Obstetric Emergencies in EMS
Pregnancy-related emergencies require rapid recognition and decisive action. While most pregnancies progress normally, complications can develop suddenly and threaten both the mother and the fetus. EMS providers must understand the normal physiological changes of pregnancy, recognize warning signs of complications, and provide appropriate stabilization and transport. Remember that in obstetric emergencies, you have two patients: the mother and the fetus. Treating the mother effectively is the best treatment for the fetus.
Normal pregnancy causes significant physiological changes: blood volume increases by 30 to 50%, heart rate increases by 10 to 20 bpm, blood pressure decreases slightly in the second trimester then returns to baseline, and respiratory rate increases slightly. These normal changes affect how you interpret vital signs in pregnant patients. A "normal" blood pressure of 130/80 in a pregnant woman might actually represent preeclampsia.
Ectopic Pregnancy
An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube (95% of cases). The growing embryo eventually ruptures the tube, causing life-threatening internal hemorrhage. Ectopic pregnancy is the leading cause of maternal death in the first trimester and affects approximately 1 in 50 pregnancies.
The classic presentation is a woman of childbearing age with unilateral lower abdominal pain, vaginal bleeding (often light), and a positive pregnancy test. However, many patients do not know they are pregnant when symptoms develop. A ruptured ectopic presents with sudden, severe abdominal pain, signs of hemorrhagic shock (tachycardia, hypotension, pallor), and referred shoulder pain (from blood irritating the diaphragm). Any woman of childbearing age with abdominal pain and signs of shock should be considered to have a ruptured ectopic until proven otherwise.
Preeclampsia and Eclampsia
Preeclampsia is a pregnancy-specific condition characterized by hypertension (systolic BP greater than 140 or diastolic BP greater than 90) and end-organ dysfunction, typically developing after 20 weeks of gestation. Symptoms include headache, visual changes (blurry vision, seeing spots), right upper quadrant pain (from liver involvement), sudden weight gain, and facial or hand edema. Severe preeclampsia can progress to HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), which is life-threatening.
Eclampsia is the development of seizures in a patient with preeclampsia. Eclamptic seizures can occur before, during, or after delivery and are a medical emergency. Management includes protecting the patient from injury during the seizure, maintaining the airway, positioning the patient on their left side (to prevent vena cava compression), and administering magnesium sulfate if available per protocol (4 to 6 grams IV over 15 to 20 minutes for paramedics). Transport to a facility with obstetric capabilities immediately.
Other Pregnancy Emergencies
Additional pregnancy complications EMS providers should recognize include placenta previa (painless vaginal bleeding in the third trimester from a placenta covering the cervical opening), placental abruption (painful vaginal bleeding with a rigid, tender uterus from premature separation of the placenta), and supine hypotensive syndrome (hypotension from the uterus compressing the inferior vena cava when the patient lies flat, resolved by positioning on the left side or placing a wedge under the right hip). For all pregnant patients beyond 20 weeks, transport in the left lateral recumbent position or with the right hip elevated to prevent vena cava compression.