The management of acute trauma in the pregnant patient relies on a thorough understanding of the underlying physiology of pregnancy. This issue reviews the evidence regarding important considerations in pregnant trauma patients, including the primary and secondary survey as well as the possibility for Rh exposure, placental abruption, uterine rupture, and the need for a prompt perimortem cesarean section in the moribund patient. Because ionizing radiation is always a concern in pregnancy, the circumstances where testing provides benefits that outweigh risks to the fetus are discussed. Emergency clinicians are encouraged to advocate for trauma prevention, including proper safety restraints for motor vehicles and screening for domestic violence, as these measures have been shown to be effective in reducing morbidity and mortality in this population. Recommendations for monitoring, admission, discharge, and follow-up are also noted.
Key words: pregnancy, trauma in pregnancy, blunt trauma, motor vehicle collision, orthopedic injury, radiation in pregnancy, fetal monitoring, Rh immunization, perimortem cesarean section
All shifts have a theme. Unfortunately, as you start your day in the ED, you realize that today’s theme is not your favorite. In the first hour of your shift, a 30-week pregnant patient arrives from a relatively minor motor vehicle collision. She was ambulatory at the scene despite presenting with lower extremity pain with an obviously deformed ankle and a sore neck. Otherwise, she looks fine, and she reassures you that she isn’t having any abdominal pain. She is insistent that she does not want any radiation, that she does not want to be observed, and that she would like to be discharged. Although rapid discharge seems attractive, you are concerned about the potential risk to the fetus and wonder what the best practice recommendations are for managing your 2 patients . . .
As you mull over how to best care for both this mother and baby, a second pregnant patient arrives. She is 24 weeks pregnant and fell while jogging. She thinks that she felt a contraction as the nurse was getting her into a gown. While well-appearing and embarrassed by her clumsiness, there is something about her that makes you feel uneasy . . .
Brooding that this just isn’t your day, the radio brings you back to reality as a very distraught paramedic hurriedly relates that they’re about 2 minutes out with another motor vehicle collision victim who looks sick and is tachycardic, hypotensive, and having agonal respirations. He relates that the husband is frantically screaming that she’s due next month to have a baby girl. As your team gears up for the ensuing disaster about to descend on your trauma room, you realize that the ambulance is going to arrive much faster than your obstetrician on call (who is coming from home). You fully appreciate that the opening moves of this drama are going to be entirely up to you. . . .
Few things in emergency practice evoke more anxiety than the pregnant trauma patient. The “package deal” of 2 patients in 1 requires that the emergency clinician simultaneously manage both patients, only 1 of whom may be able to verbalize complaints. Pregnancy provokes anxiety in the patient (who often is concerned about possible complications to her unborn child due to trauma) as well as healthcare providers (who realize that intrauterine complications can be hidden). Careful attention to differences in maternal physiology during pregnancy and a broad differential of the possible complications of pregnancy (even with relatively minor trauma) are requisite to avoid catastrophe, as the physiology and nature of injuries can be strikingly different in a pregnant patient. In this issue of Emergency Medicine Practice, the approach to the pregnant trauma patient is reviewed; pitfalls of management are highlighted; and controversies in testing and imaging are discussed, including issues regarding radiation exposure for the fetus. An evidence-based approach to clinical decision making from the care of minor injuries to the perimortem cesarean section are presented.
A literature search of current articles from 1946 to present was conducted with Ovid MEDLINE® and PubMed utilizing the following search terms coupled with pregnant and pregnancy: trauma, blunt trauma, penetrating trauma, motor vehicle collision, orthopedic injury, fracture, perimortem cesarean section, trauma management, radiation, imaging, ultrasound, abruption, fetal monitoring, Kleihauer-Betke, Rh immunization, amniotic fluid embolism, uterine rupture, and carbon monoxide. The resulting 12,000 articles were limited to those published in the last 20 years, and they were evaluated for relevance and applicability. The remaining 162 articles were evaluated using standard evidence-level scales to determine their weight with regard to current practice. Bibliographies of relevant articles were then used to uncover further articles pertinent to the topic. The Cochrane Database of Systematic Reviews was searched using the terms pregnancy and trauma; the only relevant review concerned effective treatments for placental abruption. The Cochrane review authors concluded that there were no available data from which to draw any guidelines.1
In assessing the body of literature as a whole, it is apparent that this is an area of emergency medicine that lacks definitive evidence and well-designed studies. Pregnant patients are often excluded from major protocols, and they represent a smaller subset of trauma patients that is frequently excluded from outcomes research. Consequently, the literature is rife with case studies and reports of small series of patients, but it is relatively scant on large prospective studies with regard to outcomes or specific interventions. A large body of case reports detail rare conditions that are difficult to effectively study. As a result, much of the evidence that exists must be interpreted in the light of expert opinion, considering the potential hazards while keeping in mind that such complications are relatively rare but cannot be missed.
Several sets of guidelines exist in the current literature; however, even these are primarily grounded in expert consensus and class III evidence, rather than well-designed studies. The American College of Obstetrics and Gynecology (ACOG) has published guidelines regarding the care of obstetric trauma patients that were last updated in 19982 (replacing Number 151, January 1991 and Number 161, November 1991). ACOG issued separate guidelines for administration of anti-Rh antibodies that specifically addressed trauma patients (last updated in 1999)3 and guidelines regarding appropriate diagnostic imaging (last updated in 2004).4 In September 2004, the American College of Emergency Physicians (ACEP) released guidelines on administration of Rh immune globulin to trauma patients in their first trimester as part of their first-trimester vaginal bleeding review,5 which mirrors ACOG guidelines. The Eastern Association for the Surgery of Trauma (EAST) has published guidelines regarding the surgical approach to trauma patients as recently as 2010.6 Likewise, Advanced Trauma Life Support® (ATLS®) general guidelines also exist for the surgical management of obstetric trauma. All of these guidelines were reviewed for this issue. To the authors’ knowledge, there is no current set of guidelines endorsed by any emergency medicine association that specifically addresses the resuscitation and care of the obstetric patient in the emergency department (ED).
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
Kurt A. Smith MD, Suzanne Bryce MD
April 2, 2013