Emergency Medicine

CONDITIONS IN L ATE PREGNANC Y

388 Obstetric and Gynaecological Emergencies

(b) loss of fetal heart acceleration to fetal movement, or late

deceleration after uterine contractions.

3 Important causes of fetal distress or fetal death in trauma include maternal

hypovolaemia, placental abruption and uterine rupture.

(i) Signs of placental abruption vary from vaginal bleeding,

abdominal pain, tenderness, increasing fundal height and

premature contractions, to maternal shock.

(ii) Signs of traumatic uterine rupture, which occurs more commonly

in the second half of pregnancy, range from abdominal pain, to

maternal shock or a separately palpable uterus and fetus.

4 Continue fetal monitoring with CTG for a minimum of 6 h, even after appar-

ently minor maternal trauma.

5 Give all rhesus-negative mothers anti-D immunoglobulin 625 IU i.m. (500

units i.m. in the UK).

6 Call the obstetric team to review and admit every pregnant trauma case. Call

the paediatric team in addition if the fetus is >24–26 weeks gestation and

immediate delivery is indicated.

Cardiopulmonary resuscitation in late pregnancy

DIAGNOSIS

1 Causes of cardiac arrest in late pregnancy include cardiac disease and aortic

dissection, pulmonary embolism, psychiatric disorders including drug

overdose, hypertensive disorders of pregnancy, sepsis, uteroplacental bleed-

ing (ante- and post-partum), amniotic f luid embolus and cerebrovascular

haemorrhage.

2 Impaired venous return from inferior vena caval compression with the

patient supine by the gravid uterus renders resuscitation ineffectual unless

deliberately minimized, after 20 weeks gestation.

3 Rapidly gain i.v. access.

MANAGEMENT

1 Key interventions in cardiac arrest in pregnancy:

(i) Tilt the patient laterally using a wedge or pillow under the right

side, and displace the uterus by lifting it manually upwards and

to the left off the great vessels.

(ii) Give 100% oxygen and administer a fluid bolus.

2 Modifications to basic life support (BLS) in pregnancy:

(i) Apply cricoid pressure whenever administering positive-pressure

ventilation as there is increased risk of regurgitation and

pulmonary aspiration.