Trauma in Pregnancy

Criddle, Laura M. PhD, RN, CEN, CCRN, FAEN

Abstract

Overview: Although serious trauma during pregnancy is uncommon, it remains a major cause of
maternal and fetal death and presents a variety of patient care challenges. The anatomic and physiologic
changes of pregnancy can affect both the nature of an injury and the body's response to it. Here, the
author describes the mechanisms of traumatic injury during pregnancy, discusses the normal changes of
pregnancy and their implications in the care of pregnant trauma patients, and offers strategies for
assessment and treatment.

When a pregnant trauma patient presents, nurses face an unusual situation: there may be two injured
patients, one inside the other. As nurses, we must assess and treat one patient whose body has been
anatomically and physiologically changed by pregnancy and another whom we cannot see, touch, insert
an IV catheter into, or place an oxygen mask on. It's essential that we understand the changes
associated with pregnancy, which can affect both the nature of an injury and the body's response to it,
and their implications in the assessment and treatment of both patients.

EPIDEMIOLOGY AND MECHANISMS OF INJURY

Traumatic injury during pregnancy occurs in about 7% of all pregnancies, 1, 2 although most cases
probably won't require hospitalization. Indeed, one large retrospective study found that in 2002, just
four of every 1,000 pregnant women nationwide were hospitalized for injuries. 3 Yet trauma remains a
major cause of maternal and fetal death. A study of 7,348 pregnancy-associated deaths found that
although 57% had obstetric causes, 27% were caused by traumatic injury. 4 One study of medical records
in Cook County, Illinois (Chicago), found trauma to be the leading cause of maternal deaths (46%). 5

The causes of injury vary widely. Studies indicate that motor vehicle collisions are by far the most
common cause of serious maternal and fetal injury. 1, 6 One study found falls and assault to be the
second and third most common causes1; another identified the same causes but in reverse order. 6 The
incidence of prenatal assault by an intimate partner has been variably reported to be between 1% and
8%.7-9 There is evidence that the gravid uterus is frequently targeted; one study among pregnant and
postpartum women who visited hospitals for assault-related injuries found that injuries to the torso
accounted for 22% of such visits during pregnancy, whereas only 9% occurred postpartum. 10 Nurses
should bear in mind that victims of abuse might be reluctant to talk about it. 11 For example, a woman
presenting with vaginal bleeding might not mention that it started after she'd sustained a blow to the
abdomen.

The risk of death after traumatic injury is similar in pregnant and nonpregnant women. 6, 12 One study
even found that the death rate among pregnant patients was lower than it was among nonpregnant
patients.6 But research indicates that the fetus is more likely to die after traumatic injury than is the
mother. For example, one retrospective study of fetal death certificates from a three-year period found
that in the 240 cases of fetal death resulting from traumatic injury, just 27 mothers died. 13 And a large
retrospective study of more than 10,000 pregnant women hospitalized for trauma over an eight-year
period found that, among women sustaining prenatal trauma, there were 25 fetal and three maternal
deaths.1

NORMAL CHANGES OF PREGNANCY AND THE TRAUMA PATIENT

In order to care for pregnant trauma patients, nurses need to understand the anatomic and physiologic
changes of pregnancy and their implications.

Compression and displacement of the pelvic, abdominal, and thoracic organs occur as pregnancy
advances. This makes some injuries more likely and others harder to detect. For example:

* the spleen becomes engorged, which predisposes it to rupture. 11, 14

* the diaphragm rises, causing the heart to rotate on its long axis and move upward and to the left.
Heart sounds are altered as well. 15

* the small bowel is displaced upward, increasing its vulnerability to penetrating injury and making
bowel sounds harder to detect.15, 16

* chronic stretching of the peritoneum results in decreased sensitivity to irritation and loss of peritoneal
signs in the third trimester.17, 18 Thus the presence of blood or other fluids in the peritoneum may not
produce the typical rebound tenderness response. 18 And the pregnant abdomen is normally firm and
distended, making physical examination less reliable.

* the expanding uterus displaces the bladder upward and out of the pelvis, making it more vulnerable to
rupture.18

The anatomic and physiologic changes of pregnancy can mask the signs of decompensation normally
present in patients going into shock. For example,

* the minute ventilation (the amount of air expelled in one minute) rises, producing respiratory alkalosis
with partial pressure of arterial carbon dioxide (PaCO 2) levels of only 25 to 30 mmHg17, 19 (the normal
nonpregnancy range is 35 to 45 mmHg). 20 An elevated PaCO2 is a sensitive indicator of respiratory
failure-and such elevation is relative. Because a pregnant woman's baseline PaCO 2 is lower than a
nonpregnant woman's, even a "high normal" PaCO 2 might indicate significant respiratory compromise. 17,
19 21
,

* pregnancy-associated hypervolemia begins as early as the 10th week of gestation; by term, a pregnant
woman's circulating blood volume has expanded by as much as 50%. 19 (This volume expansion also
contributes to the 30% to 50% rise seen in cardiac output. 15) Although hypervolemia helps to protect
against shock, it can mask a gradual maternal blood loss of 30% to 35% (about 1,500 mL) or an acute
blood loss of 10% to 15%.22 Indeed, signs of hemorrhage in the pregnant patient are often absent until
volume loss is severe.11
* pronounced peripheral vasodilation (a drop in systemic vascular resistance) 21, 23 can leave the pregnant
trauma patient's skin pink, warm, and dry, despite significant blood loss. Because she will be slow to
exhibit the pale, cool, and clammy skin characteristic of shock, major hemorrhagic losses can go
unnoticed.

* the glomerular filtration rate increases by 30% to 50% by the end of the first trimester, 15 resulting in
increased urination frequency.22 Urine output is thus a poor indicator of shock in pregnant trauma
patients.

* as pregnancy advances, mild hypotension, tachycardia, and dilutional anemia (anemia resulting from
hypervolemia) occur: the heart rate increases by 15 to 20 beats per minute, 21 the systolic blood pressure
decreases by 5 to 10 mmHg in mid-pregnancy, 17, 21 and hemoglobin and hematocrit levels drop. 15 Each of
these normal changes mimics a finding associated with bleeding, but there's a risk they will be
overlooked in a pregnant patient who is actually in hemorrhagic shock.

Pregnancy and pregnancy-associated changes can increase the risk of complications after injury. For
example,

* the upper respiratory passages narrow as a result of capillary engorgement, compounding the extent
of bleeding in patients with facial injuries and complicating endotracheal intubation and gastric tube
insertion.22

* the lower esophageal sphincter relaxes and gastric emptying time decreases, even while appetite and
oral intake increase; the result is a heightened risk of aspiration. 17, 18

* the expanding uterus displaces the diaphragm upward, decreasing the lungs' functional residual
capacity (the "spare tank" reserve).17 This reduction, along with a 15% to 20% increase in resting oxygen
demand, makes hypoxia more likely.18, 24

* uterine blood flow increases tenfold, from about 60 mL/min in a nonpregnant woman to about 600
mL/min by term.25 Injury to this highly perfused organ can result in substantial blood loss.

* the levels of fibrinogen and most clotting factors rise significantly, increasing the risk of
thromboembolism, especially after trauma.16, 17, 26

And several injuries are unique to the pregnant trauma patient, including placental abruption, preterm
labor, uterine laceration, and uterine rupture.

THE PREGNANT TRAUMA PATIENT: FIRST RESPONSE

As with nonpregnant trauma patients, the focus of initial interventions remains the "ABCs": airway,
breathing, and circulation. Trauma care priorities don't change when the patient is pregnant; indeed, the
fetus's best chance for survival is vigorous resuscitation of the mother. 27 Maternal death is the most
common cause of fetal death.16, 27, 28
Airway and breathing. Maintaining maternal oxygen levels is paramount. The pregnant trauma patient's
decreased functional residual capacity and increased oxygen consumption make hypoxia likely.
Administer oxygen, monitor oxygen saturation levels continuously, and intubate early if oxygenation or
ventilation is inadequate.19 The normal fetal level of partial pressure of arterial oxygen (PaO 2), measured
at the umbilical artery at term, has been measured at between 26 and 30 mmHg 29; any decrease will be
poorly tolerated by the fetus. Augmenting maternal PaO 2 has been shown to improve fetal oxygen
levels.28, 30, 31

After determining that it's safe to do so, raise the head of the bed to reduce the weight of the uterus on
the diaphragm and facilitate breathing. The elevated level of the diaphragm during pregnancy has
implications for chest tube placement and emergency thoracotomy: these procedures should be
performed one to two intercostal spaces higher than usual. 18 In a pregnant patient with a tension
pneumothorax, the site for needle decompression remains the same (second intercostal space,
midclavicular line). The diaphragm's elevated position will need to be taken into account when placing a
needle. Thoracotomy and tube and needle placement procedures might also be complicated by the
patient's enlarged breast tissue; for example, the vascular engorgement seen in pregnancy could mean
increased blood loss.

Circulation. A typical adult heart rate is about 65 to 70 beats per minute; in a pregnant woman at term,
this increases by about 15 to 20 beats per minute. 21 Typical systolic blood pressure is about 115 to 120
mmHg; in a pregnant woman mid-pregnancy, this drops by 5 to 10 mmHg. 21 Thus the maternal heart
rate should be below 100 beats per minute and the systolic blood pressure should be above 100 mmHg.
Values outside those parameters should prompt immediate investigation; the patient's baseline blood
pressure, if known, should also be considered. Because central venous pressure is unaffected by
pregnancy (except during delivery) it can serve as a reliable indicator of maternal volume status. 21

The pregnant trauma patient requires early, vigorous fluid replacement to support herself and her fetus,
which is extremely sensitive to maternal hypovolemia: fetal hypoxia and bradycardia can develop
quickly. Except in cases of minor injury, pregnant trauma patients typically require two or more large-
bore (14-to-16-gauge) intravenous catheters for fluid replacement. Plan on early and aggressive red
blood cell transfusion-using O negative or type-specific (noncrossmatched) blood-until crossmatched
units are available.32

By 24 weeks' gestation, the gravid uterus has become significantly larger and heavier than a nongravid
uterus. In a supine pregnant patient, the combined weight of the uterus, fetus, placenta, and amniotic
fluid can compress the inferior vena cava enough to obstruct venous blood return to the heart; the
phenomenon is known as supine hypotension syndrome. 21 Such compression also increases venous
pressure below the level of the uterus, which in the trauma patient can exacerbate pelvic, placental, and
lower-extremity bleeding.19 Simply tilting the patient to her left side will shift uterine weight off the vena
cava and alleviate pressure,21 dramatically improving perfusion to both mother and fetus. If the patient
is in spinal immobilization on a backboard, the same result can be achieved by raising the right side of
the backboard about 15°. If the patient cannot be tipped, the uterus must be manually displaced to the
left.21
ASSESSMENT AND INTERVENTIONS

Obstetric assessment. Although it might seem obvious, one of the most important steps in caring for a
pregnant trauma patient is to recognize that she is pregnant. Every injured female patient of
childbearing age should be asked when she last menstruated and whether she could be pregnant. If her
obstetrical status isn't known, perform urine or serum pregnancy tests. 27 When pregnancy is obvious but
more detailed information can't be obtained, estimate gestational age by assessing the height of the
uterine fundus. At 12 weeks' gestation, the fundus will be palpable just over the rim of the pelvis; at 20
weeks' gestation, at about the level of the umbilicus. Thereafter the fundus rises at the rate of about 1
cm (one finger's breadth) per week, reaching its maximum height at about the level of the xiphoid at 36
to 38 weeks' gestation.11, 32

It's important to obtain an obstetric history. Determine the patient's estimated date of delivery and the
numbers of previous pregnancies and deliveries. Ask whether she has developed any complications
related to this or earlier pregnancies. Also ask whether she's currently experiencing contractions, vaginal
bleeding, or backache, any of which could indicate impending delivery; contractions or vaginal bleeding
might also indicate placental abruption. Inspect the perineum for any sign of blood, amniotic fluid, a
prolapsed cord, or fetal crowning (or the visible presentation of other fetal parts).

Maternal management. It benefits neither the mother nor the fetus to miss or undertreat injuries.
Pregnant trauma patients require the same diagnostic studies and interventions as nonpregnant
patients. This includes all indicated radiographic studies such as plain film X-ray, computed tomography,
angiography, and magnetic resonance imaging. That said, the uterus should be shielded during
radiographic procedures, except during abdominal or pelvic imaging. 27 Bedside ultrasonographic
examination can be helpful in detecting fluid in the intraperitoneal cavity and confirming fetal heart
rate, among other uses.11, 28

Given the pregnant patient's lax lower esophageal sphincter, decreased gastrointestinal motility, and
increased oral intake, gastric tubes should be inserted as needed to prevent vomiting and aspiration. 22, 28
Although having an indwelling catheter increases the pregnant patient's risk of urinary tract infection
and pyelonephritis, it's essential for monitoring urine output in critically injured patients. 11 Check for any
contraindications in pregnancy before administering medications and alert the pharmacist that the
patient is pregnant. Many drugs-including tetanus toxoid, heparin, narcotic analgesics, acetaminophen,
contrast dyes, and some antibiotics-can be safely administered during pregnancy.

Many trauma patients require psychosocial intervention to help them cope with their injuries; when the
patient is pregnant, she and her partner will also be worried about known or possible injuries to her
fetus. Such parental anxiety should be continually addressed by the nurse. 33 Short, frequent
conversations relaying information about fetal status and explaining planned or likely procedures are
helpful. If the fetus is not in distress, the mother will usually be allowed to deliver vaginally; if her
condition is critical, a cesarean section may be performed. If the fetus has died, spontaneous vaginal
delivery may be delayed by a few days. A bereavement protocol suggesting specific interventions to help
the family cope with fetal loss is recommended. 33 Nurses can provide referrals to social workers and
help patients access community resources such as clergy or support groups. Victims of assault or
domestic violence might need help finding a shelter, contacting the police, or obtaining legal
representation.

Evaluation and care of the fetus. Reported direct fetal injuries include skull fractures, intracranial
hemorrhage, and splenic rupture.16 As the largest abdominal organ, the fetal liver is also likely to sustain
injury. Placental abruption-the detachment of the placenta from the uterine wall-is common after
serious trauma and is a major cause of fetal death. 16, 34, 35 Other causes include preterm labor,
premature rupture of the membranes, placental lacerations, uterine rupture, and umbilical cord
thrombosis. Emergent interventions for the treatment of fetal injuries are limited.

It's important to remember that even during pregnancy, the body never considers the uterus an
essential organ. In a pregnant woman in shock, uterine perfusion will decrease before renal perfusion
(or that of any other major organ). Although a pregnant woman might tolerate considerable blood loss
with little consequence, a fetus inside a hypoperfused uterus will not. 22 Because the signs of
hypovolemia and shock are delayed in a pregnant woman, any signs of maternal hypovolemia indicate
that the fetus is already compromised.19 Maternal blood and fluid replacement must be initiated
immediately.

Between 60% and 70% of fetal deaths are the result of minor traumatic events. 16 Placental abruption
can occur up to 48 hours after the injury. 27 Thus early evaluation by an obstetrician or perinatologist and
fetal heart rate monitoring-even after minor trauma-are essential. 31 Fetal heart rate is the only fetal vital
sign easily monitored; fortunately, the fetal heart is extremely sensitive to oxygenation and volume
status, making the heart rate a good indicator of fetal well-being. Until continuous electronic fetal heart
rate monitoring is available, perform serial measurements using a stethoscope or Doppler
ultrasonography. Normal values range from 120 to 160 beats per minute; slower rates are far more
ominous than faster ones.22 Once electronic monitoring begins, it should continue for at least four to six
hours.27, 31 Monitoring must be performed by an obstetric nurse trained in waveform interpretation and
able to identify and rapidly respond to nonreassuring waveforms. 31 If the hospital lacks an obstetrics
service, the patient should be transferred to a facility that has one; if the pregnancy is high risk, arrange
for transport to a perinatal specialty center.

In the rare event of maternal cardiac arrest, perform all standard life support interventions, including
defibrillation and drug administration. The only deviation is an added measure: manually move the
gravid uterus off the vena cava to facilitate perfusion. If maternal death appears imminent and if the
fetus is alive with a gestational age of at least 24 weeks, case reports indicate that rapidly performing a
perimortem cesarean section can improve the odds of survival for both patients, 11, 19, 27, 31 although one
study found it was "rarely successful" for the fetus. 32

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