Trauma in Pregnancy

Thu, 01/31/2019 - 8:15pm
Author: 
Chad Simpkins, MD

Trauma in Pregnancy

Epidemiology – MVC, assault (often intimate partner), falls

  • placement of the seat belt over the pregnant abdomen increases the risk of fetal death (patient should be counseled on proper positioning) 

Gestational Age Changes:

  • Prior to 12 weeks gestation, the uterus is well protected by the pelvis
  • After 16 weeks, placental abruption becomes a concern
  • After the age of viability (24 weeks), continuous fetal monitoring for a period of 4 hours should be performed in all pregnant trauma patients

Physiologic Changes Remember, Because Maternal Resuscitation is Key for Fetal Resuscitation

  •  Increase in circulating plasma volume by 45% à may lose 30-35% of circulating blood volume before showing signs of shock
  •  Therefore, need more volume resuscitation à be aggressive with up to 50% more volume
  •  Avoid vasopressors due to poor blood flow to fetus
  •  Compression of IVC by gravid uterus occurs when supine à Place on left lateral decubitus or place towels/sheets under right side of pelvis
  • Respiratory rate remains unchanged; tachypnea is not normal and should be sign of further work up
  • Diaphragm elevation occurs (up to 4cm higher)

Pregnancy Specific Injuries

      Placental abruption

  •  2nd most common cause of fetal death in trauma (#1 is maternal death)
  •  Occurs in 1-5% of minor trauma and 50% of major trauma
  •  Relatively elastic uterus, relatively inelastic placenta
  •  Can have spontaneous rupture of membranes, vaginal bleeding and uterine tenderness as a result of trauma
  •  Concern for shedding of placental products into maternal circulation à risk for DIC and amniotic fluid embolism
  •  Remember ultrasound cannot rule out an abruption (this is why tocomonitoring is crucial prior to discharge)

      Uterine Rupture

  •  Less than 1% of all injuries
  •  Abdominal pain without vaginal bleeding
  •  Loss of typical uterine contour with easily palpated fetal parts
  •  Ultrasound imaging to start if concerned

      Direct Fetal Injury

  •  More frequent late in gestation – fetal skull and brain (high mortality)

 

Abdominal trauma will require Rho(D) immunoglobulin to Rh negative patients.

See our related post on cardiac arrest in a pregnant patient:

http://emdaily.cooperhealth.org/content/advanced-practice-cardiac-arrest-pregnancy

See our related post on perimortem c-section:

http://emdaily.cooperhealth.org/content/emconf-perimortem-c-section