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.
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 . . .
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.
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
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.
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.
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.
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.
Kurt A. Smith, MD, FACEP; Suzanne Bryce, MD
Kaushal Shah, MD, FACEP
October 15, 2020
October 15, 2023
4 AMA PRA Category 1 Credits.™ Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.
Date of Original Release: October 15, 2020. Date of most recent review: October 1, 2020. Termination date: October 15, 2023.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional requirements.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
CME Objectives: Upon completion of this activity, you should be able to: (1) describe the perinatal life-threatening or serious conditions inherent in obstetric trauma, including placental abruption, amniotic fluid embolus, uterine rupture, and maternal cardiac arrest; (2) explain the imaging modalities used in assessing the pregnant trauma patient and their risks and benefits; and (3) assess the indications for and the timeline of a perimortem cesarean section as well as the technique used.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosures: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Bryce, Dr. Shah, Dr. Smith, and their related parties report no relevant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
Commercial Support: This supplement to Emergency Medicine Practice did not receive any commercial support.
Earning Credit: Read the PDF and complete the CME test online.
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