In the postpartum period, secondary postpartum hemorrhage (SPPH) and endometritis are two conditions that frequently present to an obstetric triage unit. These complications may coexist and can occur from 24 hours postpartum to 6 weeks postdelivery. SPPH is typically not as severe as a primary bleeding episode. Postpartum women ultimately diagnosed with endometritis are generally stable, but less commonly can present in septic shock. This chapter discusses presenting symptomatology, history and data collection, physical examination, laboratory and imaging studies, differential diagnosis, and clinical management and follow-up of secondary postpartum hemorrhage and postpartum endometritis. Prompt treatment of both SPPH and postpartum endometritis can reduce maternal morbidity and mortality. SPPH is managed with the same guiding principles as primary postpartum hemorrhage. Initial treatment for postpartum endometritis is intravenous clindamycin and gentamicin.
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Pregnant women presenting with abdominal pain to an emergency department or obstetric triage setting frequently have a diagnostic ultrasound (US) to assess fetus, placenta, and adnexae. In the first trimester, symptomatic adnexal masses typically present with unilateral or bilateral pelvic cramping or pressure. Obtaining a history in a pregnant woman with abdominal pain is similar to doing so for the nonpregnant patient. In addition to routine cardiopulmonary examination, abdominal examination, and assessment for costovertebral angle tenderness, a sterile speculum and vaginal examination are performed to evaluate for adnexal or uterine tenderness, cervical dilation, and potential rupture of membranes. If a mass is suspected, US is the preferred imaging modality. Magnetic resonance imaging can be employed if additional imaging is needed. Differential diagnosis of abdominal pain in pregnant women must include other obstetric and nonobstetric causes of pain. This chapter describes clinical management and follow-up of pregnant women with adnexal masses.
Maternal sepsis is a common pregnancy-related condition; in the United States, it is a leading cause of maternal mortality, accounting for up to 28” of maternal deaths and up to 15” of maternal admissions to the intensive care unit. One contributing and modifiable factor to these deaths is failure to recognize sepsis, leading to delays in treatment. Therefore, rapid and accurate diagnosis and initial management of sepsis in pregnancy in the emergency department (ED) is paramount. Pregnancy poses a unique challenge given the baseline physiologic changes and the need to care for the mother while simultaneously caring for the fetus. Therefore, without clear pregnancy-specific data, recommendations are to follow the current guidelines for nonpregnant adults, yet be cognizant of the ways in which pregnancy may change maternal physiology and affect fetal well-being. Prompt identification and treatment of maternal sepsis will undoubtedly lead to the best possible maternal and neonatal outcomes.
Intimate partner violence (IPV) and sexual assault are common violent crimes perpetrated on women. Obstetric (OB) complications associated with trauma include miscarriage, preterm labor, and placental abruption. Ongoing mental health issues, including depression and anxiety, are more prevalent in pregnant women subjected to any form of IPV, whether or not direct physical violence is involved. One study showed that pregnant women subjected to verbal threats were twice as likely to deliver low-birth-weight infants. All women who present to an OB triage unit or an emergency department (not just those who present with an injury or complication) must be screened for IPV. An organized plan for providing the victim with resources must be readily available when a screen is positive. This chapter discusses presenting symptomatology, history and data collection, physical examination, laboratory and imaging studies, differential diagnosis, clinical management and follow-up care of IPV and sexual assault.
Obstetric triage is one of the most critical perinatal services to emerge in the past three decades in the United States. The obstetric triage unit improves efficiency and utilization of both personnel and bed capacity. Emergency Medical Treatment and Active Labor Act (EMTALA) pertains to care provided to women who present to obstetric triage with complaint of labor. This chapter reviews following categories of risk: assessment in a timely manner, discharge from obstetric triage without evidence of fetal well-being, recognizing active labor, inappropriate and incomplete evaluation or documentation, delay in timely response from consultants, and the use and misuse of clinical handoffs. The chapter describes patient satisfaction in obstetric triage settings. Quality-related issues in obstetric triage involve reducing excessive waiting times, early recognition of significant clinical events, and avoidance of overcrowding and delays. Use of a best-practices model for obstetric triage can enhance overall effectiveness of any obstetric triage unit.
The postpartum woman who presents to triage can be a clinical challenge. Common postpartum complaints can result from benign causes in the postpartum course or from a serious, potentially life-threatening complication. Triage clinicians must be thorough in both history taking and physical examination, and quickly determine the appropriate clinical management. Some of the most critical postpartum conditions that a triage clinician may face include cardiomyopathy, deep vein thrombosis (DVT), and pulmonary embolism (PE). This chapter discusses presenting symptomatology, history and data collection, physical examination, laboratory and imaging studies, differential diagnosis, and clinical management and follow-up of peripartum cardiomyopathy (PPCM), postpartum deep vein thrombosis, and pulmonary embolism. DVT during pregnancy and the postpartum period may develop in un-common locations such as pelvic or abdominal veins. Both ventilation perfusion (V/Q) scan and computed tomography pulmonary angiogram (CTPA) are acceptable options for use in the postpartum period.
Premature rupture of membranes (PROM) is defined as spontaneous rupture of the membranes prior to labor. When PROM occurs at less than 37 weeks gestational age, it is defined as preterm premature rupture of membranes (PPROM). The physical exam includes assessment of fetal well-being with continuous fetal heart rate monitoring. Contractions are assessed by palpation and/or tocometry. Since women with PPROM are at risk for chorioamnionitis, presence or absence of pertinent physical exam findings consistent with infection are noted. Ultrasound examination is a critical part of the evaluation for PPROM. Oligohydramnios offers supporting evidence for PPROM having occurred but is not the gold standard for the diagnosis. Fetal presentation and placentation are additionally noted. An estimated fetal weight determined by biometry is obtained. In terms of laboratory work, a complete blood count is performed, as well as a GBS culture if the woman’s status is unknown.
The Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986 and the Health Information Portability and Accountability Act (HIPAA) of 1996 specifically address the legal requirements for emergency and labor care. The essential components of the law include medical evaluation and transfer of care. Any person presenting to an emergency department; or an obstetric triage unit if that is where pregnant women are evaluated, must receive a medical screening examination. The woman must then be treated for the emergency condition, including stabilization prior to transport. The chapter discusses labor and birth, common allegations under EMTALA, record keeping and patient follow-up, and EMTALA and risk reduction. Protected health information covered under HIPAA includes both medical and financial records. The care of adolescent women raises confidentiality issues that go beyond the scope of HIPAA. In emergency settings, HIPAA specifically permits the exchange of information without written consent to facilitate quality care.
With improvements in neonatal care and interventions that have reduced morbidity and mortality, there has been a shift in viability to earlier gestational ages. Assessment and management of a periviable gestation is one of the most complex problems encountered in an obstetric triage unit. This chapter discusses presenting symptomatology, history and data collection, physical examination and diagnostic studies, differential diagnosis, and clinical management and follow-up of previable and periviable preterm labor, previable and periviable premature rupture of membranes, cervical insufficiency, and stillbirth. Obstetric complications that occur in the periviable period are difficult not only for the patients, but also for the providers. Careful counseling is required when discussing the route of delivery of periviable gestations. Most cesarean deliveries at these gestational ages require classical incisions and have increased maternal morbidity and impact on future reproductive outcomes, without benefit to the neonate.
Preterm births are classified as either spontaneous (i.e., premature rupture of membranes or preterm labor with cervical dilatation) or indicated (i.e., induction of labor for maternal or fetal complications). Preterm births are also categorized by gestational age at delivery. For example, preterm births occurring between 34 and 36 weeks are referred to as late preterm births (Hamilton et al., 2016). This chapter presents the diagnosis and management of spontaneous preterm labor in singleton pregnancies occurring between 24 and 34 weeks gestation. Regular and painful uterine contractions that result in cervical change have been the long-accepted definition of labor. Once the diagnosis of spontaneous preterm labor is made, clinical management is focused on strategies that have been shown to improve neonatal outcomes such as expeditious transfer to a neonatal intensive care facility. Other key interventions include antenatal corticosteroids, delay of delivery, administration of antibiotics, and fetal neuroprotection.