Triage of the Pregnant Female. Part 2.

Here is the second part of my notes from Kelly’s talk on managing the pregnant female at triage.

Part 1 covered the physiological changes in pregnancy and some tips during the initial evaluation at Triage.
Part 2 covers some of the common pregnancy related presentations that you may encounter at the Triage desk.

As I said in part 1, any errors or omissions are probably due to my poor transcription than from Kelly’s presentation. Corrections/additions welcomed.
OK,  lets get midwifical:

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Presentations less than 20 weeks.

Vaginal Bleeding.

IMPLANTATION

• Light vaginal spotting. May occur at time of expected period and so may be mistaken for this.

BLEEDING FROM CERVIX

• bright bleeding or spotting
• painless
• Resolves spontaneously

ECTOPIC PREGNANCY

• Pregnancy outside uterine cavity.
• ALWAYS Exclude in child bearing age or Hx of sterilization
• Occurs > 6wks. Ectopic pain develops when conceptus grows beyond capacity of tube.
• “Classic” Amenorrhoea, lower abdo pain, vaginal bleeding.
• “Acute” Sudden onset, generalised pain, +/- shoulder tip pain.
• “Sub acute” light period, followed by irreg vaginal bleeding. Also may be reported as abdominal pain & diarrhoea. May not be diagnosed as ectopic.
• High Risk for Haemorrhage, Potentially * Life Threatening
• P V bleeding late sign. There may be signs of shock before this.

MISCARRIAGE/ABORTION

• Spontaneous < 12 wk
• Brownish Red = older
• Bright red-active bleeding
• Severe period pain
• Cervical shock- products trapped in cervix cause vagal response and hypotension
• Abnormal Vital Signs and Severe pain warrants urgent medical attention
• Expulsion of products < 20 weeks doesnt usually lead to hypovolaemia as placenta not normally well formed.
• Rh-ve mother should be given Anti-D within 72hrs of foetal maternal blood mixing- (eg miscarriage ,placental abruption) to prevent Rhesus Isoimmunisation.

VOMITING IN PREGNANCY

• “Morning sickness” is not confined to the morning.
• Nausia +/- vomiting common in 1st trimester in 85% women.
• Usually resolves in 12 to 14 weeks.

HYPEREMESIS GRAVIDARUM

• Excessive nausea and vomiting requiring treatment
• Commences 4–10wks lasting until 20wks
• Causes
  Dehydration
  electrolyte imbalance
  wt loss up to 10%
• Signs of severe dehydration include
  Dryness and reduced skin elasticity.
  Rapid Pulse.
  Hypotension.
  Dry furry tongue.
  Acetone breath.
• Etiology unknown
• Exclude non pregnancy causes
• Severe- jaundice occurs
• Complications:
  Wernicke’s encephalopathy: lack vit B1
  Hepatic and renal involvement lead to coma and death
• Termination may be considered to reduce maternal morbidity

Presentations greater than 20 weeks.

ANTEPARTUM HAEMORRHAGE

• Vaginal bleeding >24 weeks and prior to labour.
• Greater than 15mls blood.
• Immediate threat to mother and foetus.

Placenta Praevia:

• Premature separation of abnormally placed placenta. Lower segment implantation near or covering OS. Poorly anchored in uterine muscle….shearing and placental seperation as uterus enlarges or cervix dilates.
• Low lying placenta
• Painless vaginal bleeding
• Bleeding compromises mother and baby
• No Vaginal exam
• Urgent caesarian mother and foetus at risk

PLACENTAL ABRUPTION

• Premature separation of normally placed placenta after 22nd week not asociated with delivery.
  Occurs in varying degrees. Partial or complete.
• Abdominal pain +/- visable blood loss.
• Blood loss not a reliable indicator of extent of abruption.
• Predominent symptom: abdominal pain.
• CAUSES
  Multiple pregnancies
  Drug use eg cocaine
  Hypertension and Fitting
  Trauma to uterus
• Management
  Potential maternal shock
  Foetal monitoring
  +/- Urgent delivery

HYPERTENSION IN PREGNANCY

• SYSTOLIC BP >/= 140mmHg
• DIASTOLIC >/= 90mmHg
• RISK GROUPS:
  1st pregnancy
  Family history.
  Multiple pregnancy.
  Autoimmune Disease.

Hypertension >120/80 – alert triage of potentially more serious problem .

PRE-ECLAMPSIA

• Hypertension after 20th week with multisystem organ involvement
• Significant Risk to mother and foetus
• Symptoms:
  Headache
  Visual disturbances
  Epigastric pain
  RUQ pain
  Non-dependant oedema.
  RISK OF FITTING, PLACENTAL ABRUPTION AND PLACENTAL UNSUFFICIENCY

PREMATURE RUPTURE OF MEMBRANES

• Occurs < 37 weeks, without onset uterine activity
• Amniotic fluid ñclear straw coloured, distinct odour
• RISK OF
  INFECTION
  PRETERM LABOUR
  CORD PROLAPSE
  MALPRESENTION
  ANTEPARTUM HAEMORRHAGE

LABOUR

SIGNS OF LABOUR

• ‘Show’:  bloody mucous plug
• Contractions
  rhythmic and regular
  increasing strength and regularity
• Backache
• +/- Ruptured membranes

Delivery imminent if compulsive urge to push or presenting part on view

• Second stage from full dilation to delivery can last 5–10 minutes up to 2 hours.
• If in labour or ruptured membranes NO NOT transfer (eg to labour ward) on wheelchair or without escort.
• If labour is imminent DO NOT TRANSFER. We are going to have a baby people.