Pregnancy Trauma Clinical Presentation

  • Author: Andrew K Chang, MD; Chief Editor: Pamela L Dyne, MD   more...
 
Updated: Jul 22, 2011
 

History

Features of the patient's history may include the following:

  • Mechanism - Direct abdominal trauma, weapons, seatbelt use, proper or improper (The American College of Obstetrics and Gynecology emphasizes that both the lap belt and shoulder harness be worn with the lap belt passing below the abdomen and over the anterior superior iliac spine and symphysis pubis and the shoulder harness passing between the patient's breasts).
  • Last menstrual period (LMP) and estimated date of confinement (EDC)
  • Uterine contractions
  • Fetal movement
  • Premature rupture of membranes
  • Vaginal bleeding
  • History of depression, substance abuse, or several ED visits (These factors may suggest intimate partner violence, which is not dependent on age, race, marital status, or socioeconomic class. A review of 13 studies found the prevalence of intimate partner violence to range from 0.5-20.1%.[3] )
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Physical

Primary and secondary trauma surveys should be performed as per usual, as the hemodynamic and ventilatory well-being of the patient are the most important factors in determining the fetus' outcome in a critically injured pregnant patient. The secondary survey should also include the following:

Abdominal examination

Inspect for ecchymoses, especially across the lower abdomen, which may indicate a possible seatbelt injury.

Palpate for uterine contractions or tenderness.

Gestational age can be estimated by the size of the gravid uterus. In general, when the fundal height reaches the umbilicus, gestational age can be estimated at 20 weeks. Once above the umbilicus, the fundal height in centimeters measured from the symphysis pubis correlates well with gestational age.

Fetal heart tones can be assessed with Doppler examination or ultrasonography.

Rebound tenderness and guarding may be less apparent in advanced gestation, making clinical diagnosis of hemoperitoneum potentially less reliable because peritoneal stretching in the third trimester decreases the density of afferent pain fibers, thereby muting peritoneal signs.

Sterile speculum examination before bimanual examination

Perform these in the absence of vaginal bleeding.

Test the fluid for pH and ferning. A pH of 7 indicates amniotic fluid. Vaginal secretions are more acidic, with a pH around 5.

Examine for vaginal lacerations, which may signify an open pelvic fracture.

Look for bone fragments in the vagina, which signify an open pelvic fracture.

Bimanual examination

In general, the obstetrician should perform this examination.

It should be performed in a setting where emergency cesarean delivery can be performed.

Evaluation for possible domestic violence

Ecchymoses of the breasts, abdomen, and upper extremities may be present.

Injuries at more than one site in varying stages of healing may be observed.

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Causes

Causes of traumatic injuries in pregnancy are similar to those in the general population; blunt injury trauma is the most common cause.

  • Motor vehicle accidents (MVAs) account for 49% of injuries.
  • Falls account for 25% of injuries (may be related to physiologic changes that result in loss of balance).
  • Assaults account for 18% of injuries.
  • Guns account for 4% of injuries.
  • Burns account for 1% of injuries.
  • Intimate partner violence

Risk factors for trauma in pregnancy include simply pregnancy itself, younger age, drug use, alcohol use, and history of intimate partner violence.

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Contributor Information and Disclosures
Author

Andrew K Chang, MD  Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center

Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Assaad J Sayah, MD  Chief, Department of Emergency Medicine, Cambridge Health Alliance

Assaad J Sayah, MD is a member of the following medical societies: National Association of EMS Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eric L Legome, MD  Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD  Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

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  2. Petrone P, Talving P, Browder T, et al. Abdominal injuries in pregnancy: a 155-month study at two level 1 trauma centers. Injury. Jul 23 2010;[Medline].

  3. Gazmararian JA, Lazorick S, Spitz AM, Ballard TJ, Saltzman LE, Marks JS. Prevalence of violence against pregnant women. JAMA. Jun 26 1996;275(24):1915-20. [Medline].

  4. Mofidi M, Hasani A, Kianmehr N. Determining the accuracy of base deficit in diagnosis of intra-abdominal injury in patients with blunt abdominal trauma. Am J Emerg Med. Oct 2010;28(8):933-6. [Medline].

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  17. Pak LL, Reece EA, Chan L. Is adverse pregnancy outcome predictable after blunt abdominal trauma?. Am J Obstet Gynecol. Nov 1998;179(5):1140-4. [Medline].

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