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Trauma in pregnancy
From WikEM
Contents
Background
- Concern for trauma, premature labor, and abruption
- Viable = >23-24wk (~fundus above umbilicus)
- nl FHR = 110-160 beats/min
- The leading cause of death in women during their reproductive years
- The leading non-obstetric cause of death and disability in pregnant women
- Trauma or accidental injury complicates up to 7% of all pregnancies
- For maternal vitals see Maternal Vitals and Labs in Pregnancy
Risk Factors for Severity (ATLS)
- Maternal heart rate > 100
- Injury Severity Score > 9
- Evidence of placental abruption
- Fetal heart rate > 160 or <120
- Ejection during a motor vehicle crash
- Motorcycle or pedestrian collisions
Clinical Features
- Airway
- Pregnant women at increased risk of aspiration
- Failed intubations 8 times more likely in pregnant trauma patients
- Increased respiratory mucosal edema, weight gain, delayed gastric emptying
- Breathing
- Increased basal O2 requirement
- Fetus is highly sensitive to maternal hypoxia
- Keep maternal SpO2 >95%
- Some recommend placement of thoracostomy tube 1-2 intercostal spaces higher than usual, when indicated[1]
- Circulation
- Fluid and blood product resuscitation should proceed according to ATLS
- Placenta is highly responsive to vasopressors and can result in decreased placental perfusion
- Compression of IVC by gravid uterus can decreased CO by 30%
- If must be kept supine, allow patient to lay in left lateral position
- May also manually displace uterus to the left if patient must be kept on backboard
- Fetal risks from defibrillation of mother are small
- Uterine rupture
- more common with direct abdominal trauma in second half of pregnancy
- Signs and Sx
- maternal shock
- abdominal distension
- abnormal uterine contour
- palpable fetal parts
- sudden abnormal FHR pattern
- Ascent of fetal presenting part
- Placental Abruption
- Most common cause of fetal demise in blunt trauma
- US on not sensitive → do not delay treatment for ultrasound if abrpution suspected
- Signs and Sx
- abdominal pain
- uterine tenderness
- vaginal bleeding (70%, may be absent if retroplacental)
- Uterine contractions or hypertonicity
- Signs of fetal distress on toco monitor are often the earliest indicator
- decelerations, tachycardia, bradycardia, and loss of variability
- Preterm labor
- Trauma in pregnancy is associated with 2x higher risk of preterm delivery
Differential Diagnosis
Abdominal Trauma
- Liver trauma
- Splenic trauma
- Pelvic fractures
- Genitourinary trauma
- Retroperitoneal hemorrhage
- Renal trauma
- Ureter trauma
- Abdominal compartment syndrome
- Trauma in pregnancy
Evaluation
- Trauma labs
- Rh factor
- Coag studies
- D-dimer
- Fibrinogen
- FAST - sensitivity similar to non-pregnant trauma population
- Radiographic imaging as directed by ATLS assesment[2]
- Radiographic imaging should not be delayed or deferred due to concern for fetal radiation exposure in the trauma setting
Treatment & Disposition
Assessment and stabilization of the mother should take first priority
- Nonviable fetus (<23-24wks)
- Standard treatment for trauma
- Consider RhoGAM 50mcg in Rh negative patients
- Viable fetus (>23-24wks)
- Consider RhoGAM 300mcg in rh neg
- Avoid pressors - compromises blood flow to uterus leading to decreased fetal O2 delivery
- Monitor (fetal) all for 4-6hrs →
- Extend Monitoring to 24hrs, if abnormal 6hr monitoring
- The duration of cardiotocographic monitoring should be extended to 24 hours if, during the first 4 hours, she develops > 4 contractions per hour, persistent uterine tenderness, a worrisome fetal monitor strip, vaginal bleeding, or rupture of the membranes. [3]
- Allow patient to roll onto left side to unload uterine compression of IVC → increases venous return to heart
- Abdominal CT imaging should be delayed or deferred due to concern for fetal radiation exposure in the setting of trauma.
Abnormal Monitoring
- >3 contractions/hr
- Persistent uterine TTP
- Worrisome strip
- Vaginal bleeding
- PROM
- Serious maternal injury
Partial abruption with stable mom/fetus and <32wk may have expectant care (with easy access to emergent C-section)
- Frequent uterine activity more predictive of abruption than US
- >8 contractions/hr for 4hrs - high risk for abruption
- 3-7 contractions/hr for 4hrs - extend monitoring for 24hrs
- <3 contractions/hr for 4hrs - safe for discharge
External Links
See Also
- Fetal Maternal Hemorrhage (RhoGAM)
- Perimortum C-Section
- Abruption
- Maternal Vitals and Labs in Pregnancy
- Trauma (main)
References
- ↑ Tsuei B. Assessment of the pregnant trauma patient. Injury 2006; 37(5)367-373
- ↑ Edmonton V, Edmonton R, Maslovitz S, et al. Guidelines for the Management of Pregnant Trauma Patient. J Obset Gynaecol Can 2015. 37(6):553-571
- ↑ Pearlman MD, Tintinalli JE, Lorenz RP. A prospective controlled study of outcome after trauma during pregnancy. Am J Obstet Gynecol. 1990;162:1502–10.
