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<< Trauma In Pregnancy: Double Jeopardy (2008)
ED Evaluation
History
The initial emergency department evaluation of a pregnant patient following major trauma should follow standard Advanced Trauma Life Support (ATLS) protocols with a few important considerations. Many pregnant patients will present to the ED following minor trauma, such as a fall from standing or isolated musculoskeletal injury, for treatment of their injuries and with concerns regarding potential injury to the fetus. During the initial assessment, information regarding the gestational age, prior pregnancy complications, circumstances around the trauma, and the potential for any associated injuries should be obtained. The patient should be asked if she has had any vaginal bleeding, abdominal pain or contractions, leakage of fluid, and if applicable, if she continues to feel fetal movement. All injured pregnant patients should be screened for intimate partner violence.
Physical Examination And Triage Of The Pregnant Patient
Fetal well-being and survival is dependent on maternal well-being; therefore, maternal stabilization must be the first priority when evaluating the pregnant trauma patient. Life saving procedures should not be withheld because of the pregnancy.
Supine hypotension from compression of the inferior vena cava can occur, so attention must be paid to the patient’s positioning from the beginning of the evaluation. The physical examination follows the standard evaluation of the trauma patient: complete an initial primary survey and assess possible life threats. This is followed by a thorough secondary survey to look for all potential injuries. The next steps depend on the severity of the trauma, the patient’s specific injuries, the presence of any symptoms suggesting placental abruption or preterm labor, and the gestational age of the fetus. Fetal monitoring, if available, should be initiated in the emergency department if the patient is greater than 20 weeks gestation. A vaginal examination to assess for bleeding and amniotic fluid should be performed. Amniotic fluid turns nitrazine paper blue and exhibits a characteristic ferning pattern on a slide. These simple tests can be helpful if the diagnosis is not clear. To decrease the risk of infection, a sterile speculum should be used to perform the examination. In patients with minor injuries that do not have symptoms suggestive of pregnancy complications, the vaginal examination is not necessary. However, placental abruption and preterm labor can occur following minor trauma, and patients greater than 20 weeks with any potential trauma to the abdomen should have a minimum of 4-6 hours of fetal monitoring after treatment of their injuries. Monitoring is typically done in the labor and delivery suite, but protocols may vary across institutions.
The initial emergency department evaluation of a pregnant patient following major trauma should follow standard Advanced Trauma Life Support (ATLS) protocols with a few important considerations. Many pregnant patients will present to the ED following minor trauma, such as a fall from standing or isolated musculoskeletal injury, for treatment of their injuries and with concerns regarding potential injury to the fetus. During the initial assessment, information regarding the gestational age, prior pregnancy complications, circumstances around the trauma, and the potential for any associated injuries should be obtained. The patient should be asked if she has had any vaginal bleeding, abdominal pain or contractions, leakage of fluid, and if applicable, if she continues to feel fetal movement. All injured pregnant patients should be screened for intimate partner violence.
Physical Examination And Triage Of The Pregnant Patient
Fetal well-being and survival is dependent on maternal well-being; therefore, maternal stabilization must be the first priority when evaluating the pregnant trauma patient. Life saving procedures should not be withheld because of the pregnancy.
Supine hypotension from compression of the inferior vena cava can occur, so attention must be paid to the patient’s positioning from the beginning of the evaluation. The physical examination follows the standard evaluation of the trauma patient: complete an initial primary survey and assess possible life threats. This is followed by a thorough secondary survey to look for all potential injuries. The next steps depend on the severity of the trauma, the patient’s specific injuries, the presence of any symptoms suggesting placental abruption or preterm labor, and the gestational age of the fetus. Fetal monitoring, if available, should be initiated in the emergency department if the patient is greater than 20 weeks gestation. A vaginal examination to assess for bleeding and amniotic fluid should be performed. Amniotic fluid turns nitrazine paper blue and exhibits a characteristic ferning pattern on a slide. These simple tests can be helpful if the diagnosis is not clear. To decrease the risk of infection, a sterile speculum should be used to perform the examination. In patients with minor injuries that do not have symptoms suggestive of pregnancy complications, the vaginal examination is not necessary. However, placental abruption and preterm labor can occur following minor trauma, and patients greater than 20 weeks with any potential trauma to the abdomen should have a minimum of 4-6 hours of fetal monitoring after treatment of their injuries. Monitoring is typically done in the labor and delivery suite, but protocols may vary across institutions.
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