Trauma in Pregnancy - Emergency Management

Related Summaries

● Placental abruption

General Information

Background

● Traumatic injury in a pregnant patient

● Considered as 2 independent patients after 24 weeks gestation

● Potential trauma and obstetrics (OB) emergency

● Tip: consider pregnancy in any female patient with trauma of childbearing age

Anatomy and physiology

● Cardiovascular 1

⚬ Cardiac output increases 40%

⚬ Heart rate increases 10%-15%
⚬ Blood pressure decreases 15%-20% late in the second trimester
⚬ Blood volume increases 30%-50%
⚬ Cellular components of blood increase 10%-15%
⚬ Physiologic anemia develops
⚬ Hypovolemic shock occurs with greater percentage of blood loss
⚬ Injuries to the spleen, liver, and retroperitoneum are more common because of increased
vascularity
⚬ Hypercoagulable state develops

● Pulmonary 1

⚬ Diaphragm displaced 4 cm superiorly

⚬ Hyperventilation develops with respiratory rates increased by 40%-50%
⚬ Arterial blood gas (ABG) shows increased pH, decreased partial pressure of carbon dioxide (pCO2),
decreased bicarbonate, decreased partial pressure of oxygen (paO2)
⚬ Greater oxygen requirement
⚬ Smaller reserve
⚬ Oxygen disassociation curve shifts to increase oxygen delivery to fetus

● Renal 1

⚬ Blood ow increases
⚬ Ureteral obstruction can develop in the third trimester
⚬ Blood urea nitrogen/creatinine (BUN/Cr) decrease

● Gastrointestinal 1

⚬ Delayed gastric emptying

⚬ Motility decreases
 ⚬ Organs protected by gravid uterus

● Liver 1

⚬ Increased brinogen and coagulation factor production

⚬ Decrease in protein S

● Endocrinology

⚬ Increased insulin resistance

● Pelvic 1

⚬ Uterus protected in the rst trimester

⚬ Uterine blood ow depends on the maternal systolic blood pressure
⚬ Uterus can compress the inferior vena cava (IVC)/aorta
⚬ Bladder is displaced anteriorly and superiorly after the rst trimester

● TIP: remember that pregnancy e ects almost all organ systems in the body 1 , 2

Table 1. Physiologic Changes in Pregnancy - Vital Sign and Laboratory Changes

Parameter Change In Pregnancy Comment

Blood pressure Down 5-15 mm Hg Late second

trimester

Heart rate Up 10%-15% Third trimester

Respiratory rate Up

WBC Up 5,000-15,000 N/A

cells/mm3

Hemoglobin Down 10-14 g/dL From increased

plasma volume

pH Up 7.4-7.47 N/A

PO2 Up 101-104 mm Hg N/A

PCO2 Down 25-30 mm Hg N/A

HCO3 Down 18-21 mEq/L N/A

 Parameter Change In Pregnancy Comment

Abbreviations: HCO3,
bicarbonate; PCO2, partial pressure of
carbon dioxide; N/A, not available; PO2,
partial pressure of oxygen; WBC, white blood
cell.

Etiology

● Assault is the most common cause of trauma during pregnancy 3

● Falls increase in the second and third trimester due to change in center of gravity 3

⚬ 1 in 4 women experience a fall during pregnancy 3

Table 2. Estimated Incidence of Type of Trauma per Pregnancy Occurrence

Type of Trauma Percentage of Incident Occurrence

Domestic violence 8%

MVA 0.2%

Falls 0.04%

Penetrating 0.0033%

Homicide 0.0029%

Suicide 0.002%

Burns 0.00017%

Abbreviation: MVA, motor vehicle

accident.

Epidemiology

● Trauma occurs during 1 in 12 pregnancies 4

● Trauma is the leading cause of death for females of child-bearing age 5

● Trauma is the leading nonobstetric (non-OB) cause of maternal death in pregnancy 2

● Fetal loss complicates 5% of minor trauma 6

● 90% of trauma in pregnancy is minor; 60%-70% of fetal loss is the result of minor trauma 7

History and Physical

History

● Typical AMPLE trauma history as per American College of Surgeons Advanced Trauma Life Support

(ATLS) guidelines 8
⚬ A: allergies
⚬ M: medicines
⚬ P: past medical history
⚬ L: last meal
⚬ E: events/environment leading to current trauma

● Last menstrual period (LMP)/due date

● Prenatal care/documented intrauterine pregnancy

● Prior pregnancy history

● Complications during pregnancy

● Blood type including Rh type

● Abdominal pain

● Vaginal bleeding

● Intimate partner violence (IPV) screening with additional screening for depression and suicidality for

those positive for IPV 7

⚬ Frequent emergency department (ED) visits
⚬ History not consistent with injuries
⚬ Partner remains in close proximity to victim at all times
⚬ Depression, self-blame, or self-abuse (including substance abuse)

Physical

● Initial evaluation and resuscitation should follow Advanced Trauma Life Support (ATLS) algorithms 8

● Common sites of assault are the head, neck, breast, and abdomen

● Obstetrics (OB) issues are addressed as part of the secondary survey 8

⚬ Fundus palpated above the umbilicus is consistent with possible viable fetus; each cm above
umbilicus is approximately 1 week gestation past 20 weeks
⚬ Discrepancy between dates and fundal height are concerning for uterine rupture or hemorrhage
 ⚬ Note abdominal tenderness, uterine tone/contractions
⚬ Perform pelvic exam with sterile speculum to evaluate for vaginal bleeding and amniotic uid leak
⚬ Perform sterile bimanual cervical exam for dilation, e acement, fetal position

● TIP: place gravid patients in left lateral decubitus or left lateral tilt position to decrease pressure on

the inferior vena cava 2

● Burns in excess of 40% carry a nearly 100% maternal and fetal mortality 9

● TIP: in pregnant burn patients, consider a gravid abdomen to be 5% of body surface area 8

Diagnostic Studies

Laboratory tests

● Highly consider obtaining

⚬ Trauma panel including complete blood count (CBC), chemistries, type and screen, arterial blood
gas/venous blood gas (ABG/VBG), lactate, and base de cit
⚬ Tip: hematocrit may not be accurate in acute hemorrhage 8

● May consider obtaining

⚬ disseminated intravascular coagulation (DIC) panel

⚬ Kleihauer-Betke test to detect transplacental hemorrhage
⚬ Drugs of abuse screen and blood alcohol
⚬ Tip: always check blood type and give Rho-gam for Rh-negative women who are bleeding 3

Imaging tests

● Highly consider obtaining

⚬ Ultrasound

– Focused Assessment with Sonography for Trauma (FAST)

● speci city and sensitivity similar to nonpregnant patients with trauma 3

– Fetal viability
– High speci city but low sensitivity for placental abruption 10

● May consider obtaining

⚬ X-ray and computed tomography (CT) scan as indicated

⚬ Magnetic resonance imaging (MRI) is considered safe in pregnancy
⚬ Avoid radioiodine and gadolinium for advanced imaging 10

⚬ Tips: do not withhold necessary imaging due to concerns of fetal e ects; well-being of fetus

depends on well-being of mother 2 , 3 , 10

⚬ Protective apron when possible
⚬ < 5 rads fetal exposure has no association with teratogenicity 1 , 11

⚬ > 12-20 rads fetal exposure increases risk for childhood cancer (1%-6%) teratogenesis, mental
retardation, and microcephaly; risk is dependent on the amount of exposure and the timing of the
exposure during fetogenesis 1 , 11
 Table 3. Estimated Fetal Exposure from Common Imaging

Imaging Study Fetal Exposure

Cervical spine x-ray (3 views) 0.0001 rads

Chest x-ray 0.00007 rads

Abdomen x-ray (2 views) 0.245 rads

Pelvis x-ray 0.17175 rads

Extremity x-ray 0.001 rads

CT head 0.05 rads

CT chest 0.1 rads

CT abdomen or lumbar spine 2.6-9 rads

Abbreviation: CT, computed tomography.Reference - Anaesth Intensive Care 2005

Apr;33(2):167 .

Management

Overview

● Decompensation may occur rapidly

● Adhere to Advanced Trauma Life Support (ATLS) guidelines and attend to obstetrics (OB) issues in
secondary survey
⚬ F (fetus) after ABCDE
⚬ Presence of pregnancy has been shown to divert attention from ATLS primary and secondary

survey 12

● Initial assessment: focus on the primary survey, as described in ATLS, aimed at recognizing and
treating immediate life threats
⚬ Airway

– Early intubation is recommended

– All pregnant females should be considered di cult intubations 13
– Preoxygenate/Proper positioning (external auditory canal on same plane as sternal notch)
– Most experienced provider should perform intubation
– Use endotracheal tube 0.5-1.0 mm smaller than predicted
– Consider awake beroptic intubation
 – Supraglottic devices may be an e ective alternative

⚬ Breathing

– Insert chest tubes 1-2 rib spaces higher than usual due to elevated diaphragm 2

– Supplemental oxygen in all pregnant traumas

⚬ Circulation

– Aggressive uid/blood product resuscitation to optimize uterine/fetal blood ow

– Blood products via massive transfusion protocol (1:1:1 for packed red blood cells, platelets, and
fresh-frozen plasma) as indicated
– Patients > 20 weeks should be in left lateral tilt of at least 15 degrees or decubitus position as
uterine compression can reduce cardiac output by 25%-30%

● Secondary survey: once patient is stabilized, assess for related injuries including a proper vaginal

examination using a sterile speculum for cervical e acement and dilation and obstetric ultrasound 14

● TIP: remember that good care of the mother results in good care of the fetus

● Obstetrical consult for fetal monitoring after age of viability (23-24 weeks gestation)

● Electronic fetal monitoring (EFM) for fetal well-being and uterine activity should be performed by a

trained health provider for at least 2-6 hours 15 , 16

⚬ Occasional uterine contractions are the most common nding after trauma
⚬ Fetal heart rate patterns such as decelerations, bradycardia, tachycardia, loss of variability, greater
than 6 contractions/hour, vaginal bleeding, or abdominal tenderness are concerning for fetal
distress and mandate further resuscitation and/or delivery 15 , 17
⚬ Prolonged fetal monitoring for suspected placental abruption, suspected preterm labor, fetal

distress, general anesthesia, severe closed head injury 10

● Tip: fetal distress may be the rst sign of maternal decompensation

● Penetrating injury 17

⚬ Lower maternal mortality than nonpregnant patient but high fetal mortality
⚬ Immediate surgical exploration for upper abdominal injuries but conservative management for
lower abdominal wounds

● Indications for trauma center 2

⚬ Viable fetus
⚬ Tachycardia
⚬ Chest or abdominal pain
⚬ Loss of consciousness

● Indications for emergency cesarean section 13

⚬ Better exposure for non-OB abdominal injury

⚬ Persistent fetal distress and gestation greater than 25 weeks
⚬ Placental abruption
⚬ Uterine rupture
● Perimortem cesarean section 3

⚬ Best outcome if initiated within 4 minutes of arrest and delivery at 5 minutes

⚬ Consider if gestation > 24 weeks
⚬ Manual displacement of uterus during cardiopulmonary resuscitation (CPR)
⚬ Delivery increases maternal cardiac output by 60%-80% 14

⚬ Need scalpel, scissors, suction, retractor, packing, sutures

⚬ Recommendations remain uncertain

Medications

● Pain medications

⚬ Fentanyl 1-2 mcg/kg IV, if concern for hemodynamic instability or early in resuscitation because of
short duration of action (typical adult dosage 50-100 mcg IV)
⚬ Morphine 0.1 mg/kg IV (typical adult dosage 4-10 mg IV)
⚬ Acetaminophen 500 mg to 1 g orally
⚬ Do not use nonsteroidal anti-in ammatory medications

● Rapid Sequence Intubation

⚬ Depolarizing and nondepolarizing paralytics if needed 18

⚬ Short-acting induction agents are acceptable but have increased hemodynamic e ects, except
ketamine

● IV crystalloid uids indications: ndings of hypovolemia or need to maximize preload (for example,
endotracheal intubation)
⚬ Give 1 L boluses

● Tetanus toxoid, diphtheria toxoid, and acellular pertussis (TDaP) as indicated

● Rho-gam if Rh-negative

⚬ 300 mcg in the rst 72 hours for all Rh-negative patients

⚬ Additional dosing for fetal-maternal hemorrhage if > 30 mL based on Kleihauer-Betke test 14

● Steroids and tocolytics if trauma induces preterm labor in consultation with an obstetrician and/or
neonatologist
⚬ Magnesium sulfate is widely used as a primary tocolytic agent; doses should not exceed 6 g initial
bolus, 1-2 g/hour, and 24 hours respectively
– Some literature suggests avoiding tocolytics in pregnant trauma patients as it may delay the

diagnosis of placental abruption 18

⚬ Betamethasone sodium phosphate-acetate (12 mg) intramuscular injection every 24 hours for 2
doses or dexamethasone 6 mg intramuscular every 12 hours for 4 doses

● Hyperbaric oxygen - consider for all carbon monoxide exposures 2

Disposition

Prognosis and complications

Prognosis
● Depends on level of injury, fetal development

● Decreased maternal mortality in blunt penetrating trauma

● Fetal prognosis depends on maternal prognosis

● Fetal decelerations and fetal bradycardia are associated with poor prognosis

Complications

● Occur in 25% of pregnant women with traumatic injuries

● Premature labor

⚬ 70% of contractions occurring after traumas resolve spontaneously

● Placental abruption

⚬ Complicates 1.7% of all maternal traumas, 4.4%-6.7% of blunt trauma 3

⚬ Signs include uterine tenderness, tetany, vaginal bleeding

⚬ Vaginal bleeding may be absent
⚬ Complications include disseminated intravascular coagulation (DIC) and shock
⚬ When present, ultrasound demonstrates ‘jiggling’ of retroplacental blood (‘Jello sign’) 1

● Uterine rupture

⚬ Uncommon
⚬ Primarily associated with pelvic fracture
⚬ Signs include severe abdominal pain, rebound/guarding, shoulder pain, uterine asymmetry,
palpation of fetal parts, shock
⚬ Management is laparotomy
⚬ Fetal mortality approaches 100%

● Amniotic uid embolism

⚬ Respiratory distress, shock, circulatory collapse in pregnant patient

⚬ Maternal mortality of 30%-50%
⚬ Consider extracorporeal membrane oxygenation (ECMO)

● Pelvic fractures 17

⚬ Rare in pregnancy
⚬ Hypovolemic shock carries high maternal and fetal mortality
⚬ Vaginal delivery not contraindicated

● Seizure

⚬ Consider eclampsia in di erential

Associated conditions

● Abruption

● Amniotic uid embolism

● Fetal demise (3 per 100,000 live births)

● Fetal distress

● Imminent delivery

● Preterm labor

● Rupture of membranes

● Uterine rupture

● Vaginal bleeding

● Injuries not associated with the pregnant state must also be considered

● Poor prognostic signs in maternal outcome 10

⚬ Need for caesarean delivery

⚬ Lack of passenger restraints in motor vehicle collision
⚬ Major head injury
⚬ Signi cant internal injuries
⚬ Shock on presentation

Indications for hospital admission

● Abnormalities during fetal monitoring

● Contractions

● Rupture of membranes

● Trauma indications

● Vaginal bleeding

● Uterine tenderness or irritability

Discharge planning

● Monitor mother and fetus for 4-6 hours 13

● Discharge if no fetal distress, premature labor, vaginal bleeding, or signi cant injury

● Return for abdominal pain or vaginal bleeding

● If trauma is a result of intimate partner violence, consult social worker or refer to appropriate
community support

● Counseling regarding proper seat belt use during pregnancy

Consultations

● Trauma
 ● Obstetrics

● Neonatology

References

General references used

1. Pearce C, Martin SR. Trauma and Considerations Unique to Pregnancy. Obstet Gynecol Clin North Am.
2016 Dec;43(4):791-808

2. Shah AJ, Kilcline BA. Trauma in pregnancy. Emerg Med Clin North Am. 2003 Aug;21(3):615-29

3. Mendez-Figueroa H, Dahlke JD, Vrees RA, Rouse DJ. Trauma in pregnancy: an updated systematic
review. Am J Obstet Gynecol. 2013 Jul;209(1):1-10

4. Hill CC, Pickinpaugh J. Trauma and surgical emergencies in the obstetric patient. Surg Clin North Am.
2008 Apr;88(2):421-40

5. Heron, M. Deaths: Leading Causes for 2008. National Vital Statistics Report. 2008 PDF

6. Mattox KL, Goetzl L. Trauma in pregnancy. Crit Care Med. 2005 Oct;33(10 Suppl):S385-9

7. Murphy NJ, Quinlan JD. Trauma in pregnancy: assessment, management, and prevention. Am Fam
Physician. 2014 Nov 15;90(10):717-22

8. American College of Surgeons (ACS) Committee on Trauma. Advanced Trauma Life Support Manual,
10th ed. Chicago, IL: ACS; 2018

9. Maghsoudi H, Samnia R, Garadaghi A, Kianvar H. Burns in pregnancy. Burns. 2006 Mar;32(2):246-50

10. Einav S, Sela HY, Weiniger CF. Management and outcomes of trauma during pregnancy. Anesthesiol
Clin. 2013 Mar;31(1):141-56

11. Harrison BP, Crystal CS. Imaging modalities in obstetrics and gynecology. Emerg Med Clin North Am.
2003 Aug;21(3):711-35

12. Sela HY, Weiniger CF, Hersch M, Smuelo A, Laufer N, Einav S. The pregnant motor vehicle accident
casualty: adherence to basic workup and admission guidelines. Ann Surg. 2011 Aug;254(2):346-52

13. Meroz Y, Elchalal U, Ginosar Y. Initial trauma management in advanced pregnancy. Anesthesiol Clin.
2007 Mar;25(1):117-29

14. Raja AS, Zabbo CP. Trauma in pregnancy. Emerg Med Clin North Am. 2012 Nov;30(4):937-48

15. American College of Obstetricians and Gynecologists (ACOG). ACOG educational bulletin. Obstetric
aspects of trauma management. Number 251, September 1998 (replaces Number 151, January 1991,
and Number 161, November 1991). American College of Obstetricians and Gynecologists. Int J
Gynaecol Obstet. 1999 Jan;64(1):87-94
16. Advanced Life Support in Obstetrics Provider Syllabus. Leawood, KS: American Academy of Family
Physicians; 2010

17. Mirza FG, Devine PC, Gaddipati S. Trauma in pregnancy: a systematic approach. Am J Perinatol. 2010
Aug;27(7):579-86

18. Weinberg L, Steele RG, Pugh R, Higgins S, Herbert M, Story D. The pregnant trauma patient. Anaesth
Intensive Care. 2005 Apr;33(2):167-80

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