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Which Pregnancy Symptoms Amount to an Emergency?


Pregnancy, for the most part, is a safe physiologic state for the mother and baby. Under some circumstances, pregnancy can be hazardous for the mother, baby, or both.

Pregnancy starts at the time that the fertilized egg implants in the uterus and lasts approximately 40 weeks, calculated with the first week starting on the day of the first missed menses. In essence, there are two weeks of the 40 weeks when technically, the woman is not pregnant because these are the two weeks leading up to ovulation – or egg release.

First trimester emergencies

Miscarriages

The rate of miscarriages (medically called an abortion) is historically approximately 5% to 15% and is mostly due to a chromosomal abnormality or congenital defect. It’s Mother Nature’s way of taking care of mistakes.

However, the rate of miscarriages has increased in the past two years, largely linked to COVID vaccines. In some reports, the rate is as high as 70%.

Miscarriages can be spontaneous, complete, incomplete, missed, or elective. Non-elective abortions usually present with spotting, cramping, passage of grey tissue, or heavier bleeding. It is considered an emergency if the miscarriage is incomplete, and the entire products of conception have not passed out of the uterus and vagina.

The uterus continues to contract and bleed and can lead to a hemorrhage that is life-threatening. Any heavy bleeding that lasts beyond two hours or passage of clots bigger than a plum warrants immediate medical attention. The solution is either medication or surgical dilatation and curettage (D&C).

Ectopic pregnancies

Tubal pregnancies are the same as ectopic pregnancies. Ectopic means ‘outside of the uterus.’ An ectopic could be attached to the ovary or intestines, but it is most commonly found in one of the fallopian tubes. The cause is due to scarring of the tubes either from an infection such as pelvic inflammatory disease (PID), endometritis (infection of the uterus), surgical scarring or endometriosis.

The scarred tubes are often distorted or narrowed in specific areas, which cause the fertilized egg to be unable to be transported to the uterus. This transport depends on tubal motility, which is also restricted by scarring or damage to the lining or muscular portion of the tube.

Once the ectopic pregnancy reaches a certain size, the tube can swell and burst. This can lead to internal hemorrhaging and is a surgical emergency. Warning signs and symptoms of ectopic pregnancies are pain or the left or right side of the pelvis/abdomen, spotting, cramping, and lightheadedness.

It is essential to get an ultrasound to determine the location of pregnancy. It can be managed with laparoscopy that removes the abnormal pregnancy and/or part of the tube. It is not considered an abortion.

Second trimester emergencies (Weeks 14 to 26)

Placenta

If the placenta is not located in the right place, it may be close to or covering the cervical opening. It is called placenta previa. This is dangerous because the placenta has large blood vessels that carry food and oxygen to the baby from the mother and removes wastes and carbon dioxide from the baby.

Another type of placental problem is vasa previa, which means that one or more blood vessels are covering the cervix without any protection from the placenta. If these blood vessels bleed from the cervix dilating, the baby could hemorrhage to death, and that could also cause the mother to lose too much blood. The mother is most at risk if the placenta previa bleeds.

None of these situations are good for either the baby or the mother.

Trauma

Any abdominal trauma or major trauma anywhere can be a risk for the mother and the baby primarily due to internal bleeding from organs like the liver. Car accidents and falls are the leading causes of trauma in pregnancy. The uterus and amniotic fluid will often shield the baby from impact, but it depends on how severe the accident is and whether the mother had her seat belt on. This is most serious when it occurs in the second and third trimesters.

Third trimester (Weeks 27 to 40)

Premature labor/premature rupture of membranes

Symptoms and signs of premature labor/ruptured membranes (water breaking) include cramping, low back pain, tightening of the uterus or contractions, burning over the abdomen, and leakage of clear or bloody fluid. This is an emergency if it occurs before 36 to 37 weeks.

Bedrest, to see if the symptoms go away, is your first remedy, unless you suspect ruptured membranes. In this case, you must go to the hospital for an evaluation.

Ruptured membranes could mean you have an intrauterine infection or seriously low fluid, which could harm the baby. Infections can harm both mother and baby. Seriously low fluid levels can lead to cord compression and lung development problems.

Premature labor can be halted with medications if significant dilation of the cervix has occurred. The medications are used to delay delivery until steroids are administered. Steroids help prevent respiratory distress syndrome and other complications of prematurity.

Preeclampsia/eclampsia

Hypertension with significant protein in the urine means that you have preeclampsia that could lead to eclampsia, which is the severest progression of the disease that means a seizure has occurred.

Prior to a seizure, the symptoms of preeclampsia are headache, visual changes, right upper quadrant pain, swelling of hands and face, and ‘hyper’ reflexes.

Any woman with these symptoms needs to see her doctor or go to the hospital for an evaluation. There is no cure for these hypertensive crises except for delivery. Delivery can be delayed depending on the severity of the preeclampsia and the gestational age of the baby.

Eclampsia is treated with magnesium via an IV and in severe forms, may be used prophylactically while in labor.

Conclusion

There are a number of conditions for which pregnant women should learn the symptoms, that may happen in the first to third trimester. Please speak with your healthcare provider about what constitutes an emergency while you are pregnant.

Key takeaways

Under some circumstances, pregnancy can be hazardous for the mother, baby, or both.

First trimester emergencies can include miscarriages and ectopic pregnancies.

Second trimester emergencies can include placental problems, or trauma to the mother.

Third trimester emergencies can include premature labor or rupture of the membranes, or pre-eclampsia and eclampsia.

Speak with your healthcare provider about what constitutes an emergency while you are pregnant.

References:

Committee on Practice Bulletins—Gynecology. (2015). The American College of Obstetricians and Gynecologists Practice Bulletin no. 150. Early pregnancy loss. Obstet Gynecol.

Mendez-Figueroa, H., Dahlke, J.D., Vrees, R.A., Rouse, D.J. (2013). Trauma in pregnancy: an updated systematic review. Am J Obstet Gynecol.

Ananth, C.V., Smulian, J.C., Vintzileos, A.M. (2003). The effect of placenta previa on neonatal mortality: a population-based study in the United States, 1989 through 1997. Am J Obstet Gynecol.

Frederiksen, M.C., Glassenberg, R., Stika, C.S. (1999). Placenta previa: a 22-year analysis. Am J Obstet Gynecol.

Huls, C.K., Detlefs, C. (2018). Trauma in pregnancy. Semin Perinatol.

Bouyer, J., Coste, J., Fernandez, H., Pouly, J.L., Job-Spira, N. (2002). Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod.

Mann, L.M., Kreisel, K., Llata, E., Hong, J., Torrone, E.A. (2020). Trends in ectopic pregnancy diagnoses in United States emergency departments, 2006-2013. Matern Child Health J.

Adhikari, S., Blaivas, M., Lyon, M. (2007). Diagnosis and management of ectopic pregnancy using bedside transvaginal ultrasonography in the ED: a 2-year experience. Am J Emerg Med.

Aggarwal, M., Khan, I.A. (2006). Hypertensive crisis: hypertensive emergencies and urgencies. Cardiol Clin.

Shayne, P.H., Pitts, S.R. (2003). Severely increased blood pressure in the emergency department. Ann Emerg Med.

ACOG practice bulletin. Management of preterm labor. Number 43, May 2003. Int J Gynaecol Obstet.

Gyamfi-Bannerman, C., Thom, E.A., Blackwell, S.C., et al. (2016). Antenatal Betamethasone for Women at Risk for Late Preterm Delivery. N Engl J Med.

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