Pregnant Pause

The day has been unusually busy for the Attack One crew. It’s been full of injuries, several severe, and it seems almost every patient has required transport to the regional trauma center. As the crew cleans the kitchen after dinner, the tones drop for a response to a “woman ill.” That should be a different type of patient on this day of blood and injury—or maybe not.

“She is bleeding like crazy!” says the lady who answers the door. “She keeps bleeding and then trying to pass out!”

“I am feeling really light-headed,” the young woman lying in the bathroom tells the crew as they walk in to assess her.

She is 26 years old and says she began bleeding from her vagina about an hour earlier. Her lower abdomen has some mild crampy pain. She is pale, and her heart rate is elevated as the EMT kneels next to her to begin an assessment. The paramedic begins to get a rapid history: “Ma’am, do you know why you might be bleeding so much? Is this usual for you? Are you on your menstrual period?”

The woman asks that the door to the bathroom be closed and that the older woman be asked to leave.

As this occurs the female EMT finishes getting vital signs and, as part of her examination, presses on the patient’s abdomen. She notes that hidden under her clothes appears to be a protuberant lower abdomen. The EMT looks at the paramedic, and as the door to the bathroom closes asks the patient, “Are you pregnant?”

“I think I am,” the woman replies, “but I haven’t been checked for a long time, and I don’t want my mother to know I am. That’s why I wanted her to leave.”

The EMT asks if she can examine the young lady’s abdomen, and the patient consents. She pulls up her shirt, and it certainly appears she’s pregnant from the size of the uterus above the umbilicus. The uterus and the rest of the abdomen are not tender on palpation, and the EMT confirms that bright red blood and clots are coming from the patient’s vagina.

The paramedic begins to move quickly through the rest of the evaluation and asks that the crew prepare for rapid transport. He also notices the woman’s pulse is very difficult to palpate, and her heart rate is rapid. Her skin is pale, she’s a little sweaty, and her capillary refill is slow. These signs of poor perfusion are consistent with an initial pulse oximeter reading in the low 90s, indicating a need for rapid transport.

“Where have you been examined for your pregnancy, and where are you going to deliver your baby, ma’am?” the paramedic asks.

“I don’t know. I was seen in a clinic, where they told me I was around 14 weeks pregnant, and I haven’t seen anyone else. I don’t have a hospital I go to. Can you just take me to the hospital up the street, and I’ll tell my mother to come later and pick me up? I don’t want her to know anything.”

“How long ago were you told you were 14 weeks pregnant?” the paramedic asks.

“It was a while ago—maybe 4 months.”

Quickly doing the math, the paramedic estimates the woman would now be at least 30–32 weeks pregnant. The EMS protocol for emergencies with pregnant women calls for the patient to be transported, if possible, to a hospital capable of dealing with a crisis delivery, with a high-level neonatal intensive care unit for the child. That means the closest hospital, the one “up the street,” will have to be bypassed, as it has no labor and delivery unit.

“Ma’am, there is obviously an emergency going on with the bleeding you’re having,” the paramedic says. “The hospital up the street does not have any of the services you need. We’ll need to take you to a hospital that has a women’s services unit. Can you please tell your mother that we are transporting you to that hospital? We will not say anything about the reason. You’ll probably need to stay at that hospital for a while, so don’t expect your mother to be picking you up today.”

The patient says she’s dizzy, like she’s going to pass out again. The crew has her on the cot, so they lower her head and place the first-in bag under her legs. Then they move her to the ambulance, place an intravenous line and deliver a bolus of fluid. The patient is comfortable rolled toward her left side, but her pulse rate and perfusion don’t improve much. The crew notifies the medical control physician in the emergency department and directs the patient to the hospital’s labor and delivery unit. Although the patient is unclear about her estimated weeks of pregnancy, the combination of a uterus higher than the umbilicus and her rapid bleeding means the services in the labor and delivery unit will be more appropriate.

Hospital Course

The patient and crew share the history with the staff there. Based on the history relayed on the phone, the obstetrical physician has prepared the ultrasound machine. She quickly scans the patient’s abdomen and finds the bleeding is from an abnormal location of the placenta. The child is between 36 and 38 weeks.

After a rapid explanation to the young lady about her condition and that of the child, the staff moves the patient to an operating room to perform an emergency cesarean section. The child is delivered successfully, and the bleeding stopped with removal of the placenta. The young lady makes an excellent recovery.

The grandmother, after her initial surprise, is thrilled at the news of a beautiful new granddaughter.

Case Discussion

Emergencies in women in the third trimester of pregnancy can have a wide range of causes. There are two common and important problems related to the position and integrity of the placenta, which is the key area where the baby and mother exchange nutrients and waste.

Placenta previa is the placenta being positioned down too low in the uterus, near the opening of the cervix. It is typically higher in the uterus and away from that opening. The position of the placenta is typically checked during the pregnancy using ultrasound, but in some patients the placenta moves quickly between examinations, and the woman has no idea a problem is evolving. In some cases, such as this one, the mother-to-be does not get checked after her initial physician visit confirming her pregnancy, and the position of the placenta is not known.

Placenta previa typically evolves with no symptoms until the woman bleeds. This can occur in the second and third trimesters. It can present with sudden unexpected bleeding. There is typically little pain, but bleeding can be severe and threaten the lives of the mother and child.

Placental abruption, the separation of the placenta from the uterine wall, causes disproportionately bad pain but typically no bleeding. These patients will often present with crampy lower abdominal pain.

This patient had placenta previa. This complication occurs in about 1 of every 200 patients. It is more common in women who have had multiple children or a prior cesarean section, or are older. The typical patient has the condition detected on prenatal screening by her obstetrician. After a placenta previa is found, the mother will be carefully monitored by the obstetrician or clinic. If severe bleeding occurs at any time late in the pregnancy, an emergency cesarean section may be done. Severe bleeding in a pregnant woman presenting to an EMS crew must prompt rapid removal to a labor and delivery center capable of performing this service. Only in an uncontrolled crisis should the mother be transported to an emergency department or hospital without a labor and delivery center.

This patient was found by the EMS crew with signs of poor perfusion. The key signs of shock were mental status change, tachycardia, pale and clammy skin, and a blood pressure that could only be palpated. As with trauma patients, signs of poor perfusion indicate a need for rapid transport and doing other procedures en route to the appropriate hospital.

With this patient, the site and amount of bleeding were obvious. Other third-trimester abnormalities may not have such evident sources of blood loss. Trauma to a pregnant woman can be rapidly life-threatening when blood loss occurs in the chest, abdomen or pelvis. Each of these areas can “hide” enough blood to cause shock.

Prehospital treatment for emergencies in third-trimester pregnancies includes placing patients in a left lateral position to avoid having the large uterus lying directly on the venous return system, initiating oxygen therapy, giving a bolus of intravenous fluids, and notifying the hospital of an unstable pregnant patient. Medical control can help determine whether the patient should be taken into the ED or directly to labor and delivery.

James J. Augustine, MD, FACEP, is medical advisor for the Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, and an editorial advisory board member for EMS World. Contact him at jaugustine@emp.com.