In a pregnant woman:
1 Headache, flashing lights and epigastric pain means pre-eclampsia until proved otherwise.
2 Vaginal bleeding must always be investigated.
3 Haemoptysis, shortness of breath or chest pain suggest pulmonary embolism.
4 Calf pain or swelling – always investigate for DVT.
5 Watery vaginal discharge may signal preterm prelabour rupture of the membranes.
6 Severe itching, especially of the palms and soles, may be due to obstetric cholestasis.
7 Do not miss preterm labour.
8 When a woman says that her baby is not moving as usual, take her seriously.
9 Continuous, worsening lower abdominal pain may indicate placental abruption.
10 Multiple changing, trivial complaints, or missed appointments, may flag up psychological or social problems, including domestic violence.










Notes




1 Pre-eclampsia
If a pregnant woman complains of headache, visual disturbance (‘flashing lights’) and epigastric pain, pre-eclampsia must be excluded. Vomiting and oedema of the hands and face may also occur. Pre-eclampsia can cause maternal death, and is a risk factor for many major obstetric emergencies. It is classically described as hypertension and proteinuria of new onset in the second half of pregnancy. The only cure is delivery.

Action: Check BP carefully. Dipstick the urine for protein. If BP $ 140/90, or if there is more than a trace of proteinuria, arrange immediate admission (by ambulance) to a maternity unit.



2 Placenta praevia
Any vaginal bleeding in the second half of pregnancy is serious. Causes include placenta praevia, placental abruption, preterm labour or even an undiagnosed cervical cancer. Placenta praevia is where the placenta is implanted close to, or covering, the cervix, classically causing painless vaginal bleeding. Often small, self-resolving warning bleeds precede a heavier bleed. These women are at risk of massive obstetric haemorrhage, both antenatally and post partum.

Action: Do not perform a digital vaginal examination. In severe haemorrhage, insert at least two wide-bore peripheral IV lines and start rescuscitation. Send off FBC and cross-match. Call obstetric service immediately. For minor bleeds, it is essential to establish more accurately the amount and source of bleeding, so a speculum (not digital) examination must be carried out by an appropriately qualified doctor. Check fetal well-being by cardiotocography.



3 Pulmonary embolism (PE)
In patients with haemoptysis, acute shortness of breath, chest pain or severe cough, PE should always be at the top of the list.Thromboembolism is a leading direct cause of maternal death in the UK. The risk remains high even in the first 6 postnatal weeks. Investigations for PE (CXR, VQ scans or spiral CT scan) are not contraindicated in pregnancy.

Action: Refer immediately for assessment and treatment. If there is clinical suspicion, commence treatment with subcutaneous low–molecular weight heparin or IV unfractionated heparin until the diagnosis is excluded by objective testing.



4 DVT
Although leg oedema, unilateral or bilateral, is a common feature of pregnancy, DVT must always be considered. Leftsided DVT is nine times more common than right-sided DVT. Classical signs of leg swelling, erythema, pain and tenderness of the calf are unreliable, so a high index of suspicion is necessary. If a positive diagnosis is made, women should wear thromboembolic deterrent (TED) stockings for 2 years to minimise the risk of post-thrombotic syndrome.

Action: Refer immediately to obstetrics or via local DVT protocols.



5 Preterm prelabour rupture of the membranes (PPROM)
Many women complain of increased vaginal loss (‘feeling damp’) in pregnancy. This could be physiological or due to urinary incontinence. However, PPROM must not be missed. The concerns are premature delivery (many women will go into labour spontaneously within 48 h) and the risk, to fetus and mother, of ascending infection. Women can develop overwhelming sepsis insidiously and quickly, and fever or tachycardia in these patients must be taken seriously.

Action: Do a sterile speculum examination with the mother in a recumbent position, to check for the presence of a pool of liquor. If this is observed, refer immediately to obstetrics.



6 Obstetric cholestasis
Itching in pregnancy is common and usually benign. Obstetric cholestasis must always be considered, however, as it can lead to a sudden intrauterine death (usually after 37 weeks of gestation), as well as preterm labour and postpartum haemorrhage. The characteristic feature is severe itching on the limbs, trunk, palms and soles of the feet, often so severe that it disrupts sleep. Although there is no associated rash, scratch marks are often evident. LFTs are abnormal and serum total bile acid (BA) concentrations are increased. There may be vitamin K deficiency because of malabsorption of fat-solublevitamins.

Action: Check LFTs and serum BA. Refer urgently to obstetrics.



7 Preterm labour
The diagnosis of labour is important at term, but is vital preterm, as preterm delivery is responsible for 80% of neonatal deaths. Abdominal pain coming for 30 s, every 2–10 min, and getting worse, is labour, until proved otherwise. In addition, constant backache, pelvic heaviness or increased vaginal discharge, which is mucous or bloody, should also ring alarm bells. Always think: has pre-term labour started, and if so, why? The only way to diagnose labour with certainty is to observe progressive dilatation of the cervix. Thus, a vaginal examination should always be performed if preterm labour is suspected.

Action: Do a vaginal examination. Refer immediately to a maternity unit if the cervix is not long and closed.



8 Intrauterine death
Although there is no good evidence for the use of ‘kick charts’, when a mother spontaneously reports reduced or absent fetal movement, take her seriously. It may indicate fetal hypoxia or death. The absolute priority is to detect fetal heart activity. If not detected, it is wise to obtain an experienced second opinion, because erroneously telling a woman her baby has died,when in fact it is still alive, is traumatic both for both parents and doctor. Furthermore, parents may need the second opinion to accept the news.

Action: Check for fetal heart activity using a portable Doppler. (Do not accept arterial pulsations alone, as this may be maternal. Always search for the characteristic, multiple signals from the heart.) Always monitor for several minutes, because occasionally a severe bradycardia can give the impression of cardiac asystole. Refer immediately to obstetrics if heart activity is not detected.



9 Placental abruption
Severe abruption is partial or complete separation of the placenta from the uterus and is a true obstetric emergency. It usually presents with pain and vaginal bleeding, but the bleeding can be concealed. The pain is variable, and if severe, may be associated with sweating, agitation and even vomiting. If the placenta is posterior, backache may be the presenting complaint. Women can become very unwell, very quickly, with cardiovascular compromise or coagulopathy. In an extensive abruption there may be fetal hypoxia or even death.

Action: Insert two wide-bore peripheral lines and commence resuscitation. Refer immediately to obstetrics.


10 Domestic violence
Women who repeatedly attend antenatal clinics, GP surgeries or emergency departments with medically trivial complaints may have serious psychological problems or social difficulties, or may be victims of domestic violence. Abuse against women unfortunately often escalates in pregnancy. It can cause depression, alcohol and drug abuse, miscarriage, stillbirth, severe maternal morbidity and even maternal death either by suicide or murder. Alarm bells should also ring when a woman misses appointments, self-discharges or is reluctant to speak in front of her partner. Domestic violence is more likely to be detected by direct and repeated questioning by health professionals.

Action: Ask about relationships, especially with partners. Make available printed information about how to get help – women’s toilets are a good place to supply it discreetly. Contact the maternity unit and speak to the designated member of staff responsible for the care of women suffering from domestic violence.