Trauma in pregnancy
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
Differential Diagnosis
Diagnosis
- Trauma labs
- Rh factor
- Coag studies
- D-dimer
- Fibrinogen
- FAST - sensitivity similar to non-pregnant trauma population
- Radiographic imaging as directed by ATLS assesment[1]
- Radiographic imaging should not be delayed or deferred due to concern for fetal radiation exposure in the trauma setting
Diagnosis (Abruption)
Symptoms
- Vag bleed 70% (may be absent if retroplacental)
- Cramps/contractions
- Uterine tenderness
- Hypovolemia
- Abnl fetal HR
US only 50% accurate
Signs of fetal distress on toco monitor are often the earliest indicator
- decelerations, tachycardia, bradycardia, and loss of variability
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 neg
- 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. [2]
- 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
- Vag bleed
- PROM
- Serious maternal injury
Partial abruption w/ 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
See Also
- Fetal Maternal Hemorrhage (RhoGAM)
- Perimortum C-Section
- Abruption
- Maternal Vitals and Labs in Pregnancy