Clinical Assessment

A multidisciplinary approach to assessment and intervention of the shocked pregnant women is required.

History

When possible take a full history. Pertinent questions include LMP, parity, gravity and outcome of previous pregnancies not resulting in a live birth, paternity of previous pregnancies, rhesus status, sexual history, contraceptive history, fertility treatment, pelvic surgery.

Ask about:

• Bleeding – amount (this can be difficult to quantify. Asking about use of sanitary products: tampons or pads? Are they using the panty liners or ‘sanitary pads for ‘night use’? How often are they changing them? Are they soaking though/or soaking through to their clothes/bed sheets? This may provide more information than patients themselves attempting to estimate a volume of blood loss, which can be very difficult to do.)
• Scans in this pregnancy
• Trauma
• Pain – location, nature and radiation

Establish if the patient is shocked:

• RR, Sats, HR, BP, CRT, UO
• Cervical shock: Cervical stimulation caused by either products of conception or blood or a foreign body, which becomes trapped within the OS. This produces a vagal response leading to bradycardia and hypotension. Removing the product of conception/clot/foreign body from the cervical os will reverse the hypotension and bradycardia.

Essential investigations

• Urine+/-serum βhCG
• FBC, U&E, clotting studies, G&S +/- cross match (at least 4 units if bleeding is heavy)
• Consider Kleihauer (if gestation greater than 20/40), this determines the need for additional anti-d
• Consider ECG

Clinical examination

• Look for evidence of abdominal trauma
• Estimate PV loss as appropriate to the history
• Do not perform a vaginal examination in women presenting with PV bleeding after the 24th week as this can precipitate catastrophic haemorrhage in undiagnosed placenta praevia.
• The need for speculum examination should be considered on a case-by-case basis and should only be performed by a clinician competent in the technique.

Use of Doppler and US

• The fetal heart is audible with a Doppler probe from 10 weeks. Ongoing fetal monitoring should be by CTG. In the case of abdominal trauma, this should be prolonged monitoring, directed by local guidelines.
• Increasing availability of US in EDs should enable a rapid scan to be performed by a competent clinician.