Scenario in a Nutshell
Patient presents with acute pulmonary embolism, with signs progressing to acute massive pulmonary embolism.
Stage 1: Patient presents with shortness of breath to triage – initial assessment and transfer to obstetric HDU.
Stage 2: Discussion of investigations and treatment required – patient not keen for X-rays/CTPA or V/Q because of possible harm to baby.
Stage 3: Patient becomes cardiovascularly unstable with signs of acute massive pulmonary embolism.
Target Learner Groups
Obstetricians, anaesthetists and midwives.
| Specific learning opportunities |
|---|
| Knowledge of differential diagnosis of acute shortness of breath in a pregnant woman and planning of appropriate investigations |
| Knowledge of management of likely pulmonary embolism in pregnancy |
| Appropriate use of senior involvement of obstetric, anaesthetic and other specialities, particularly when patient deteriorates |
| Suggested learners (to represent their normal roles) | In the room from the start | Available when requested |
|---|---|---|
| Anaesthetic ST3+ | √ | |
| Obstetric ST1 | √ | |
| Obstetric ST3+ | √ | |
| Midwife Coordinator | √ | |
| Midwife in room | √ | |
| Suggested facilitators | ||
| Faculty to play role of patient’s partner | √ |
Details for Facilitators
Patient Demographics
Name: Toni Age: 37 Gestation: 31+1 Booking weight: 92 kg Parity: P0 |
Scenario Summary for Facilitators
37-year-old, 31-week pregnant primiparous woman. Attended obstetric triage with shortness of breath. Been under follow-up in Fetal Medicine Unit (FMU) for polyhydramnios.
BMI 39.
Two-day history of shortness of breath, sudden onset, progressively worsening. No chest pain.
Found to be tachypnoeic, tachycardic and hypoxic.
Transferred to obstetric HDU from triage.
Assessed by Obstetric and Anaesthetic Registrar.
Portable CXR unremarkable.
ECG sinus tachycardia and right bundle branch block.
Plan further investigations. Patient not keen for CTPA or V/Q – needs further explanation of the risks involved.
Treatment with unfractionated/low molecular weight heparin.
Patient then deteriorates cardiovascularly with BP falling. Massive acute PE. Need consultant involvement from obstetrics, anaesthetics, medicine/respiratory, radiology and cardiothoracic surgery to aid decision-making for treatment options of acute massive PE in pregnancy.
Set-up Overview for Facilitators
| Clinical setting | On a trolley in triage |
| Patient position | Sitting upright |
| Initial monitoring in place | Pulse oximeter NIBP cuff CTG |
Medical Equipment
For core equipment checklist, see Chapter 9.
| Additional equipment specific to scenario | ||
|---|---|---|
| Arterial line | Thrombolysis according to local guidelines |
| Local guidelines for IV heparin therapy/thrombolysis | ||
Information Given to the Learners
Handover to obstetric ST1 from triage midwife.
Situation: This is Toni, who has just arrived in triage feeling short of breath.
Background: 37-year-old otherwise fit and well. BMI 39. 31 weeks pregnant, first pregnancy.
Attending FMU for follow-up scans for polyhydramnios – conservative management.
She has been feeling short of breath for the last 2 days but had attributed this to late pregnancy and polyhydramnios. Partner reports she struggled to catch her breath walking to the unit.
Assessment: I am just doing her first set of observations. She feels quite short of breath so I came to get you.
Recommendation: Would you mind reviewing her please?
