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Tintinalli's Emergency Medicine Manual, 8e

Chapter 159: Trauma in Pregnancy

John Ashurst

INTRODUCTION
Trauma is the leading cause of nonobstetric morbidity and mortality in pregnant women. Motor vehicle collisions followed by falls and domestic
violence are the most common causes of trauma in pregnancy and fetal survival is highly dependent on maternal stabilization.

CLINICAL FEATURES
Physiologic changes of pregnancy make it difficult to determine the severity of injury. Heart rate increases 10 to 20 beats per minute in the second
trimester while systolic and diastolic blood pressures drop 10 to 15 mm Hg. Blood volume can increase by 45%, but red cell mass increases to a lesser
extent, leading to a physiologic anemia of pregnancy. It may be difficult to determine whether tachycardia, hypotension, or anemia is due to blood loss
or normal physiologic changes. Due to the relative hypervolemic state, the patient may lose 30% to 35% of blood volume before manifesting signs of
shock. Pulmonary changes in pregnancy include elevation of the diaphragm and a decrease in residual volume and function residual capacity. Tidal
volume increases, resulting in hyperventilation with associated respiratory alkalosis. However, renal compensation causes the serum pH to remain
unchanged. Gastric emptying is also delayed, which places the pregnant trauma patient at a higher risk of aspiration.

The anatomic changes in pregnancy affect the types of injuries that are typically seen in the mother. Splenic injury remains the most common cause of
abdominal hemorrhage in the pregnant trauma patient. After the 12th week of gestation, the enlarging uterus emerges from the pelvis and by 20 weeks
reaches the level of the umbilicus. Uterine blood flow increases, making severe maternal hemorrhage from uterine trauma more likely. The uterus also
can compress the inferior vena cava when the patient is supine, leading to the “supine hypotension syndrome.” As pregnancy progresses, the small
intestines are pushed cephalad, which causes an increased likelihood of injury in penetrating trauma to the upper abdomen. The bladder moves into
the abdomen in the third trimester, thereby increasing its susceptibility to injury.

Abdominal trauma affects not only the mother but also the fetus. Fetal injuries are more likely to be seen in the third trimester and are often associated
with pelvic fractures or penetrating trauma in the mother. Uterine rupture is rare but is associated with a very high fetal mortality rate. More common
complications of trauma include uterine irritability, preterm labor, and placental abruption. Classically, the mother will demonstrate abdominal pain,
vaginal bleeding, and uterine contractions. Fetal–maternal hemorrhage occurs in more than 30% of cases of significant trauma and may result in
rhesus (Rh) isoimmunization of Rh-negative women.

DIAGNOSIS AND DIFFERENTIAL

Maternal stability and survival offer the best chance for fetal well-being, and no critical interventions or diagnostic procedures should be withheld out
of concern for potential adverse effects to the fetus. The initial sequence of trauma resuscitation is unchanged. Special attention should be directed to
the gravid abdomen, examining for evidence of injury, tenderness, or uterine contractions. If abdominal or pelvic trauma is suspected, perform a
sterile pelvic examination to assess for genital trauma, vaginal bleeding, or ruptured amniotic membranes after pelvic ultrasound to determine
placental location. Fluid with a pH of 7 in the vaginal canal suggests amniotic rupture, as does “ferning,” a branch-like pattern on drying of vaginal fluid
on a microscope slide.

Initial laboratory studies include a complete blood count, serum chemistries, blood type, Rh status, and coagulation studies including fibrin split
products and fibrinogen to determine the presence of disseminated intravascular coagulation. The Apt test or Kleihauer–Betke test should be
obtained to assess for the presence of fetal hemoglobin in the maternal blood.

Obtain radiographs based on fundamental principles of trauma management. Adverse fetal effects from radiation are negligible from doses <5 rad,
which is an exposure far greater than that received from most plain radiographs. Reducing the number of imaging CT cuts and shielding of the
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abdomen and pelvis when possible may decrease radiation exposure from medical imaging. Bedside ultrasonography is a highly sensitive, specific,
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and radiation-free alternative for imaging the abdomen. In addition to evaluating fetal heart rate, ultrasonography can assess gestational age, fetal
activity or demise, placental location, and amniotic fluid volume. Diagnostic peritoneal lavage has largely been replaced by ultrasonography. If it is
indicated, use the open supraumbilical technique.
Initial laboratory studies include a complete blood count, serum chemistries, blood type, Rh status, and coagulation studies including fibrin split
Campbell University
products and fibrinogen to determine the presence of disseminated intravascular coagulation. The Apt test or Kleihauer–Betke testAccess Provided by:
should be
obtained to assess for the presence of fetal hemoglobin in the maternal blood.

Obtain radiographs based on fundamental principles of trauma management. Adverse fetal effects from radiation are negligible from doses <5 rad,
which is an exposure far greater than that received from most plain radiographs. Reducing the number of imaging CT cuts and shielding of the
abdomen and pelvis when possible may decrease radiation exposure from medical imaging. Bedside ultrasonography is a highly sensitive, specific,
and radiation-free alternative for imaging the abdomen. In addition to evaluating fetal heart rate, ultrasonography can assess gestational age, fetal
activity or demise, placental location, and amniotic fluid volume. Diagnostic peritoneal lavage has largely been replaced by ultrasonography. If it is
indicated, use the open supraumbilical technique.

Auscultate fetal heart tones to determine fetal viability and identify fetal distress early in the evaluation. A Doppler stethoscope or ultrasound
facilitates this assessment. A normal fetal heart rate ranges between 120 and 160 beats per minute. Fetal bradycardia is most likely a result of hypoxia
due to maternal hypotension, respiratory compromise, or placental abruption. Fetal tachycardia is most likely due to hypoxia or hypovolemia. In the
setting of blunt abdominal trauma, external fetal monitoring is indicated for at least 4 to 6 hours for all patients beyond week 20 of gestation. Fetal
tachycardia, lack of beat-to-beat or long-term variability, or late decelerations on tocodynamometry are diagnostic of fetal distress and may be
indications for emergent cesarean section if beyond the viable gestational age.

EMERGENCY DEPARTMENT CARE AND DISPOSITION

As is the case of all trauma patients, initial priorities are the primary and secondary surveys directed at the pregnant trauma patient. Coordinate care
with surgical and obstetric consultants.

1. Aggressive maternal resuscitation generally leads to the best possible fetal resuscitation.

2. Initiate supplemental oxygen and crystalloid infusions at 50% above that given to nonpregnant patients. For patients beyond week 20 of gestation
who must remain supine, place a wedge under the right hip, tilting the patient 30° to the left, thus reducing the likelihood of supine hypotension
syndrome. Otherwise, keep the patient in a left lateral decubitus position.

3. Avoid vasopressors if possible as they can have deleterious effects on uterine perfusion.

4. Administer tetanus prophylaxis when indicated.

5. Give Rho (D) immunoglobulin for all Rh-negative pregnant patients if indicated.

6. Institute cardiotocodynamometry as soon as possible to monitor for fetal distress and uterine irritability.

7. Tocolytics have a variety of side effects, including fetal and maternal tachycardia. Administer only in consultation with an obstetrician.

8. Indications for emergent laparotomy in the pregnant patient remain the same as those in the nonpregnant patient.

9. The decision to admit or discharge a pregnant trauma patient is first based on the nature and severity of the presenting injuries. Women at 20
weeks of gestation require observation or admission for a minimum of 4 to 6 hours for external tocodynamometric monitoring.

10. Screen for potential intimate partner violence.

11. Instruct discharged patients to seek medical attention immediately if they develop abdominal pain or cramps, vaginal bleeding, leakage of fluid, or
perception of decreased fetal activity.

FURTHER READING

For further reading in Tintinalli's Emergency Medicine: A Comprehensive Study Guide , 8th ed., see Chapter 256, “Trauma in Pregnancy,” by Deiorio
Nicole M.

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