Obstetric and Gynaecological Emergencies
Early pregnancy
Any woman of reproductive age with abdominal pain, syncope or vaginal bleeding gets a pregnancy test - this single step prevents most missed ectopic pregnancies. A ruptured ectopic with haemodynamic instability goes to theatre; a stable patient with a small unruptured ectopic and no fetal cardiac activity may be eligible for methotrexate if hCG is low and follow-up is reliable.
Late pregnancy bleeding: placenta praevia causes painless bleeding - never perform a vaginal examination; abruption causes painful bleeding with a woody uterus and fetal distress.
Pre-eclampsia: hypertension after 20 weeks with proteinuria or end-organ dysfunction. Severe features (160/110 or above, symptoms, abnormal liver enzymes, platelets below 100, renal impairment, pulmonary oedema) require magnesium sulphate 4 g loading over 20 minutes then 1 g/h, plus labetalol, hydralazine or nifedipine. Watch for magnesium toxicity - loss of deep tendon reflexes, respiratory depression, oliguria - and antidote with calcium gluconate 10%.
Postpartum haemorrhage: the commonest cause is uterine atony - bimanual massage, oxytocin, then ergometrine, carboprost (avoid in asthma) and misoprostol, tranexamic acid 1 g within 3 hours, then balloon tamponade or surgery.
Cord prolapse: knee-chest position or elevate the presenting part and go straight to theatre.
Rule of thumb: in a woman of childbearing age, pregnancy status is a vital sign.