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fluid embolus

       Metabolic (e.g. diabetic ketoacidosis)

       Neuromuscular (e.g. myasthenia gravis)

      Table 5.2 Red flag symptoms and signs

      Source: Adapted from RCP (Royal College of Physicians). Acute Care Toolkit 15: Managing Acute Medical Problems in Pregnancy. London: RCP, 2019. © 2019 Royal College of Physicians

Breathlessness	Especially if:of sudden onsetworse on lying flatif associated with tachycardia, chest pain or syncoperespiratory rate >20SAO2 <94% or falls to <94% on exertion
Headache	Especially if:sudden onset/thunderclap or worst headache everheadache that takes longer than usual to resolve or persists for more than 48 hoursthere are associated fever, seizures, focal neurology, photophobia or diplopiait requires opioids
Chest pain	Especially if:pain severe enough to require opioidsradiates to arm, shoulder, back or jawsudden onset, tearing or exertional chest painassociated with haemoptysis, breathlessness, syncope or abnormal neurologyassociated with abnormal observations
Palpitations	Especially if:the woman has a family history of sudden cardiac deaththere is structural heart disease or previous cardiac surgeryassociated with syncopeassociated with chest painpersistent severe tachycardia
Pyrexia >38°C	Absence of pyrexia does not exclude sepsis, as paracetamol and other antipyretics may temporarily suppress the pyrexia; equally, absence of pyrexia in the presence of sepsis is worrying
Abdominal pain	That requires opioids (excluding contractions)Associated with diarrhoea and/or vomiting
Reduced or absent fetal movements or fetal heart rate
Uterine (excluding contractions) or renal angle pain or tenderness
Generally unwell especially if distressed and anxious	Signs of a deteriorating condition

      It is important also to remember that because respiratory rate does not increase in normal pregnancy, a rise in respiratory rate will often be the subtle first sign of impending critical illness in pregnancy and should prompt a systematic ABCDE clinical assessment.

      Headache

      This is a common problem in pregnancy. It is one of the most difficult symptoms to manage as it can not be seen, examined or measured. Most of the time it will have a benign cause, but there are a wide variety of serious conditions presenting with headache or confusion as the predominant feature (see Chapter 25). The red flag features should be sought in the history taking (Table 5.2).

      Abdominal pain and diarrhoea

      In early pregnancy it is essential to exclude ectopic pregnancy. Vaginal bleeding may be absent. Fainting and dizziness would not usually occur with gastroenteritis unless there is significant dehydration, but is seen with hypovolaemia from blood loss. A pregnancy test is essential to rule out pregnancy in women of childbearing age with abdominal pain.

      Abdominal pain and diarrhoea can also be symptoms of intra‐abdominal sepsis. See also Chapter 23 on abdominal emergencies.

5.3 Summary

       All pregnant women should have systematic measurements of vital signs, which should be plotted on a MEWS chart

       There should be an understanding of the triggering of escalation to senior medical review when vital signs are abnormal as deterioration can be rapid in pregnancy

       When a pregnant woman presents to a non‐obstetric area of the hospital the obstetric team should be informed and a MEWS chart commenced

       Respiratory rate does not increase in normal pregnancy therefore tachypnoea should not be ignored

       Recognition of both significant red flag symptoms and often subtle clinical signs in pregnancy is essential to enable appropriate timely intervention to reduce maternal mortality and morbidity

5.4 Further reading

      1 Knight M, Bunch K, Tuffnell D, et al. (eds), on behalf of MBRRACE‐UK Saving Lives, Improving Mothers’ Care – Lessons Learned to Inform Maternity Care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015–17. Oxford: National Perinatal Epidemiology Unit, University of Oxford, 2019.

      2 Knight M, Bunch K, Tuffnell D, et al. (eds), on behalf of MBRRACE‐UK. Saving Lives, Improving Mothers’ Care – Lessons Learned to Inform Maternity Care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2016–18. Oxford: National Perinatal Epidemiology Unit, University of Oxford, 2020.

      3 RCP (Royal College of Physicians). Acute Care Toolkit 15: Managing Acute Medical Problems in Pregnancy. London: RCP, 2019.

Appendix 5.1 Blood gas interpretation

      Lactate

      Modern blood gas analysers are able to measure the blood lactate, a product of anaerobic metabolism and marker of the state of the microcirculation. In shock, elevated blood lactate levels can be used to predict mortality, and in septic shock raised lactate predicts the development of multiple organ failure more reliably than clinical observations. Failure of the lactate to fall with therapy is associated with higher mortality. Even haemodynamically stable patients with raised lactate levels, a condition referred to as compensated shock, are at increased risk of death. Lactate measurements >4 mmol/l can be taken as a marker of severe illness and used as a trigger to start resuscitation (see Chapter 7).

      ABG interpretation

Normal values for both the non‐pregnant and the pregnant state are given in Table 5A.1. To interpret a blood gas, review the following:

       Check PaO2 (normal values 11–13 kPa ON AIR): if it is low, then the patient is hypoxaemic

       Check the pH value: to determine the direction of primary change (normal, acidosis or alkalosis); compensation is always incomplete

       Check PaCO2, which is determined by

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