At approximately 10:30 in the morning, you are called to a school for a 14-year-old female who collapsed during gym class.
When you arrive, you find the patient lying supine on a gym floor. Her head is propped on some clothing, and there is a crowd of students surrounding her. The gym teacher tells you that earlier the patient had asked to sit down because she complained of some abdominal cramping. The teacher thought she was faking an illness to get out of gym class.
Minutes later, the student had a syncopal episode. You and your partner move the other students out of the way, and when you approach the patient, you see she is pale and diaphoretic. The patient is altered and only moans with painful stimuli. Her pupils are equal and reactive to light. There is a small hematoma to the right side of her forehead from when she fell. Your partner places a c-collar. The gym teacher states she doesn’t believe the patient has any medical history but is unsure if she has any allergies or takes any medications. The teacher sends another student to the front office to try to obtain emergency contact information.
Upon your examination, the patient vitals are:
You quickly load the patient onto your stretcher and start toward your ambulance. Once at your ambulance, you place the patient on 12-lead ECG, start an IV, begin a fluid bolus, and she starts to respond more to verbal stimuli. The patient is now able to tell you that her lower right abdomen hurts. She screams on palpation to her lower right abdomen. She does still have her appendix, but she has had gallstones before. She is unsure of her last menstrual period, but she believes it might have been a few months ago. She does admit to being sexually active but states she hasn’t had sex for about a month and a half. The patient states she did have some spotting this morning and abdominal pain but didn’t think much of it and thought her period must be starting.
On re-evaluation of vital signs, her blood pressure is now 104/68, her heart rate is now 110, and her O2 saturation is 98% on room air. She rates her pain 10/10. She states she has no medical history. She does not take any medications and she denies allergies to any medications. She says that she did not feel hungry this morning and she usually skips eating breakfast.
The patient weighs approximately 110 lbs and is 5’4”. You administer 2.5mg of morphine and the rest of your transport is uneventful. You arrive at the hospital and transfer care. You state you suspect ectopic pregnancy due to her lower right abdominal pain and spotting this morning. Upon further testing, the patient was diagnosed with a right tubal pregnancy and she required surgery. The patient admits she did not know she was pregnant, and she had not received any prenatal care prior to this syncopal episode. So, what type of risk factors did she display?
Have you ever heard someone say to a pregnant woman that they are now eating for two? What exactly does that mean? Are there nutritional requirements that are different for a pregnant woman?
The road to prenatal diet begins weeks, maybe even months before a woman even becomes pregnant. As with any person, a pregnant woman will have some regular dietary needs, but they will require some extra nutrients that will improve individual and fetal health. We already know that fetal development is affected by prenatal dietary intake. Let’s take a look at some of the basic dietary needs of pregnant women.
Before pregnancy, a healthy diet can actually help with fertility and help increase her odds of a healthy baby that is born at term. When a woman is malnourished, the embryo does not have the nutritional support necessary to develop properly. In order for the embryo to grow into a fetus, where it will begin to develop human-like characteristics, there must be a store of nutritional elements such as proteins, iron, folic acid, and other essential nutrients. As Health Engine notes, “Maternal malnutrition can adversely affect the division and replication of cells in the embryo at this stage, impairing development.”
The foods we eat are how we maintain our body and the metabolic needs we require and will set the stage for the basic nutritional health of our children. Eating a balanced diet of vegetables, fruits, whole grains, and lean proteins is an excellent start. Yet these are the basics of all healthy diets. A pregnant woman will also require some extra nutrients to help the baby grow big and strong. Those fetuses will require a higher amount of calcium, iron, protein, and folic acid. It is believed that many pregnancy complications are due to nutritional deficiencies.
Calcium is needed for the baby’s bones and teeth to grow. Approximately 1000 milligrams daily is the starting requirement. There are several different ways a woman can increase her calcium content. Milk, eggs, yogurt, and cheese are just a few examples. The pregnant woman should try to include 3-4 servings a day.
Iron is important to keep the pregnant woman from becoming anemic. Many obstetric physicians suggest iron supplements or prenatal vitamins with iron to increase blood volume and reduce the risk of anemia. During pregnancy, the woman will increase her plasma volume to facilitate the growing needs of her fetus. Her red blood cell count usually falls, and there is risk of her having thrombocytopenia. The decrease in iron in the blood decreases the amount of oxygen the mother can supply to the fetus. This can produce low birth weight. It is recommended that pregnant women should have 2-3 servings of a cup of green leafy vegetables each day.
Protein affects fetal tissue growth and brain development. It also helps the mother’s breast and uterine tissues to grow and provide the nutrients needed to increase blood supply. Approximately 75-100 grams of protein a day is recommended. A serving size is compared to a deck of cards and should include 2-3 servings a day.
Legumes also provide a rich source of protein and can be included for a protein supplement. Serving size is generally about ½ cup. 2-3 servings are recommended.
Folic acid is another very important nutrient in the development of the fetus. It plays an important role in neural tube development. Folic acid is a B vitamin that helps make new cells that produce things like skin, hair, nails, and prevents brain and spinal cord deformities. Women of productive age should consider a diet that consists of 400mcg of folic acid to prevent birth defects. The Centers for Disease Control and Prevention note, “Major birth defects of the baby’s brain or spine occur very early in pregnancy (3-4 weeks after conception), before most women know they are pregnant.” Conditions such as spina bifida in the baby are more likely when the pregnant mother does not ingest enough folic acid to promote healthy neural tube development. 2-3 servings of ½ cup of fruit or 3 servings of ½ cup of whole grains are a great way to get several servings of folic acid.
Water consumption will also play a vital role in both the fetus and the pregnant patient’s diet. It is estimated that the pregnant mother should increase her consumption of water in order to reduce the risk of complications, such as hemorrhoids. Drinking enough water helps the appropriate nutrients get absorbed and then transferred to the fetus via the umbilical cord and placenta. It is estimated that the pregnant patient should drink about 10 8oz. glasses of water a day. Milk, juice, soup, and other liquids, except caffeine, can generally be included as water consumption. The extra fluid will help combat constipation, decrease risk of urinary tract infections, and will be essential in producing amniotic fluid.
The pregnant patient who doesn’t drink enough fluids may find herself hypovolemic and she may even experience a syncopal episode.
There are also foods pregnant women should avoid that can cause harm to the fetus.
Undercooked meats can carry toxoplasmosis and salmonella. Toxoplasmosis is the result of an infection caused by a common parasite. Symptoms generally involve flu-like symptoms and can be passed from mother to fetus via the placenta. Early infection can lead to miscarriage or stillbirth. Salmonella is another gastrointestinal infection that occurs after eating undercooked foods like chicken or eggs. Salmonella poisoning can lead to severe dehydration due to excessive diarrhea. While normally a person infected with toxoplasmosis or salmonella is likely to feel ill and have symptoms for about a week, the pregnant female may need more invasive treatment in order to recover and protect the fetus during the gestational stages of life.
Caffeine can cause low birth weight, which in turn increases the risks of health issues later in the baby’s life. While low dosages do not appear to be a major cause of miscarriage or preterm birth, it is suggested that larger daily doses of caffeine can lead to low birth weight and may be a reason for some miscarriages and preterm birth. Many physicians suggest limiting amounts of caffeine to 200 mg a day (ACOG).
Tobacco use is another substance also known to lead to low birth weight and can lead to miscarriage and even make getting pregnant more difficult. Smoking during pregnancy can lead to tissue damage in the unborn fetus, and some studies have linked maternal smoking to cleft lip (CDC). The Centers for Disease Control and Prevention notes, “One in five babies born to mothers who smoke during pregnancy has low birth weight.” Even mothers who were exposed to secondhand smoke were more likely to have babies with a higher degree of complications than those whose mothers were not exposed. “Both babies whose mothers smoke while pregnant and babies who are exposed to secondhand smoke after birth are more likely to die from sudden infant death syndrome (SIDS) than babies who are not exposed to cigarette smoke” (CDC).
Illegal drugs and even prescription drug can also cause low birth weight, placental abruption, preterm labor, and further complications, such as developmental delay. Any drug, whether illegal or prescription, can cross or alter the function of the placenta, thus causing narrowing of the blood vessels and reducing the amount of oxygen and nutrients the fetus receives from the mother (Patil). Some medications can have long-lasting effects even after their use is discontinued. You should discuss any change in medications, even over-the-counter medications, with a healthcare provider. Illegal drugs should obviously be avoided before, during, and after pregnancy in order to reduce the negative effects on a growing fetus or newborn.
Maternal requirements for nutrients increases, therefore “a direct link between chronic maternal deficiencies and poor outcomes for the mother and the infant” (Institute of Medicine) have been found in several studies. During the history taking, the EMS provider should attempt to ascertain if the mother has had any issues during her pregnancy or previous pregnancies. Do they find the environment to be clean and well kept? Does the patient appear to be eating well, or does the patient appear dehydrated? “For some patients, especially teenage patients, conducting the interview in private is preferred, as a denial of pregnancy may prevent EMS personnel from obtaining an accurate history” (Navarro).
In a study comparing diet to pregnancy complications, it was found younger subjects, those between the ages of 14 and 20, were at much higher risk. There may also be some delay in receiving prenatal care, either due to denial of pregnancy or lack of education or financial stability. Healthier food choices were selected by the older participants of the study (Spurling). Pregnancy is a time when all members of the family may be more willing to try to stop substance abuse of all kinds because of their concern for the fetus, and all members of the family should be offered help (Institute of Medicine).
What types of calls might emergency services expect to see when dealing with prenatal calls? Remember the call may not come in as a prenatal call and the pregnant woman may not look pregnant.
Diabetes Mellitus or gestational diabetes can be of concern for patients who are unable to maintain their normal blood glucose. An increase in energy intake may make controlling blood glucose difficult for some, especially those with a preexisting diabetes mellitus diagnosis. Blood glucose levels will need to be closely monitored to sustain normal levels in order to minimize risks for fetal complications. Women who have gestational diabetes tend to give birth to very large neonates and risk complications at birth, including the possible need to have an emergency cesarean section. “The expertise of a dietician is highly desirable when providing nutrition services for pregnant women with diabetes mellitus” (Institute of Medicine). Food must be carefully eaten, and blood glucose reading should be taken frequently. Food intake and medications like insulin will need to be closely monitored as well in order to keep blood glucose levels at acceptable ranges. The EMS provider should check the blood glucose level of any pregnant patient they encounter and provide either sugar supplementation with either oral glucose, D10, or glucagon to any patient with very low readings and provide normal saline or lactated Ringer’s to those with very high readings per protocol.
Diabetes Mellitus can also lead to a condition known as preeclampsia or eclampsia. Since pregnancy increases the body’s need for sodium, there is also an increased risk of hypertension and hypertension-related symptoms. Water will follow sodium, and excessive intake of sodium increases the pregnant woman’s blood pressure. While the pregnant woman will need an increase in blood pressure to adequately provide the blood flow of nutrient-rich blood to the fetus, overly high blood pressure has negative effects on both mother and fetus. When blood pressure remains severely elevated for long periods of time, the mother risks damage to organs. The kidneys and liver are not able to filter all of the extra sodium and proteins in the blood and the mother might begin experiencing severe headaches, abdominal pain, vision changes, or vomiting.
The most severe symptom would be uncontrolled seizures when the woman goes from preeclampsia to full-blown eclampsia. Preeclampsia is generally closely monitored by taking the mother’s blood pressure. “Sudden weight gain and swelling (edema) – particularly in the face and hands – may occur with preeclampsia” (Mayo Clinic). Complications of preeclampsia can include fetal growth restriction, preterm birth–which hosts several concerns for the fetus or newborn, and eclampsia when the mother begins to experience seizures which can be life-threatening to both mother and fetus. The general treatment of eclampsia is magnesium sulfate given as an IV drip.
While women who are pregnant often experience vomiting in their first trimester, known as morning sickness, a much more severe form of vomiting, known as hyperemesis gravidarum, is a severe complication of pregnancy. Women with this condition will have uncontrollable vomiting that leads to severe dehydration and electrolyte imbalances. It can even lead to death if left untreated. The inability to eat and digest the necessary daily nutrients needed to keep both the mother and the growing fetus healthy can eventually lead to pregnancy complications. Treatment is therefore generally geared toward prevention of nausea, vomiting, and diarrhea. Treatment begins with IV fluids and anti-nausea medications. In very severe cases, parental nutrition monitored in-hospital is necessary to provide the dietary needs of the pregnant patient.
Understand that there are a few important vital sign changes that occur when a woman is pregnant. Expect the heart rate of a pregnant female to be higher than a woman who is not pregnant. “By the third trimester, her heart rate may be 15-20 beats per minute higher than the non-pregnant patient” (Navarro). The pregnant mother may also have lower blood pressure in her second trimester, which tends to normalize by the time she is to deliver. However, during her third trimester, a pregnant woman who is positioned supine may experience supine hypotension due to the weight of the fetus over her inferior vena cava. This can reduce blood flow back to the heart by as much as 25 to 30 percent. Keep this in mind when transporting any third-trimester patient regardless of the complaint. If transporting a trauma patient who is secured to a backboard, tilting the backboard to the left approximately 15-30 degrees is suggested to keep the weight of the patient and fetus off of the patient’s inferior vena cava.
Pre-hospital treatment of the pregnant patient may require simple observation and transfer to more definitive care. Or, it can include the management of severe shock. The EMS provider must be able to prepare and manage life-threatening shock regardless if the signs or symptoms have fully developed. Rescuers should administer oxygen, initiate IV fluids, keep the patient warm, and begin transport to an appropriate emergency facility as soon as possible. While not all obstetric calls will be life-threatening, many can have serious complications for both the mother and the fetus. Pregnant women with severe vaginal bleeding will require aggressive fluid resuscitation. Eclamptic patients will require advanced EMS personnel to administer benzodiazepines and magnesium sulfate to stop seizure activity. Oxygen delivery will also need to be monitored in the seizing patient. Understand that the emergency medical provider may be called to the scene of a miscarriage. “In most cases, the primary focus for EMS providers is to provide psychological support to the female patient and family. The patient doesn’t often present with an acute condition. If the patient has passed fetal tissue, collect all parts for examination by a physician. Transport to the hospital is necessary because the patient will require follow-up care to ensure that no fetal parts remain” (Brocato).
Understanding the signs, symptoms, and complications that may arise with obstetric patients will help you provide thorough care that could prove life-saving for both the mother and baby.
Brocato B. How to assess and treat common pregnancy complications. JEMS. Aug 2013; 7:38. https://www.jems.com/2013/06/21/how-assess-treat-common-pregnancy-compli/.
de Bellefonds C. Are you drinking enough water during pregnancy? Oct 2019. https://www.whattoexpect.com/pregnancy/drink-enough-water/.
Gunatilake R, Patil A. Drug use during pregnancy. Merck Manual. Nov 2018. https://www.merckmanuals.com/home/women-s-health-issues/drug-use-during-pregnancy/drug-use-during-pregnancy.
Institute of Medicine (US) Committee on Nutritional Status During Pregnancy and Lactation. Nutritional concerns of women in the preconceptional, prenatal, and postpartum periods. Nutrition Services in Perinatal Care: Second Edition. Washington (DC): National Academies Press (US); 1992. https://www.ncbi.nlm.nih.gov/books/NBK235913/.
Navarro K. Prehospital management of obstetric complications. Texas EMS Magazine. Jan 2009.
Moderate caffeine consumption during pregnancy. American College of Obstetricians and Gynecologists. Aug 2010. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2010/08/moderate-caffeine-consumption-during-pregnancy.
Preeclampsia. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/preeclampsia/symptoms-causes/syc-20355745.
Pregnancy nutrition. American Pregnancy Association. https://americanpregnancy.org/pregnancy-health/pregnancy-nutrition/.
Smoking during pregnancy. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/basic_information/health_effects/pregnancy/index.htm.
Kuo Downing-Reese is a 16-year veteran of EMS. She started her career in Los Angeles County in a variety of settings, including private ambulance, fire, and hospital ED. Kuo went to paramedic school at UCLA-Daniel Freeman. She has a degree in EMS management from George Washington University and currently practices as a full-time critical care paramedic in Rochester, New York. She also does a variety of EMS and medical training as an NYS Certified Lab Instructor (CIC intern), NAEMT instructor, and as an AHA regional/training center faculty.