A pregnant woman presenting at an ED can be at risk from any number of known or hidden complications which need to be managed differently because of the pregnancy. Women over 40, those whose IVF has resulted in pregnancy and women from a black or ethnic background have a higher risk of morbidity and mortality.

Because two lives are at risk, mother and baby, it is essential that ED staff have measures in place to deal with any acute medical presentations where decisions may need to be taken regarding the timing of delivery.

Red Flags

The most common medical causes of maternal death, which can occur during pregnancy or post-partum, are cardiac disease, venous thromboembolism, neurological or psychiatric disorders and suicide. Longstanding and multiple health conditions in pregnant women require close monitoring by a named clinical lead liaising with obstetrics and contact details for emergency on-call midwife or obstetrician should be available to ED staff.

Complex problems such as connective tissue disease, cardiac disease or inflammatory bowel disease require a joint inpatient medical and obstetric care plan in place with scope for escalation in the event of deterioration.

Recurring presentations at A&E or readmission should be discussed with the obstetric and medical teams.

Chest Pain Red Flags

·      Pain requiring opioids

·      Pain radiating to arm, shoulder, back or jaw

·      Pain which is sudden-onset, tearing or worse on exertion

·      Pain with haemoptysis, breathlessness, syncope or abnormal neurology

·      Abnormal observations

Chest pain is possible at any time and should be managed as in non-pregnancy.

Red Flags with Palpitations

·      Where there is a family history of sudden cardiac death

·      A patient who had previous cardiac surgery or structural heart disease

·      Palpitations with syncope, chest pain, or severe tachycardia

Supraventricular tachycardias are common and should be managed the same as in non-pregnant women.

Red Flags with Breathlessness

·      Sudden-onset breathlessness

·      Orthopnea

·      Accompanied by chest pain or syncope

·      Respiratory rate of less than 20 breaths per minute

·      O2 sats of less than 94% or falls to this on exertion

·      Accompanied by tachycardia

Breathlessness is common and can affect up to 75% of pregnant women who will often describe it as ‘air hunger’. Watch for cardiomyopathy in the 3^rd trimester or postpartum and for deterioration of pre-existing or undiagnosed heart disease from the 2^nd trimester onwards.

Headaches are common in pregnancy but ED staff should attempt to find out the cause(s) of any sudden-onset or unusual headaches or those which take longer to resolve than usual. Associated symptoms can include fever, seizures or photophobia. The use of opioids should be investigated.

Normal Physiology of Pregnancy

ED staff looking after pregnant women with medical problems should acquaint themselves with the Modified Early Obstetric Warning Signs scoring system and should record observations on the locally agreed MEOWS chart. This covers standard tests such as heart and respiration values, blood pressure, O2 sats, renal and liver function, troponin levels (which can elevate in cases of pre-eclampsia, pulmonary embolism, myocarditits and other potentially fatal conditions.)

During pregnancy, a woman’s physical and mental well-being should always be closely monitored by clinical and ED staff to prevent or treat any problems which arise.