosis and
hydroureter of pregnancy is seen in 90% of pregnancies and is usually
The woman with symptomatic hydronephrosis often presents simi- larly to the patient with pyelonephritis or renal calculi, exhibiting severeflank pain that may be acute or chronic, but usually without fever. If hy-dronephrosis threatens kidney function, the patient may require percu-taneous or stent drainage. Rarely, hydronephrosis can exacerbatehypertension or cause renal failure.
PEARLS Hydronephrosis can persist for months, sometimes causing
intractable pain for the pregnant woman. Many patients aremanaged on narcotic medications and taught techniques to re-duce pressure on the kidneys and ureters, such as urinating while positioned on hands and knees in a bathtub. Pain from hy-dronephrosis may increase if the condition worsens or if she developsa urinary tract infection.
Renal calculi can form in pregnant women and present as in non- pregnant patients, with a typical flank-loin-abdomen distribution andoften with severe pain. Uncommonly, kidney stones can lead to pre-mature labor or preeclampsia. Urinary obstruction with concurrent Chapter 3
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 87 infection is unusual, but carries a high risk of spontaneous abortionand premature labor.
Whereas calculi can affect either side, physiologic hydronephrosis is usually more pronounced on the right. Pain from appendicitis, chole-cystitis, perforated intestine, preterm labor, and other conditions maypresent similarly in the pregnant women, so consider differential diag-noses carefully.
Chorioamnionitis and PelvicInflammatory Disease When disease-causing microorganisms ascend from the vagina into theupper reproductive tract, they can cause infection in the mother, fetus, placenta, or membranes. Chorioamnionitis, or infection of the fetal
membranes, is most likely to develop if the mother has had prolonged fetal membranes.
rupture of the amniotic sac. Ruptured membranes can present as a leakso subtle that the woman may not be aware of it or as an unmistakablegush. When the membranes are no longer intact, vaginal microorgan-isms may ascend and cause infection. Women who have undergone cerclage (a suture that secures the cervix in an attempt to prevent pre-
A suture that se- mature delivery) are at higher risk for chorioamnionitis.
cures the cervix in The woman with chorioamnionitis will present with abdominal an attempt to pre- pain, uterine tenderness, fever, foul-smelling vaginal discharge, and a generalized feeling of illness. The fetus usually shows signs of distress— often tachycardia—before the mother becomes symptomatic.
Chorioamnionitis is always an emergency and is potentially life threat-ening to both mother and fetus. Chorioamnionitis may also contributeto cerebral palsy in the infant.
Pelvic inflammatory disease, or PID (infection of the upper genital tract), may also occur in pregnancy and is most commonly caused bychlamydia or gonorrhea. PID can be life threatening to the fetus.
Gallstone formation is accelerated in pregnancy, and as many as 6% ofpregnant women develop cholelithiasis (gallstones). Progesterone slowsthe emptying of the gallbladder, increases the proportion of cholesterolpresent in the bile, and the bile salt pool decreases. Symptoms are thesame in pregnant and nonpregnant women, and include • Nausea
• Right upper quadrant tenderness
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 88 • Lancing or cramping epigastric pain that radiates to the right up-
per quadrant, around the back, or to the right scapula • Sudden onset of colicky pain or a deep ache, building to peak in-
tensity in 15–60 minutes, then receding over several hours.
Symptoms are aggravated by eating a greasy meal, and pale or gray stools may occur if the bile duct is completely obstructed. Laparoscopiccholecystectomy (removal of the gallbladder) is sometimes performed inthe first or second trimester but is usually avoided during the thirdtrimester.
Pregnant women have intestinal gas or diarrhea cramps just like the restof the population. A woman may have benign fibroid tumors within heruterus, which can cause bleeding and pain, especially if they becometwisted. Any woman who has had uterine or abdominal surgery mayhave adhesions—scar tissue—that bind and anchor her organs painfully as they try to expand and shift position. Abdominal pain in a pregnant A benign tumor of woman can indicate placental abruption, uterine rupture, preeclampsia, the uterine smooth or trauma. Pancreatitis, peptic ulcer disease, gastric reflux, ruptured or twisted ovarian cysts, and degenerating fibroid tumors (leiomyomas) of
the uterus can also cause abdominal pain.
Low back pain affects 50–90% of women during pregnancy, especiallywith prior history of back problems, lack of exercise, increasing parityand age, poor posture, or improper lifting. When the pregnant abdomenmoves out of the pelvis, abdominal muscles become stretched and losetone, and become less effective at maintaining neutral posture and sta-bilizing the pelvis. Elevated levels of the hormone relaxin, which loosensjoints, increases mobility of the lumbar spine. The pregnant woman de- velops progressive lordosis, and her center of gravity shifts backward
and down, increasing the workload of the muscles of the back.
ward curvature of The hormones of pregnancy transform the previously rigid pelvic joints into a series of hinges with the ability to stretch open during child- birth. These changes in the pelvis can cause back pain. The symphysis mal in pregnancy); pubis widens throughout pregnancy, placing stress on the sacroiliac joints. Increased mobility of the sacroiliac joints can cause discomfortwhen the associated ligaments are stretched.
When evaluating the pregnant patient with back pain, always con- sider the possibility of hydronephrosis, pyelonephritis, pancreatitis, Chapter 3
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 89 pelvic deep vein thrombosis, or renal calculi. Preterm labor can presentas back pressure or pain. Fever, sensory loss, motor weakness or paraly-sis, or incontinence may indicate a neurologic emergency.
Syncope is not unusual in the pregnant patient, and it is a common rea-son for an emergency response. It is frequently caused by hypoglycemia,prolonged standing, orthostatic hypotension, vena caval compressionfrom supine positioning, overheating, or a vagal response. Early in preg-nancy consider ectopic pregnancy as an etiology. Syncope infrequentlycan be attributed to pathological conditions such as stroke or arrhyth-mia, long QT syndrome, hypertrophic cardiomyopathy, or Wolf Parkin-son White syndrome. The syncopal patient may show brief tonic-clonicactivity with bradycardia and hypotension, but quickly recovers. (A trueseizure would be followed by a postictal state and would not show thesecardiovascular changes.) Hyperemesis gravidarum is severe, persistent nausea and vomiting
with weight loss, dehydration, hypokalemia, or ketonuria. Unlike Severe, persistent morning sickness, which is generally confined to the first trimester and nausea and vomit- does not often interfere with nutrition, hyperemesis can occur at any point in the pregnancy and can result in ketosis and dehydration.
form of pregnancy- Hyperemesis appears multifactorial. It can be related to vitamin B deficiency, endocrine imbalances such as hyperthyroidism, allergies, sickness" that can psychological disturbances, and conditions that increase the levels of cause weight loss, human chorionic gonadotropin (hCG), for example, multiple gestation ketosis, dehydra- and hydatidiform mole. Severe cases can lead to hypokalemia that can disrupt kidney function and heart rhythm, hypovolemia and syncope pokalemia or other from dehydration, acidosis or alkalosis, muscle wasting, and severe pro- electrolyte imbal- tein and vitamin deficiencies. Wernicke's encephalopathy can uncom- monly occur from severe thiamine deficiency, presenting with altered consciousness, double vision, constant eye movement, and poor muscle coordination. Hyperemesis gravidarum can cause irreversible metabolicchanges or even death, but both are extremely uncommon.
Symptoms usually develop between 4 and 9 weeks' gestation, and • Intractable vomiting.
• Poor appetite.
• Poor nutritional and fluid intake.
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 90 • Weight loss greater than 5% of prepregnant weight.
• Dehydration (dry mucous membranes, orthostatic hypotension,
concentrated urine, possible syncope especially in hot weather,poor skin turgor).
• Advanced cases may show jaundice, bleeding gums, peripheral
neuropathy, arrhythmia, changes in level of consciousness.
Morning sickness is common in pregnancy and can make a woman feel unable to hold anything down, but it does not result in the dehy-dration, ketosis, and weight loss experienced in hyperemesis gravi-darum. Differential diagnoses are infectious disease such as hepatitis,drug reaction, intestinal obstruction, peptic ulcer, food poisoning, dia-betes, and gastroenteritis. Treatment involves intravenous rehydrationand electrolyte, glucose, and vitamin administration with no oral intakefor 48 hours. This regimen can be accomplished at the hospital orthrough home nursing services. Antiemetics are used to suppress nau-sea. After vomiting ceases, food is gradually reintroduced. Refractorycases may require nasogastric feedings or total parenteral nutrition.
Emergency medical personnel should focus on the ABCs when car- ing for the patient with hyperemesis gravidarum. Carefully assess theseverity of her condition and consider other possible causes. Check glu-cose levels. If she is dehydrated, infuse lactated Ringer's or normal salineat a rate consistent with her condition. If she is severely affected, moni-tor for arrhythmias and be prepared for the possibility of coma. If sheshows signs of Wernicke's encephalopathy, your medical control mayadvise intramuscular thiamine administration. If the patient is hypov-olemic, position for shock—on her left side if pregnancy is advanced.
Try to avoid exposing her to strong smells or excessive motion that maytrigger vomiting, and maintain a clear airway if she does vomit.
Pregnancy-induced hypertension (PIH) is a widely studied and poorlyunderstood condition that remains responsible for 15% of maternaldeaths in the United States, second only to embolism. It involves sys-temic vasospasm that can lead to poor perfusion and eventually tissueischemia, affecting placental blood flow and the maternal cardiovascu-lar, renal, neurologic, hepatic, and hematologic systems. Often usedsynonymously with the term preeclampsia (and once called toxemia), Chapter 3
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 91 PIH complicates 6–8% of pregnancies and may be superimposed on un-derlying chronic hypertension. It is more common in African Ameri-cans, women with multiple gestation, teenagers of lower socioeconomicclass, diabetics, and women over 35. Other maternal risk factors are nul-liparity (or first baby with a new partner), family history of PIH, under-lying chronic hypertension, chronic renal disease, and antiphospholipidsyndrome (an autoimmune clotting disorder). The fetus of a womanwith PIH may suffer growth restriction and hypoxia or experience thechallenges of premature birth.
Dietary, immunological, genetic, and hemodynamic factors have been implicated in PIH, but researchers do not fully understand the dis-ease or its etiology. Central to the condition is vasospasm, which leads toincreased resistance to blood flow with resultant hypertension that canlead eventually to multisystem organ damage. Hypertension can leaddirectly to cardiac failure, brain hemorrhage, or pulmonary edema.
Kidneys damaged by restricted blood flow are poor filters that allowproteins to escape the bloodstream while allowing toxins to remain; insome cases kidneys may fail altogether. A poorly perfused liver may pro-duce fewer blood proteins, the lack of which allows fluid to escape fromblood vessels and cause edema. Liver damage also elevates hormone andtoxin levels (the liver metabolizes both) and interferes with clotting andother vital processes. Abnormal liver-function tests with elevation ofliver enzymes are often seen with PIH, and occasionally the liver will be-come necrotic or rupture. Central nervous system involvement cancause convulsions, coma, altered mental status, and cortical blindness.
The woman with PIH may experience significant third-spacing as fluidmoves from her intravascular space to the interstitial space, causingedema and intravascular depletion. The woman may also experienceplacental abruption or DIC.
Preeclampsia is a condition classically distinguished by a triad of hypertension, proteinuria, and generalized edema developing in the sec-ond half of pregnancy; but symptoms can vary widely between individ-uals. Preeclampsia is a progressive disorder, and in its mild or early formsymptoms can develop subtly and appear benign.
Hypertension in pregnancy is defined as a sustained elevation of blood pressure to 140/90 or above. Research once suggested that an in-crease of 30 mmHg systolic and 15 mmHg diastolic over baseline wasdiagnostic of PIH, but this concept is outdated. Generally, blood pres-sure elevation that begins after 20 weeks is considered preeclampsia.
Hypertension before 20 weeks is usually a manifestation of preexistingchronic hypertension. The exception is the patient with hydatidiformmole—whereby the patient exhibits signs of preeclampsia during eitherthe first or early in the second trimester.
Generalized edema may be present, but because edema is com- monplace in pregnancy and one-third of women with preeclampsia URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 92 never demonstrate edema, the presence of edema is no longer seen asimportant to diagnosis. Proteinuria, measured routinely with a dip-stick at office visits or more precisely though 24-hour urine collection,is not evaluated in the prehospital setting, but a reading of 2 orgreater on dipstick or greater than 300 mg of protein in a 24-hoururine is significant.
While the woman with mild preeclampsia may be managed at home on bed rest, severe preeclampsia is an emergency situation. Severepreeclampsia may develop suddenly and presents with • Hypertension with a systolic pressure of 160 mmHg or greater and
a diastolic pressure of 110 mmHg or greater.
• Proteinuria. Abnormal amounts of protein in the urine.
• Oliguria: Urine is dark, concentrated, and scanty.
of protein in the • Visual disturbances: Blurred or double vision, flashing lights, or
spots before the eyes. Visual disturbances can indicate impendingseizure. Loss of vision may precede cerebral hemorrhage.
• Hyperreflexia: Exaggerated patellar reflexes.
Exaggerated patel- • Epigastric pain: Liver ischemia, swelling, or rupture can cause epi-
lar reflexes, some- gastric pain or tenderness in the right upper quadrant.
• Nausea and vomiting.
• Pulmonary edema.
• Poor blood clotting.
• Fetal distress or poor growth; decreased amniotic fluid.
• Headache: Can be bitemporal, frontal, occipital, or diffuse; but it is
progressive and does not respond to over-the-counter remedies.
• Seizures (eclampsia).
• Anxiety, malaise, or restlessness.
• Cerebral hemorrhage.
The only cure for preeclampsia is delivery of the fetus. Some au- thorities advocate immediate induction if preeclampsia is severe, re-gardless of gestational age. Others support allowing pregnancy tocontinue in the hospital until the fetus demonstrates lung maturity, ma-ternal or fetal distress develops, or a gestational age of 34 weeks isachieved.
When preeclampsia progresses to seizures or coma, the condition istermed eclampsia. The usual presentation is tonic-clonic seizures lastingless than a minute following signs of severe preeclampsia. Partial seizures Chapter 3
URQUMC03_0131199900.QXD 8/8/05 9:43 PM Page 93 or complex partial seizures also can occur, and some patients will movedirectly into coma without observed seizure. Coma can also result from abrain hemorrhage or brain swelling without hemorrhage.
Convulsions can occur antepartum, during labor, or postpartum.
Most patients who develop eclampsia show marked edema, significantlyincreased blood pressure, and increased proteinuria prior to seizing; butup to 30% do not. Therefore, rather than trying to determine which pa-tients are at the highest risk, the EMS professional should remain alertwhen transporting any preeclamptic woman.
EMS Treatment and Transport of the Woman with PIH
Preeclampsia and eclampsia are life threatening to both mother and fe-
tus. It is important to take a comprehensive history, including assess-
ment for the signs of severe preeclampsia mentioned earlier using the
OLDCART checklist (see chapter 2), and to carefully document the in-
formation gleaned to serve as a baseline for hospital personnel.
Blood pressure can vary greatly with position. Pressure will usually diminish if she rests on her left side, and lower pressure increases per-fusion of her organs and placenta. See Figure 3-7. Therefore, it is prefer-able to take a baseline blood pressure while she is seated, then totransport her on her left side with subsequent vital signs taken in thatposition, taking care to use the proper-sized cuff. See Figure 3-8. Docu-ment position with each blood pressure. Record the fetal heart tones, iftaken. If she is complaining of dyspnea or coughing, assess for pul-monary edema and transport in Fowler's position. Assess and documentpatellar reflexes.
Left Lateral Position.
Placental perfusion is maximized when the pregnant woman is in a left lateral position.
Photographed by Bonnie U. Gruenberg
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 94 FIGURE 3-8
Transport of Woman with Severe Preeclampsia.
The woman with severe preeclampsia should be
transported in left lateral position, on oxygen, with
intravenous access in place and minimal noise,
jostling, or stimulation. Vital signs should be
Photographed by Bonnie U. Gruenberg
Make an effort to reduce environmental stimulation in order to de- crease the potential for seizures. The PIH patient should be trans-ported without flashing lights or sirens. Dim the interior lights andspeak quietly. Separate the patient from family members if they are ag-itating her.
Establish an intravenous line of normal saline and run it at a KVO (keep vein open) rate, and draw blood if required by protocol. Localmedical control may order an antihypertensive medication to reduce herblood pressure. Magnesium sulfate is sometimes used in prehospitalcare of preeclampsia to raise the seizure threshold, and it is the anticon-vulsant of choice in the hospital.
If the woman begins to seize, protect her from injury (as in any other seizure) and do not attempt to restrain her. Keep her airwayclear. Some protocols allow the paramedic to administer a bolus ofmagnesium sulfate (2–5 g diluted in 50–100 ml normal saline givenslow IV push) for eclampsia. Some protocols allow for diazepam(Valium) to stop the seizure, but apnea or cardiac arrest may result Chapter 3
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 95 from rapid administration. Suctioning may be necessary to maintainthe airway. Give oxygen to ensure adequate oxygenation, and supportrespirations in the unlikely event that spontaneous breathing doesnot resume when the seizure breaks. Monitor cardiac rhythm and vi-tal signs.
The seizure will be followed by a postictal period, and she may be- come agitated as she regains consciousness. The provider should moni-tor the woman and fetus for signs of abruption following the seizure,including auscultating the fetal heart, checking for vaginal bleeding, andpalpating the uterus for rigidity. Listen to the mother's lungs frequently,because aspiration and pulmonary edema commonly occur witheclampsia.
The woman with preeclampsia can decompensate rapidly, moving from mild, ambiguous symptoms to full-blown eclampsia, organ dam-age, and fetal death in a very short time. Keep potential complications inmind while treating her, and monitor for the earliest indication of de-compensation, such as signs of abruption or central nervous system dys-function. Monitor her level of consciousness—remembering thatmagnesium sulfate can make a woman groggy, cause slurred speech andaffect muscle tone.
If you must assist delivery of a preeclamptic patient, remain vigilant for changes in her condition and take steps to keep her stimulation leveland blood pressure as low as possible. Position her on her side for de-livery, and do not coach forceful pushing or prolonged breath holdingwith each contraction. If a woman responds to natural urges, a womanwill usually push frequently for very short intervals, as in defecation.
This moves the baby down at a reasonable rate and results in better pla-cental oxygenation and improved maternal blood pressure (see PushingTechniques, chapter 6). Administer low-flow oxygen to maximize fetaloxygenation.
PEARLS When attending the delivery of a patient with preeclampsia, the
EMS provider remains vigilant for changes in her condition andkeeps her stimulation level low. Position her on her left side fordelivery, and discourage her from prolonged breath holding and forceful pushing. Instead, coach her to push in short grunts, as indefecation.
Because a woman with preeclampsia third-spaces fluids from her blood vessels to her interstitial spaces, she may not have the in-travascular reserve to tolerate blood loss after delivery. Rememberthat a woman with PIH is at high risk for eclamptic seizures for48 hours after delivery and occasionally may seize within 2 weekspostpartum.
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 96 The medical community has yet to agree on whether HELLP syndromeis a separate category of preeclampsia or a variant of severe preeclamp-sia. HELLP syndrome is a multiple-organ-failure syndrome that is lifethreatening to mother and fetus. Unlike preeclampsia, it is diagnosedonly through laboratory studies. The acronym describes the physiologic Table 3-1
Danger Signs in Pregnancy and Possible Causes
Sudden gush of fluid
Premature rupture of membranes, urinary incontinence,vaginal infection.
Placenta previa, placental abruption, bloody show,polyps, lesions of cervix or vagina. Sometimes a womanwill spot after a recent vaginal exam or intercourse.
Preterm labor, placental abruption, appendicitis, roundligament pain, gallbladder, urinary tract infection, renalcalculi, hydronephrosis, pancreatitis.
Many causes, some of them benign. May relate to hyper-tension, medications, low blood sugar, or orthostatichypotension.
Hyperemesis gravidarum, gastroenteritis, or other gas-trointestinal disorder. May occur with appendicitis, headinjury, or other condition. Patient requires hospital eval-uation if intake and output are poor.
Edema of hands, feet, or face
Preeclampsia. Pedal edema is often normal in pregnancy.
May be related to preeclampsia or may result from ten-sion headache, migraine, or head injury.
Severe leg pain
Thrombophlebitis; or may be leg cramps.
Preeclampsia; or may result from preexisting seizuredisorder or head injury.
Preeclampsia, gallbladder inflammation, heartburn.
Reduced urine output
Preeclampsia, poor fluid intake, renal dysfunction.
Urinary tract infection, vaginal or vulvar infection.
Absence of or decrease in
Fetal compromise or death, maternal distraction, medication, maternal obesity.
Premature labor; may also be triggered by urinary tractinfection or dehydration, uterine irritability.
Elevated temperature, chills
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 97 abnormalities that define the syndrome: Hemolysis, Elevated Liver en-
zymes, and Low Platelets.
The patient may present with the same symptoms as the preeclamp- tic—epigastric pain, chest pain or right upper quadrant pain, headache,nausea and vomiting, and malaise—but sometimes with very few phys-ical manifestations. Sometimes HELLP syndrome will develop beforesigns of preeclampsia appear. The patient with HELLP syndrome is of-ten transferred by ambulance from a community hospital to a tertiary-care facility, and in that case the EMS professional will know thediagnosis and laboratory findings. Otherwise, in the field, HELLP is in-distinguishable from any other case of preeclampsia and sometimes notrecognizable at all. Definitive treatment of antepartum HELLP involvesdelivery of the fetus, even if remote from term. Rarely, HELLP may de-velop postpartum.
Triaging the Pregnant Woman Pregnancy alters the functioning of the healthy woman's body and canworsen certain preexisting conditions. Some potentially life-threateningconditions occur only during pregnancy. Table 3-1 lists potential dangersigns and symptoms and their possible etiologies.
While a majority of pregnancies proceed without complication, a signif-icant percentage develop problems that could become life threatening.
Many complaints are difficult to diagnose even in a hospital. Conditionssuch as urinary tract infections, deep vein thrombosis, and cholecystitisoccur in the nonpregnant population, but pregnancy can increase boththe incidence and severity of these problems. Disorders such as hyper-emesis gravidarum and preeclampsia develop only in pregnant women.
Because of the intimate connection between mother and fetus, mostconditions that prove catastrophic to one party necessarily affect the lifeand well-being of the other.
Complications of pregnancy can present a formidable challenge in the field. The mastery of basic principles remains paramount. For thepresent discussion, the most important of these are • Any female of apparent reproductive age may be pregnant.
• Any pregnancy may have undiagnosed complications or may
become complicated without warning.
URQUMC03_0131199900.QXD 8/5/05 1:50 PM Page 98 Describe the signs and symptoms of placental abruption and how it can be differenti-ated from placenta previa.
Describe the field management of a patient with first trimester bleeding.
Describe potential complications of preeclampsia.
What are some nonobstetric causes of abdominal or pelvic pain that may be experi-enced by the pregnant patient? List some conditions that present with similar signs and symptoms to ectopic pregnancy.
Drugs 2012; 72 (17): 2187-2205 Adis ª 2012 Springer International Publishing AG. All rights reserved. Advances in Drug Development forAcute MigraineRyan J. Cady,1 Candace L. Shade2 and Roger K. Cady2 1 Center of Biomedical & Life Sciences, Missouri State University, Springfield, MO, USA2 Banyan Group, Inc., Springfield, MO, USA Triptans revolutionized medical recognition and the acute treatment of