Management of the Pregnant Trauma Patient in the Emergency Department - Trauma EXTRA Supplement (Trauma CME)

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.

1. El Kady D, Gilbert WM, Anderson J, et al. Trauma during pregnancy: an analysis of maternal and fetal outcomes in a large population. Am J Obstet Gynecol. 2004;190(6):1661-1668. (Retrospective cohort study; 10,316 patients)
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)
4. Chames MC, Pearlman MD. Trauma during pregnancy: outcomes and clinical management. Clin Obstet Gynecol. 2008;51(2):398-408. (Review article)
5. * Pearlman MD, Tintinalli JE, Lorenz RP. A prospective controlled study of outcome after trauma during pregnancy. Am J Obstet Gynecol. 1990;162(6):1502-1510. (Prospective cohort study; 86 pregnant patients) DOI: 10.1016/0002-9378(90)90913-r
6. Schiff MA, Holt VL. The injury severity score in pregnant trauma patients: predicting placental abruption and fetal death. J Trauma. 2002;53(5):946-949. (Retrospective study; 294 patients)
7. * Deshpande NA, Kucirka LM, Smith RN, et al. Pregnant trauma victims experience nearly 2-fold higher mortality compared to their nonpregnant counterparts. Am J Obstet Gynecol. 2017;217(5):590.e1-590.e9. (Clinical policy) DOI: 10.1016/j.ajog.2017.08.004
8. * Curet MJ, Schermer CR, Demarest GB, et al. Predictors of outcome in trauma during pregnancy: Identification of patients who can be monitored for less than 6 hours. J Trauma. 2000;49(1):18-25. (Retrospective study; 271 patients) DOI: 10.1097/00005373-200007000-00003
9. Oyelese Y, Ananth CV. Placental abruption. Obstet Gynecol. 2006;108(4):1005-1016. (Review article)
10. Cahill AG, Bastek JA, Stamilio DM, et al. Minor trauma in pregnancy—is the evaluation unwarranted? Am J Obstet Gynecol. 2008;198(2):208.e1-5. (Prospective cohort study; 317 patients)
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)
12. Weed BC, Borazjani A, Patnaik SS, et al. Stress state and strain rate dependence of the human placenta. Ann Biomed Eng. 2012;40(10):2255-2265. (Nonclinical study; 11 placentas)
13. Enakpene CA, Ayinde OA, Omigbodun AO. Incomplete uterine rupture, following blunt trauma to the abdomen: a case report. Niger J Clin Pract. 2005;8(1):60-62. (Case report)
14. Smith K, Deimling DL, Hinckley WR. Transporting the pregnant patient in shock: case report and review. Air Med J. 2009;28(1):37-39. (Case report)
15. Kramer MS, Rouleau J, Liu S, et al. Amniotic fluid embolism: incidence, risk factors, and impact on perinatal outcome. BJOG. 2012;119(7):874-879. (Retrospective population-based cohort study; 4,508,462 patients with 292 affected)
16. * Simpson KR, James DC. Efficacy of intrauterine resuscitation techniques in improving fetal oxygen status during labor. Obstet Gynecol. 2005;105(6):1362-1368. (Randomized study; 42/51/49 patients in each arm) DOI: 10.1097/01.aog.0000164474.03350.7c
17. * Jeejeebhoy FM, Zelop CM, Windrim R, et al. Management of cardiac arrest in pregnancy: a systematic review. Resuscitation. 2011;82(7):801-809. (Meta-review article) DOI: 10.1016/j.resuscitation.2011.01.028
18. Fromm C, Likourezos A, Haines L, et al. Substituting whole blood for urine in a bedside pregnancy test. J Emerg Med. 2012;43(3):478-482. (Randomized blinded trial; 633 patients)
19. * Jain V, Chari R, Maslovitz S, et al. Guidelines for the management of a pregnant trauma patient. J Obstet Gynaecol Can. 2015;37(6):553-571. (Guidelines) DOI: 10.1016/s1701-2163(15)30232-2
20. Abouleish EI, Abboud TS, Bikhazi G, et al. Rapacuronium for modified rapid sequence induction in elective caesarean section: neuromuscular blocking effects and safety compared with succinylcholine, and placental transfer. Br J Anaesth. 1999;83(6):862-867. (Randomized blinded trial; 42 patients)
21. American College of Obstetricians and Gynecologists Committee on Practice Bulletins--Obstetrics. ACOG practice bulletin. Prevention of Rh D alloimmunization. Number 4, May 1999 (replaces educational bulletin Number 147, October 1990). Clinical management guidelines for obstetrician-gynecologists. Int J Gynaecol Obstet. 1999;66(1):63-70. (Guidelines)
22. Muench MV, Baschat AA, Reddy UM, et al. Kleihauer-Betke testing is important in all cases of maternal trauma. J Trauma. 2004;57(5):1094-1098. (Retrospective study; 166 pregnant patients)
23. Salim R, Ben-Shlomo I, Nachum Z, et al. The incidence of large fetomaternal hemorrhage and the Kleihauer-Betke test. Obstet Gynecol. 2005;105(5, Part 1):1039-1044. (Prospective cohort study; 313 cases and 253 controls)
24. Hahn SA, Lavonas EJ, Mace SE, et al. Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med. 2012;60(3):381-390. (Clinical policy)
25. * Stout MJ, Cahill AG. Electronic fetal monitoring: past, present, and future. Clin Perinatol. 2011;38(1):127-142. (Review article) DOI: 10.1016/j.clp.2010.12.002
26. Richards JR, Ormsby EL, Romo MV, et al. Blunt abdominal injury in the pregnant patient: detection with US. Radiology. 2004;233(2):463-470. (Retrospective study; 2319 total patients, 328 pregnant)
27. Goodwin H, Holmes JF, Wisner DH. Abdominal ultrasound examination in pregnant blunt trauma patients. J Trauma. 2001;50(4):689-694. (Retrospective study; 127 patients)
28. Brown MA, Sirlin CB, Farahmand N, et al. Screening sonography in pregnant patients with blunt abdominal trauma. J Ultrasound Med. 2005;24(2):175-181. (Retrospective study; 1567 total patients, 102 pregnant)
29. * Wang PI, Chong ST, Kielar AZ, et al. Imaging of pregnant and lactating patients: part 1, evidence-based review and recommendations. Am J Roentgenology. 2012;198(4):778-784. (Committee guidelines) DOI: 10.2214/ajr.11.7405
30. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. ACOG committee opinion. Number 299, September 2004 (replaces No. 158, September 1995). Guidelines for diagnostic imaging during pregnancy. Obstet Gynecol. 2004;104(3):647-651. (Committee guidelines)
31. Kopelman TR, Berardoni NE, Manriquez M, et al. The ability of computed tomography to diagnose placental abruption in the trauma patient. J Trauma Acute Care Surg. 2013;74(1):236-241. (Retrospective review; 176 patients)
32. * Kopelman TR, Bogert JN, Walters JW, et al. Computed tomographic imaging interpretation improves fetal outcomes after maternal trauma. J Trauma Acute Care Sur. 2016;81(6):1131-1135. (Retrospective observational study; 41 patients) DOI: 10.1097/ta.0000000000001210
33. Roderique EJD, Gebre-Giorgis AA, Stewart DH, et al. Smoke inhalation injury in a pregnant patient. J Burn Care Res. 2012;33(5):624-633. (Review article)
34. Wolf SJ, Lavonas EJ, Sloan EP, et al. Clinical policy: critical issues in the management of adult patients presenting to the emergency department with acute carbon monoxide poisoning. Ann Emerg Med. 2008;51(2):138-152. (Committee guidelines)
35. Elkharrat D, Raphael JC, Korach JM, et al. Acute carbon monoxide intoxication and hyperbaric oxygen in pregnancy. Intensive Care Med. 1991;17(5):289-292. (Prospective study; 44 patients)
36. El Kady D, Gilbert WM, Xing G, et al. Association of maternal fractures with adverse perinatal outcomes. Am J Obstet Gynecol. 2006;195(3):711-716. (Retrospective cohort study; 3292 patients)
37. Cannada LK, Pan P, Casey BM, et al. Pregnancy outcomes after orthopedic trauma. J Trauma. 2010;69(3):694-698. (Observational study; 1055 total patients, 65 pregnant patients)
38. Greenberg EM, McFarlane J, Watson MG. Vaginal bleeding and abuse: assessing pregnant women in the emergency department. MCN Am J Matern Child Nurs. 1997;22(4):182-186. (Cross-sectional survey; 261 patients)
39. Leone JM, Lane SD, Koumans EH, et al. Effects of intimate partner violence on pregnancy trauma and placental abruption. J Womens Health. 2010;19(8):1501-1509. (Retrospective study; 2873 patients)
40. McFarlane J. Assessing for abuse during pregnancy. JAMA. 1992;267(23):3176-3178. (Prospective cohort study; 691 patients)
41. Ellingsen CL, Eggebø TM, Lexow K. Amniotic fluid embolism after blunt abdominal trauma. Resuscitation. 2007;75(1):180-183. (Case report)
42. Conde-Agudelo A, Romero R. Amniotic fluid embolism: an evidence-based review. Am J Obstet Gynecol. 2009;201(5):445.e1-445.e13. (Review article)
43. Dijkman A, Huisman CMA, Smit M, et al. Cardiac arrest in pregnancy: increasing use of perimortem caesarean section due to emergency skills training? BJOG. 2010;117(3):282-287. (Retrospective cohort study; 55 patients)
44. * Katz V, Balderston K, DeFreest M. Perimortem cesarean delivery: were our assumptions correct? Am J Obstet Gynecol. 2005;192(6):1916-1920. (Literature review article; 38 cumulative cases) DOI: 10.1016/j.ajog.2005.02.038
45. Katz VL. Perimortem cesarean delivery: its role in maternal mortality. Sem Perinatol. 2012;36(1):68-72. (Clinical policy)
46. * Bukar M, Bello M, Pius S, et al. Post-mortem caesarean section 20 minutes after cardiac arrest with neurologically normal baby at 15 months. J Obstet Gynaecol. 2017;37(5):675-676. (Case report) DOI: 10.1080/01443615.2016.1268580
47. Sirin H, Weiss HB, Sauber-Schatz EK, et al. Seat belt use, counseling and motor-vehicle injury during pregnancy: results from a multi-state population-based survey. Matern Child Health J. 2007;11(5):505-510. (Cross-sectional study; 37,081 patients)
48. Klinich KD, Schneider LW, Moore JL, et al. Investigations of crashes involving pregnant occupants. Annu Proc Assoc Adv Automot Med. 2000;44:37-55. (Case series; 16 patients)
49. Klinich KD, Flannagan CAC, Rupp JD, et al. Fetal outcome in motor-vehicle crashes: effects of crash characteristics and maternal restraint. Am J Obstet Gynecol. 2008;198(4):450.e1-450.e9. (Retrospective study; 57 patients)
50. Bard MR, Shaikh S, Pestaner J, et al. Direct fetal injury due to airbag deployment and three-point restraint. J Trauma. 2009;67(4):E98-E101. (Case report)
51. Metz TD, Abbott JT. Uterine trauma in pregnancy after motor vehicle crashes with airbag deployment: a 30-case series. J Trauma. 2006;61(3):658-661. (Case series; 30 patients)
52. Schiff MA, Mack CD, Kaufman RP, et al. The effect of air bags on pregnancy outcomes in Washington state. Obstet Gynecol. 2010;115(1):85-92. (Retrospective cohort study; 3348 patients)