CONDITIONS IN L ATE PREGNANC Y384 Obstetric and Gynaecological Emergencies
Terminology
Two terms are easy to confuse in obstetric practice:
● Gravida is the number of times a woman has been pregnant, with twins
counting as one. A first pregnancy is a ‘primigravida’.
● Parity is defined as the number of times a woman has given birth to a fetus
with a gestational age of 24 weeks or more.Antepartum haemorrhage
DIAGNOSIS AND MANAGEMENT
1 Vaginal bleeding after 24 weeks gestation can be a life-threatening
emergency, particularly if associated with placenta praevia, placental abrup-
tion or uterine rupture.
2 Placenta praevia
(i) This is classically associated with painless vaginal bleeding and
uterine hypotonia, although mild abdominal cramping pain may
occur if a small abruption coexists.
(ii) Abdominal examination confirms a ‘soft’ uterus with a high
presenting part.
(iii) The fetal condition is usually good and obstetric management is
often conservative.
3 Placental abruption
(i) This is associated with minor trauma, pre-eclampsia, essential
hypertension, a history of previous abruption, and use of cocaine.
(ii) Patients present with severe lower abdominal pain and vaginal
bleeding if the abruption is ‘revealed’. Examination shows a hard
‘woody’ uterus, which is painful to palpate.
(iii) There is a high incidence of fetal demise prior to delivery.
4 Never perform a vaginal or speculum examination in the ED on a patient
with an antepartum haemorrhage, as this may precipitate torrential vaginal
haemorrhage from a low-lying placenta.
(i) Such examination should only be performed by an experienced
obstetrician in an operating theatre prepared for an immediate
caesarean section, preferably after an urgent ultrasound scan.
5 Give oxygen, place the patient in the left lateral position, insert two large-
bore i.v. cannulae and send blood for FBC and coagulation profile, and cross-
match 4 units. Start an i.v. infusion if the patient is hypotensive or shocked.
6 Give non-sensitized rhesus-negative mothers anti-D immunoglobulin
625 IU i.m. (500 units i.m. in the UK).
7 Request an ultrasound to differentiate the potential causes of antepartum
haemorrhage. It can localize the placental position and determine the
presence and size of a concealed abruption bleed.
8 Refer the patient immediately to the obstetric team.