Trauma in pregnancy

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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

Assessment

Airway
- Prepare for potentially difficult airway
  - Increased soft tissue edema, breast enlargement, weight gain
- Pregnant women at increased risk of aspiration due to delayed gastric emptying
- Failed intubations 8 times more likely in pregnant trauma patients

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

Complications

Uterine rupture
- More common with direct abdominal trauma in second half of pregnancy
- Occurs in severe MVAs resulting in pelvic fractures, penetrating trauma
- Signs and Sx
  - maternal shock
  - abdominal distension
  - abnormal uterine contour
  - abnormal fetal lie (oblique or transverse)
  - palpable fetal parts
  - sudden abnormal FHR pattern
  - ascent of fetal presenting part

Placental Abruption
- Most common cause of fetal demise in blunt trauma
- US alone not sensitive → do not delay treatment for ultrasound if abruption 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

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
Tocographic and fetal monitoring - VEAL CHOP
- Variable - Cord compression
- Early - Head compression
- Accelerations - Okay
- Late - Placental insufficiency

Treatment & Disposition

Assessment and stabilization of the mother should take first priority

Nonviable fetus (<23-24wks)
- Standard treatment for trauma
  - No obstetric intervention will alter the outcome of a pre-viable fetus
- Consider RhoGAM 50mcg in Rh negative patients
Viable fetus (>23-24wks)
- Consider RhoGAM 300mcg in Rh negative patients
- Avoid pressors - compromises blood flow to uterus leading to decreased fetal O2 delivery
- Fetal monitoring (continuous cardiotocographic monitoring)
  - If no risk factors for fetal loss, minimum 4-6 hours
  - If risk factors for fetal loss/abruption, monitor for 24 hours
    - 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
In the setting of maternal cardiac arrest, consider Perimortem Cesarean delivery if no ROSC within 4 minutes

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)

Abruption = risk DIC

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

MDCalc - Pregnancy Due Dates Calculation

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.

Authors:

[1] Tsuei B. Assessment of the pregnant trauma patient. Injury 2006; 37(5)367-373

[2] 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

[3] Pearlman MD, Tintinalli JE, Lorenz RP. A prospective controlled study of outcome after trauma during pregnancy. Am J Obstet Gynecol. 1990;162:1502–10.

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