eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology
Pregnancy, Trauma: Treatment & Medication
Updated: Feb 3, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
As in any trauma patient, the ABCs of trauma resuscitation must be followed in treating the pregnant patient. The mother should always receive supplemental oxygen. Several additional issues must be considered in treating the trauma patient who is pregnant.
- For patients beyond the 20th to 24th week of gestation, the patient should be tilted 15° to the left by placing rolled towels beneath the spinal board. This is completed to prevent supine hypotension syndrome, which occurs when the gravid uterus compresses the inferior vena cava. Such compression can decrease cardiac output by up to 28%, which then may cause significant hypotension. Alternatively, one person may be designated to manually displace the uterus to the left. If the patient does not require spinal immobilization, then she can be asked to assume the left lateral decubitus position.
- If warranted, fetal heart tones may be auscultated as part of the initial fetal assessment and to reassure the mother.
- Military antishock trousers (MAST) are considered a class III intervention (inappropriate, possibly harmful) for gravid patients. If they are used, inflate only the leg compartments.
Emergency Department Care
Patients who have minor trauma and who are at less than 20 weeks' gestation do not require specific intervention or monitoring. All pregnant women beyond 20-24 weeks' gestation who have direct or indirect abdominal trauma should undergo at least 4 hours of cardiotocographic monitoring. Resuscitation of the more serious trauma patient must focus on the mother because the most common cause of fetal death is maternal shock or death. It is important to remember that the mother will maintain her vital signs at the expense of the fetus. Because plasma volume is increased 50% and the mother is able to shunt blood away from the uterus, maternal shock may not manifest itself until maternal blood loss exceeds 30%. During the initial ABC assessment, the fetus is addressed only during evaluation of circulation.
If the patient is more than 20-24 weeks' pregnant, the patient should be tilted 15° to the left. Alternatively, one person may be designated to manually displace the uterus to the left. If the patient does not require spinal immobilization, then she can be asked to assume the left lateral decubitus position.
- Airway and breathing
- All pregnant trauma patients should receive supplemental oxygen because the fetus is extremely sensitive to hypoxia and because the oxygen reserve is significantly diminished in the pregnant patient.
- In general, pregnancy does not affect the decision to intubate, although the risk of aspiration is increased (decreased gastric tone, delayed gastric emptying, and cephalad displacement of intra-abdominal organs). The use of medications for rapid sequence intubation in pregnancy is not well studied; however, no absolute contraindications exist.
- If a chest tube is placed, enter the chest 1 or 2 interspaces higher than usual, because the diaphragm is elevated during pregnancy.
- Circulation
- It is extremely important to maintain adequate maternal blood volume as a first step in fetal resuscitation. A decrease in maternal blood pressure may result in a decrease in uterine blood flow, even without uterine artery vasoconstriction.
- Resuscitate the patient with warmed crystalloid administered through large-bore catheters placed for intravenous lines because the relative hypervolemia of pregnancy allows for a 30-35% loss of blood volume before hypotension develops.
- Rule out occult sources of bleeding because maternal blood flow is maintained at the expense of fetal blood flow.
- If blood is needed on an emergency basis, use Rh-negative blood unless the patient's Rh status is known.
- Blood pressure returns to prepregnancy levels as the gestational age approaches 40 weeks.
- Fetal assessment should be performed early as part of the maternal secondary survey.
Consultations
The pregnant patient with serious traumatic injury requires a multidisciplinary team, which includes an obstetrician, trauma surgeon, and neonatologist.
Medication
The goal of therapy is to prevent immune response to Rh-negative fetus after trauma.
Immune serum
Suppresses immune response of nonsensitized Rho(D)–negative mothers who are exposed to Rho(D)–positive blood from the fetus, resulting from a fetomaternal hemorrhage, abdominal trauma, amniocentesis, abortion, full-term delivery, or transfusion accident.
Rho(D) immune globulin (RhoGAM)
Administered if the patient is Rh-negative, unless the father also is Rh-negative. Suppresses the immune response of nonsensitized Rh-negative mothers after delivery of Rh-positive infant. Prevents sensitization to Rho(D) factor. Prevents erythroblastosis fetalis in subsequent pregnancy. When administered near the time of delivery, RhIgG may interfere with Rh typing of the newborn.
Adult
300 mcg covers up to 15 mL fetomaternal hemorrhage; administer within 72 h to prevent isoimmunization
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; patients who have received Rho(D)-positive blood within the last 3 mo
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in thrombocytopenia, bleeding disorders, or IgA deficiency
More on Pregnancy, Trauma |
| Overview: Pregnancy, Trauma |
| Differential Diagnoses & Workup: Pregnancy, Trauma |
 Treatment & Medication: Pregnancy, Trauma |
| Follow-up: Pregnancy, Trauma |
| References |
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References
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].
Bochicchio GV, Haan J, Scalea TM. Surgeon-performed focused assessment with sonography for trauma as an early screening tool for pregnancy after trauma. J Trauma. Jun 2002;52(6):1125-8. [Medline].
Connolly AM, Katz VL, Bash KL, McMahon MJ, Hansen WF. Trauma and pregnancy. Am J Perinatol. Jul 1997;14(6):331-6. [Medline].
Crosby WM, Costiloe JP. Safety of lap-belt restraint for pregnant victims of automobile collisions. N Engl J Med. Mar 25 1971;284(12):632-6. [Medline].
Curet MJ, Schermer CR, Demarest GB, Bieneik EJ 3rd, Curet LB. Predictors of outcome in trauma during pregnancy: identification of patients who can be monitored for less than 6 hours. J Trauma. Jul 2000;49(1):18-24; discussion 24-5. [Medline].
Dhanraj D, Lambers D. The incidences of positive Kleihauer-Betke test in low-risk pregnancies and maternal trauma patients. Am J Obstet Gynecol. May 2004;190(5):1461-3. [Medline].
El-Kady D, Gilbert WM, Anderson J, Danielsen B, Towner D, Smith LH. Trauma during pregnancy: an analysis of maternal and fetal outcomes in a large population. Am J Obstet Gynecol. Jun 2004;190(6):1661-8. [Medline].
Esposito TJ. Trauma during pregnancy. Emerg Med Clin North Am. Feb 1994;12(1):167-99. [Medline].
Fildes J, Reed L, Jones N, Martin M, Barrett J. Trauma: the leading cause of maternal death. J Trauma. May 1992;32(5):643-5. [Medline].
Goldman SM, Wagner LK. Radiologic management of abdominal trauma in pregnancy. AJR Am J Roentgenol. Apr 1996;166(4):763-7. [Medline].
Harper M, Parsons L. Maternal deaths due to homicide and other injuries in North Carolina: 1992-1994. Obstet Gynecol. Dec 1997;90(6):920-3. [Medline].
Mattox KL, Goetzl L. Trauma in pregnancy. Crit Care Med. Oct 2005;33(10 Suppl):S385-9. [Medline].
Muench MV, Baschat AA, Reddy UM, et al. Kleihauer-betke testing is important in all cases of maternal trauma. J Trauma. Nov 2004;57(5):1094-8. [Medline].
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].
Pearlman MD, Tintinalli JE, Lorenz RP. Blunt trauma during pregnancy. N Engl J Med. Dec 6 1990;323(23):1609-13. [Medline].
Pearlman MD, Tintinallli JE, Lorenz RP. A prospective controlled study of outcome after trauma during pregnancy. Am J Obstet Gynecol. Jun 1990;162(6):1502-7; discussion 1507-10. [Medline].
Poole GV, Martin JN Jr, Perry KG Jr, Griswold JA, Lambert CJ, Rhodes RS. Trauma in pregnancy: the role of interpersonal violence. Am J Obstet Gynecol. Jun 1996;174(6):1873-7; discussion 1877-8. [Medline].
Shah AJ, Kilcline BA. Trauma in pregnancy. Emerg Med Clin North Am. Aug 2003;21(3):615-29. [Medline].
Theodorou DA, Velmahos GC, Souter I, et al. Fetal death after trauma in pregnancy. Am Surg. Sep 2000;66(9):809-12. [Medline].
Further Reading
Keywords
trauma in pregnancy, blunt trauma in pregnancy, accidental injury in pregnancy, penetrating trauma in pregnancy, domestic violence in pregnancy, falls in pregnancy, assaults in pregnancy, trauma-related injuries in pregnancy
