SIGNS AND SYMPTOMS 
History
- Mechanism of injury
- Last menstrual period
- Abdominal pain
- Uterine contraction
- Vaginal bleeding or leakage of fluid
- Previous pregnancies, C-sections
- Substance use/abuse
Physical Exam
- Perform with patient in left lateral recumbent position if possible
- Primary survey
- Secondary survey
- Tertiary survey
- Placental abruption:
- Uterine rupture:
- Uterine tenderness and variable shape
- Palpation of fetal body parts
- Determine the gestational age (EGA) to assess viability:
- Estimate last menstrual period
- EGA = fundal height (FH; distance from pubic bone to top of uterus in cm after week 16
- Vaginal exam to assess for:
- Blood
- Amniotic fluid
- Cervical dilation and effacement
ESSENTIAL WORKUP
- Maintain spinal immobilization
- Identify maternal condition 1st:
- Airway management and resuscitate as indicated
- Determine the EGA to assess viability:
- EGA = FH after week 16
- Doppler fetal heart tones
- Sonography (may miss small abruptions)
- Fetal/maternal monitoring for > 4–6 hr:
- Only monitor viable fetuses (typically with an EGA > 24 wk)
- Abruption unlikely if no contractions during 1st 4 hr of monitoring
- > 8 contractions/hr over 4 hr is associated with adverse outcome
- If > 1 contraction every 10 min, there is a 20% incidence of abruption
- The occurrence of bradycardia, poor beat-to-beat variability, or type II "late" deceleration indicates fetal distress
- An abnormal tracing has a 62% sensitivity and 49% specificity for predicting adverse fetal outcomes
- A normal tracing combined with a normal physical exam has a negative predictive value of nearly 100%
DIAGNOSIS TESTS & INTERPRETATION
Lab
- CBC, urinalysis
- Blood gas and electrolyte panel
- Type, Rh, and screening of blood
- The Kleihauer–Betke (KB) stain:
- Identifies FMH in vaginal fluid or blood
- Indicated when quantification of FMH is important
Imaging
- Shield the uterus if possible, but obtain necessary maternal radiographs
- Inform the mother of the potential risks of radiation exposure
- No definite evidence of increased risk for congenital malformation or intrauterine death
- Cancer risk is debated
- Radiation < 1 rad (10 mGy) believed to carry little risk
- Increased risk of fetal malformation at 5–10 rad
- The radiation exposure is estimated at the following:
- CXR (2 views): Minimal
- Pelvis (anteroposterior): 1 rad
- Cervical spine x-ray: Minimal
- Thoracic spine x-ray: Minimal
- Lumbar spine x-ray: 0.031–4.9 rads
- CT head: < 0.05 rads
- CT thorax: 0.01–0.59 rads
- CT abdomen: 2.8–4.6 rads
- CT pelvis: 1.94–5 rads
- Ultrasonography:
- Focused assessment with sonography for trauma (FAST) exam
- Evaluate for solid-organ injury or hemoperitoneum
- Fetal heart activity
- Gestational age
- Amount of amniotic fluid (amniotic fluid index)
- Misses 50–80% of placental abruptions
- Test vaginal fluid with Nitrazine paper (turns blue) and for ferning
- Likely rupture of membranes and presence of amniotic fluid
- With stable penetrating trauma, triple-contrast CT is advocated, particularly with stab wounds
Diagnostic Procedures/Surgery
As indicated by traumatic injury
DIFFERENTIAL DIAGNOSIS
Differential diagnosis is broad and should include careful exam for occult traumatic injuries
[Outline]
PRE-HOSPITAL
- Maintain spinal immobilization
- Patients in late 2nd and 3rd trimesters should be transported to a trauma center
- Advise trauma center early of pregnancy and EGA to facilitate mobilization of appropriate resources
- Place patient (while on backboard) in the left lateral recumbent position to avoid supine hypotension (after 20 wk EGA or earlier in multiple gestations)
- Mast suit inflation over the abdomen is contraindicated
INITIAL STABILIZATION/THERAPY
- Direct therapy to the mother with no delays due to pregnancy:
- Manage airway and resuscitate as indicated
- Cardiac, pulse oximetry, and cardiotocographic monitoring
- Tilt patient or board 15–30° to the left (or manually displace uterus to the left)
ED TREATMENT/PROCEDURES
- Lactated Ringer preferred for IV fluids:
- Large volumes of normal saline may induce hyperchloremic acidosis
- Replace estimated blood loss in a 3:1 ratio:
- O-negative packed red blood cells if type-specific blood is not available
- In cases of severe hemorrhage transfusion of fresh frozen plasma, platelets and packed RBC at 1:1:1 ratio lowers the rate of coagulopathy and may improve survival
- Resort to transfusions after 1 L of estimated blood loss or if hypovolemia persists after 2 L of crystalloid
- Nasogastric tube decompression (higher risk of aspiration in pregnancy)
- Foley catheterization to assess urinary output
- Tube thoracostomy:
- Use a higher intercostal space to avoid diaphragm
- Rapid sequence intubation:
- Safe and preferred method
- Avoid aspiration and deoxygenation
- If diagnostic peritoneal lavage is necessary, use supraumbilical open technique
- Use tocolytic therapy only for hemodynamically stable patients:
- Contraindicated if cervix dilated > 4 cm or if FMH and abruption have not been reasonably ruled out
- Use tocolytics only when > 8 contractions/hr have lasted > 4 hr
- A perimortem cesarean delivery may be attempted within 4–5 min of cardiopulmonary arrest. See Cesarean Section, Emergency.
- In minor trauma after week 20, fetal and maternal monitoring is best done in the labor and delivery area
- If burns are > 50% BSA + fetus in the 2nd or 3rd trimester consider delivery
- RhoGAM in all Rh-negative women (within 72 hr):
- 50 µg IM in women < 12 wk pregnant
- 300 µg IM in women > 12 wk pregnant
- 24 hr recheck for ongoing FMH:
- Tocolytics: Magnesium sulfate 4 g IV
- Avoid aspirin, hypnotics, nonsteroidals, vasopressors when possible
[Outline]
DISPOSITION
Admission Criteria
- Vaginal bleeding or amniotic fluid leakage
- Fetomaternal hemorrhage
- Abdominal pain
- Uterine contractions
- Evidence of fetal distress
- Abruption placenta
- Hemoperitoneum or visceral or solid-organ injury
- Fetal survival begins at week 24 (9.9%):
- Survival becomes significant after week 26 (54.7%)
Discharge Criteria
- All the following criteria must be met:
- No uterine contractions for > 4 hr of tocodynamometry
- No evidence of fetal distress
- No vaginal bleeding or amniotic fluid leakage
- No abdominal pain or tenderness
- Timely obstetric follow-up
- Specific instructions to return if any of the above symptoms occur
- Discharge only in consultation with obstetrics.
FOLLOW-UP RECOMMENDATIONS
A pregnant trauma patient being discharged after appropriate evaluation and observation needs prompt follow-up with obstetrician.
[Outline]
- Chames MC, Pearlman MD. Trauma during pregnancy: Outcomes and clinical management. Clin Obstet Gynecol. 2008;51:398–408.
- Cusick SS, Tibbles CD. Trauma in pregnancy. Emerg Med Clin North Am. 2007;25:861–872.
- Dunning K, Lemasters G, Bhattcharya A. A major public health issue: The high incidence of falls during pregnancy. Matern Child Health J. 2010;14:720–725.
- Hill CC, Pickinpaugh J. Trauma and surgical emergencies in the obstetric patient. Surg Clin North Am. 2008;88:421–440.
- Maghsoudi H, Kianvar H. Burns in pregnancy. Burns. 2006;32:246–250.
- Mendez-Figueroa H, Dahlke JD, Vrees RA, et al. Trauma in pregnancy: An updated review. Am J Obstet Gynecol. 2013;209(1):1–10.
- Muench MV, Canterino JC. Trauma in pregnancy. Obstet Clin North Am. 2007;34:555–583.
- Schiff MA. Pregnancy outcomes following hospitalisation for a fall in Washington state from 1987 to 2004. BJOG. 2008;115:,1648–1654.
- Wiencrot A, Nannini A, Manning SE, et al. Neonatal outcomes and mental illness, substance abuse, and intentional injury during pregnancy. Matern Child Health J. 2012;16:979–988.
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