Trauma remains the leading cause of nonobstetric morbidity and mortality in pregnant women.1 The severity of maternal injuries may be a poor predictor of fetal distress and outcome after a traumatic event (even minor ones). Trauma during pregnancy is associated with an increased risk of preterm labor, placental abruption, fetomaternal hemorrhage, and pregnancy loss. Achieving successful outcomes for both mother and fetus requires a collaborative effort by the prehospital provider, emergency physician, trauma surgeon, obstetrician, and neonatologist.
Trauma during pregnancy is common. One study estimated that 32,810 pregnant women sustain injuries in motor vehicle crashes every year in the United States, a rate of 9 per 1000 live births.2 Motor vehicle crashes are the most common cause of blunt abdominal trauma, accounting for up to 70% of acute injuries. This is followed by falls and direct assault in decreasing order of frequency.3 The incidence of falls appears to increase with the advancement of pregnancy, presumably due to alterations in maternal balance and coordination. Penetrating injuries are less common than blunt trauma during pregnancy.
Physiologic changes in pregnancy are discussed in detail in the chapter titled "Resuscitation in Pregnancy." In addition to normal physiologic changes, conditions such as pregnancy-induced hypertension, placenta previa, pre-eclampsia, and eclampsia may significantly alter the presentation and complicate evaluation and treatment in the setting of trauma (see the chapter titled "Emergencies after 20 Weeks of Pregnancy and the Postpartum Period").
Table 1 in the "Resuscitation in Pregnancy" chapter summarizes important physiologic changes in pregnancy that affect resuscitation. Maternal blood volume expands at approximately week 10 of gestation and peaks at about a 45% increase from baseline at week 28. Because plasma volume increases more than red cell mass, mild physiologic anemia may be evident. Cardiac output increases by 1.0 to 1.5 L/min at week 10 of pregnancy and remains elevated until the end of pregnancy. Heart rate in the mother is generally increased by 10 to 20 beats/min in the second trimester, accompanied by decreases in systolic and diastolic blood pressures of 10 to 15 mm Hg.
Table 1 Checklist for Trauma in Pregnancy |Favorite Table|Download (.pdf)
Table 1 Checklist for Trauma in Pregnancy
Before arrival: Assemble ED, obstetrics, and trauma team, as appropriate for >20 wk gestation
Attend to maternal airway, breathing, and circulation as a priority for both mother and fetus. Increase volume resuscitation 50% above that given to nonpregnant patients.
Maintain patient in the semi-left lateral decubitus position, or manually deflect the uterus to the left.
Bedside US: FAST for intraperitoneal fluid and to determine fetal heart rate and estimate fetal age to determine viability.
Initiate fetal cardiotocographic monitoring as soon as possible and continue for at least 4–6 h even if the patient is apparently uninjured.
Perform needed imaging.
Include blood typing and Rh status in laboratory studies.
Administer Rho(D) immunoglobulin to Rh-negative mothers. Give tetanus as ...