Trauma in Pregnancy

TRAUMA IN PREGNANCY

Maternal trauma is one of the leading causes of morbidity and mortality in pregnancy. The most common cause of traumain pregnancy is motor vehicle accidents. The second most common cause is physical violence against women, most frequently partner violence. Traumatic injury can result in maternal injury anddeath, as well as placental abruption, uterine rupture, fetal– maternal hemorrhage, premature rupture of membranes, or preterm labor. In addition to the above conditions, which can compromise fetal well-being, direct fetal injury is also possible.

The primary goal for evaluation of a pregnant trauma pa-tient is maternal stabilization. Management is essentially thesame as for the nonpregnant patient. Vital signs should be assessed and the patient stabilized, followed by obstetric assessment. If the gestational age is 20 weeks or beyond, the patient should be placed in a decubitus lateral tilt po-sition. If this is not feasible (for example due to cervical spine stabilization), manual displacement of the uterus off of midline will promote adequate maternal venous return. Fetal assessment includes verification of fetal heart tones with Doppler, followed by electronic fetal monitoring once the secondary survey is complete. Fetal ultrasound is also helpful for identifying location of placenta, fetal well-being, amniotic fluid volume, and estimated gestational age.

After a minor trauma, electronic fetal monitoring (includ-ing tocometry) is recommended from 2 to 6 hours (there are nolarge studies available to guide a consensus on the appro-priate length of time for monitoring to occur). If, during that interval, there are any signs of uterine tenderness, irri-tability or contractions, vaginal bleeding, rupture of mem-branes, or non-reassuring fetal status, continued monitoring for at least 24 hours is advocated. Any moderate or major trauma necessitates at least 24 hours of continuous fetal monitoring.

Feto-maternal hemorrhage is another complicationof maternal trauma, and determination of Rh status is an important part of the management. The extent of feto-maternal hemorrhage can be determined using one of several tests (e.g., the Kleihauer-Betke test). Most often a regular dose of Rh immunoglobulin is protective for all Rh-negative mothers.

If a pregnant woman undergoes cardiopulmonary ar-rest, attempts at resuscitation should begin immediately. Emergent cesarean delivery should be considered after 4 min-utes of failed resuscitation efforts if the patient is in the third trimester of pregnancy. Maternal resuscitation is made eas-ier once the fetus has been delivered. Fetal survival is not likely if maternal vital signs have been absent for more than 15 to 20 minutes