Pregnant women may present with disorders specific to pregnancy; with problems related to chronic disorders exacerbated by pregnancy or with unrelated disorders. Achieving a good outcome for mother and fetus requires close collaboration between the medical and obstetric services.

Up to 70% of pregnant women will report breathlessness. The physiology of pregnancy predisposes to breathlessness. However, serious cardiorespiratory disorders may also occur (Table 32.1).

The pregnant patient with shock presents unique medical and management Chest pain/shock (see Chapters 2 and 7)challenges. The differential diagnosis needs to include obstetric complications not often presenting to acute medical services, for example amniotic fluid embolus (Table 32.3). Furthermore, resuscitation of the pregnant woman carries particular challenges, including optimum position of the gravid uterus and potentially difficult airway management.

Headache is a common symptom reported by pregnant women and although benign in most cases, awareness of warning symptoms is required so that important pathology is not missed (Table 32.4).

Seizures are uncommon in pregnancy, but when they occur, are potentially life threatening to both mother and fetus (Table 32.5).

Pre-Eclampsia and Acute Fatty Liver of Pregnancy

Each year on average 2 women in the UK die from eclampsia or pre-eclampsia and one from acute fatty liver of pregnancy (MBRRACE-UK report 2016).

Pre-eclampsia is defined as new hypertension and proteinuria after 20 weeks of gestation, and can lead to complications including seizures (eclampsia) and HELLP syndrome (Haemolysis, Elevated Liver enzymes, Low Platelets) (Table 32.6). Pre-eclampsia complicates 3–5% of all pregnancies and its course is unpredictable.

Women with pre-eclampsia often present to maternity services. However, pre-eclampsia should be considered in any woman presenting to acute care services with signs and symptoms suggestive, as undiagnosed or concealed pregnancy is not uncommon.

Acute fatty liver of pregnancy (AFLP) is a distinct condition but it is likely to be related (Table 32.7). AFLP is rare but can cause fulminant liver failure (Chapter 77).

Patients with pre-eclampsia or acute fatty liver of pregnancy should be admitted to hospital. If they show features of severe disease (Table 32.6), they should be managed on a high-dependency unit.

• Fluid balance – women with pre-eclampsia are often transiently oliguric but are at increased risk of pulmonary oedema, therefore use caution with fluid resuscitation.
• Antihypertensive treatment – hypertension tends to peak 3–5 days post-partum. Calcium channel blockers, beta blockers and the ACE inhibitor enalapril can all be used while breastfeeding.
• Organ dysfunction – in severe disease, organ support such as haemofiltration may be required, but renal function usually recovers. In acute liver impairment (i.e. AFLP) N-acetyl cysteine can be used.
• Blood products – may be required depending on the severity of the anaemia, thrombocytopenia or coagulopathy.
• Seizure prophylaxis – IV magnesium sulphate as treatment and prophylaxis for eclampsia (see Table 32.8).
• Delivery – this is the only curative intervention for these conditions and should be expedited but only once the mother has been medically stablized with coagulopathy corrected and blood pressure controlled.
• Long-term issues – lifetime risk of cardiovascular disease is increased in women who develop pre-eclampsia.