# Pregnant Pt constant and excruciating abd pain



## Zartage (Oct 8, 2014)

Female 27y/o 32 weeks pregnant with constant/excruciating pain, in the abdominal area with preeclampsia, lethargic, denies any bleeding. Vitals, HR 116, RR 32, BP 124/84. 

What is your diagnosis and why is this a dangerous situation for the baby?

Any thoughts?


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## OnceAnEMT (Oct 8, 2014)

Right off the bat I'm worried about oxygen perfusion. SpO2? Get it on room air then NRB at 15 L on board. Will attempt to coach her breathing down, but will quickly move to assist with BVM if she doesn't calm down. Timing there depends on her SpO2. 

I'll go ahead and make my case for transporting her, and assuming she consents, we get in the truck and get rolling code 1 to the ED. 

OPQRST? Seizures, if so elaborate? Did pain or lethargy come first? Has this happened before while pregnant or not?


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## Zartage (Oct 8, 2014)

Thanks Grimes thats all I got as far as info its a vague bonus question. Its looking for more of a diagnosis, could this be  x y or z and if so what dangers do they pose to the baby such as death or ? Im with you on the O2


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## OnceAnEMT (Oct 8, 2014)

I had a feeling this was answer seeking.


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## Angel (Oct 9, 2014)

not very much info for a diagnosis, but i think of placental abruption when i hear severe abd pn and pregnant pt


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## JWalters (Oct 9, 2014)

Angel said:


> not very much info for a diagnosis, but i think of placental abruption when i hear severe abd pn and pregnant pt



Agreed. 

peripartum cardiomyopathy also comes to mind. Again, I also think there is not nearly enough information here but with the gestational age and vitals that she is presenting with I would keep this as a strong possibility.


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## Zartage (Oct 9, 2014)

Grimes said:


> I had a feeling this was answer seeking.



I have an answer just wanted to see if I was in the ball park since it was so vague Sorry I'm not trying to use anyone to answer the question. My classmates are also a bit stumped on this one. 

Jwalters thanks for the extra info n peripartum cardiomyopathy we have not gone over that yet but now I know


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## Carlos Danger (Oct 9, 2014)

JWalters said:


> peripartum cardiomyopathy also comes to mind.



Just curious what part of that presentation you feel indicates cardiomyopathy?


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## JWalters (Oct 9, 2014)

Remi said:


> Just curious what part of that presentation you feel indicates cardiomyopathy?



A number of years ago I did my CNM training and one of the things that we learned about that is really and truly different in pregnancy versus non-gestational times is cardiomyopathy. While it is not super common, it is most likely in the last eight weeks and this woman has some indications for sure that things are not right based on vitals She has a history of hypertension but her bp isn't THAT bad, her respirations are certainly trying to compensate for something but we don't know the rhythm and quality of them. However, most concerning to me would be the severe abdominal pain with the absence of any type of contractions or bleeding....abruptions do not generally cause that described type of pain, at least not until the bleeding inside the uterus is enough to cause pressure-type pain, at which point it certainly would be unrelenting pain and eventually excruciating, as the pressure builds and builds. Abruptions sometimes cause bleeding (most EMS texts will say usually, but in the world of obstetrics it is much less likely that you would think), more so if there is a previa that has a full or partial abruption but there is no complaint of bleeding. While we don't see a whole lot of MI's in pregnant women who have no previous medical history of heart disease, when we do it can very often present as abdominal pain rather than chest pain.

Beyond that, I really don't know. It was what popped into my head when I read the scenario. Perhaps because I was so fore-warned of it in midwifery school that I also tend to be on the cautious side regarding it but the constant abdominal pain raised a flag. One thing that I would also be sure to ask if I were on scene would be prior c/s hx. Uterine tearing would present like this.







One thing


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## Carlos Danger (Oct 9, 2014)

JWalters said:


> A number of years ago I did my CNM training and one of the things that we learned about that is really and truly different in pregnancy versus non-gestational times is cardiomyopathy. While it is not super common, it is most likely in the last eight weeks and this woman has some indications for sure that things are not right based on vitals She has a history of hypertension but her bp isn't THAT bad, her respirations are certainly trying to compensate for something but we don't know the rhythm and quality of them. However, most concerning to me would be the severe abdominal pain with the absence of any type of contractions or bleeding....abruptions do not generally cause that described type of pain, at least not until the bleeding inside the uterus is enough to cause pressure-type pain, at which point it certainly would be unrelenting pain and eventually excruciating, as the pressure builds and builds. Abruptions sometimes cause bleeding (most EMS texts will say usually, but in the world of obstetrics it is much less likely that you would think), more so if there is a previa that has a full or partial abruption but there is no complaint of bleeding. While we don't see a whole lot of MI's in pregnant women who have no previous medical history of heart disease, when we do it can very often present as abdominal pain rather than chest pain.
> 
> Beyond that, I really don't know. It was what popped into my head when I read the scenario. Perhaps because I was so fore-warned of it in midwifery school that I also tend to be on the cautious side regarding it but the constant abdominal pain raised a flag. One thing that I would also be sure to ask if I were on scene would be prior c/s hx. Uterine tearing would present like this.



CNM huh? Interesting. Thanks for the info.


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## JWalters (Oct 9, 2014)

Remi said:


> CNM huh? Interesting. Thanks for the info.



What would you have leaned towards in this scenario?

(Honestly, my biggest hurdle in pre-hospital care training has been my prior education. I did about 3/4 of an RN program here before deciding I hated it and didn't want to be a med pass nurse before doing the CNM program which, here in MA, is not a medical based scope aside from emergency situations. I'm finding that a lot of what I learned in my "past life" is not nearly as applicable and accurate to emergency care I envisioned it would be and it's a daily struggle to change my mind-set. I need all the help I can get with that!)


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## Carlos Danger (Oct 9, 2014)

JWalters said:


> What would you have leaned towards in this scenario?



Severe abd pain in a third-trimester parturient with pre-eclampsia = placenta abruption, most likely.  Uterine rupture came to mind as well, but it seems unlikely at this point in gestation, at least without a history of trauma.

At least that's what I remember from my OB rotations and exam - I certainly do not claim to be anything even remotely resembling an OB expert....and I'm fine with that!


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## Rialaigh (Oct 10, 2014)

I can tell you from personal experience with a spouse who was preeclamptic that this could be as simple as progressive liver failure. When the protein in a clean catch urine skyrockets the woman can rapidly go into liver failure (12-16 hours) with severe ruq abd pain only relieved by narcotics most of the time.  On Friday my wife was fine on bed rest with elevated protien. On Saturday her protien had almost 7X and she was in constant severe pain...then a c section. She never had seizures even in liver failure and her bp was fairly regularly controlled. 


Just a possibility


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## chaz90 (Oct 10, 2014)

Rialaigh said:


> I can tell you from personal experience with a spouse who was preeclamptic that this could be as simple as progressive liver failure. When the protein in a clean catch urine skyrockets the woman can rapidly go into liver failure (12-16 hours) with severe ruq abd pain only relieved by narcotics most of the time.  On Friday my wife was fine on bed rest with elevated protien. On Saturday her protien had almost 7X and she was in constant severe pain...then a c section. She never had seizures even in liver failure and her bp was fairly regularly controlled.
> 
> 
> Just a possibility


Sounds like HELLP syndrome...Glad she's okay!


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