Table of Contents

 

Management of the pregnant trauma patient presents a particular challenge. The emergency clinician must simultaneously manage both mother and baby, and there is a broad differential of possible complications, including potentially catastrophic outcomes such as uterine rupture, placental abruption, and amniotic fluid embolism. Awareness of the changes in maternal physiology during pregnancy is needed in order to make effective management decisions for both patients, and diagnostic benefits must be weighed against risks to the fetus when making decisions about imaging tests. This supplement provides evidence-based recommendations for the care of the pregnant trauma patient in the emergency department.

What are the major changes to a woman’s physiology during pregnancy, and how do those changes impact assessment and management of traumatic injuries?

Why is it important to determine both the Rh status of the pregnant trauma patient and the gestational age of her fetus?

What role does fetal cardiac monitoring play in emergency department management of a pregnant trauma patient? If fetal distress is detected, what are the next steps?

What risks for adverse outcomes are associated with orthopedic injuries in pregnancy?

How is ultrasound used to detect traumatic injury during pregnancy? When are other imaging modalities indicated, and what are the special considerations for exposure to ionizing radiation during pregnancy?

When can a pregnant patient who has experienced a minor traumatic injury be discharged home?

When is perimortem cesarean section indicated and how is it be performed?

1. Abstract
2. Case Presentations
3. Introduction
4. Epidemiology and Outcomes
5. Pathophysiology
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. History
   2. Primary Survey
   3. Secondary Survey
9. Diagnostic Studies
   1. Laboratory Abnormalities
   2. Maternal Rh Status and Kleihauer-Betke Testing
   3. Fetal Cardiac Monitoring
   4. Imaging
      1. Ultrasound
      2. X-Ray and Computed Tomography
      3. Magnetic Resonance Imaging
10. Treatment
11. Special Circumstances
    1. Carbon Monoxide and Cyanide Poisoning
    2. Isolated Orthopedic Injuries
    3. Domestic Violence
    4. Amniotic Fluid Embolism
    5. Perimortem Cesarean Section
    6. Seat Belt and Airbag Injuries
12. Disposition
13. Summary
14. Time- and Cost-Effective Strategies
15. Risk Management Pitfalls for Pregnant Trauma Patients
16. Case Conclusions
17. Clinical Pathway for Management of Pregnant Trauma Patients in the Emergency Department
18. Tables and Figures
    1. Table 1. Overview of the Physiological Changes of Pregnancy
    2. Table 2. Life-Threatening Diagnoses in Pregnant Trauma Patients
    3. Table 3. Estimated Conceptus Doses From Radiographic and Fluoroscopic Examinations
    4. Table 4. Estimated Conceptus Doses From Single Computed Tomographic Acquisition
    5. Figure 1. Fundal Height and Estimated Gestational Age
    6. Figure 2. Prolonged Deceleration on Fetal Heart Rate Tracing
    7. Figure 3. Late Decelerations on Fetal Heart Rate Tracing
    8. Figure 4. Variable Decelerations on Fetal Heart Rate Tracing
    9. Figure 5. Third-Trimester Pregnancy Ultrasound
    10. Figure 6. Positive FAST Examination in the Right Upper Quadrant
    11. Figure 7. Positive FAST Examination in the Left Upper Quadrant
    12. Figure 8. Perimortem Cesarean Section
    13. Figure 9. Correct Positioning of a Seat Belt in a Pregnant Woman
19. Additional Reading
20. References

Abstract

This supplement 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 a concern in pregnancy, the circumstances in which benefits of testing outweigh risks to the fetus are discussed. Emergency clinicians are encouraged to advocate for trauma prevention, including proper use of safety restraints in motor vehicles and screening for domestic violence, as these measures have been shown to be effective in reducing morbidity and mortality in this patient population. Recommendations for monitoring, admission, discharge, and follow-up are also provided.

Case Presentations

In the first hour of your shift, a 30-week pregnant patient arrives from a relatively minor MVC. She is limping due to ankle pain and reports a sore neck. Otherwise, she appears well, and she reassures you that she doesn't have 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. You are concerned about the potential risk to the fetus and wonder what the best practice recommendations are for managing the mother and fetus in this situation . . .

As you mull this over, 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 clinical presentation that causes you concern.

Just then, a distraught paramedic radios and hurriedly relates that they’re about 2 minutes out with another MVC victim who appears sick and is tachycardic, hypotensive, and having agonal respirations. He relates that the husband is frantically screaming that she’s due to have a baby girl next month. As your team prepares for the patient, you realize that the ambulance is going to arrive much faster than the obstetrician on call (who is coming from home). You consider your management options for the mother and fetus prior to arrival of the obstetrician . . .

Introduction

Few things in emergency practice evoke more anxiety than the pregnant trauma patient. Emergency clinicians must simultaneously manage both the mother and the baby, only 1 of whom can verbalize complaints. Trauma in pregnancy provokes anxiety in the patient (who often is concerned about possible complications to her unborn child due to the trauma) as well as in clinicians (who recognize that intrauterine complications may not have outward manifestations). Awareness of the changes in maternal physiology during pregnancy and attention to a broad differential of possible complications of trauma in 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 than in a nonpregnant patient. This supplement reviews the approach to the pregnant trauma patient, highlights pitfalls of management, and discusses controversies in testing and imaging, including issues regarding radiation exposure for the fetus. An evidence-based approach to clinical decision-making is presented, from the care of minor injuries to the perimortem cesarean section.

Epidemiology and Outcomes

The biggest risk for maternal death during pregnancy is trauma, with motor vehicle crashes (MVCs) accounting for nearly half of all obstetric trauma in the United States, followed by falls and assault.¹ Major trauma is estimated to complicate between 3% and 8% of pregnancies in the United States.^2-4 In 1990, one of the few prospective analyses of outcomes after trauma in pregnant patients demonstrated that serious complications (such as abruption or premature delivery) occurred in a significant number of patients with only mild or moderate injuries.⁵ This was further substantiated by a retrospective review of pregnant trauma patients in the state of Washington that showed that injury severity scores were poor predictors of adverse outcomes and that even minor injuries could result in fetal demise.⁶ A study by Deshpande et al found that pregnant victims of violent trauma (eg, assault or domestic violence) had a 3.14-fold greater risk of death when compared to pregnant victims of nonviolent trauma (eg, MVC or accidental fall), even when adjusting for demographic factors and severity of injury.⁷ Efforts to determine predictors of adverse fetal outcomes have produced variable findings, but few studies have found any predictors that can be utilized reliably to make determinations without a minimum of 6 hours of maternal and fetal monitoring.⁸

Pathophysiology

Pregnancy is typically divided into 3 trimesters: weeks 1 through 13 mark the first trimester; weeks 14 through 26 comprise the second trimester; and weeks 27 through 40+ comprise the third trimester. During the course of pregnancy, a woman’s physiology changes dramatically. The major changes are summarized in Table 1.

Differential Diagnosis

While minor trauma in pregnant patients appears straightforward, even minor injuries can result in severe morbidity to the fetus. Consequently, the emergency clinician should be cognizant of several potential threats to both the mother and the fetus, including placental abruption, which has been shown to occur in even relatively minor trauma.^9-11 Sheer forces to an elastic uterus with the relatively inelastic placenta increases the risk for more serious effects of blunt force trauma (eg, placental abruption).¹² Uterine rupture is a less common but much more significant threat to the life of the mother that can occur when the uterine wall is torn, resulting in intraperitoneal hemorrhage and placental abruption.^13,14 Premature rupture of membranes and subsequent premature labor can result in significant morbidity for the fetus and can lead to potential infection. Amniotic fluid embolism occurs in < 1% of all normal deliveries, but the fatality rate approaches 30%.¹⁵ Amniotic fluid embolus may present similarly to a pulmonary embolus, with extreme cardiovascular collapse and hypoxia, and it necessitates immediate resuscitation. Additionally, exposure to fetal blood during trauma can result in Rh alloimmunization in Rh-negative mothers. While this is not an immediate life threat to the mother, it is essential to manage this in order to avoid significant problems with future pregnancies. Table 2 describes life-threatening diagnoses that can occur in pregnant trauma patients.

Risk Management Pitfalls for Pregnant Trauma Patients

4. “I wasn’t worried about bleeding, so I didn’t order Rho(D) immune globulin.”

Even minor trauma can result in fetal-maternal hemorrhage and complications in subsequent pregnancies in Rh-negative mothers. All pregnant patients with abdominal trauma or a significant mechanism of injury should be Rh(D) typed and administered empiric Rho(D) immune globulin if they are Rh-negative.

7. “I wanted to give the mother CPR and check for fetal heart activity before doing a perimortem cesarean section.”

The indication for perimortem cesarean section is loss of vital signs, and in order to have the baby delivered in < 5 minutes, delays should be avoided before performing this potentially life-saving maneuver.

10. “We just laid her down, and she suddenly lost her vital signs.”

The supine hypotensive syndrome is common later in pregnancy and can result in syncope and dramatically reduced cardiac output. The patient should be placed in the left-lateral decubitus position or the spine board should be tilted 15° to the left by placing a pillow beneath the right side of the board.

Tables and Figures

References

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, such as the type of study and the number of patients in the study will be included in bold type following the references, where available. 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.

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2. Hyde LK, Cook LJ, Olson LM, et al. Effect of motor vehicle crashes on adverse fetal outcomes. Obstet Gynecol. 2003;102(2):279-286. (Retrospective cohort study; 322,704 patients)
3. Brown HL. Trauma in pregnancy. Obstet Gynecol. 2009;114(1):147-160. (Retrospective study; 1567 total patients, 102 pregnant patients)
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11. El Kady D, Gilbert WM, Xing G, et al. Maternal and neonatal outcomes of assaults during pregnancy. Obstet Gynecol. 2005;105(2):357-363. (Retrospective population-based study; 2070 patients)
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