History
Features of the pregnant patient's history may include the following:
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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).
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Last menstrual period (LMP) and estimated date of confinement (EDC)
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Uterine contractions
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Fetal movement
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Premature rupture of membranes
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Vaginal bleeding
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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% to 20.1%. [7] )
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Infants with mothers who have childhood histories of abuse/neglect, particularly those with unresolved trauma and trauma-specific reflective function, appear to be disproportionately insecure and exhibit attachment disorganization. [8] Canadian investigators suggested that a strong concordance between mother and infant attachment may be indicative of intergenerational transmission of attachment in women with childhood histories of abuse/neglect and their infants. [8]
Physical Examination
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.
