This chapter will focus on initial assessment and management and not on specific conditions (Boxes 9.1 and 9.2). There are numerous texts which will give the basic outline of symptoms for different pathologies.^2,³ More than 30 women die each year in the UK as a direct consequence of pregnancy. The Confidential Enquiry into Maternal Deaths 1997–99⁴ stated that ‘Women are still dying of potentially treatable conditions where the use of simple diagnostic guidelines may help to identify conditions such as ectopic pregnancy, sepsis and pulmonary embolism’.

The primary survey

All patients should be assessed using the ABCDE approach. Abdominal pain can be immediately life threatening (primary survey positive). Such cases need to be identified early so that appropriate care can start immediately (Box 9.3).

The unusual cause of shock-like syndrome in pregnancy is supine hypotension. If a pregnant woman is laid on her back for a prolonged period the uterus obstructs the inferior vena cava resulting in a drop in venous return, cardiac output and hypotension. If the uterus is palpable above the umbilicus, lie the patient in the left lateral position.

TIP

Do not lie a heavily pregnant woman on her back

Primary survey positive

These patients present in a variety of ways but airway and breathing assessment requires the same approach as in any other life-threatening situation. Shock is the main immediately life-threatening problem in patients with abdominal pain (Box 9.4).

Box 9.4 Common presentations of ‘primary survey positive’ patients

Collapse

Shock

Rigid abdomen

Heavy vaginal bleeding

Complications of labour

Shock can be due to either hypovolaemia or sepsis. On route to hospital obtain IV access and draw blood for cross-matching. Remember to complete the patient details on the blood specimen tube. No intervention should delay transfer to definitive medical care. IV fluid resuscitation in abdominal haemorrhage should be based on the principle of hypotensive resuscitation, aiming to give enough fluid to maintain a radial pulse.⁴

TIP

If the radial pulse is palpable, the blood pressure can be assumed to be adequate. If absent, aim to give fluid until radial pulse is palpable again

These patients are likely to be in pain. IV opiate analgesia may be given en route but monitor the BP closely and titrate small doses in unstable patients. Evidence shows that pain relief does not affect subsequent clinical assessment and that it removes damaging physiological stresses and improves accuracy of examination ⁵ (Box 9.5).

The most common life-threatening problems are summarised in Box 9.3. However many common abdominal problems such as acute appendicitis can be life-threatening if not promptly diagnosed and treated. This emphasises the importance of reassessment of patients with continuing or worsening symptoms.

Consider potentially serious medical conditions not directly related to the gastrointestinal tract that can also present as abdominal pain (Box 9.6). A focused history and examination will help in identifying such cases (see below). Specific potential threats to life in women are shown in Box 9.7.

Box 9.6 Medical conditions presenting with abdominal pain

Inferior myocardial infarction

Pneumonia

Pulmonary infarction

Diabetic ketoacidosis

Inflammatory bowel disease

Pyelonephritis

Box 9.7 Potential threats to life in women

Ectopic pregnancy

Incomplete miscarriage

Genital tract trauma

Pulmonary embolism

Toxic shock syndrome

Ectopic pregnancy classically presents with vaginal bleeding and abdominal pain, but there may also be associated internal bleeding which may give rise to shoulder tip pain. The degree of shock may be disproportional to the observed blood loss. The woman may be unaware of pregnancy and may not give a history of a missed period. These patients need fast transport to an appropriate unit. Obtain venous access en route if possible. Give enough fluids to maintain the radial pulse and high flow oxygen. Alert the receiving unit and ensure the gynaecologist is aware.

An incomplete miscarriage may result in products of conception caught in the cervix which leads to profound vagal stimulation with bradycardia and shock. These patients need urgent hospital admission because removal of these products will lead to a rapid clinical improvement and reduction in bleeding. Any tissue passed should accompany the woman to hospital.

Pulmonary embolism is still responsible for a number of maternal deaths. Have a low index of suspicion and refer pregnant women with shortness of breath or pleuritic chest pain.

Toxic shock syndrome is caused by invasive staphylococcal or streptococcal infections and is usually associated with tampon use. The picture is one of septicaemic shock. Manage by fast transport, IV access en route and oxygen.

Problems in later pregnancy

A number of complications of pregnancy pose potential threats to life, not only for the mother but also to the fetus (Box 9.8). This is a very high risk area of practice where the inexperienced practitioner must ask for the patient to be reviewed by the obstetric team.

Box 9.8 Potential threats to life in late pregnancy

Placental abruption

Placenta praevia

Pregnancy-induced hypertension (pre-eclampsia and eclampsia)

Pulmonary embolism

Pre-eclampsia is a condition specifically associated with pregnancy, usually but not always occurring in the late stages of pregnancy. Classically it presents with hypertension, proteinuria and oedema (Box 9.9). When the condition worsens the woman may complain of upper right sided or epigastric abdominal pain, headache, nausea and vomiting. She may become confused and have very brisk reflexes. Fitting can then follow. Unless the woman is a known epileptic, any fit in pregnancy is managed as a probable eclamptic fit. Fits due to eclampsia may pose significant airway problems. Manage these as in any other fit by simple airway manoeuvres. If the fit is not self-limiting intravenous diazemuls should be given supplemented by magnesium sulphate once the patient arrives in hospital. It is also essential to control the blood pressure as soon as possible. Urgent transfer to an obstetric unit is required.