The Art of Obstetrical Triage Katherine Degen, MD Black Hills Ob/Gyn

Objectives Identify common obstetrical emergencies and immediate treatment Hypertensive disorders Vaginal bleeding Preterm labor Care of the pregnant trauma patient Physiologic changes unique to pregnancy Placental abruption Maternal fetal hemorrhage and Rh disease Approach to the patient without prenatal care Identification of medical issues Identification of social barriers Initial evaluation and testing

Basics of Triage Proceed with high level of suspicion Sick or not sick Appropriate location to evaluate patient Term vs Preterm Vitals Medical comorbidities Pregnancy complications Capabilities of facility EMTALA Proceed with high level of suspicion Something is wrong until proven otherwise

Bread and Butter of Triage Labor check Term vs Preterm Membrane rupture check Decreased fetal movement Vaginitis Urinary tract complaints

Common Obstetrical Emergencies: HTN Chronic HTN HTN prior to 20 weeks gestation Gestational HTN HTN after 20 weeks gestation Preeclampsia With/without severe features BP 140/90, +/- proteinuria, low plt, high LFT, renal failure, cerebral disturbances, etc Chronic HTN with superimposed preeclampsia Eclampsia Preeclampsia + seizure

Hypertension in Pregnancy Assess level of hypertension Neurological symptoms? Headache/visual changes Stroke sx Is it preeclampsia? Signs and symptoms of placental abruption? Other potential causes for hypertension? Administer antihypertensive medications per the ACOG “Emergent Therapy for Acute-Onset, Severe Hypertension in Pregnancy and Postpartum.”

Hypertension in Pregnancy Initial workup CBC CMP Urine dip UDS Spot urine protein to creatinine ratio NST Ultrasound IV access

Common Obstetrical Emergencies: Vaginal Bleeding Very common complaint amongst pregnant women Sources Vagina Rectum Bladder Cervix Uterus/Placenta/Membranes Painful= abruption, labor, uterine rupture, vaginal laceration, UTI, anal fissure Painless= placenta previa, vasa previa, hemorrhoid, post coital cervical bleed

Vaginal Bleeding in Pregnancy Assess quantity and patient status (both of them) Other physical signs Uterine contractions, previous cesarean scar What was patient doing when bleeding started? Trauma, intercourse Examine the perineum/vagina Where is it really coming from? Know where her placenta is prior to digital vaginal exam!! Sterile speculum with caution 500ml/min blood flow to uterus at term…

Vaginal Bleeding in Pregnancy Initial Workup CBC +/- type and screen At least know her Rh status from records IV access Coags Remember fibrinogin is normally elevated in pregnancy, a normal value is not necessarily reassuring Do not let her leave without Rhogam if indicated!!

Common Obstetrical Emergencies: Preterm Labor Labor: Uterine contractions along with cervical change Term: > 37 weeks gestation Risks are numerable History of PTB, short cervix, ROM, multiple gestations, drug use, UTI, smoking, eco status 50-80% of admissions are later discharged and deliver at term

Preterm Labor How long have the contractions been present? Increasing in frequency and strength? Trauma? Urinary or vaginal symptoms? Pregnancy history? Leakage of fluid? Last intercourse? Vaginal bleeding?

Preterm Labor Initial Workup Sterile speculum exam vs digital exam Fetal fibronectin Recent intercourse/vaginal exam, vaginal bleeding= false positive Toco pattern CBC UA/UDS GBS Assess fetal position

Preterm Labor Optimize Fetal Outcome if delivery imminent Antibiotics for GBS unknown or positive status Betamethasone for lung maturity Now up to 37 weeks!! Think about diabetes, have they had a GTT? Magnesium for neuroprophylaxis Try Terb to get Time To Transfer… but no ambulance/helicopter unstable patients

Care of the Pregnant Trauma Patient THE LEADING CAUSE OF MATERNAL DEATH (NON-OBSTETRICAL) 20% of maternal deaths are from trauma Trauma affects 1:12 pregnant women Most importantly: TREAT MOTHER FIRST!! Quickly assess gestational age by fundal height 1cm=1 week If 18-20 weeks, left lateral tilt

Physiologic Changes in Pregnancy

Placental Abruption Separation of placenta from uterus 5-50% of cases of obstetrical trauma Largest risk 2-6hrs after trauma, up to 24 hours Maintain high index of suspicion Minor trauma Ultrasound poor diagnostic test PAINFUL VAGINAL BLEEDING

Maternal Fetal Hemorrhage and Rh Factor 17 % of women Rh D negative who do not receive Rhogam will become alloimmunized 28 weeks, any bleeding, and after birth (if indicated) 12 week duration of action SAB, TAB, abruption, trauma, amniocentesis, version 30mL of fetal blood covered by 300mcg of Rhogam Screen for excessive fetomaternal hemorrhage with KB, or rosette Paternity Alloimmunization Hemolytic anemia, Hyperbilirubinemia, Hydrops Fetalis

Approach to the Patient Without Prenatal Care Access records from outside facilities if possible Detailed history and physical Look for cesarean scar(s) Treat the patient as though she will not seek care after she leaves your facility Ob package (including RAPID HIV), fetal anatomical survey, GBS, gonorrhea and chlamydia cx, urine cx, glucose testing (gtt or FSBG) Healthy living education, side sleeping, hydration, seat belt use, safe medications, etc Compassionate care! Social Services Consultation

Hypertensive Patient 16 yo G1P0 @ 37 weeks gestation Blood pressure 140/90 No history of HTN per history or records Headache and scotomata Fundal height 34cm Abdominal pain and uterine irritability on toco

Patient with Vaginal Bleeding 38 yo G3P2 @ 36 wks presents with copious bright red bleeding Was sleeping when awakened by bleeding, no pain Vital stable, but… FHT Category 3 Examination: bright red blood from cervical os on SSE CBC WNL, Rh positive

Pregnant Woman Involved in Trauma 25 yo presents to ED unconscious after MVA, gestational age unknown Fundal height 40cm, FHT 170s After stabilization by ED staff and your suggestion of displacing uterus off of midline you finally get records from labor and delivery She is only 32 weeks, singleton What is the diagnosis? Why is the fundal height so large? What would you expect her labs to be?

Patient in Possible Preterm Labor 23 yo G3P2 @ 33 weeks, Q5 min uterine contractions for several hours Some small vaginal bleeding, increased rectal pressure Vitals stable, FHT 130s reassuring, Toco: q5 min contractions Cervix appears closed on SSE, digitally 1cm Send FFN? After 2 hours continued contractions, no cervical change

Points to Remember Keep a high index of suspicion for something being wrong Frequent Flyers Common things are common, but remember the zebras Treat the mother first Think of DV in all trauma patients Triage is the first line Remember the physiologic changes in pregnancy, tachycardia can be normal, dilutional anemia, leukocytosis, hypoalbuminemia, etc