Experience Summary

In this 360-degree video, observe the A-E assessment (ABCDE) approach in an acutely unwell pregnant patient.

Haemodynamic instability in a pregnant patient is a critical clinical scenario requiring immediate, systematic assessment and intervention to protect both maternal and fetal wellbeing. The A to E (Airway, Breathing, Circulation, Disability, Exposure) approach is a structured, rapid method used to assess and stabilise acutely unwell patients. In pregnancy, specific physiological and anatomical adaptations must be considered, making tailored assessment essential.

Clinical Context

Pregnancy induces significant changes that alter normal physiology. These include increased heart rate and blood volume, decreased systemic vascular resistance, and altered respiratory function. These adaptations mean that signs of deterioration may be masked until late, and pregnant patients can compensate well before suddenly decompensating. Conditions causing haemodynamic instability in pregnancy may include:

• Obstetric causes: e.g. uterine rupture, placental abruption, postpartum haemorrhage, eclampsia.
• Non-obstetric causes: e.g. sepsis, trauma, pulmonary embolism, cardiac disease.
• Mixed causes: e.g. amniotic fluid embolism or anaesthetic complications.

Immediate structured assessment is critical for rapid diagnosis and resuscitation, and the A to E framework ensures no aspect of care is missed.

A – Airway

Assess airway patency. Pregnancy increases the risk of difficult airway due to mucosal oedema and weight gain. Early airway management planning is crucial, especially if the patient is obtunded.

B – Breathing

Look for signs of hypoxia, tachypnoea, or respiratory fatigue. Pregnancy reduces functional residual capacity, making desaturation faster during hypoventilation or apnoea. Oxygen should be administered early to optimise maternal and fetal oxygenation.

C – Circulation

Check heart rate, blood pressure, capillary refill, and signs of bleeding. Assess for concealed haemorrhage (e.g. in abruption). Remember that hypotension is a late sign of shock in pregnancy. Position the patient in left lateral tilt or manually displace the uterus to prevent aortocaval compression, which can worsen hypotension and compromise fetal perfusion.

D – Disability

Assess consciousness (AVPU or GCS), pupil size/reactivity, and blood glucose. Consider pre-eclampsia or intracranial causes in altered mental status.

E – Exposure

Fully expose the patient to identify signs of trauma, bleeding, or rash, while maintaining dignity and warmth. Look for uterine tenderness, contractions, or fundal height discrepancies.

Learning Outcomes

1. Revise the ABCDE approach
2. Understand that structure and reassessment are key in the A to E assessment
3. Observe an A to E assessment in a pregnant patient with haemodynamic instability

External Resources

• 2021 Resuscitation Guidelines 
  
• Resus Council UK Website