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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Gender Specific Issues Key Feature 1: In the assessment of clinical problems that might present differently in men and women, maintain an inclusive differential diagnosis that allows for these differences (ex: women with coronary artery disease, depression in males). Skill: Clinical Reasoning Phase: Hypothesis generation Pregnancy Key Feature 7a: In a pregnant patient presenting with features of an antenatal complication (ex: premature rupture of membranes, hypertension, bleeding): Establish the diagnosis. Skill: Clinical Reasoning, Selectivity Phase: Hypothesis generation, Diagnosis Key Feature 7b: In a pregnant patient presenting with features of an antenatal complication (ex: premature rupture of membranes, hypertension, bleeding): Manage the complication appropriately. Skill: Clinical Reasoning, Selectivity Phase: Treatment Vaginal Bleeding Key Feature 2a: In pregnant patients with vaginal bleeding: Consider worrisome causes (ex: ectopic pregnancy, abruption, abortion), and confirm or exclude the diagnosis through appropriate interpretation of test results. Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 2b: In pregnant patients with vaginal bleeding: Do not forget blood typing and screening, and offer Rh immunoglobulin treatment, if appropriate. Skill: Clinical Reasoning Phase: Treatment, Hypothesis generation Key Feature 2c: In pregnant patients with vaginal bleeding: Diagnose (and treat) hemodynamic instability. Skill: Clinical Reasoning Phase: Diagnosis, Treatment Common antenatal complications that can bring patients into the office or emergency department include decreased fetal movement, blood or fluid loss from the vagina, and cramping. Patients may also be found with signs suggestive of possible antenatal complications on routine prenatal assessment, including hypertension and symphysis-fundal height measuring small for gestational age. Here I will review how one might diagnose and manage these common antenatal complications. One common theme with all antenatal complications is the need to decide whether or not the complication is of high enough risk to the mother or fetus to warrant delivery vs the risk of watchful waiting. Many factors come into play, but of particular sway is the gestational age of the fetus. As well, for all possible concerns, a complete history and physical examination is always warranted, and when there is confirmation of a concern to fetal or maternal wellbeing, most of the time consultation with an obstetrician is warranted. Note that the all of the information below comes from a conglomeration of various resources, including the SOGC ALARM course, many UpToDate articles, resources provided on maternity care and obstetrical rotations, and from my own experience in clerkship and residency in seeing how these issues are managed in real life. DECREASED FETAL MOVEMENT -DDx: If a pregnant woman presents with concern about decreased fetal movement, this could mean there really is decreased or absent fetal movement (which could reflect an unwell fetal state, or worse), or it could be that she has noticed decreased movement during a time when the fetus is asleep or less active. -Hx: Asking about fetal movement is a routine part of any obstetrical encounter. If ever patients are concerned about decreased fetal movement, they should count the number of kicks they feel in a 2 hour period while laying on their side. If they count less than 6, they should seek medical attention. -PE: Fetal heart rate assessment by Doppler can be reassuring, but even a normal FHR auscultated this way isn’t sufficient to rule out concerns of fetal wellbeing after mom has been concerned about decreased fetal movement. Standard of care is to asses FHR by Doppler and to proceed regardless with further investigations. -Ix: If a woman has presented for medical attention with a concern of decreased fetal movement, obtaining a non-stress test (NST) is always warranted. If this appears normal and the woman feels return of fetal activity, no further investigations are needed. However, if the non-stress test is normal but the woman continues to perceive decreased fetal activity, the next step is to get an ultrasound (US) exam within 24-48 h for further assessment. Ultrasound examination should include assessment of fetal activity, breathing, tone, and amniotic fluid volume, as well as fetal growth and anatomic survey if not recently performed. If both the non-stress test and ultrasound are unremarkable, but there is persistent perception of decreased fetal movement, then obtaining a biophysical profile (non-stress testing and ultrasound examination that assesses the above-listed 4 parameters) in women under 37 weeks’ gestation on a biweekly basis is appropriate. Once at 37 weeks' gestational age, consideration may be given to inducing labour before the EDD. -Tx: Decreased fetal movement can be a general sign of poor fetal wellbeing. If investigations confirm fetal compromise, determining and attempting to treat any reversible etiologies is warranted, or else delivery may be indicated. NST results are classified as either reactive (i.e., normal, showing a healthy fetus) or nonreactive, which may suggest impaired fetal oxygenation, but on the differential is also maternal medication or substance use including smoking close to the time when the test is performed, fetal neurologic or cardiac anomalies, and sepsis. As well, it is important to know that up to 50% of nonreactive NSTs are false positives, so other tests are useful to confirm compromised fetal status, particularly US assessment. Abnormal investigations prompt decision-making as to whether or not delivering the infant sooner rather than later is best, if the circumstances leading to abnormal fetal assessment are not correctable. SMALL FOR DATES -DDx: In the patient who measures small for gestational age on routine symphysis-fundal height assessment, this may suggest there is intrauterine growth restriction. Alternatively, the fetus may simply be constitutionally small, but further workup is always warranted to investigate for growth impairment. -Hx: A complete history is warranted to look for risk factors for intrauterine growth restriction. These include known fetal genetic or structural abnormalities, ischemic placental disease or placental/cord abnormalities, maternal medical and obstetrical disease including structural uterine abnormalities and a history of prepregnancy radiation or trauma, risk associated with medication or substance use, extremes of maternal age, use assisted reproduction technologies or multiple gestation, and risk factors for fetal infection. -PE: On examination, symphysis fundal height is measured as abnormal if it differs by greater than 2 cm from from the gestational age. Other physical exam maneuvers include all of those done on routine antenatal assessment. (An aside: Although typically less worrisome, a fetus may measure large for dates, and the reasons for this include multiple pregnancy, molar pregnancy, inaccurate dates, hydramnios, macrosomia, fibroid uterus, adnexal and/or abdominal masses. Investigations tend to be similar as for a fetus that measures small for gestational age.) -Ix: If a fetus measures small for gestational age, or if there are risk factors for intrauterine growth restriction despite normal symphysis-fundal height measurement, further investigation by ultrasound is indicated. (Note that clinical assessment is not accurate enough to rule out restricted intrauterine growth in the presence of risk factors.) If a fetus measures small for gestational age on ultrasound (<10th percentile), further investigations are indicated to look for evidence as to whether there is restricted growth or if the fetus is well and just constitutionally small. This workup includes detailed ultrasound examination with umbilical artery Doppler for fetal, placental, and uterine abnormalities. If clinically suspected, maternal serum can be tested for evidence of infection. If fetal growth restriction is evident before 24 weeks’ gestation, or if there is evidence of structural feta anomalies, evaluation of the fetal karyotype to look for genetic abnormalities is indicated. Depending on the suspected cause and severity of fetal growth restriction, the decision to manage expectantly versus deliver must be evaluated. If the decision is made to manage expectantly, the fetus will need regular ongoing monitoring, one to seven times a week if there is concern about fetal wellbeing, or two to four times weekly to reevaluate growth progress in the absence of concern about fetal wellbeing. Monitoring is done by non-stress testing and biophysical profile assessment. -Tx: Any reversible causes for fetal growth restriction should be addressed, and in those cases in which the cause is not remediable, the risks must be pitted against the benefit of managing expectantly versus inducing delivery, taking into account gestational age and assessment of fetal wellbeing, among other factors. MALPOSITION -Fetal malposition is basically the finding that the fetus is positioned in any way other than head down (i.e., cephalic presentation). If suspected on physical exam by Leopold’s maneuvers (see image below), ultrasound assessment for confirmation is generally done as fetal malpositioning changes the approach to delivery. By 32 to 36 weeks’ gestation, the fetus has generally assumed it’s birth position, so if fetal malposition is confirmed by ultrasound and the birth position is expected to have been assumed based on gestational age, consultation with an obstetrician is warranted. The patient may choose to have a trial of external cephalic version, in which there is an attempt at turning the fetus in uterus into a cephalic presentation. Alternatively, the patient may choose to deliver by C-section or attempt a vaginal breech delivery. All 3 options have risks and benefits, and the choice must be based on informed discussion between the patient and the obstetrician, taking into account patient factors and clinician training.  VAGINAL BLEEDING
-DDx: Vaginal bleeding can occur for a number of different reasons. In the first trimester, these include: ectopic pregnancy; spontaneous abortion (aka miscarriage); subchorionic hematoma; gestational trophoblastic disease; pathology of the cervix, vagina, or uterus; or the physiologic “implantation bleed;”. In the second and third trimesters, these include: bloody show associated with labor (by definition, labour occurs after 20 weeks) or cervical insufficiency; spontaneous abortion (by definition, spontaneous abortion occurs before 20 weeks); placenta previa; placental abruption; and rarely, uterine rupture or vasa previa. Cervical, vaginal, or uterine pathology (ex: polyps, inflammation/infection, trophoblastic disease); non-tubal ectopic pregnancy; and marginal separation of the placenta are other etiologies to consider. -Hx: Before taking a thorough history, ensure the woman is stable. If there are signs of circulatory compromise, addressing this urgently in an emergency room setting is warranted. If and when stable, it is then important to get a thorough history of the bleeding. Although the quantity of bleeding is not predictive of the etiology per se, in that bleeding described as scant can still be how worrisome pathology presents, the heavier the bleeding, and if any clots/tissue have been passed, along with the presence of associated features such as pain, increase the likelihood that there is something ominous going on. Identifying any factors that may have precipitated the bleeding, such as trauma or intercourse, is important. -PE: When a women presents with a concern of vaginal bleeding, it is important to assess maternal general appearance and vital signs, along with performing an assessment of fetal status by auscultating for fetal heart rate with Doppler (which should be able to be detected after 12 weeks of gestation), measuring symphysis-fundal height, and assessing fetal position and presentation if in the third trimester. Performing an abdominal examination, complete pelvic examination (sterile speculum should be used, and if a woman has reached second trimester, digital examination should only be performed after an ultrasound assessment in second trimester that shows no placenta or vasa previa), and examination of any passed tissue is also helpful. -Ix: While the clinical assessment is important to narrow the differential and to triage the concern, all women with a complaint of vaginal bleeding warrant an ultrasound (transvaginal +/- abdominal) to assess fetal wellbeing and for information that is helpful in assessing etiology and for complications (ex: placenta previa, retained products of conception in the setting of suspected miscarriage). Other investigations to consider include quantitative beta-hCG, blood type & screen, CBC, and Kleihauer-Betke test (a test that can assess for fetal blood in the maternal blood stream). -Dx: Ectopic pregnancy, although not common, is serious and must always be ruled out. Confirmation of an intrauterine pregnancy makes this unlikely, although one must always consider a heterotypic pregnancy, particularly in the patient who has had in vitro fertilization. Vaginal bleeding with cramping is worrisome for spontaneous abortion, and this is also diagnosed/confirmed by ultrasound. Ultrasound may also detect a subchorionic hematoma. Gestational trophoblastic disease should be suspected when beta-hCG levels are elevated beyond that expected for the gestational age, and with absence of a viable intrauterine pregnancy. Bleeding from a cervical or vaginal source may be apparent on physical exam, but ensuring there is nothing else going on via ultrasound is prudent. Bleeding associated with labour may be a ‘bloody show’ that precedes onset of contractions, so this must be considered if the woman develops regular cramping/contractions. Cervical insufficiency is diagnosed via transvaginal ultrasound, as are placenta and vasa previa. Placental abruption and rupture are not routinely detected on ultrasound exam, and warrant high suspicion with associated risk factors (risk factors for placental abruption include prior placental abruption, trauma, smoking, cocaine use, hypertension, and preterm premature rupture of the membranes; risk factors for uterine rupture include previous cesarian or transmyometrial surgery) in the setting of vaginal bleeding with pain, with or without signs of maternal or fetal compromise. Implantation bleeds or attributing bleeding to marginal separation of the placenta are diagnoses of exclusion. Tx: If a women has had significant bleeding from any cause and is hemodynamically unstable, addressing this is the first priority, with attempts to first stabilize much as would be done with a nonpregnant patient. If maternal or fetal status continues to be compromised, delivery may be warranted. If the patient has an ectopic pregnancy, medical or surgical treatment is indicated. If the patient is diagnosed with spontaneous abortion, unless already complete, the management may be expectant, medical, or surgical. A finding of gestational trophoblastic disease is typically followed by surgical evacuation, with further management dependent on further disease classification. There are a number of possible causes of pathological bleeding from the vagina, cervix, or uterus (including trauma, vaginitis, warts, polyp, tumour, or uterine fibroids), that would need to be managed much as they would in a non-pregnant woman, although choice of management may differ in pregnancy. In the setting of cervical insufficiency, a cervical pessary, cerclage, or progesterone supplementation may be warranted, depending on cervical length and whether or not they have had previous preterm deliveries attributed to a shortened cervix. Most patients with placenta previa will have resolution by the third trimester. If the placenta previa does not resolve, delivery by C-section is warranted. Management of placental abruption depends on just how compromised the fetus and mom are, with options being to manage conservatively or plan for delivery. A diagnosis of uterine rupture alway warrants emergency C-section. A diagnosis of vasa previa also warrants delivery by C-section, although if it is diagnosed on US rather than following an active bleed, the timing of the C-section may be such that it is performed as a planned or elective procedure. Last but not least, for all causes of vaginal bleeding in pregnancy, if the woman is Rh- per the type and screen, she will need to be given Rh immune globulin to prevent Rhesus alloimmunization. The Kleihauer-Betke test quantifies how much fetal and maternal blood have mixed to be able to provide a sufficient dose of Rh immune globulin. HYPERTENSION -DDX: If a patient has hypertension in pregnancy, it can be classified as chronic (existing prior to pregnancy) or gestational (onset after becoming pregnant), and with or without pre-eclampsia or eclampsia (preeclampsia is a state that increases risk of seizure, while eclampsia is diagnosed if seizure has actually happened). Women with hypertension in pregnancy are also more likely to develop HELLP syndrome. -Hx: If hypertension is detected on routine prenatal assessment, it is important to assess for symptoms that may occur with preeclampsia (defined as hypertension with at least one of the three following features: proteinuria, maternal organ dysfunction, or uteroplacental dysfunction). Manifestations of preeclampsia to ask about include cardiovascular symptoms (chest pain or dyspnea, extremity swelling), hematological symptoms (bleeding), hepatic symptoms (RUQ or epigastric pain, severe nausea/vomiting), renal symptoms (decreased urine production), and neurologic symptoms (severe headache, visual disturbance, tremulousness). If there is uteroplacental dysfunction that is compromising the infant, the mom may have noticed decreased fetal movement. -PE: On examination, it is important to ensure accurate blood pressure assessment. This includes having the patient seated comfortably for 10 minutes prior to blood pressure assessment, and during measurement, her feet should be flat on the ground with her arm at heart level. The blood pressure cuff should be sized appropriately, and a manual sphygmomanometer should be used. Hypertension in pregnancy is diagnosed with a systolic blood pressure of 140 or greater, or a diastolic blood pressure of 90 or greater. The patient is diagnosed with severe hypertension is the systolic blood pressure is 160 or greater, or if the diastolic blood pressure is 110 or greater. The diagnosis is based on at least 2 readings separated by 15 min in the same arm. (The arm that reads highest for blood pressure should be the one used to perform all blood pressure checks.) If accurate blood pressure measurement confirms hypertension, looking for signs associated with preeclampsia is also important. The signs to look for, in the same order as per the history for associated symptoms, involve the cardiovascular system (SpO2, elevated JVP, edema), haematological system (evidence of bleeding or petechiae), hepatic pain manifesting as tenderness on abdominal examination of the right upper quadrant or epigastrium, and signs of neurological compromise (irritability, somnolence, hyperreflexia). Obstetrical assessment may reveal an abnormal fetal heart rate or a symphysis-fundal height measuring small for gestational age. If a woman reports a history of, or is seen to have seizure-like activity, this suggests eclampsia in a patient who does not have epilepsy. -Ix: Investigations that follow a diagnosis of hypertension include those to look for preeclampsia (urine studies to look for evidence of proteinuria) or associated complications including HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome or DIC (disseminated intravascular coagulopathy). Bloodwork includes: CBC, electrolytes, creatinine, urea, AST, ALT, LDH, type and screen (if blood type unknown), INR, PTT, fibrinogen. Urine studies can start with urine dipstick for protein, which are routinely done at every obstetrical assessment, and if 2+ protein is detected, this is significant and establishes the presence of proteinuria. If 1+ protein is detected, further measurement of a 24 hour urine collection for protein can be obtained. If dipstick is <1+ in the setting of new HTN, a random urinary protein to creatinine ratio should be ascertained <30 mg/mmol rules out proteinuria. To asses fetal status and for signs of uteroplacental dysfunction, obtain an ultrasound for fetal growth and amniotic fluid volume, with umbilical artery Doppler assessment if abnormal ultrasound findings are present. -Tx: Treatment of hypertension is to decrease the risk of stroke, which is increased once into the severely hypertensive blood pressure range. It is important understand that managing blood pressure does not lower risk of developing eclampsia or intrauterine growth restriction, so monitoring for these complications is important despite well-controlled blood pressure. The target treatment for systolic blood pressure is generally between 135 and 155 mmHg, and for diastolic blood pressure is generally between 80 and 105 mmHg, below the threshold for which stroke risk is elevated. Targets may vary in a patient who has other complicating comorbidities such as target-organ damage (left ventricular hypertrophy, microalbuminuria, retinopathy), dyslipidemia, maternal age over 40 years, history of stroke, previous perinatal loss, or diabetes. Antihypertensive medication options, if needed, include labetalol (starting dose 100 mg twice daily) or nifedipine extended-release (starting dose 20 mg once daily). If diagnosed with severe HTN, preeclampsia, eclampsia, or HELLP, women have increased risk of seizing, and so seizure prophylaxis is given: magnesium sulphate. This patient would also need monitoring in a hospital setting. A diagnosis of HELLP syndrome warrants consideration for blood and platelet transfusion, corticosteroids, and delivery within 48 hours from time of diagnosis. Last but not least, it is important to know that risk of seizure extends into the postpartum period, peaking on postpartum days 3-5. If a women is at risk for having hypertension, it is important to continue to monitor her blood pressure in the days following delivery. VAGINAL FLUID LOSS -DDx: If a pregnant woman notes vaginal fluid loss, this must be differentiated from normal physiologic discharge, which often increases during pregnancy, from pathological discharge attributed to infection of the genital tract, from the rupture of membranes that may precede the onset of labour (prelabour rupture of membranes) or that may occur after the onset of labour. -Hx: Rupture of membranes presents as a gush of fluid prior to or after the onset of labour (regular contractions leading to cervical change), and diagnostic accuracy of membrane rupture by history alone is 90%. In the setting of ongoing labour, no further workup is warranted, as membrane rupture is part of the natural history of labour. In the setting of vaginal fluid loss prior to the onset of labour, it is important to take a complete history of the nature of the fluid loss, including the presence of ongoing leaking, estimated total amount lost since onset, timing of the fluid loss, along with characteristic of the fluid itself such as odour and colour (green/brown suggests meconium, which can be a nonspecific sign that the fetus is doing so great). Taking a sexual history is important, as sexually transmitted infections can be a reason for prelabour rupture of membranes, particularly if preterm. Urinary tract infections can also increase risk of preterm labour, so asking about symptoms of a UTI is indicated. -PE: If there is suspicion for ruptured membranes, it is important to reduce sources of contamination that could increase risk for fetal infection. This means digital pelvic examination should be deferred unless membrane rupture has been excluded on further assessment. Instead, the pelvic examination is first performed visually with a sterile speculum to look for a pool of fluid in the vagina, with or without evidence of ongoing leaking from the cervix. If the pool test is positive, samples of this fluid can be used for investigations to confirm or rule out rupture of membranes. Swabs can also be taken for cultures and sensitivities in the preterm patient. -Ix: Vaginal fluid collected on sterile speculum exam can be assessed for membrane rupture via the nitrazine and ferning tests. If testing for membrane rupture is equivocal (there may be insufficient fluid for adequate testing, or there may be suspicion of a falsely positive or negative test), then followup testing with ultrasound to assess amniotic fluid volume can be helpful. In the setting of normal amniotic fluid volume, rupture of membranes is less likely. In the setting of suspected term prelabour rupture of membranes (TPROM), no other investigations are necessarily indicated, although an NST is commonly done to assess fetal wellbeing. In the preterm prelabour rupture of membranes (PPROM), because of associated increased risk of infection, other investigations to obtain as part of standard care include swabs for culture and sensitivity (vaginal for yeast, bacterial vaginosis, and trichomoniasis; cervical for chlamydia and gonorrhea; anogenital for GBS if GBS status unknown), urine sample for urinalysis and culture and sensitivity, and a CBC. Ultrasound monitoring is also indicated to assess amniotic fluid volume and cervical status, among others. -Dx: A diagnosis of membrane rupture is typically clinical, with investigations supporting this diagnosis. Likewise, there may be a high clinical suspicion of infection, and empiric antibiotics may be initiated before confirmatory investigations have resulted. -Tx: Management of prelabour rupture of membranes will depend upon gestational age and other risk factors for whether to proceed with expectant management vs induction of labour. If full term, induction of labour is generally recommended, as the associated risks are outweighed by the risk of infection that can occur with prolonged rupture of membranes. If less than 34 weeks’ gestation, the risks of preterm labour generally outweigh the risk of infection, and expectant management is instead indicated (antibiotics are administered prophylactically, along with steroids to enhance fetal lung maturity should the woman go into preterm labour), and if less than 32 weeks’ gestation, a dose of magnesium sulphate may also be given for fetal neuroprotection. If the pregnancy is between 34 and 36 weeks’ gestation, the evidence is not conclusive as to the best approach to take, so careful consideration will need to be had by the care team and mother regarding best approach in the particular circumstance. If swabs are positive for infection, it can be treated as indicated, including for group B strep positivity. CRAMPING/ABDOMINAL PAIN -DDx: There is a good chance that a woman who presents after 20 weeks of gestation with a complaint of regular cramping is likely in labour and having uterine contractions. By regular, I mean having cramps that are no more than about 5 minutes apart, that last from 30 seconds to 1 minute at a time, and that have been going on for about 1 hour (aka the 511 rule, which I teach patients about in the second trimester of pregnancy). If patients are full term, this is the natural expectation of how labour will begin, and there is no need to necessarily rush to seek medical attention. If a patient is preterm however, seeking medical attention sooner rather than later is important as there are more investigations and interventions that will need to be undertaken to try to obtain the best outcomes possible for mom and baby. If cramping is only intermittent, not meeting the criteria of the 511 rule, while it may still be that the women is experiencing uterine cramping, it is unlikely that she is in labour per se (which is defined as starting once the onset of regular uterine contractions has begun that leads to cervical change). These women having intermittent uterine cramps are often labeled as having Braxton-Hicks contractions, which are normal and occur from time-to-time in the later stages of pregnancy as the woman gets closer and closer to being full term. If pain is characterized as constant rather than cramping, the differential diagnosis should focus on other obstetrical sources of pain. In the presence of vaginal bleeding or new-onset hypertension, consider the DDx associated with those signs and symptoms as mentioned above. If there is no bleeding or hypertension, then obstetrical emergencies must first be considered (ex: uterine abruption), and then a more comprehensive differential for abdominal pain in the woman of reproductive age must be considered.* -Hx: Obtaining a good history of the cramping or abdominal pain is critical in determining whether the pain is from uterine contractions that signify the onset of labour, or if the search for other diagnoses ought to begin. For a history of regular cramping, it is important to ask about their frequency, duration, when they started to occur regularly, and how the pattern has changed over time. Infection is a risk factor for preterm labour, so inquiring about symptoms of genitourinary infection is important in the patient who is preterm and having regular cramping. -PE: A complete obstetrical physical examination is indicated, including assessment of the cervix to look for changes associated with labour. -Ix: If a diagnosis of labour is made, the patient who is full term does not require any investigations (unless there is missing information from routine investigations done in the antenatal period, which may be the case in a preterm patient who has not reached gestational age at which tests such as GBS testing is done, or if a woman has risk factors that warrant further investigations). For most women, knowing their blood type based on their initial prenatal labs suffices. But in patients with increased risk of having a postpartum hemorrhage, it is recommended that a type and screen be repeated, or that a type and crossmatch be done, depending on their degree of risk. In the preterm patient, as for PPROM, we want to assess for possible infectious reasons for why the women may have gone into labour preterm. This includes assessing a CBC, urine for UA and C&S, vaginal swab for C&S, and cervical swab for Chlamydia and Gonorrhea C&S. Last but not least, in patients with risk factors for complications, getting a baseline NST tends to be standard of care, but is not indicated in an uncomplicated pregnancy. -Tx: The cure for labour is delivery! Standard practice is to admit women to the labour and delivery ward if they are in the active first stage of labour (meaning their cervix has dilated to approximately 4 cm), if their membranes have ruptured despite not yet being in labour, or if any complications are identified. If a woman is not yet in active labour but is having significant pain, she is usually given morphine 10-15 mg IM and dimenhydrinate 50 mg IM and sent home, to return when pain has significantly worsened again, membranes have ruptured, or if any concerns arise. If the patient is in preterm labour, she will be admitted straight away, and some interventions to think about include giving steroids if less than 34 weeks gestation to promote fetal lung development, giving magnesium sulphate if less than 32 weeks gestation for neuroprotection if delivery is imminent, and considering the use of a tocolytic to slow down contractions while a women is being transferred to a centre with higher capacity (such as with a NICU, as the preterm infant may need extra supports) or to allow a full 48 hours for steroids to work their magic. *Although we tend to focus in on pregnancy-related complications when a patient who is pregnant presents with a concern, it is important not to lose sight of the fact that this is still a normal person who may have any of a number of reasons for a presenting complaint just as a non-pregnant person. The same principle applies to examining any "special population." Yes, we need to consider the disease processes for which their population group is specifically at increased risk, but we cannot lose sight of other possibly life-threatening or common reasons for which they could be presenting as they are. Even when not part of a "special population" per se, just being male or female can alter risk for various disease processes (ex: being male is a risk factor for having a heart attack, more female are diagnosed with depression). Despite this, we need to consider the individual's risk factors without letting them tunnel our vision too much.
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