S E M I N A R S I N P E R I N A T O L O G Y 42 (2018) 13–20

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Seminars in Perinatology

www.seminperinat.com

Trauma in pregnancy
Christopher Kevin Huls, MD, MSca,⁎, and Corey Detlefs, MD, FACSb
a
Department of Obstetrics and Gynecology, University of Arizona College of Medicine, Banner University Medical
Center, Phoenix, AZ
b
Department of Surgery, University of Arizona College of Medicine, Banner University Medical Center, Phoenix, AZ

article info abstra ct

Keywords: Trauma is the leading non-obstetric cause of death during pregnancy and approximately 6–8%
Trauma of all pregnancies are complicated by injury, both accidental and intentional. The initial
Pregnancy evaluation and management of the injured pregnant patient often requires a multidiscipli-
Domestic violence nary, collaborative team to provide the optimal outcome for both mother and fetus. It is
Motor vehicle collision important to recognize that even minor mechanisms of injury may result in poor outcomes
Abruption for both fetus and mother. Injured pregnant patients meeting admission criteria experience a
Burns progressive increase in the number of complications as well as the number of patients that
Inhalation require delivery. There exists opportunity to identify patients who require admission and
Emergency provide supportive measures that may reduce the complications of prematurity. Patients that
are admitted may benefit from a multidisciplinary approach including on-going care from
obstetricians or maternal-fetal medicine physicians. Placental abruption is the most common
pregnancy complication, and may occur with even minor mechanisms of injury. Increasing
severity of trauma increases the frequency of abruption, admission, delivery, and fetal demise.
& 2018 Published by Elsevier Inc.

Introduction The most common type of trauma was domestic violence,

Trauma complicates 1 in 12 pregnancies, although the exact
incidence is not known.1 Non-obstetrical and obstetrical
complications can occur as a consequence of trauma. Mater-
nal deaths as a result of trauma are a leading cause of non-
obstetric mortality.2 Trauma is also a leading cause of mortal-
ity worldwide.3 For the obstetrical patient, complications
from trauma during pregnancy include contractions, preterm
labor, fetal maternal hemorrhage, spontaneous abortion,
premature rupture of membranes, preterm birth, uterine
rupture, placental abruption, and intrauterine fetal demise.
The estimated incidence and prevalence of injury was
summarized in a systematic review of the available litera-
ture.4 The authors were able to assess that estimated inci-
dence or prevalence of injuries in pregnancy by comparing
the rates to non-pregnant women from multiple sources, and
estimated that the relative incidence of injuries from trauma.
which increased from 5239/100,000 women to 8307/100,000
live births which was a 58% increase during pregnancy. The
risk of homicide also increased during pregnancy from 2.3/
100,000 women to 2.9/100,000 live births. Trauma from motor
vehicle collisions, falls, burns, suicide, penetrating trauma,
and toxic exposure all decreased during pregnancy.4
Domestic violence
Domestic violence occurs the most frequently of all the
reported traumas in pregnancy and is reported to occur in
4–8% of all pregnancies.5 Using the National Vital Statistics
Reports for 2015,6 it is estimated that as many as 159,
109–318,219 pregnant women are affected by intimate partner
violence. The types of violence include intimate partner
violence, although abuse itself can include physical,

n
Corresponding author.
E-mail address: Kevin_Huls@mednax.com (C.K. Huls).

https://doi.org/10.1053/j.semperi.2017.11.004
0146-0005/& 2018 Published by Elsevier Inc.
14 SE M I N A R S I N PE
psychologic, sexual, and reproductive coercion.7 A retrospec-
tive cohort study in Massachusetts of linked natal and
hospital data (emergency department, observations, and
inpatient) for women presenting with assault used IC-9 codes
to find that 42.2% of initial injuries were to the head and neck.
Torso injuries were identified in 21.5% of patients during
pregnancy versus 8.7% during the postpartum period, and the
leading physical injury was a contusion or superficial injury
in 25.4% of patients.8
The risks to pregnancy associated with intimate partner
violence or domestic violence is extensive. Reported risks
include poor pregnancy weight gain, infection, anemia,
tobacco, stillbirth, pelvic fracture, placental abruption, fetal
injury, preterm delivery, and low-birth weight. A population-
based study examined 4,833,286 deliveries from the Vital
Statistics-Patient Discharge Database in California during the
years 1990–1999, determined 2070 patients were assaulted
and then hospitalized (0.04%). Admitted patients had an
increased risk of prematurity (24%) OR ¼ 2.4 (95% CI: 1.8–3.3),
maternal death (0.71%) OR ¼ 19 (95% CI: 2.7–144.7), fetal death
(9.3%) OR ¼ 8 (95% CI: 4.6–14.3), and uterine rupture (0.7%) OR
¼ 46 (95% CI: 6.5–337.8). The study further analyzed other
immediate risks that followed assault which includes preterm
premature rupture of membranes of 7.6-fold increase (95% CI:
3.9–14.7, P o 0.000) and blood transfusions.9
Motor vehicle accidents
Motor vehicle accidents account for a significant portion of
trauma during pregnancy. In a retrospective review of linked
national data in Sweden, an estimated 207/100,000 live births
were complicated by a motor vehicle accident.10 The mortal-
ity risk was 1.4 maternal fatalities and 3.7 fetal fatalities for
every 100,000 pregnancies.10 The reported number of preg-
nant patients that seek medical attention after a motor
vehicle collision is 87%,11 although it is not known how many
of those patients are evaluated in an emergency room or an
Ob triage. A cross-sectional study from self-reported data in
22 states to the Centers for Disease Control and Prevention
estimated that 92,500 pregnant women are hurt each year in
motor vehicle collisions, and that most women do not report
being counseled about seat belt use during prenatal visits.12
The greatest obstetrical risk is that of abruption which may
occur from shear force (coup) or tensile force (counter coup),
and may complicate up to 40% of severely injured patients
following a motor vehicle collision.13
Burns
Burn injuries have a mechanism of injury that differs signifi-
cantly from other forms of trauma. There is direct thermal
injury to tissue, inhalation injury to the lung, and accumulation
in the maternal blood stream of toxic substances released by
combustion. The estimated incidence of burns is 0.17/100,000
person-years in the obstetric patient versus 2.6/100,000 person-
years in the non-obstetric patient.4,14 In a review by Parikh
et al., the effect of total body surface injuries were systema-
tically reviewed and summarized (N ¼ 139 cases) to determine
R I N A T O L O G Y 42 (2018) 13–20
the effect of total body surface area burned (TBSAB) on
maternal and fetal outcomes. There was an effect of TBSAB
on maternal mortality, but when controlling for maternal
mortality, there was no effect of TBSAB on fetal mortality.15
Fetal survival was dependent on maternal survival.15
Management of trauma
The initial evaluation of a pregnant trauma patient may occur
in either the Emergency Department (ED) or present to an
obstetrical triage area.16 Significant or major trauma resulting
from motor vehicle accidents, domestic violence, burns, hom-
icide, transportation by Emergency Medical Services, or prior to
fetal viability are more likely to present to an ED. Minor trauma,
domestic violence, falls, late 2nd or 3rd trimester gestational
age, and patients delaying their presentation after a waiting
period may be more likely to present to Ob triage. Regardless of
where and when the patient presents, both areas of the
hospital need to be prepared for pregnant trauma patients.
Centers must develop and implement specialized multidisci-
plinary teams, training, education, protocols, and equipment to
be highly functional in multiple locations within the hospital.
Trauma centers and neonatal intensive care units (NICU)
have designated levels of service which influence where
patients are stabilized or transported to. Each state desig-
nates its own process to review centers and establish levels of
care, and services may differ from state to state, or by
location. Trauma centers have 5 levels of service with a Level
I center considered a comprehensive regional resource that is
a tertiary center and critical to the trauma system. The
American College of Surgeons will verify services at each
center, but does not designate. Designation of NICU levels
occur at the state or local level, with Level III or IV signifying
the most comprehensive neonatal care within the system.
Recently ACOG and the Society of Maternal-Fetal Medicine
proposed designation for maternal levels of care. Maternal
levels of care include designation of a Birth Center, Level I
(Basic Care), Level II (Specialty Care), Level III (Subspecialty
Care), and Level IV (Regional Perinatal Health Care Center)
with specific requirements defined elsewhere.17 Obstetrical
trauma patients should be expected to present to all levels of
maternal or neonatal care. Maternal Levels of Care do not
integrate trauma because Trauma Levels already incorporate
pregnancy with the expectation that pregnant patients will
receive the same level of trauma care as non-pregnant
patients. The Emergency Medical Treatment and Labor
Act18,19 stipulates that:
• An individual(s) designated as qualified by hospital policy
must perform an appropriate medical screening exam and
determine if an emergency condition exists.
• If an emergency medical condition exists, that patient may
be transferred if there is written certification that the
benefits outweigh the risks.
• When deemed necessary, arrange transfer to an appropri-
ate facility once the patient is stabilized or if the benefits of
transfer outweigh the risks. The patient may decline, but
the transfer should be carried out by qualified personnel
and equipment.
 SE M I N A R S I N P E R I N A T O L O G Y 42 (2018) 13–20 15

Emergency suggests that teams should practice drills in common emer-

**Warning Signs**
Department or Ob
Warning
Yes gencies such as hypotension, vagal reactions, hemorrhage,
Triage Cardiac Arrest
Signs
and allergic reactions.22 The purpose of simulations includes
Airway Unresponsive
education of the healthcare team, proficiency of decision-
Breathing Loss of airway
making, teamwork, SBAR communication, debriefing, and
Circulaon No Respiratory Arrest process improvement.23
Warning
Vital Signs Signs BP <80/40 Rapid Response Teams are defined by ACOG and are
HR <50 >140 composed of 4 key components. Those components are
Airway Assess, Oxygen, Intubaon (1) Activators, (2) Responders, (3) Quality Improvement, and
Breathing Venlaon, chest tube
Circulaon 2 large bore IV’s, crystalloid/blood (4) Administration. The use of an Obstetric Trauma response
resuscitaon
Disability GCS, pupillary response
team is used by many institutions and follows these same
Advanced
Exposure Keep Warm/Secondary evaluaon
Trauma/Cardiac principles. Trauma Centers or Emergency Departments
Fetus Displace uterus, Fundal height,
ultrasound, fetal monitoring
Life Support where patients are brought by first responders will have the
trauma surgeons or emergency medicine physician take the
primary role, and the obstetrical providers will serve as a
Consultants: Labs: Imaging: consultant. Obstetrical consultants will take an active role in
Trauma CBC, CMP, glucose. Cervical Spine the evaluation of the pregnancy during the initial survey.
Anesthesia
Blood type, Rh,
X-rays
The obstetrical providers will often take the primary role
lactate
with a trauma provider consulting when a patient presents
Neonatology As indicated: FAST Ultrasound
or Peritoneal to Ob triage and then identified as having a trauma-related
Ob/MFM Kleinhauer-Betke, Lavage complaint.
Orthopedic Coagulaon
(PT/PTT/fibrinogen), CT scans The initial evaluation includes history, ABCs, assessment of
Others as Urinalysis, Ob Ultrasound vital signs, fundal height, and deflection of the uterus off the
indicated Toxicology
inferior vena cava. Resuscitative efforts should be performed
If fetus viable:
Observaon or
Admit with any of the following: simultaneously with the primary survey and not delayed for
Betamethasone and
Admission Connuous Fetal Uterine Contracons, preterm labor, definitive diagnoses if the patient is seriously injured. Uterine
Monitoring uterine tenderness
displacement is important after 20 weeks gestation and is
accomplished by placing the patient on a 15° wedge or
Fig. – Trauma initial workflow. Initial workflow originates in
manually displacing the uterus to the patient’s left side.
the emergency room or obstetrical triage. The presence of
Another option is to position the patient in the left lateral
warning signs requires immediate attention and activation
decubitus or prone position once there is assurance of
of response team. Common elements of evaluation,
cervical spine stability.
consultants, laboratory, and diagnostic imaging are
After the patient’s initial presentation, and a triage evalua-
presented. Indications for obstetrical admission and
tion process is initiated, it is critical to be aware of warning
antenatal corticosteroids are included.
signs. Warning signs are surrogates for adverse outcomes,
emergencies, and typically require immediate attention.
• Insurance status or payment method is not appropriate to Signs of blood loss may not appear initially due to maternal
delay the medical screening of patients. compensation and go unrecognized prior to the onset of
warning signs as represented by Stages of Hemorrhage in
The initial evaluation of the pregnant patient includes a the Table. Expert opinions have posited several thresholds as
provider trained and knowledgeable about the physiologic warning signs previously.4 There is the MEOWS24 system
changes of pregnancy, obstetrical complications, and man- which uses Respiratory rate o10 or 430, O2 saturation
agement of complications. Hospitals often use a team-based o95%, HR 4120 or o40, SBP 4160 and o90 and DBP 4100,
approach to managing obstetrical patients. Each hospital and more recently MERC25,26 which utilizes slightly different
must develop its own protocol for evaluating and managing criteria including temperature ≥38 or ≤36°C, pulse oximetry
pregnant trauma patients as they are positioned to know the ≤93%, heart rate 4110 or o50, respiratory rate 424 or o12,
locally available resources. A workflow for an Obstetric and SBP 4155 or o80. Early warning systems are not specific
Emergency Department Team is represented in the Figure. to trauma, or the pregnant trauma patient, but are general-
A virtual care team may be an appropriate model, and is ized to many settings. Trauma guidelines utilize cardiac
based on the premise that the patient receives the care in the arrest, loss of an airway, blood pressure o80/40 mmHg, HR
location or unit that is most appropriate for the patient with o50 or 4140 bpm, RR o10 or 424,27 although there is no
additional services and consultants brought to the patient’s clear validation of thresholds for blood pressure, heart rate, or
location, wherever that may be in the hospital, or by tele- respiratory rate that requires activation of a pathway for
medicine.20 There is limited information regarding telemedi- obstetrical trauma.
cine use for trauma and pregnancy. After the initial survey with simultaneous resuscitative
The Institute of Medicine identified the need to prepare for efforts, a detailed history and exam is performed, and
emergencies, and calls on interdisciplinary collaboration incorporated with a focused assessment using sonography
between hospitals, nursing staff, administration, and pro- for trauma (FAST) evaluation, obstetrical ultrasound, and
viders to plan for emergencies.21 ACOG has examples and fetal monitoring. A FAST evaluation evaluates the 4 areas
resources for creating an emergency response team, and where blood or fluid may accumulate and include the
16 SE M I N A R S I N PE
Table – Adaptation to blood loss.
Class 1 Up to 15% of blood volume
o1200 ml
Class 2-Mild Blood loss up to 30% of blood volume
1200–1500 ml
Class 3-Moderate 30–35% of blood volume
1500–2000 ml
Class 4-Severe 440% of blood volume
42000 ml
subxiphoid pericardial window, hepatorenal recess,
perisplenic and suprapubic view. The obstetrical ultrasound
assessment includes fetal heart rate, gestational age, presen-
tation, placenta, abruption, evidence of fetal injury, and
evidence of intraabdominal/pelvic fluid. Fetal monitoring
evaluates for evidence of uterine activity or fetal heart rate
decelerations within the first 4–6 hours.
Diagnostic imaging is not contraindicated in pregnant
patients, and may demonstrate obstetrical complications
such as abruption or uterine rupture. Ultrasound may only
detect 25–60% of the cases of abruption.28–30 A CT scan
demonstrating a decrease in the percentage of placental
enhancement is associated with an increase in diagnosis of
placental abruption.31,32 When 25–50% of placenta perfusion
is decreased on CT there is a correlation with abruption and
the need for emergent delivery.31,33 The sensitivity for CT is
100% and specificity 54–56% and performs better than ultra-
sound at detecting clinical abruptions.34 If the patient is
stable, and free fluid is identified, there may be a role for
diagnostic peritoneal lavage.
A laboratory work up is done with input from the trauma
evaluation and often includes a complete blood count, meta-
bolic panel, urinalysis, or toxicology screening. Additional
laboratories for obstetrical patients may include blood type,
Rh status, coagulation studies with fibrinogen,35 and the
Kleinhauer–Betke (KB) test.35 Additional tests may be per-
formed depending on the patient’s clinical history and
directed management plan.
Post-evaluation management
Maternal health remains the primary objective in the treat-
ment of the pregnant trauma patient. Interventions for fetal
benefit are only recommended after stabilization of the
mother. Interventions include uterine displacement, volume
replacement, and oxygen in order to optimize maternal
R I N A T O L O G Y 42 (2018) 13–20
Pulse rate o100 bpm
Blood pressure may increase
Pulse pressure no change
Tachycardia 4100 bpm
Vasoconstriction—cold, pale
Narrow pulse pressure
Orthostatic hypotension
Mean arterial pressure—decreases 10–15% (70–75 mmHg)
Tissue hypoxia
Tachycardia 4120 bpm
Hypotension
Mean arterial pressure 25–30% drop (50–60 mmHg)
Oliguria (o0.5 ml/kg)
Hemorrhagic shock
Tissue hypoxia
Tachycardia 4140 bpm
Mean arterial pressure o50 mmHg
Anuria
DIC
Mental status changes
physiology to the benefit of uterine blood flow and oxygen
delivery to the fetus. Identification of maternal warning signs
may require activation of response teams and multidiscipli-
nary management regardless of where the patient is in the
hospital. A cesarean delivery is not recommended at the time
of an exploratory laparotomy, unless there are other
indications.
Maternal cardiac arrest will follow Advanced Cardiac Life
Support resuscitation guidelines. Notable changes from past
guidelines include that there is no modification of hand
placement for compressions and the use of manual uterine
displacement to avoid caval compression rather than tilting
the patient. If cardiopulmonary resuscitation is not success-
ful within 4 minutes36 then a perimortem cesarean delivery is
recommended in order to help facilitate maternal resuscita-
tion, and possibly infant survival when the gestational age is
periviable ~22–23 weeks. Katz et al.37 reported several cases of
trauma-related perimortem cesarean deliveries with
improved outcomes, though most case reports focus on
nontraumatic maternal cardiopulmonary arrest. A recent
review that evaluated the reported time from arrest to
delivery was unable to confirm that there is an advantage
by waiting for 4 minutes.38 It is also important to perform a
perimortem cesarean without the delay of moving the patient
to an operating room or sterilization of the abdomen. Addi-
tionally, there should be no delay to assess fetal viability.39
Universal personal protective equipment for the individuals
performing the delivery is recommended. The patient may
require immediate intervention including exploratory
laparotomy.
Abruption and fetomaternal hemorrhage
Abruption remains a clinical diagnosis and is identified by the
presence of painful uterine contractions or by palpation in
the presence of vaginal bleeding. Trauma patients may have
 SE M I N A R S I N P E R I N A T O L O G Y
concealed abruption, or even direct injuries to the placenta or
fetus and may not exhibit vaginal bleeding or even painful
contractions. A high degree of suspicion is warranted in the
setting of a fetal heart rate o110 bpm or 4160 bpm which is a
warning sign for fetal complications. Patients presenting with
bradycardia are not recommended to undergo an immediate
cesarean delivery until stabilization of the mother and in a
setting that is deemed appropriate for her care. Persistent
uterine activity 41 every 10 minutes or variable decelerations
in the initial 4–6 hours should be considered for admission.
Consideration should be given to betamethasone adminis-
tration, and if near term, delivery may be recommended.
A reasonable follow-up for patient’s following an abruption
may include sonograms for evaluating amniotic fluid, fetal
growth, and antenatal testing following discharge.
A KB test is not a reliable test for abruption, but may be
useful for patients that are Rh negative. The KB test deter-
mines the presence of fetal cells in maternal circulation and
estimates the amount of fetal red blood cells. A standard
300 μg dose of Rhogam will protect up to 30 ml of fetal blood,
but abdominal trauma may exceed 30 ml of fetal blood in the
maternal circulation more frequently.35,40 Therefore blunt
abdominal trauma has a greater incidence of requiring more
than 1 dose of Rhogam.40 Relying on physician discretion to
decide when to order the KB has only moderate performance
for identifying and treating appropriate patients, and is not
recommended.41 The Canadian Task Force guidelines recom-
mend that all Rh negative women receive Rhogam and that
Rh testing is obtained for each patient to ensure adequate
treatment, which is based on level III-b evidence.35,40 If the Rh
is negative, Rhogam is indicated for the trauma patient
within 72 hours.42 A positive KB is recommended to be
admitted to the hospital, and may require middle cerebral
artery Doppler evaluation for fetal anemia. There may be a
limited role for intrauterine transfusions.43
Penetrating trauma
The management of penetrating trauma does not differ in the
pregnant patient. There is a decrease in visceral injuries with
penetrating injuries anterior and below the uterine fundus.44
There may be role for placing needed chest tubes at a higher
intercostal space, particularly in late gestation. Exploratory
laparotomy is not an indication for cesarean delivery.
Orthopedic trauma
Orthopedic trauma in pregnancy may include injury to the
pelvis, spine, or extremities. The injuries may be open or
closed injuries which may impact the decision for immediate
management, or in some cases deferring definitive treatment
until the postpartum period. There is an increased risk of
mortality with pelvic or acetabular fractures.45 External fix-
ation or open reduction and internal fixation should be
performed within 3 weeks of the injury.46 A history of pelvic
fracture is not a contraindication to a vaginal delivery and the
patient should be counseled at that time.47 Radiation expo-
sure during fluoroscopic procedures may be reduced with the
42 (2018) 13–20 17
use of real-time dosimetry,48 use of a mini-C-arm,49 and
shielding of the fetus.50 Immobilized patients will need to
have thromboprophylaxis with sequential compression devi-
ces, heparin, or enoxaparin.
Burns
Burns may occur from motor vehicle collisions, structural
fires within a closed space, or from electrical fires. Injuries
occur from direct thermal injury, inhalation injury to the
airway, carbon monoxide, cyanide, or dissipation of electrical
current. Fetal injuries are not typically direct injuries unless
the injury is a severe thermal or electrical injury, but rather
secondary to maternal adaptive changes, loss of airway,
changes to uterine blood flow, loss of oxygen dissociation,
or toxicity from cyanide.
Maternal and fetal mortality risk depend on the amount of
total body surface area burned (TBSAB). The rule of 9’s is used
for TBSAB with each area divided into an anterior and
posterior. The compartments include chest, abdomen, and
each leg are assigned 9%, each arm 4.5%, face 4.5%, and the
genitalia 1%. The TBSAB is associated with maternal death,
but in a review and analysis of the literature, maternal death
mediates the risk to fetal death with no effect from trimes-
ter.15 Maternal odds of death increased by 8% for every 1% in
TBSAB.15 The risk for maternal mortality is similar to non-
pregnant which approaches 50% when the TBSAB is 70%.
There are reports of fetal survival with burns more than 50–
60%, but the increasing risks reflect the increasing risk to
maternal mortality which develops subsequently. Urgent
cesarean delivery is recommended with burns of 55% or more
for viable fetuses without delaying for antenatal corticoste-
roids. For burns of o55%, antenatal corticosteroids may be
administered with expectant management.
The Ob-consultant needs to ensure that appropriate mater-
nal care is not delayed or altered due to pregnancy. The
immediate thermal injury leads to hypovolemia which
requires sufficient fluid resuscitation to avoid renal injury,
while avoiding pulmonary edema or ARDS. With TBSAB of
more than 20% resuscitation with lactate Ringers is recom-
mended to maintain adequate urine output. A common
formula to calculate fluid resuscitation is the Parkland for-
mula using 4 ml/kg per hour multiplied by the TBSAB% and
calculated for the first 24 hours. Initially 50% of that total
volume is administered in the first 8 hours from the time of
burn, and the remaining volume given over the next 16 hours.
Monitoring the physiologic response is necessary to guide
and adjust the fluid resuscitation volumes during this time.
Pregnant patients may be a benefit by increasing the total
amount of fluid by 30–60%.15,51 Skin grafting may need to be
performed within the first 48 hours.52,53
Inhalation
Inhalation injury for a pregnant patient is potentiated by
the underlying physiologic changes of pregnancy. With
pregnancy there is increased edema of the oropharynx and
larynx, increased tidal volume, decreased functional residual
18 SE M I N A R S I N PE
capacity, and a decrease in PaCO2 to ≤30 mmHg. Inhalation
injuries can cause a significant increase in edema shortly
after injury, and may be an inhibition of pulmonary function
from soot. Therefore early intubation for the pregnant burn
patient is recommended prior to edematous changes and to
assist in the management of carbon monoxide poisoning.
Carbon monoxide has increased affinity for the hemoglobin
molecule and displaces oxygen. Oxygen and carbon
monoxide both transfer to the fetal compartment by passive
and facilitated diffusion. Fetal circulation has a 15% increase
in carbon monoxide and cyanide levels compared to maternal
levels. Carbon monoxide then decreases the ability for oxy-
genation of the fetus, which may lead to fetal heart rate
changes. Cyanide disrupts the respiratory chain in the
mitochondria by uncoupling electron transfer for the
mitochondrial cytochrome complex which results in lactic
acidosis for the fetus. Cyanide toxicity is treated with
hydroxocobalamin which will also help to dissociate carbon
monoxide from hemoglobin. Carbon monoxide toxicity
is treated by 100% oxygenation, although if available,
hyperbaric oxygenation may be safely used.
Pharmacology
Acute blood loss from trauma may require the activation of
massive transfusion protocols (MTP). The most common
approach is a 1:1:1 replacement of fresh frozen plasma,
platelets ,and packed red blood cells. There are multiple
factor replacement therapies available including cryoprecipi-
tate, and prothrombin complex concentrate. There are also
topical hemostatic agents that are used which are considered
safe to use during pregnancy. Chitosan-covered gauze (Com-
bat Gauze) is used in trauma patients and has even been
shown to be effective during pregnancy.54
Tranexamic acid is an anti-fibrinolytic medication that may
decrease mortality and bleeding by reducing the breakdown
of fibrin for life-threatening injuries associated with signifi-
cant bleeding and blood product usage. It was studied in the
CRASH-2 study and when given within 6 hours of the initial
injury, there was a reduction in mortality.55 Subsequent
studies have suggested that mortality increases if tranexamic
acid is given more than 3 hours after injury.56 Tranexamic
acid has also been studied with interest in pregnancy as an
adjunct for patients undergoing cesarean delivery,57 vaginal
delivery,58 postpartum hemorrhage,59 prophylaxis for post-
partum hemorrhage with favorable or mixed results. In the
authors’ current institution, tranexamic acid is being insti-
tuted as the first line treatment for postpartum hemorrhage.
In the setting of a trauma with the onset of significant
bleeding, tranexamic acid would be considered safe for the
fetus. It is unknown if the use of tranexamic acid in the
pregnant trauma patient reduces mortality.
Prophylaxis for venous thromboembolism may be done
with sequential compression devices, heparin, or enoxaparin.
Heparin and enoxaparin do not cross the placenta. Treatment
of an acute venous embolism, deep vein thrombosis may
require therapeutic levels of heparin or enoxaparin. If there
are additional risk factors, or concern about labor near the
R I N A T O L O G Y 42 (2018) 13–20
time of an acute clot, then a temporary Greenfield filter may
be placed.
Sepsis is a significant risk for patients that remain hospi-
talized from injuries with major trauma, burns, penetrating
injuries, surgical infections, and may require follow-up after
discharge. The choice for antibiotics should initially consider
the recommended treatment of the non-pregnant patient
with attention toward the known risks of that medication
use during pregnancy. It is likely best to avoid tetracycline,
although most antibiotics may be used with life-threatening
infections.
Summary
Interdisciplinary collaboration between hospitals, nursing
staff, administration, and providers is needed to plan for a
wide array of emergencies. The evaluation of a pregnancy
trauma patient is a multidisciplinary approach and incorpo-
rates training, education, and quality improvement into its
approach for managing trauma patients. The initial evalua-
tion focuses on stabilizing the mother with attention on
warning signs of adverse maternal or fetal outcomes. A
pregnant patient must have the same evaluation and man-
agement as a non-pregnant patient, and without regard to
where the patient is located in the hospital. The use of
diagnostic imaging, laboratory testing, and treatment should
not be withheld from the pregnant patient, although consid-
eration of pregnancy changes, gestational age, or alterna-
tively appropriate testing is recommended in consultation
with a qualified provider. Whenever feasible, the initial
evaluation of a pregnant trauma patient should occur
simultaneously with the providers, and evaluation of the
mother and fetus is recommended to occur simultaneously,
not sequentially. Fetal intervention must be weighed
against the risk to maternal health, although performing a
perimortem cesarean within 4 minutes of cardiac arrest
may improve maternal and possibly fetal outcomes.
Management after the initial evaluation requires on-going
consultation and multidisciplinary approach with obstetrical
providers.
re fe r en ces
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2. Files J, Reed L, Jones N, Martin M, Barrett J. Trauma:
the leading cause of maternal death. J Trauma. 1992 May;32:
643–645.
3. World Health Organization. Global burden of disease. World
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