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CE ARTICLE Destination Considerations *EFBMMZ UIF QSFHOBOU QBUJFOU XJUI WBHJOBM CMFFEJOH TIPVME CF USBOTQPSUFE UP B IPTQJUBM XJUI PCTUFUSJDBM 0# DBQBCJMJUJFT BOE UIJT CFDPNFT NPSF JNQPSUBOU BU XFFLTś HFTUBUJPO 7FSZ PGUFO QBUJFOUT VOEFS XFFLTś HFTUBUJPO XJMM CF TFFO JO UIF FNFSHFODZ EFQBSUNFOU XIJMF QBUJFOUT PWFS JU XJMM CF TFFO CZ UIF 0# TFSWJDF JO B IPTQJUBM BT B GFUVT JT DPOTJEFSFE WJBCMF BGUFS XFFLT CVU OPU CFGPSF 8JUI QBUJFOUT PWFS XFFLTś HFTUBUJPO NBLF FWFSZ FƋPSU UP USBOTQPSU UP B IPTQJUBM XJUI 0# DBQBCJMJUZ *G ZPV IBWF BOZ RVFTUJPOT BCPVU USBOTQPSU EFTUJOBUJPO DPOUBDU NFEJDBM DPOUSPM placenta: The uterus is relatively elastic BOE DBO TUSFUDI BOE DPOUPSU XIJMF UIF QMBDFOUB JT SFMBUJWFMZ JOFMBTUJD BOE XJMM OPU TUSFUDI BOE DPOUPSU BT FBTJMZ %VSJOH blunt-force trauma, the shearing forces DSFBUFE CFUXFFO UIF FMBTUJD VUFSVT BOE inelastic placenta can cause them to separate. The clinical characteristics of abruptio placentae include vaginal bleeding, uterine pain and uterine tetany (contractions). Vaginal bleeding occurs in up to 70% of all cases. The amount can vary and gives no indication as to the severity of the event; a significant amount of blood can be lost before vaginal bleeding occurs. The descrip- tion of abdominal pain can vary from mild cramping to severe tearing, and up UP XJUIPVU QBJO 6 PG XPNFO XJUI BCSVQUJP QSFTFOU Uterine tetany occurs XIFO UIF VUFSVT CFDPNFT JSSJUBUFE BOE contracts as a result. These are not true contractions of labor and should not be confused for them. Mild abruption is characterized by slight bleeding, no fetal distress and little or no uterine irritability. As the abruption progresses and involves more of the placenta, CMFFEJOH XIJDI NBZ PS NBZ OPU SFTVMU in vaginal bleeding), uterine tetany and GFUBM EJTUSFTT JODSFBTF *O SFTQPOTF UP UIF CMPPE MPTT NBUFSOBM UBDIZDBSEJB XJMM BMTP EFWFMPQ *O DBTFT PG TFWFSF BCSVQUJP severe blood loss leads to hypotension and fetal distress, and the uterus is contracted and painful to palpation. The patient in this case seems to fall into this category; consider her unstable and in 78 NOVEMBER 2012 | EMSWORLD.com need of ALS intervention. Fetal distress and death occur in approximately 15% of QBUJFOUT XJUI BCSVQUJP QMBDFOUBF 6 Prehospital treatment of abruptio placentae centers on correcting hypo- WPMFNJD TIPDL *O B IFNPEZOBNJDBMMZ TUBCMF QBUJFOU XJUI OP TJHOT PS TZNQ- UPNT PG TIPDL #-4 DBSF JT BQQSPQSJBUF *G UIF QBUJFOU IBT BDUJWF WBHJOBM CMFFEJOH place a feminine pad over the vagina. 5IF QBUJFOU JO UIJT DBTF TIPXT OVNFSPVT TJHOT BOE TZNQUPNT PG TIPDL 4IF JT tachycardic, hypotensive (especially XIFO ZPV DPOTJEFS TIF IBT DISPOJD IZQFSUFOTJPO BOE JT OPU UBLJOH IFS NFEJ- DBUJPOT IFS TLJO JT DPPM BOE TMJHIUMZ QBMF XJUI EFMBZFE DBQJMMBSZ SFGJMM BOE TIF FYQF- SJFODFT EJ[[JOFTT XIFO TIF TUBOET BOE XBMLT BSPVOE "MM PG UIJT JOEJDBUFT UIBU she has experienced significant blood loss and is in decompensated hypovo- MFNJD TIPDL 5IJT QBUJFOU TIPVME SFDFJWF supplemental oxygen via nasal cannula, be placed on the cardiac monitor and IBWF B MBSHF CPSF *7 DBUIFUFS QMBDFE Administer an isotonic crystalloid such as normal saline to help correct hypo- tension. Another cause of bleeding in the second half of pregnancy is placenta QSFWJB 1MBDFOUB QSFWJB PDDVST XIFO UIF placenta either partially or completely covers the internal cervical os, the PQFOJOH CFUXFFO UIF VUFSVT BOE WBHJOBM canal. A marginal placenta previa occurs XIFO UIF QMBDFOUB BQQSPBDIFT UIF border of the os but does not touch it. %VSJOH DIJMECJSUI UIF EFMJWFSJOH GFUVT can damage the placenta, resulting in bleeding that can be significant and MFBE UP IZQPWPMFNJD TIPDL 5IF FYBDU DBVTF PG QMBDFOUB QSFWJB JT VOLOPXO BOE SJTL GBDUPST JODMVEF NVMUJQBSJUZ multiple gestation, advanced maternal age, previous cesarean delivery or other VUFSJOF TVSHFSZ BOE TNPLJOH 17 Bleeding from a torn placenta is particularly dangerous because the placenta has no ability to contract to tamponade bleeding. 5IVT XIFO UIF QMBDFOUB CFHJOT UP CMFFE it essentially bleeds uncontrollably. The QBUJFOU JO UIJT DBTF XPVME CF DPOTJEFSFE to have an advanced maternal age, a IJTUPSZ PG TNPLJOH BOE QSFWJPVT VUFSJOF surgery in the form of cesarean sections and elective abortions. Placenta previa occurs in about 0.3%–0.5% of all pregnancies, and NPSUBMJUZ BTTPDJBUFE XJUI JU JT BT IJHI as 1%. Of all placenta previas, about 20%–45% are complete, 30% partial, and the remaining 25%–50% marginal.18 The classic presentation for placenta previa is painless bright-red bleeding. The GJSTU CMFFE UFOET UP PDDVS BU o XFFLT gestation, and the onset is usually acute and may accompany uterine contrac- tions. Bleeding often resolves spontane- PVTMZ CVU NBZ SFDVS XJUI DPOUSBDUJPOT This patient's episode of vaginal bleeding is accompanied by abdominal pain and IZQPUFOTJPO NBLJOH QMBDFOUB QSFWJB MFTT MJLFMZ UIBO BCSVQUJP QMBDFOUBF The prehospital treatment for placenta previa is mostly supportive. Place a feminine pad over the vagina if UIFSF JT BDUJWF CMFFEJOH 'PS QBUJFOUT XJUI severe bleeding that leads to hypovo- MFNJD TIPDL "-4 JOUFSWFOUJPO BOE WPMVNF SFTVTDJUBUJPO XJUI BO JTPUPOJD DSZTUBMMPJE is necessary. Conclusion 3FNFNCFSJOH TPNF HFOFSBM QSJO- ciples can help the EMT and paramedic JO NBLJOH EFDJTJPOT SFHBSEJOH UIF DBSF and transport of the pregnant patient XJUI WBHJOBM CMFFEJOH t -JHIU WBHJOBM CMFFEJOH JT OPU uncommon in pregnancy, but heavy bleeding or bleeding accompanied by BCEPNJOBM QBJO JT BOE SFRVJSFT FWBMVB- tion in the emergency department. t 5IF EFWFMPQNFOU PG IZQPWP-