1. Prehospital Management of the Pregnant Patient
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Prehospital Management of the Pregnant Patient

2. Introduction
Variety of anatomical and physiological changes during pregnancy
Most cases, minimal impact on the mother
Care can present unique challenges
Always remember you are caring for two patients
Mother & Fetus

3. Terminology Antepartum Gravidity Multigravida Multipara Natal
Time interval prior to delivery of fetus
Gravidity
Number of times pregnant
Multigravida
Has been pregnant more than once
Multipara
A female who has delivered more than one child
Natal
Birth
Nulligravida
Has not been pregnant

4. Terminology Nullipara Parity Postpartum Prenatal Primigravida
A female who has not delivered a child
Parity
Number of times a viable fetus has been delivered
Postpartum
Time interval after delivery of fetus
Prenatal
Time interval prior to birth, synonymous with antepartum
Primigravida
Pregnant for the first time
Primipara
A female who has delivered her first child

5. Anatomical & Physiological Changes

6. Placenta Normally develops in the endometrium Several function
Mucus membrane that lines uterus
Several function
Exchange of respiratory gases
Transports nutrients to fetus
Produces hormones
Umbilical cord connects the placenta to the fetus
Present from week 6 to delivery
Contains 1 vein and 2 arteries
Vein delivers nutrients to fetus
Arteries transport wastes from fetus

8. Amniotic Sac Membranes that cover the fetus
Provides protect for the fetus
Environment that is optimal for fetal development
Up to 1000cc of fluid present
Maintained by fetal urination and swallowing of fluid

9. Fetal development
Begins immediately following implantation of a fertilized egg
Normal duration is 40 weeks
Often described in trimesters
First trimester 1-15 weeks (1-3 months)
Second trimester weeks (4-6 months)
Third trimester weeks (7-9 months)
Also described in halves
1-20 weeks
20-delivery

10. Nine Week Gestation

11. Fetal Development Time Frames
End of 3rd month
Determine fetal sex
After 13 wks, major organs developed
End of 5th month
Fetal heart tones audible with stethoscope
Movement of baby
Middle of 9th month
Baby is “term” or fully developed

12. Oxygen delivery to fetus
Fetal oxygenation dependent on mother’s arterial oxygen content and uterine blood flow
Uterine blood flow (total cardiac output)
Normally 2% in non-pregnancy
18% during third trimester
Any factor that affects maternal oxygenation will have profound affect on fetus
Hypotension
Vasoconstriction of uterus

13. Maternal System Changes

14. Cardiovascular Undergoes unique changes during pregnancy
Total uterine blood flow increases from 60mL/min to max of 600mL/min
Maternal total blood volume increases by 40%
Cardiac output increases 50% by week 10
Maternal heart rate increases 15BPM by week 12
Normal range during pregnancy (120% of baseline)
May experience BP rise 5-15mmHg
Mostly due to decreased PVR
Greatest occurs by week 24
Factors reducing BP include
Dilation of peripheral blood vessels
Presence of placental circulation

15. Cardiovascular Importance of changes:
Any stress on cardiovascular system, fetal blood flow will be sacrificed
Response will benefit the mother
Fetus will suffer
Prompt recognition and correction of condition will be life-saving to mother and fetus

16. Blood Pressure
Most pregnancies maternal BP is lower than non-pregnant state
Hypertension can occur during pregnancy
Borderline hypertension prior to pregnancy
May become dangerously elevated
Complications:
Placental risk
Fetal compromise
Maternal stroke
Renal system compromise

17. Blood Pressure
Hypertensive disorders occur in approx 10% of pregnancies
Etiology:
Abnormal maternal vasospasm
Increased circulating volume

18. Forms of Pregnancy-Induced Hypertension
Condition
Overview
Pregnancy-induced hypertension (PIH)
140/90 or greater
Currently pregnant and was normotensive prior to the pregnancy
Preeclampsia
The above, plus: abnormal weight gain, headaches, edema, protein in the urine, abdominal pain that is epigastric in nature, and potential visual impairments
Eclampsia
The above, plus: seizure activity
Visual disturbances including flashing lights or spots
Epigastric pain and/or upper right abdominal pain

19. Blood Pressure
More common in first pregnancies, pre-existing hypertension and DM
Higher risks for complications:
Cerebral hemorrhage
Renal failure
Pulmonary edema
Focus questioning on:
Excessive weight gain
Visual difficulties
Headaches
Abdominal pain
Seizures

20. Preeclampsia Occurs in as many as 10% of pregnancies
Second most common cause of maternal mortality after 20wks
Primary cause remains unclear
Complications include compromise of:
Cardiovascular
Neurologic
Hepatic
Uteroplacental
Renal system

21. Preeclampsia Risk factors include: Family history Nulliparity
Age greater than 40
African-American race
Chronic hypertension
Renal disease
Diabetes
Multiple gestations

22. Preeclampsia Classified as mild or severe Mild Severe Hypertension
Edema
Proteinuria (protein in urine)
Severe
Headache / Visual disturbances (cerebral vasospasm)
Shortness of breath (pulmonary vasospasm)
Epigastric or right upper quad pain (hepatic compromise)

23. Eclampsia Seizures during pregnancy considered to be eclampsia
Determine other possible causes
Hypoxia
Hypoglycemia
Sepsis
Drug overdose
Prompt recognition is critical (fetal oxygenation/circulation)

24. Treatment of Hypertension
Needs careful evaluation
Treatment may compromise maternal/fetal outcome
Severe maternal hypertension (SBP>160 or DBP>110)
Increased risk of intracranial hemorrhage
Increased risk of placental abruption
Part of goal is to avoid sudden decrease in BP
Difficult to control pre-hospital

25. Supine-hypotension Syndrome
Results in decreased BP
Occurs mostly during 3rd trimester and in 25% of pregnancies
Weight of gravid uterus in supine patient places pressure on inferior vena cava reducing maternal blood return
Reduction in cardiac output
May reduce by 30mmHg and decrease blood flow to placenta

26. Supine-hypotension Syndrome
Managed through appropriate patient positioning
Have the patient lay on their left side
Will help deflect the uterus off the vena cava
Preventing the patient in a supine position helps to alleviate unwanted hypotensive episodes

27. Respiratory Undergoes changes during pregnancy
Diaphragm elevated up to 4cm and functional capacity reduced by gravid uterus
Anteroposterior and transverse diameter of chest increases
Increased wall circumference
Vital capacity remains unchanged
Tidal volume may increase by 40%
Chest wall and total respiratory compliance may be reduced in late term

28. Hormonal
A number of hormonal changes occur that influence maternal systems
Changes may affect
Upper respiratory system (congestion) hyperremia
Mucosal edema
Hypersecretion production
Increased levels of estrogen
Tissue edema
Capillary congestion
Hyperplasia (increased production of cells) of mucous glands

29. Gastrointestinal
Gastric motility is reduced with bowels moved in a superior direction
Peritoneum and abdominal walls stretched and bladder displaced
Increased risk of aspiration
Greater risk of injury to bladder & upper abdominal contents
Inaccurate abdominal assessments

31. Gastrointestinal
After 12th week, uterus rises out of pelvis and is no longer protected
Increased blood flow to uterus increases danger of trauma to uterus

33. Gastrointestinal Additional symptoms Nausea and vomiting
During 1st half of pregnancy 50% experience N/V
Less than ¼ experience N/V throughout the pregnancy
Constipation due to progesterone can also occur

34. Complications of Pregnancy

35. Medical Pregnancy can influence pre-existing medical conditions
Can contribute to onset of new conditions
Gestational diabetes
Affects as many as 4% of pregnancies
Once born the infant may not be free of the complications
Infants may be born larger
Difficulty controlling body temperature
More likely to be diabetic
Pre-existing diabetics may have more difficulty in controlling disease
Hypoglycemia affects fetus

36. Vaginal Bleeding Warrants careful assessment
May result from a variety of conditions
Timing and severity may vary
May not be possible to determine exact cause of bleeding
Questioning:
When the bleeding started
Estimated rate of flow (pads/hr)
Pain associated
Trauma was involved

37. Potential Causes of Bleeding in Pregnancy
Bleeding during first half of pregnancy
Bleeding during second half of pregnancy
Threatened spontaneous abortion
Inevitable spontaneous miscarriage
Incomplete spontaneous miscarriage
Complete spontaneous abortion
Ectopic pregnancy
Molar pregnancy
Vaginal trauma
Non-pregnancy related trauma
Placenta previa
Placenta abruption
Cervical lesion
Vaginitis
Cervicitis

38. Vaginal Bleeding
Spontaneous abortion may or may not be associated with bleeding
Defined as a termination of pregnancy prior to fetal viability and can occur in 15% of pregnancies
Signs and symptoms vary greatly from patient to patient
Traditional S/S include
Abdominal cramping
Pain
Vaginal bleeding or discharge

39. Some Types of Abortion Spontaneous Threatened Incomplete Inevitable
Description
Spontaneous
Occurs on its own time frame, often within 2wks of conception. May be confused for a menstrual period.
Threatened
Cervix opens and places fetus at risk. Any amount of uterine bleeding in 1st 20wks without passage of tissue or cervical dilation.
Incomplete
Loss of some but not all fetal tissue
Inevitable
Fetus has not passed and pregnancy cannot be saved. Bleeding and cervical dilation in 1st 20wks; assoc with profuse bleeding and cramping

40. Some Types of Abortion Criminal Therapeutic Elective Complete Missed
Description
Criminal
Attempt to terminate pregnancy by non-licensed/trained individual
Therapeutic
Mother’s health is at risk. Procedure is considered to be medically justified
Elective
Mother makes a request for procedure to be performed
Complete
Passage of all fetal tissue; often accompanied by decrease in cramping, bleeding
Missed
Intrauterine pregnancy exists but development has ceased

41. Vaginal Bleeding
Embryonic abnormalities account for 75% of 1st trimester spontaneous abortions
Maternal causes contribute to a majority of 2nd trimester abortions
Maternal IDDM
Hypertension
Renal disease
Infection
Potential contributing factors
Caffeine
Alcohol
Tobacco
Cocaine

42. Ectopic Pregnancy
Occurs when a fertilizer ovum implants outside the uterus
Fetal development normally does not exceed 10wks
Leading cause of pregnancy related deaths in 1st trimester
Accounts for 10% of maternal deaths
Teens of minority races more common than whites
More common among women 25-34

43. Ectopic Pregnancy Should be considered a medical emergency
If rupture occurs, hemorrhage into abdominal or pelvic cavity
May erode fallopian tube wall if occurs there
Leads to intra-abdominal bleeding without vaginal bleeding
If bleeding is involved, it may be minimal

44. Ectopic Pregnancy Predisposing factors: Variety of complaints PID
Tubal ligation
Fertility pills
IUD
Variety of complaints
Abdominal pain
Referred shoulder pain
Vaginal bleeding

45. Abruptio Placenta
Premature separation of the placenta from the uterine wall
Can be partial or complete
May have no bleeding
May have lots of bleeding
Leads to reduction or termination of gas exchange
Predisposing factors:
Preeclampsia
Maternal hypertension
Multiparity
Abdominal trauma
Short umbilical cord

46. Abruptio Placenta
Bleeding occurs mostly behind the placenta, minimal external
If the placenta abruptly separates, bleeding can be severe
Symptoms:
Constant, severe abdominal pain, tearing in nature
Bleeding may be dark in color
May complain of contractions
Loss of fetal movement

48. Placenta Previa
Placenta attaches low in the uterus resulting in a partial or complete obstruction of the internal cervical opening
Can be complete, partial or marginal
Predisposing factors:
Women over 35
Multiparity
Pregnancies of rapid succession
Occurs in 5 in 1000 pregnancies
Less than 1% are fatal to mother

49. Placenta Previa
Most cases are in 3rd trimester with history of the complication
Bleeding may be painless and bright red
May or may not be associated with contractions, cervical dilation or placenta separation
Bleeding is the hallmark sign

52. Trauma Estimated that 5-20% of pregnancies are complicated by trauma
Over ½ of the pregnancy related trauma cases are a result of MVA and falls
Major trauma affects about 5% of pregnancies
Maternal death is the main cause of fetal death

53. Trauma Aggressively caring for the mother is best for the fetus
Many fatal fetal injuries are not apparent in the field
Placental shear major cause of fetal compromise
In 70% of fetal deaths, the mother lives

54. Trauma Potential for circulatory volume loss great
Fetal tolerance to maternal blood loss is impacted by several factors:
Maternal sympathetic response
Tachycardia / Vasoconstriction
¼ of maternal blood loss can cause reaction
Oxygen carrying capacity of maternal blood
Maternal BP

55. Assessment Assessment varies slightly to non-pregnant patient
Questions specific to pregnancy
Remember organs may be displaced
After 12th week, uterus may rise out of pelvic protection
Consider fundal location in trauma assessment
Medical questions directed at complaint
Vital signs should be assessed with patient on her left side

56. Management Consideration for 2 patients
Best way to treat the fetus is to treat the mother
Begin with the ABC’s
Aggressive airway management may prove to be invaluable
Administer O2 at liberal flows
Carefully evaluate the use of medications
Administration of IV fluid will be influenced by maternal assessment

57. Prehospital Treatment
Condition
Treatment Summary
PIH
Consider treating HTN using antihypertensive appropriate for use in pregnancy
Preeclampsia
Keep patient calm; reduce disturbances. LLR position. Depending on patients condition and transport time, consider use of Mag Sulfate
Supine-Hypotensive Syndrome
If no signs of volume depletion, consider placing in LLR position. If there are signs of volume depletion, consider volume replacement
Braxton-Hicks contractions
May be normal for many pregnancies and may not require interventions. If required, labor may need to be stopped. Contact Med Cont.

58. Prehospital Treatment
Condition
Treatment Summary
Cephalopelvic disproportion
Monitor vital signs. Cesarean section may be needed.
Prolapsed cord
Mother in Trendelenburg. If presenting part is against cord, use 2 gloved fingers to relieve pressure on cord. Check for cord pulsations.
Shoulder dystocia
Mother on edge of bed. Open hand above symphysis pubis; apply firm but gentle pressure.
Precipitous delivery
Attempt to support and control baby’s head.
Postpartum hemorrhage
Fluid replacement. Consider Pitocin; contact Med Cont

59. Management Trauma patients need traditional management techniques
May not be optimal to place mother in supine position
If mother becomes hypotensive, maintain ABC’s and immobilization
May require creative packaging

60. Conclusion Knowledge of maternal / fetal physiology is paramount
Keys points to remember:
Patient can appear well despite having a dangerous injury
Hypotension should be managed with LLR position
Treating the mother is the best way to treat the fetus

61. Questions???