BJA Education, 21(1): 10e19 (2021)

doi: 10.1016/j.bjae.2020.08.005
Advance Access Publication Date: 19 November 2020

Matrix codes: 1B04,

2A02, 3B00

Trauma during pregnancy

T. Irving1,*, R. Menon2 and E. Ciantar2
1
Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK and 2Leeds Teaching Hospitals NHS
Trust, Leeds, UK
*Corresponding author: Tom.Irving@liverpoolft.nhs.uk

Keywords: injury; pregnancy; trauma

Learning objectives Key points

By reading this article, you should be able to:

Outline the complex management challenges
that traumatic injury during pregnancy presents.

Describe expected variations in the pattern of
injury and appropriate modification of trauma
care principles after trauma in the pregnant
patient.

Discuss the potential for obstetric complications
after trauma and their subsequent assessment
and management.
Trauma during pregnancy is a leading cause of maternal
mortality in the UK and around the world. Deaths are pre-
dominantly attributable to road traffic collision (RTC), violent
suicide, and homicide.1e3 It presents unique and complex
management challenges requiring prompt and wide-ranging
multidisciplinary input to optimise outcomes.
Clinical decision-making in such scenarios is complicated
by many factors:
Tom Irving FRCA is a consultant anaesthetist at the Royal Liverpool
and Broadgreen University Hospitals NHS Trust. His areas of in-
terest are obstetric and regional anaesthesia and education. He acts
as lead anaesthetist for simulation and instructs on the MOET
course.
Rashmi Menon MD FRCA is a consultant anaesthetist at Leeds
Teaching Hospitals NHS Trust. Her areas of interest are obstetric
anaesthesia, major trauma, and education. Until recently, she was
lead anaesthetist for trauma and has contributed to development of
national and local trauma guidance.
Etienne Ciantar MD MRCOG FHEA is a consultant obstetrician at
ment of the multiply injured pregnant patient may explain the
Leeds Teaching Hospitals NHS Trust. His areas of interest are high-
findings of a recent large retrospective cohort study in the USA
risk obstetrics, obstetric haematology, education, and research. He
that identified pregnancy as an independent predictor for
has published several articles on obstetric haematology.

Trauma is a leading cause of maternal mortality
and presents unique challenges that require ur-
gent multidisciplinary input to optimise
outcomes.

Initial management must be focused on maternal
assessment, resuscitation and stabilisation, and
requires significant modification of contempo-
rary trauma care principles.

Establishing maternal stability may not be
possible without obstetric intervention and
emptying of the uterus.

Concerns regarding fetal irradiation should not
delay standard trauma imaging.

Fixed-ratio blood product replacement strategies
during massive transfusion may not be appro-
priate in advanced pregnancy.
(i) The needs of both mother and fetus must be considered.
(ii) Multiple and dynamic anatomical and physiological
changes of pregnancy mandate modification of trauma
management principles.
(iii) Life-threatening obstetric complications can occur even
after seemingly minor trauma and may require urgent
delivery of the fetus.3
(iv) Fetal injury can predominate over that of the mother.4
(v) Obstetric teams may be unfamiliar with the emergency
department (ED) environment and contemporary man-
agement of major trauma.
(vi) Emergency department and trauma teams may be
unfamiliar with aspects of emergency obstetric care, as
this usually takes place in dedicated areas distant to
the ED.
The great challenges faced by clinicians during manage-

Accepted: 7 August 2020

© 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
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10
 Trauma during pregnancy

mortality after trauma.5 Pregnant women were found to be 1.6
times more likely to die after trauma than non-pregnant
women with traumatic injuries of comparable severity.5
Anaesthetists are well placed to facilitate coordination of
multidisciplinary care for injured pregnant patients, being
familiar with principles of both obstetric and trauma man-
agement. Evidence is limited regarding optimal management
of trauma during pregnancy, and multiple aspects of
contemporary care remain controversial. Specific guidelines
have been developed in recent years and are largely based on
expert consensus.6,7 In this article, we will discuss current
views on best practice in the initial resuscitation and subse-
quent care of the pregnant trauma patient. Considerations
relating to non-obstetric surgery during pregnancy will not be
discussed in detail and have been covered previously in BJA
Education.8
Epidemiology
Trauma is a leading cause of mortality. On a global scale, it
accounts for 10% of all deaths annually, and this is predicted
to increase over the coming years.9 The UK has seen a pro-
gressive decline in morbidity and mortality after trauma over
the last decade. This is attributed in large part to the inception
of regional trauma networks, increasing experience at major
trauma centres (MTCs), and the development of novel clinical

Table 1 Trauma call: typical sequence of events, usual actions of the trauma team and modifications required when trauma affects
pregnant patients.14 *Typical role allocations: ED consultant (team leader); ED specialist trainee (performs primary survey); senior
anaesthetist (airway management and vascular access); operating department practitioner (assists the anaesthetist); senior ortho-
paedics and general surgeons (specialty-specific advice and intervention); trauma nurse coordinator (scribe; ED nurses 2 [team task
support]); healthcare assistant (runner); radiographer (bedside radiographs).

Sequence of events Usual actions of the trauma Modifications required for the pregnant trauma patient
team

Pre-alert Information transfer If childbearing age, active enquiry regarding pregnancy status and
gestation
Trauma call Team assembly and briefing Urgently request obstetric and neonatology attendance. Discuss
(Te15 min) standard care modification.
Team leader assigns roles* Manual uterine displacement and fetal heart rate assessment
(nurse/midwife)
Resuscitative hysterotomy team (obstetrics)
Neonatal resuscitation team (neonatology)
Preparation of equipment and Resuscitative hysterotomy pack preparation
drugs Neonatal resuscitation equipment preparation
Contact haematology and transfusion laboratories to ensure
awareness of pregnancy and gestation.

Patient’s arrival Rapid assessment: ensure Ensure immediate and continuous uterine displacement if gestation
(Tþ0 min) airway patent, central pulse, >20 weeks.
and absence of catastrophic Structured handover from pre-hospital team to include details of
bleeding before handover. gestation if available.
Immediate Primary survey: concomitant Team raises index of suspicion for cardiorespiratory
management and assessment and intervention decompensation and pelvic fracture, and acts accordingly.
ongoing review (<C> ABCD) Team ensures thoracic decompression performed at appropriate
(Tþ0e15 min) level.
Assessment to include fetal heart rate and examination for obstetric
complications.
Urgent request for coagulation thromboelasticity assay results and
input from haematologist.
KBT and Clauss fibrinogen to be added to usual blood test requests.
Team to determine whether permissive hypotension and fixed-ratio
blood product replacement are appropriate strategies relative to
gestation and likely source of bleeding.
Cardiopulmonary If gestation >20 weeks, ensure manual uterine displacement and
resuscitation prepare for resuscitative hysterotomy within 4 min of
cardiorespiratory arrest.
Situational update CT vs DCS Appreciation that single trauma CT carries minimal risk to fetus and
(Tþ15 min) is entirely appropriate where indicated. DCS may require delivery of
the fetus and mandates obstetric presence.
Secondary survey if stability Must include full obstetric and fetal assessment to identify covert
achieved complications.
Command huddle Senior level team discussion Team to determine whether early delivery of the fetus is required to
(Tþ20e30 min) regarding next steps improve maternal outcome and appropriate location for definitive
surgery if needed. If stability is achieved without need for further
intervention, discuss admission to critical care vs maternity ward.

BJA Education - Volume 21, Number 1, 2021 11

Trauma during pregnancy
approaches to trauma management. Trauma victims who
reached English hospitals alive in 2017 had 19% increased
odds of survival compared with those in 2008.10 It is unknown
if improvements in survival apply to pregnant trauma
patients.
A total of 6e8% of all pregnancies are reported to be
complicated by some degree of trauma.11 In the UK, it can be
expected that 1 in 100 women of childbearing age suffering
major trauma will be pregnant, although this is likely to be an
underestimate because of lack of routine screening for preg-
nancy on admission to the ED.12 The most common mechanism
of injury in these patients is RTC, followed by falls and assault.12
Trauma call
The vast majority of patients with major trauma in England
will be transferred directly from the scene of injury to an MTC
for optimal care. Prehospital services will provide the ED with
advanced notification (‘pre-alert’) of their arrival as soon as is
practicable detailing patient characteristics, time of injury,
mechanism of injury, vital signs, treatment provided, and
estimated time of arrival. Specific enquiry should be made at
this point to determine the pregnancy status in women of
childbearing age. Any suspicion of pregnancy must prompt an
urgent request for obstetric and neonatologist support to join
the trauma team as they are called to the ED before the arrival
of the patient. This is of particular importance if the receiving
centre does not have on-site obstetric services to allow
adequate time to organise.
A senior ED doctor will usually act as team leader and
facilitate preparative discussions regarding what in-
terventions the patient may require based on the pre-alert
information. The team leader will then assign roles to the
wider team in order that a synchronous approach to assess-
ment and management of trauma can be taken that equally
prioritises the logical provision of organ system support and
intervention, alongside urgent control of catastrophic hae-
morrhage (i.e. primary survey ‘<C> ABCD approach’).13,14 The
standard sequence of events and usual actions of the majority
of the trauma team will be altered to some degree to meet the
needs of the pregnant trauma patient (Table 1). Obstetric
specialists must play a key role in the preparatory period to
identify and discuss these issues with the wider team before
the patient’s arrival in the hospital.
Initial assessment and resuscitation
The anatomical and physiological changes that occur as
pregnancy advances mandate multiple modifications to
trauma management principles (Table 2). It is therefore
essential that all women of childbearing age who suffer
trauma are considered pregnant until proven otherwise by
testing for urinary human chorionic gonadotrophin or ultra-
sound (US) scanning. Clinical suspicion of pregnancy may be
raised by direct enquiry, clinical examination, and review of
the available clinical information whilst definitive confirma-
tion is awaited.
After confirmation of pregnancy, an estimate of gestational
age must be made to inform subsequent management.
Palpation of fundal height provides a crude, but clinically
relevant estimate of gestation in the absence of definitive in-
formation. The fundus can be palpated projecting above the
level of the pubic symphysis as the second trimester com-
mences, at which point many of the physiological changes of
12 BJA Education - Volume 21, Number 1, 2021
pregnancy are beginning to become apparent. Once the
fundus has reached the level of the umbilicus, corresponding
with a gestational age of 20 weeks in a singleton pregnancy,
aortocaval pressure becomes clinically significant and will
require immediate relief by means of uterine displacement as
the patient arrives in the ED.15 Increases in fundal height
above the level of the umbilicus approximate to 1 week’s
gestation for every centimetre advanced cephalad.
The prime objective of initial management must be
resuscitation and stabilisation of the mother. Prompt man-
agement of maternal hypoxaemia and hypotension will opti-
mise oxygen delivery to the fetus and improve the odds of a
favourable fetal outcome.
Airway and spinal immobilisation
The initial focus of management, alongside control of cata-
strophic haemorrhage, is to ensure airway patency and se-
curity whilst maintaining spinal immobilisation as indicated.
It is well recognised that obstetric airway management is
increasingly difficult as pregnancy advances into the second
trimester and beyond, with increased rates of failed intuba-
tion owing to tissue oedema, difficult laryngoscopy, and po-
tential for airway soiling.17 This will be further compounded
by the presence of neck and spinal immobilisation, airway
trauma, and facial burns. Mortality after failed intubation in
obstetrics approaches 1%, significantly higher than in non-
obstetric patients, and is usually secondary to aspiration of
gastric contents.17 If airway problems are present or antici-
pated, early intubation is therefore appropriate and allows
time for planning and preparation to reduce risk. Modified
rapid sequence induction should be performed by an experi-
enced anaesthetist and follow guidelines from the Difficult
Airway Society and Obstetric Anaesthetists’ Association.16
Induction drugs and neuromuscular blocking agents must be
tailored to the individual circumstances, accounting for hae-
modynamic instability and maternal comorbidity.
Careful positioning and preoxygenation are essential
before induction. A 30 head-up tilt improves functional re-
sidual capacity (FRC) and associated oxygen stores whilst
reducing aortocaval compression. It also reduces regurgita-
tion risk and results in caudad breast movement facilitating
laryngoscope insertion. If spinal immobilisation is necessary,
the whole trolley is tilted head up to achieve similar results.
Cervical collar removal, with alternative provision of manual
in-line stabilisation, is recommended before induction to
allow for effective laryngoscopy. Apnoeic oxygenation tech-
niques are advocated and will attenuate precipitous desatu-
ration after induction. This may be achieved through a
combination of maintenance of airway patency, provision of
10 cmH2O continuous positive airway pressure via a tightly
fitted face mask, and supplemental oxygen flow through nasal
cannulae. However, high-flow (>15 L min1) nasal cannula
techniques are contraindicated in patients with possible base
of skull fracture, nasal fracture, or epistaxis.
If intubation efforts fail, maternal oxygenation must be
prioritised. Prompt placement of a second-generation supra-
glottic airway device may allow time for alternative intubation
techniques or a less pressured environment, in which to
perform front-of-neck access (FONA). Adipose tissue and
oedema can make FONA challenging in obstetric patients, and
a longitudinal incision before blunt finger dissection may be
required to allow identification of the cricothyroid
membrane.16
 Trauma during pregnancy

Table 2 Dynamic anatomical and physiological changes of pregnancy and associated implications for initial trauma management.

System Changes by full term15 Implications Management

Airway [ Tissue vascularity and
oedema
[ Breast size and neck
adiposity
[ Intra-gastric pressure
Y Oesophageal sphincter tone
Difficult laryngoscopy and intubation
High risk of regurgitation
Airway bleeding more likely
Difficult FONA
Difficult Airway Society guidelines.16

Early rapid sequence induction. 30
head up. Remove neck collar and
provide manual in-line stabilisation.
Avoidance of nasal or blind airway
interventions.
Longitudinal incision during FONA
may help identify an impalpable
cricothyroid membrane.

Breathing Y FRC (30%)
[ Oxygen consumption (60%)
[ Minute ventilation (50%)
Y Arterial CO2 tensions (4kPa)
Diaphragm raised 4cm
Precipitous hypoxaemia may develop
as a result of respiratory compromise
or apnoea. High normal PaCO2
represents hypoventilation.
Iatrogenic diaphragmatic / visceral
injury. Thoracic trauma risks
abdominal organ injury.
Liberal O2 supplementation. 30 head
up improves FRC. Pre/apnoeic
oxygenation techniques before
intubation. Aim PaCO2 of 4.0kPa if
mechanically ventilated.
Place thoracostomy tubes 1-2 spaces
higher. High index of suspicion. CT
imaging.

Circulation, Aortocaval compression:
catastrophic YPreload, [afterload
haemorrhage, and YSupine cardiac output (30%)
cardiac arrest YSupine uteroplacental
perfusion
High cardiac reserve:
Y Systemic vascular
resistance
[ Cardiac output
[ Blood volume (40%)
Loss of uterine autoregulation
Haematological changes:
Hypercoagulability
Physiological anaemia
Physiological
thrombocytopaenia
Once fundal height reaches
umbilicus aortocaval compression
becomes significant and reduces
cardiac output when supine.
Blood loss of 1.5L or more (at term)
may occur before signs of
hypovolaemia develop at which
point there is an increased risk of
cardiac arrest. Dilatation of uterine
and pelvic vessels e potentially
catastrophic bleeding after injury.
Uteroplacental perfusion relies upon
maternal mean arterial pressure.
Altered interpretation of laboratory
blood tests and consumption of
clotting factors depending on source
of haemorrhage and gestation.
Continuous uterine displacement:
manual preferred over tilt as it
maintains spinal alignment and
allows for effective cardiopulmonary
resuscitation. Resuscitative
hysterotomy within 4 minutes of
cardiac arrest.
High index of suspicion; early arterial
line; fetal assessment to provide
information regarding maternal
volume status and obstetric
haemorrhage; improvised pelvic
binder may be necessary; damage
control may not be possible without
emptying uterus.
Consider appropriateness of
restrictive fluid replacement
strategy. Avoid vasopressor use.
Early haematology input; frequent
point-of-care and coagulation tests;
individualised clotting factor and
fibrinogen replacement strategy; aim
fibrinogen >2gL-1; activated partial
thromboplastin time and
prothrombin time ratios <1.5;
platelets >100 x 109L-1.

Disability [ Neck adiposity Impossible placement of cervical Continuous manual in-line

(neurological) collar. stabilisation.
Exposure and Uteroplacental haemorrhage Concealed haemorrhage may be Ensure assessment for per vaginal
environment revealed by vaginal blood loss. blood loss during primary survey.

Breathing thoracic decompression.13 As pregnancy advances, cephalad

displacement of abdominal viscera and the diaphragm oc-
Respiratory compromise often provokes rapid development of
curs.7,15 To avoid iatrogenic injury, thoracostomy tubes should
maternal hypoxaemia, owing to increases in demand and
be placed one to two spaces above the usual fifth intercostal
reductions in supply of oxygen that develop during the second
space within the safe triangle.3,7 If time allows, preliminary US
and third trimesters. Initial provision of high-concentration
scanning will provide reassurance of suitability of insertion
oxygen supplementation is therefore recommended.7 Sup-
site and may assist in confirming diagnosis. CT has a higher
plemental oxygen concentrations may subsequently be
sensitivity than US when diagnosing haemopneumothorax,
titrated down, targeting oxygen saturations of 94% or above,
and is recommended before decompression in the absence of
thereby avoiding the negative consequences of hyperoxaemia
maternal instability, thereby reducing unnecessary interven-
whilst ensuring sufficient uteroplacental oxygen gradient to
tion and associated complications. Nevertheless, if clinical
maintain adequate oxygen transfer to the fetus.7
suspicion is high, appropriate measures must be taken to
Haemodynamic instability and severe respiratory compro-
allow urgent performance of decompression during transfer in
mise secondary to haemopneumothorax warrant immediate
case subsequent deterioration occurs.13

BJA Education - Volume 21, Number 1, 2021 13

Trauma during pregnancy
Circulation
Gestations more than 20 weeks mandate immediate relief of
aortocaval pressure either by manual uterine displacement or
left lateral tilt of the patient from the moment she arrives in
the ED.15 Two large-bore cannulae must be inserted promptly.
If i.v. access is difficult, intraosseous access should be sought
urgently, followed by central venous access once time allows.
Routes for drug administration are ideally placed above the
level of the diaphragm to allow entry into the central circu-
lation without impedance caused by caval compression.
Standard venous blood tests must be arranged urgently
(group and save or cross-match, full blood count, urea and
electrolytes, liver function tests, coagulation screen, and Clauss
fibrinogen). Point-of-care testing (POCT), including measure-
ment of arterial blood gases, acidebase balance, thromboelas-
ticity assays, haemoglobin, electrolyte, and lactate
concentrations, will allow appropriate and expeditious treat-
ment. Interpretation of results must be relative to expected
changes associated with advancing pregnancy.15 Early insertion
of an arterial line is recommended when compromised cardio-
respiratory function is expected and will allow rapid identifi-
cation of decompensation and facilitate ongoing POCT.
The KleihauereBetke blood test (KBT) should also be sent to
provide an indication of the degree of fetomaternal haemor-
rhage after uteroplacental injury. It allows correct dosing of
anti-D immunoglobulin to be calculated for rhesus (Rh)-nega-
tive mothers exposed to Rh-positive blood. It also indicates the
severity of uteroplacental haemorrhage and assists in fetal
prognostication after major trauma, regardless of Rh status.3,7
Catastrophic haemorrhage
Contemporary management of traumatic haemorrhage pri-
oritises early identification of the source of bleeding, provision
of rapid haemostasis, and efforts to prevent deterioration to
coagulopathy. The urgent need to achieve rapid haemostasis
after trauma is compounded by pregnancy. The index of
suspicion for haemorrhage must be high, as circulatory
decompensation presents increasingly late and precipitously
as pregnancy advances into the second trimester, owing to
increases in cardiac output and blood volume that develop.
During the third trimester, 1.5 L blood or more may be lost
before clinical signs of hypovolaemia present; at this point,
the pregnant patient is at even higher risk of progressing to
cardiac arrest than the non-pregnant patient.
Early identification of bleeding sources allows for rapid and
appropriate intervention, and is achieved through a combi-
nation of systematic examination, bedside investigation, and
trauma series CT during the primary survey. Abdomino-pelvic
examination must be modified during the primary survey to
specifically seek out clinical evidence of placental abruption
(common) and uterine rupture (rare), which may be a signifi-
cant source of concealed non-compressible haemorrhage
even after seemingly minor trauma (Table 3). Pelvic fractures
are of extreme concern, and thresholds for intervention dur-
ing the primary survey must be even lower than in non-
pregnant patients. They may result in injury and laceration
to an increasingly dilated pelvic vasculature, the highly
perfused uterus or the fetus, and result in rapid exsanguina-
tion. Pelvic binders must be applied immediately if pelvic
fracture is suspected and removed only after control of
bleeding is achieved.13 They sit over the greater trochanters,
but may need to be improvised if purpose-made binders
14 BJA Education - Volume 21, Number 1, 2021
cannot be properly applied in advanced pregnancy. Trauma
CT imaging provides rapid and accurate identification of
bleeding sources, and is entirely appropriate in the stable and
injured pregnant patient. The potential benefit to maternal
and consequently fetal outcomes achieved through identifi-
cation and rapid control of haemorrhage outweighs the min-
imal risk to the fetus secondary to irradiation. If the mother
remains unstable despite resuscitation, transfer to CT may
not be safe. Bedside investigations, such as plain radiographs
and US, can be performed rapidly and may provide useful
clinical information to direct emergent intervention appro-
priately. Fetal assessment and monitoring must also be
included within the primary survey. Evidence of fetal distress
can support the diagnosis of placental abruption and uterine
rupture, or may provide the first indication of impending
maternal decompensation attributable to hypovolaemic
shock as uteroplacental perfusion is sacrificed in favour of
ongoing maternal organ perfusion.
Modern trauma principles in the non-obstetric patient
advocate a restrictive fluid replacement and blood-product-
based approach to resuscitation of haemorrhagic shock,
permitting a degree of hypotension whilst titrating therapy to
a palpable central pulse, for the minimum time period
possible until control is achieved.13 Rapid restoration of pre-
injury blood volume and pressure is thought to risk clot
disruption and development of coagulopathy, and can there-
fore lead to further haemorrhage. Crystalloid infusion is now
avoided during the early resuscitation of trauma patients in
favour of blood products. Crystalloids may exacerbate
bleeding and reduce oxygen delivery to the tissues as a result
of the unintended and diametric development of haemodilu-
tion, coagulopathy, and hypothermia.13 Restrictive fluid
replacement strategies are a source of controversy in preg-
nant patients, as they may result in reduced uteroplacental
perfusion and fetal compromise, and an increased potential
for sudden and rapid maternal deterioration to cardiac arrest.
The primary objective of ensuring maternal well-being must
be remembered, and careful consideration by the multidisci-
plinary team will help guide appropriate management. Fac-
tors, such as the severity of maternal injury and haemorrhage,
fetal condition and viability, and amenability of bleeding
points to rapid control, must be considered.
Multiple injuries and hypovolaemic shock in the pregnant
patient are most appropriately managed aggressively using
contemporary principles, accepting that a period of reduced
uteroplacental perfusion, fetal compromise, or delivery of the
fetus may be required to allow maternal survival. Clearly, if
fetal demise has occurred or is highly likely, these decisions
are simplified. In cases of isolated injury, such as external
haemorrhage, amputation, and limb fracture where the
mother remains stable and bleeding can be rapidly controlled
through compression, use of a tourniquet or by bone reduc-
tion permissive hypotension may not be necessary. A more
appropriate plan in these circumstances would aim to restore
maternal arterial blood pressure to pre-injury levels with
blood-product-based resuscitation to maintain uteroplacental
perfusion and prevent unnecessary fetal compromise.
Mothers who remain stable after initial resuscitation will
require definitive control of the sources of bleeding identified
during CT scanning, and this may involve delivery of the fetus
to manage haemorrhage and provide the viable fetus with the
best chance of a favourable outcome. Those who remain un-
stable or go on to develop the alarming triad of acidosis, coa-
gulopathy, and hypothermia will require damage control

resuscitation. The aims of which are to provide rapid control of
haemorrhage and management of peritoneal soiling through
emergency surgery or intervention to achieve stability as soon
as possible, alongside medical efforts to replace blood loss,
prevent coagulopathy, and maintain adequate maternal organ
perfusion. Exploratory thoracic and abdominal surgery may
need to be performed with limited information on the source or
number of bleeding points. The obstetric team must be present
at the time of exploratory surgery in case emptying of the uterus
and delivery of the fetus are necessary to achieve haemostasis
and maternal stability. Emptying of the uterus is indicated in
cases of penetrating uterine injury, placental abruption, and
uterine rupture, and to allow surgical access for control of
alternative sources of pelvic and abdominal haemorrhage.
Medical management of haemorrhagic shock should
continue whilst efforts are made to achieve haemostasis.
Early activation of major haemorrhage protocols is essential
to ensure availability of blood products. O negative blood must
be used until group and Rh status is determined. Rapid in-
fusers and blood warming devices should be available and
prepared for use. Where blood is not immediately available,
small boluses of warmed crystalloid are appropriate and
should be targeted to the desired response, only until blood
arrives. Hypocalcaemia and hyperkalaemia must be actively
sought during massive transfusion, and be corrected in a
timely manner to maintain coagulation and prevent associ-
ated haemodynamic instability. Tranexamic acid (1 g i.v.) is
thought to be safe during pregnancy and confers survival
benefit if given within 3 h of injury.18,19
Vasopressor use to treat hypotension risks clot dislodge-
ment and may encourage further bleeding whilst simulta-
neously reducing uteroplacental perfusion. Vasopressors
should be reserved for patients in whom evidence of inade-
quate organ perfusion is present and where there is a failure
in response to further volume administration.
Standard fixed-ratio blood product replacement protocols
to prevent the development of coagulopathy during massive
transfusion may be harmful after trauma in pregnant women,
once the hyper-coagulable state of advanced pregnancy de-
velops. It is important to note that circulating fibrinogen
concentrations increase significantly as pregnancy advances
into the second trimester and beyond, and that these con-
centrations eventually reach a point at which they exceed
those present in fresh frozen plasma (FFP). Furthermore,
studies relating to peripartum haemorrhage have demon-
strated that rapid consumption of fibrinogen often occurs
with relatively little decrease in clotting factor concentrations
despite the significant volumes of blood lost.20 Unnecessary
administration of FFP in these circumstances will likely result
in unintended dilution of fibrinogen concentrations and
worsening coagulopathy, and risk the development of
transfusion-associated circulatory overload, pulmonary
oedema, and transfusion-associated acute lung injury to
which the pregnant patient is particularly prone. Fibrinogen
concentrations <2 g L1 before delivery of the fetus have been
demonstrated to have a 100% positive predictive value for
subsequent development of severe postpartum haemorrhage
(PPH) in advanced pregnancy.20 Fibrinogen concentrations
that fall within the normal range for non-pregnant patients
may therefore represent onset of disseminated intravascular
coagulopathy (DIC) in advanced pregnancy, and must be
appreciated and corrected aggressively to maintain a fibrin-
ogen concentration >2 g L1.7,20
Trauma during pregnancy
Although evidence relating to PPH cannot be directly
extrapolated to early pregnancy or severe non-obstetric hae-
morrhage, there remains a need to tailor blood product
replacement to the individual circumstances, taking into ac-
count the stage of pregnancy and the severity and source of
haemorrhage. Standard fixed-ratio major haemorrhage
transfusion protocols are appropriate for non-obstetric hae-
morrhage in early pregnancy. As pregnancy advances and
particularly in cases of traumatic obstetric haemorrhage, the
early use of cryoglobulin precipitate or fibrinogen concentrate
will often be more appropriate than use of FFP. This is of
extreme importance if fibrinogen levels are falling and
emptying of the uterus is planned to avoid subsequent pro-
gression to severe PPH and DIC. Regular clotting studies,
point-of-care viscoelastic assays, and early involvement of
obstetric haematology expertise are essential to guide
ongoing blood product replacement appropriately.
Maternal cardiac arrest
Cardiac arrest is managed according to adult life support
principles, but must be modified once gestations of 20 weeks
or more have been reached to include uterine displacement
and resuscitative hysterotomy. Immediate manual uterine
displacement is preferred over left lateral tilt in these cir-
cumstances, as it allows for more effective cardiac compres-
sion.7 Resuscitative hysterotomy should be performed within
4 min of arrest.3 It relieves aortocaval pressure, improves
respiratory dynamics, and provides placental auto-
transfusion, thereby optimising chest compressions, oxygen
delivery, and cardiac output simultaneously.3,15 It also pro-
vides the best chance of fetal survival if a viable gestational
age (24 weeks) has been reached.
Resuscitative hysterotomy should be performed in the
location that cardiac arrest occurs by the most appropriately
experienced member of the trauma team, ideally an obste-
trician, and requires only basic equipment. Prompt support
from midwives and neonatologists must be available to pro-
vide neonatal resuscitation to the viable fetus. Successful
restoration of maternal circulation will require subsequent
transfer to operating theatre for laparotomy and stabilisation.
Traumatic cardiac arrest associated with abdominal or
thoracic injury may also mandate simultaneous emergency
thoracotomy, clearly creating difficult logistical issues.
Disability (neurological)
Level of consciousness and pupillary reactions to light are
assessed to identify evidence of brain injury and determine
the need for airway protection. Suspected traumatic brain
injury requires measures to maintain cerebral perfusion
pressure and oxygen delivery to prevent secondary insult.
Head-up tilt, maintenance of adequate mean arterial pressure
and oxygenation, avoidance of venous congestion at the neck,
and control of PaCO2 may be needed. If both haemorrhage and
head injury are present and it is thought that head injury is
the dominant condition, then a less restrictive volume
replacement strategy is recommended, in order that adequate
cerebral perfusion pressure is prioritised.13
Intracranial hypertension and associated brain herniation
will necessitate maternal hyperventilation, allowing hypo-
capnia and alkalosis to develop, resulting in intentional cerebral
vasoconstriction and reduction in intracranial blood volume
BJA Education - Volume 21, Number 1, 2021 15
Trauma during pregnancy
and pressure. These measures may be at the expense of fetal
oxygenation. Maternal alkalosis also results in uterine vaso-
constriction and left shift of the maternal oxygen dissociation
curve, thereby reducing uteroplacental oxygen transfer.15
The precautions for spinal injury must be reassessed. Cor-
rect placement of cervical collars might be impossible because
of neck oedema, adipose tissue, and large breasts, and requires
continuous provision of manual in-line stabilisation. Spinal
boards should be removed as soon as appropriate.
Blood glucose concentrations are monitored, as control
may be required. Hyperglycaemia is associated with poor
prognosis after head injury, and hypoglycaemia must be
prevented to allow adequate glucose transport to the fetus.
Exposure and environment
Hypothermia must be prevented to avoid coagulopathy and
further bleeding. It will also prevent shivering and resultant
increases in oxygen demand. The use of warming devices and
blankets and removal of wet clothes may be necessary.
Particular attention should be made to identify concealed
injury or haemorrhage during exposure of the patient,
including an assessment for vaginal blood loss.
Trauma imaging
Radiological investigations, if clinically indicated, must be
undertaken without delay. Pregnant patients with high-risk
mechanisms of injury often have appropriate imaging with-
held because of concerns relating to fetal irradiation and
exposure to i.v. contrast.21 This can result in diagnostic and
therapeutic delay, potentially resulting in serious conse-
quence for both mother and fetus.
A single trauma series CT scan is not thought to increase
the risk of fetal developmental problems (miscarriage, pre-
maturity, teratogenesis, growth retardation and neurological
conditions).7,22 However, radiation effects are cumulative, and
efforts must be made to minimise unnecessary or repeated
exposure. Early input from radiology colleagues is therefore
recommended. I.V. iodinated and gadolinium-based contrast
agents appear to be safe in pregnancy and are essential to
identify areas of internal haemorrhage.23
The use of extended focused assessment with sonography
for trauma (eFAST) US scans and plain radiographs is appro-
priate during initial resuscitation efforts in unstable patients to
identify intraperitoneal haemorrhage, pericardial effusion and
haemopneumothorax, and to determine appropriate inter-
vention and damage control surgery (DCS).13 However, eFAST
scans will provide increasingly limited information with
advancing gestation, as the gravid uterus may obscure the
desired imaging target. Trauma series CT is the gold standard
in stable and fluid-responsive patients, and will guide defini-
tive surgery. It is worth noting that the diagnosis of placental
abruption is significantly improved after CT compared with
US.24 As placental abruption may occur even with seemingly
minor trauma, there should be a lower threshold to performing
abdominal CT in pregnant patients after trauma.
Diagnostic peritoneal lavage (DPL) has largely been super-
seded by CT and US. DPL risks visceral injury and may lead to
unnecessary surgery in patients where CT imaging suggests
conservative management to be appropriate.
16 BJA Education - Volume 21, Number 1, 2021
Mechanisms and patterns of injury during
pregnancy
Road traffic collision
Road traffic collisions account for more than half of all
maternal trauma.12 Intrauterine shear forces and the contre-
coup mechanism associated with rapid deceleration can
result in placental abruption or uterine rupture in the absence
of other obvious injury. Incorrect use or non-use of seatbelts
increases the risk of such injuries.
Falls
Low-height falls are common in pregnancy, particularly dur-
ing the third trimester, as altered centre of gravity develops.3
The majority of falls do not result in significant injury
although in rare cases, shear forces or direct abdominal
trauma may result in obstetric complications.
Physical assault and self-inflicted violence
Around 8% of females experience some form of domestic
abuse.25 Many women are assaulted for the first time during
pregnancy and are at an increased risk of progression of pre-
existing abuse to homicide whilst pregnant and post-
partum.2,26 Homicide is usually perpetrated by a partner or
family member, and is violent in nature (stabbing, strangu-
lation, and blunt head injury).2,26 The abdomen is most
commonly targeted, followed by the genital area, potentially
resulting in both maternal and fetal injury. A vague history of
mechanism of injury during pregnancy raises suspicion of
domestic violence and should prompt referral to the safe-
guarding team according to local protocols.
Suicide attempts are more often by violent means during
pregnancy.2 Common mechanisms include hanging, falling
from a height and stepping into the path of a vehicle.2
Burns
Burn and inhalational injuries are rare in pregnancy.3 Evi-
dence of maternal airway burn requires expeditious intuba-
tion before further oedema renders this impossible.
Significant burns result in major fluid shift and insensible loss
requiring urgent correction to maintain organ and uteropla-
cental perfusion. Hypoxaemia secondary to smoke and toxin
inhalation must be identified and managed urgently to
maintain oxygen delivery to mother and fetus. Remember
that the abdomen in late pregnancy represents an increased
proportion of total body surface area, which may lead to un-
derestimation of burn area if abdominal burns are present. All
pregnant patients with significant burns should be transferred
to a tertiary burns care unit with available obstetric services as
soon as feasible.3 Maternal burns of more than 40% indicate a
poor fetal and maternal prognosis, and increase the strength
of the argument for early fetal delivery.3
Blunt vs penetrating trauma
The vast majority of trauma in both pregnant and non-
pregnant patients is blunt. However, there is a higher inci-
dence of penetrating trauma in pregnant patients compared
with their non-pregnant counterparts (5e10% vs 2%).3,5,12 This
may be explained by the increased likelihood of violent
 Trauma during pregnancy

assault and self-harm during pregnancy. Both maternal and
fetal mortality rates are increased after penetrating trauma.4,5
The consequence of either blunt or penetrating trauma
depends on the site of injury and the gestational age. As the
uterus rises into the abdomen, the abdominal viscera are
shifted posterior and cephalad. The gravid uterus may
therefore protect other maternal viscera after anterior
abdominal trauma, at the expense of uterine and fetal injury.
Thoracic trauma can result in unexpected and easily missed
gastrointestinal, splenic, or hepatic injuries. Pelvic trauma
and fracture may not only result in catastrophic haemor-
rhage, but are also highly likely to result in uterine or fetal
injury, with an associated poor fetal outcome.3
Obstetric assessment and management
Where stabilisation of the injured pregnant patient is ach-
ieved without the need for obstetric intervention, an urgent
and thorough obstetric and fetal assessment must be
performed during the secondary survey to ensure prompt
identification and management of obstetric complications
(Table 3). The viability of the pregnancy can be confirmed by
fetal heart auscultation in early pregnancy. After 26 weeks’
gestation, cardiotocographic (CTG) monitoring will provide
useful information relating to both fetal well-being and uter-
ine activity. Non-reassuring fetal heart rate patterns and early
contractions may indicate maternal pathology, such as direct
uterine trauma, uterine rupture, and placental abruption that
were not apparent during initial assessment and resuscita-
tion. Ultrasound examination allows an estimation of gesta-
tional age, may diagnose uteroplacental pathology and fetal
injury, and provides important information on placental
localisation.
The ideal period of CTG monitoring is uncertain. A prac-
tical and evidence-based approach is to continue intermittent
monitoring for 4 h initially, extended to 24 h if any of the
following are present: contractions of more than one every 10
min, uterine tenderness, significant abdominal pain, ruptured

Table 3 Obstetric complications after traumatic injury: presentation, diagnosis, and management.

Complication Clinical presentation Diagnosis Management

Fetomaternal Variable depending on cause Clinical Management depends on cause and

haemorrhage (10 Fetal distress Imaging severity of presentation.
e30%)7 Fetal demise Abnormal CTG KBT results allow Rh immunoglobulin
KBT dose determination for Rh eve mother
carrying Rh þve fetus, and may also act
as an indicator for severity of trauma.
Placental abruption Majority present within 2e6 h. Clinical: difficult if concealed Maternal resuscitation
(5e50%)3,7 May be asymptomatic or Abnormal CTG: fetal distress Early fetal delivery if fetal compromise
follow minor trauma and contractions or maternal instability
Abdominal (anterior) or back US: poor sensitivity
pain (posterior) CT: more appropriate in
Uterine tenderness and context of trauma
rigidity; preterm labour,
vaginal bleeding, and
haemodynamic instability
Fetal distress and death
Uterine rupture Usually after direct trauma in Clinical Maternal resuscitation
(rare)7 advanced gestation Abnormal CTG: fetal distress Laparotomy to control haemorrhage and
Severe abdominal pain and US allow fetal delivery
distension, uterine rigidity,
haemodynamic instability,
palpable, and freely mobile
fetal parts
Fetal distress and death
(approaches 100%)

Preterm labour and After direct uterine trauma,
spontaneous placental abruption, or
miscarriage traumatic rupture of the
membranes
Contractions, vaginal
bleeding, and pelvic pressure
Pelvic fracture Pelvic pain
Haemodynamic instability
Fetal distress and death: fetal
injury more likely if head
engaged
Clinical Tocolytics are not recommended after
Abnormal CTG: contractions traumatic initiation of preterm labour,
Fibronectin test as it represents pathology.
Maternal corticosteroid administration
if gestation 24e34 weeks and delivery
imminent
Magnesium sulphate for fetal
neuroprotection if gestation <32 weeks;
neonatal support
Clinical Pelvic binder
Imaging Damage control: interventional
radiology or open surgery
Conservative management or surgical
fixation
If stable fracture, future vaginal delivery
is appropriate3

BJA Education - Volume 21, Number 1, 2021 17

Trauma during pregnancy
membranes, vaginal bleeding, a positive KBT, or a non-
reassuring fetal heart rate pattern.3,7
The decision on whether to continue pregnancy compared
with early delivery after trauma will depend upon the degree
of fetal maturity, presence of uteroplacental and fetal injury,
severity of maternal trauma, and any implications of
continuing pregnancy on maternal prognosis. The optimal
location for early delivery will depend on the circumstances. If
the fetus is viable and the mother appropriately resuscitated
and stabilised, then obstetric theatres may be considered for
best access to obstetric and neonatal support. Conversely, if
the mother remains unstable or requires additional inter-
vention, then general operating theatres or the ED may be
more appropriate to minimise delays attributable to transfer
and to ensure best access to specialist support. If maternal
outcome is unlikely to be significantly affected, then preg-
nancy should be continued as far as is possible to improve the
chance of optimal fetal outcomes. These decisions require
careful consideration and input by the wider multidisciplinary
team.
If pregnancy is unaffected and no complications are
apparent, then the patient may be discharged from obstetric
care. The patient should be warned of the risks of preterm
labour and advised to return for urgent obstetric assessment if
abdominal pain or vaginal bleeding occurs. Ongoing man-
agement of injuries should be as for the non-obstetric patient.
Particular care must be taken to assess the need for venous
thromboembolism prophylaxis after trauma, as pregnancy is
in itself a prothrombotic state.15 Obstetric follow-up should
continue as usual until delivery. The mode of delivery will
depend on the patient’s preferences, obstetric considerations,
and any residual effects of the trauma (such as a major pelvic
fracture). Patients may also need psychological support and
counselling after major trauma, especially if they have
encountered fetal loss.
Education and training
Given the relative rarity and potential complexity of trauma
care in the pregnant patient, we recommend development of
clear local protocols and regular multidisciplinary training
and simulation in order that best care can be provided during
such scenarios.
Future directions
Maternal deaths secondary to trauma, such as RTC, are
currently classified as coincidental deaths (i.e. unrelated to
pregnancy). We argue that the sequelae of trauma are aggra-
vated by the physiological effects of pregnancy and that
associated deaths should therefore be classified as indirect, in
order that they be subject to thorough review of care and
lessons may be learned from such unfortunate
circumstances.
Declaration of interests
The authors declare that they have no conflicts of interest.
MCQs
The associated MCQs (to support CME/CPD activity) are
accessible at www.bjaed.org/cme/home by subscribers to BJA
Education.
18 BJA Education - Volume 21, Number 1, 2021
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