Clinical Assessment
A multidisciplinary approach to assessment and intervention of the shocked pregnant women is required.
History
When possible take a full history. Establish why the patient has attended the ED. 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, colour and consistency and any previous bleeding in this or previous pregnancies
- Scans in this pregnancy
- Trauma
- Pain – location, nature and radiation
Establish if the patient is shocked:
- RR, Sats, HR, BP, CRT, UO
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