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. Note the following:
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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.
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If warranted, fetal heart tones may be auscultated as part of the initial fetal assessment and to reassure the mother.
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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.
A study conducted at a level I trauma center found that implementation of a perinatal emergency response team reduced the mean time to obstetrical evaluation by 30 minutes. [10]
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.
Admission and discharge criteria for pregnant trauma patients
Hospitalization is warranted in pregnant trauma patients with the following:
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Abnormal obstetric findings, such as vaginal bleeding
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Abnormal fetal heart rate tracings (eg, variable decelerations)
All serious trauma victims who are beyond 23 weeks EGA require 24 hours of fetal monitoring.
Discharge criteria include no abnormal obstetric findings and normal fetal heart tracings.
Instruct the patient to return in the event of decreased fetal activity, vaginal bleeding, uterine contractions and/or cramping, or spontaneous premature rupture of the membranes.
Transfer
Transfer the patient to a level I trauma center with obstetric and neonatal intensive care units (NICUs).
Consultations
The pregnant patient with serious traumatic injury requires a multidisciplinary team, which includes an obstetrician, trauma surgeon, and neonatologist.
