1st Trimester Overview
The 1st trimester of pregnancy is characterized by overwhelming physical and emotional changes. Numerous physiologic issues surround patient concerns, and complaints are numerous. From a telephone triage standpoint, a few issues dominate the picture. Risk of ectopic pregnancy and miscarriage may occur until a viable intrauterine pregnancy has been documented. Even then, and particularly in the case of multiple miscarriages, confirmation of early viability may not yield enough reassurance.
Ectopic pregnancy accounts for 10% of maternal mortality. The failure to recognize the signs of ectopic pregnancy is an issue of great medicolegal concern. It also is a cause of much patient suffering. Patients who have experienced repeated ectopic pregnancies have greatly reduced fertility potential and are at higher risk for another ectopic pregnancy.
Within the 1st trimester, miscarriage occurs in approximately 10% of documented pregnancies. The rate of repeat miscarriage is higher for some patients. The emotional cost of miscarriage is of concern as well. Although little can be done to alter the course of pregnancy loss in most 1st trimester cases, the emotional impact can be minimized by sensitive, supportive care.
Ambivalence is common during the 1st trimester as patients adjust to the reality of assuming parenthood. Depression and anxiety may surface for the first time. Domestic violence (intimate partner violence) often is increased. These emotional issues, coupled with the physical complaints of nausea, vomiting, and fatigue, make the 1st trimester a telephone triage challenge.
This chapter proposes a comprehensive approach to aid women coping with the myriad of mood and anxiety disorders that may plague women of reproductive age and beyond. In 2017, an interdisciplinary workgroup formed by the Council on Patient Safety in Women’s Health Care published their work based on taking existing best practice evidence and formatting it into recommendations. This Consensus Bundle on Maternal Mental Health: Perinatal Depression and Anxiety was simultaneously published in three journals that allowed for a wide distribution to perinatal health practitioners. Appearing concurrently in the 2017 March/April Journal of Midwifery & Women’s Health (Vol. 62, No. 2), the March issue of Obstetrics & Gynecology (Vol. 129, No. 3), and the March/April issue of the Journal of Obstetric, Gynecologic & Neonatal Nursing (Vol. 26, No. 2), the recommendations are used as a framework throughout this book to focus on the need for providers and their practices to create a consistent, organized approach to such patient needs. The following chapters dealing with the three trimesters of pregnancy
present maternal anxiety and maternal depression as separate entities. Chapter 11 focuses on postpartum depression. As an additional recognition of the complexities of maternal mental health, maternal ambivalence regarding pregnancy is also introduced in this first chapter because it is frequently common in the 1st trimester. Finally, Chapter 24 discusses these pertinent mental health issues as they relate to women’s health care in general. It is important to note that the guidelines introduced in the Consensus Bundle, although intended for the scope of perinatal mental health concerns, are very pertinent to the entire spectrum of mental health disorders throughout a woman’s life span. We have further adapted those guidelines for all aspect of women’s health, as mental health concerns deserve an organized, consistent approach. Of note, “depression,” as referred to in the protocols which follow, refers to unipolar depression.
present maternal anxiety and maternal depression as separate entities. Chapter 11 focuses on postpartum depression. As an additional recognition of the complexities of maternal mental health, maternal ambivalence regarding pregnancy is also introduced in this first chapter because it is frequently common in the 1st trimester. Finally, Chapter 24 discusses these pertinent mental health issues as they relate to women’s health care in general. It is important to note that the guidelines introduced in the Consensus Bundle, although intended for the scope of perinatal mental health concerns, are very pertinent to the entire spectrum of mental health disorders throughout a woman’s life span. We have further adapted those guidelines for all aspect of women’s health, as mental health concerns deserve an organized, consistent approach. Of note, “depression,” as referred to in the protocols which follow, refers to unipolar depression.
Triage personnel need to be especially mindful that these issues often surface in insidious ways throughout the perinatal period, and it is necessary to be alert for them from the onset of pregnancy. Of note is the fact that these issues may surface at any time and that women who have suffered from maternal mental health concerns in the past may be prone to these issues resurfacing in a subsequent perinatal event. We encourage you to study the Consensus Bundle in detail on your own, and we refer you to Table 8-1 for a summary of recommendations and resource information. All major professional organizations involved in maternal care recommend that routine screening for these common mental health disorders be a planned part of all perinatal care. This is emphasized in the Consensus Bundle, and triage personnel are urged to take a leading role in the active formation of plans for screening and follow-up.
Table 8-1 Maternal Mental Health: Perinatal Depression and Anxiety Patient Safety Bundle From the Council on Patient Safety in Women’s Health Care | |||||||||
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1st Trimester Abdominal Pain
» Key Questions
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» Actions
STEP A: Vaginal Bleeding
Unless you are familiar with the patient’s situation, determining if a pregnancy has been documented is important. Women with a history of previous pregnancy loss may be very distraught at this juncture. If pregnancy is expected or assumed without positive confirmation, this is an important initial step. Do not delay evaluation of bleeding if pregnancy has not been confirmed and bleeding is determined to be severe. Lab tests for confirmation can be initiated at the time of bleeding evaluation.
If the patient is experiencing vaginal bleeding, determine how much. If she is soaking one or more pads per hour or six or more in a 12-hour period, or if she is light-headed, she meets the criteria for serious vaginal bleeding. The patient should be instructed to come to the office immediately or go to the nearest emergency room (ER). The patient should not drive herself. If there is any question of loss of sensorimotor skills, the patient or her agent should call 911.
If the bleeding is not heavy, determine the history of the following ectopic risk factors: prior ectopic pregnancy, prior tubal surgery, prior pelvic infection, endometriosis, prior abdominal surgery, and prior ruptured appendix.
Determine the history of prior pregnancy loss, miscarriage, more than three spontaneous abortions, or five or more voluntary pregnancy terminations.
Continue to Question 2.
STEP B: Severe Abdominal Pain
If abdominal pain is severe regardless of the risk factors, immediate referral to an available obstetric care provider, on-call provider, or ER is warranted. The patient should not drive herself. If there is any question of loss of sensorimotor skills, the patient or her agent should call 911.
STEP C: Problems to Consider
Threatened pregnancy loss: If the pregnancy has been confirmed by a sensitive testing method, the patient may be experiencing the early symptoms of spontaneous abortion. Have her rest, drink at least 8 oz of water per hour, and call the office again within the next 24 hours for a status report. If vaginal bleeding develops, pain worsens, fever occurs, or she experiences additional symptoms, she should call back immediately.
Urinary tract infection: If she experiences pain on urination or unusually frequent urination, she should see a provider in the next 24 hours for urine culture and sensitivity and possible treatment. In the meantime, the patient should increase her intake of
water and other non-stimulating fluids by at least 1 quart during the next 24 hours. If she is experiencing low backache, flu-like symptoms such as nausea or vomiting, or a fever, she should be given a same-day appointment to be evaluated for a kidney infection (pyelonephritis).
water and other non-stimulating fluids by at least 1 quart during the next 24 hours. If she is experiencing low backache, flu-like symptoms such as nausea or vomiting, or a fever, she should be given a same-day appointment to be evaluated for a kidney infection (pyelonephritis).
Appendicitis: If the patient still has her appendix, the pain is in the right lower abdominal quadrant, she has a fever, or she is experiencing bowel changes, she should be given a same-day appointment or sent to the ER or urgent care center for an acute abdominal evaluation.
Gastrointestinal problem: If the patient has any bowel changes, such as constipation or diarrhea, or associates the pain with eating, it is a good idea to have her contact her primary care provider to see if a gastrointestinal evaluation is warranted.
» Patient Education
Some women may experience mild to moderate abdominal pain as a normal part of early pregnancy. If the patient does not have any other accompanying symptoms, urge her to continue to monitor her symptoms and call if they persist for more than 24 hours, additional symptoms develop, or if she has any questions or concerns.
1st Trimester Ambivalence Regarding Pregnancy
» Key Questions
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» Actions
STEP A: Ambivalence in Pregnancy
Research indicates that 4 of 5 women experience some degree of ambivalence during pregnancy. Even during a planned pregnancy, a woman may not feel totally sure about the concept of being pregnant.
Suggest that the patient make a list of the positive and negative aspects of being pregnant to aid in decision making.
Talking with a partner, significant other, close friend, or family member may be beneficial for some patients.
In the event of an unplanned pregnancy, the patient may find it helpful to talk to a counselor about whether or not to continue the pregnancy.
In our practice, we recommend the following counselors who may be of value in helping to sort out feelings of ambivalence and pregnancy continuation: _________________________ _________________________________________________________________________________________.
STEP B: Possible Underlying Depression or Anxiety
Major life events may unmask or precipitate depression or anxiety. If there is any question that the patient is experiencing uncontrolled mood swings, thoughts about harming herself or others, feeling out of control, or becoming withdrawn, do the following:
Make a same-day appointment with a mental health provider and ensure that a friend, family member, or social services worker accompanies the patient to the appointment.
Ensure that a high-risk patient is not left alone.
If necessary, have another person in your office call emergency services and remain on the line with the patient until help arrives.
Notify a provider in your practice of the problem and your actions.
If the patient is of no danger to herself or others, do the following:
Refer her to a mental health counselor for an appointment within the next 3 to 5 days.
Reassure the patient that she may call back at any time if the symptoms worsen.
Your practice should have a system for identifying patients possibly at risk for depression early in pregnancy.
In our practice, we do the following to identify patients at risk for depression during pregnancy (and thus, possibly at risk for postpartum depression): ______________________________ ________________________________________________________________________________________________.
STEP C: History of Depression or Other Mental Health Disorders
Patients with a history of depression or mental health issues may be at greater risk with a new pregnancy. This may be a particular risk if such issues surfaced during a previous pregnancy or during a previous postpartum period.
Repeat the actions in Step B.
STEP D: Desire to Harm Oneself or Others
If the patient is experiencing uncontrolled mood swings, thoughts about harming herself or others, feeling out of control, or becoming seriously withdrawn, make a same-day appointment for her with a mental health counselor and ensure that a friend, family member, or social services worker accompanies her to the appointment.
Ensure that a high-risk patient is not left alone.
If necessary, have another person in your office call emergency services and remain on the line with the patient until help arrives.
Notify a provider in your practice of the problem and your actions.
» Patient Education
Reassuring a patient that ambivalence is common in early pregnancy may be reassurance enough that her thoughts are not abnormal.
Do not be judgmental if the patient sounds as if she is considering termination of pregnancy. Patients need to talk through their feelings for validation; it does not necessarily mean that you agree with her decision if you listen without passing judgment.
Patients with a history of depression during pregnancy or the postpartum period need education regarding the possible recurrence and to know that help is available. Avoid being judgmental. Many patients have the misconception that all feelings can be controlled by will.
Refer a patient with a preexisting counseling relationship to that therapist or assist her on finding another counselor for the coming months.
1st Trimester Anxiety
» Key Questions
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» Actions
STEP A: Ambivalence in Pregnancy
Research indicates that 4 of 5 women experience some degree of ambivalence during pregnancy, particularly in the 1st trimester. Even during a planned pregnancy, a woman may not feel totally sure about the concept of being pregnant. Reassure patients although there may be a relationship between ambivalence, anxiety, and depression in early pregnancy, ambivalence is not uncommon and may cloud her perceptions of anxiety and depression.
Suggest that the patient make a list of the positive and negative aspects of being pregnant to aid in decision making.
Talking with a partner, significant other, close friend, or family member may be beneficial for some patients.
In the event of an unplanned pregnancy, the patient may find it helpful to talk to a counselor about whether or not to continue the pregnancy.
In our practice, we recommend the following counselors who may be of value in helping to sort out feelings of ambivalence and pregnancy continuation: _________________________ _________________________________________________________________________________________.
STEP B: Possible Underlying Depression or Anxiety
Major life events may unmask or precipitate depression or anxiety. If there is any question that the patient is experiencing uncontrolled mood swings, thoughts about harming herself or others, feeling out of control, or becoming withdrawn, do the following:
Make a same-day appointment with a mental health provider and ensure that a friend, family member, or social services worker accompanies the patient to the appointment.
Ensure that a high-risk patient is not left alone.
If necessary, have another person in your office call emergency services and remain on the line with the patient until help arrives.
Notify a provider in your practice of the problem and your actions.
If the patient is of no danger to herself or others, do the following:
Refer her to a mental health counselor for an appointment within the next 3 to 5 days.
Reassure the patient that she may call back at any time if the symptoms worsen.
Your practice should have a system for identifying patients possibly at risk for depression early in pregnancy.
In our practice, we do the following to identify patients at risk for depression during pregnancy (and thus, possibly postpartum depression): ____________________________________________ __________________________________________________________________________________________________.
STEP C: History of Depression or Mental Health Disorders
Patients with a history of depression or mental illness may be at greater risk with a new pregnancy.
Repeat the actions in Step B.
Continue to other questions as appropriate.
STEP D: Recognition and Treatment of a Panic Attack
Panic disorders are twice as common in women as in men. People with panic disorder have sudden attacks of terror when there is no actual danger. Panic attacks may cause a sense of unreality, a fear of impending doom, or a fear of losing control. A fear of one’s own unexplained physical symptoms is also a sign of panic disorder. People having panic attacks sometimes believe they are having heart attacks, losing their minds, or dying.
If the patient is experiencing uncontrolled fear and anxiety, coupled with physical symptoms, do the following:
Determine if there is anyone else present with the patient with whom she feels comfortable. It is particularly important to know if there is anyone nearby who is making the patient uncomfortable. Women with a history of abuse, sexual victimization, posttraumatic stress disorder (PTSD), or other trauma may experience symptoms related to panic when confronted by what they perceive as a threatening situation. It is not uncommon for others around the woman not to perceive the same level of threat or any threat at all. Have her remove herself from the situation if possible and align herself with someone with whom she feels safe.
Have her do the following for self-help:
First, ask her to become aware of any tension that she may be feeling. Ask her to take a deep sigh and relax her shoulders.
Provide reassurance (the triage personnel will be able to hear if she has taken a deep sigh; if not, repeat that command). Instruct her to gently progressively tense and relax all the large muscle groups. For example, instruct her to tighten her right leg while taking a deep breath in. Then, have her hold the breath for a few seconds, release the tense leg, and let the breath out. Repeat this with muscle groups working back up to her shoulders.
Ask her to continue to slow down her breathing. Having her place a hand on her stomach may allow her to further control her symptoms by feeling her breathing slowing down.
If a patient has been diagnosed with any serious medical illness which may also present with similar physical symptoms, particularly cardiovascular disease, advise this patient to seek same-day treatment in an urgent care center, an emergency department, or with her regular health care provide. Home treatment may not be appropriate, even if this patient has experienced previous panic attacks. Certain medical conditions (notably heart disease and asthma) may be mimicked or worsened by panic. Depression, irritable bowel syndrome, and chronic pain may also be worse with severe anxiety.
STEP E: Desire to Harm Oneself or Others
If the patient is experiencing uncontrolled mood swings, thoughts about harming herself or others, feeling out of control, or becoming seriously withdrawn, make a same-day appointment for her with a mental health counselor and ensure that a friend, family member, or social services worker accompanies her to the appointment.
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