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Trauma in pregnancy

General principles of trauma in pregnancy

The best outcome for the foetus is dependent upon optimal management of the mother.

Pregnant trauma patients should, for the most part, be approached and managed like any other trauma patient, using a standard ABCD approach. However, there are some important physiological, psychological and practical differences to bear in mind.

All women of childbearing age are pregnant until proven otherwise!

Trauma affects around 8% of pregnancies, and is the second leading cause of death in the pregnant population. Around 90% of such trauma is classified as ‘minor trauma’, however even minor trauma can result in uterine rupture, foeto-maternal haemorrhage, placental abruption, pre-term labour and foetal loss.

Pregnant trauma patients must undergo a very thorough physical assessment, whilst recognising the anatomical and physiological changes which occur in pregnancy.

The goals of treatment are to maintain adequate foeto-uterine perfusion and oxygenation, by preventing hypoxia, hypotension, acidosis and hypothermia.

Trauma in 1st trimester

Trauma in the first trimester of pregnancy is managed like any other trauma, with the obvious additional awareness about radiation.[i] Concern about potential radiation exposure to the foetus should never override what is in the best interests of the Mother. Physiologically, the trauma patient in the first trimester will grossly respond and behave like any other patient. The emotional impact will likely be significant, and must be considered in management, referral and follow up for the patient.

Always consider rhesus status of the mother after any potentially sensitizing event and administer anti-D as required.

Trauma in 2nd and 3rd trimesters

The best outcome for the foetus is dependent upon optimal management of the mother.

Airway considerations

  • Potentially difficult airway: enlarged breasts – consider short handled ETT.
  • Laryngeal oedema: consider bougie use.
  • Increased aspiration risk: relaxed UGI sphincter due to progesterone, delayed gastric emptying – consider cricoid pressure, early NGT to empty stomach.

Breathing considerations

  • Increase in Oxygen demand: due to increased metabolic rate and increased oxygen consumption – always apply supplementary oxygen to avoid relative hypoxia.
  • Functional Residual Capacity (FRC) reduced – predisposes to desaturation, especially important to consider in RSI.
  • Increased Tidal Volumes – ‘normally’ should have compensated respiratory alkalosis, pCO2 = 30mmHg.
  • Decreased thoracic compliance due to breast tissue/large abdomen – makes bag mask ventilation more difficult.
  • Chest drains should be placed higher (e.g. 3rd or 4th inter-costal space), as diaphragm will be elevated.

Circulation (haemodynamic) considerations

  • Increased heart rate (by 10-20bpm at term).
  • Lowered BP (10-15mmHg in 2nd trimester).
  • Increased cardiac output.
  • Increased blood volume: may initially mask shock from blood loss.
  • Uterine blood flow is NOT auto-regulated – err on side of caution with aggressive fluid resuscitation.
  • Supine hypotension from IVC compression: may reduce cardiac output by up to 30% - position in the left lateral position, can wedge the whole spinal board if a spinal injury is suspected.

Abdominal considerations

  • Delayed gastric emptying (see above) – early gastric decompression with NGT.
  • Bladder becomes and intra-abdominal organ after 1st trimester.
  • Other abdominal organs displaced by the uterus.

Haematological considerations

  • Transplacental haemorrhage – all Rhesus negative mothers should receive anti-D within 72 hours of injury. A negative Kleihauer-Betke test DOES NOT rule out clinically significant haemorrhage.
  • 250iU units in first trimester, 625iU beyond first trimester
  • Pregnant women will have a relative anaemia due to larger increase in plasma volume than red cell volume.
  • Increased fibrinogen and D dimer from first trimester – hyper-coagulable state.
  • Consider rheusus status when initiating blood product transfusion.

Musculoskeletal considerations

  • Increased joint laxity due to progesterone.
  • Pelvic binders don’t fit.
  • Normal to see widened SI joints and pubis symphis on X-ray.
  • Consider significant injury to foetus if pelvic fracture detected or suspected.

Social considerations

  • Domestic and sexual abuse is high in the pregnant population – affecting 5-20% of pregnancies, depending on the population.
  • Trauma in pregnancy or at delivery is risk factor for postnatal depression and anxiety (PNaDA), post-traumatic stress disorder (PTSD) and postpartum psychosis.
  • Early involvement of obstetric teams and social work are essential for providing optimal antenatal care.

Foetal considerations

  • Continuous CTG required for minimal 6 hours post trauma in pregnancies >24 weeks, even for minimal trauma.
  • Ultrasound is poor at excluding placental abruption.
  • Feotus most at risk of CNS damage from radiation from 8–15 weeks, at limits around 20-40 rad (however most data is retrospective and incidental).[i]

Remember these injuries and conditions specific to pregnancy

  • Amniotic fluid embolism.
  • Placental abruption.
  • Uterine rupture.
  • Uterine vessel damage.
  • Maternal-foetal haemorrhage.
  • Prevention of Rhesus immunisation.
  • Premature rupture of membranes/ premature labour.
  • DIC (as with any major trauma or massive transfusion, but may also be due to placental abruption, amniotic fluid embolism, foetal death).

Cardiac Arrest in Pregnancy

Manage as per standard cardiac arrest algorithms. Remember to consider manual uterine displacement, left lateral tilt (15-30 degrees) in order to increase venous return.

Follow standard drugs, doses, routes and protocols. If pregnancy >24 weeks, as soon as cardiac arrest confirmed, should start preparing for peri-mortem C section.

**Remove CTG leads before defibrillation**

Perimortem Caesarean section

Is considered a resuscitative procedure primarily aimed at improving maternal survival. Best outcome for foetus is achieved if delivery within 4-6 minutes of cardiac arrest.[ii] No survival benefit demonstrated to foetus if delivered after 30 minutes of maternal cardiac arrest.[iii]

Take home principles

  • Always continue to manage as per ATLS guidelines.
  • Routinely apply oxygen to mother.
  • >20 weeks, position in left lateral position (use wedge under right hip).
  • Multi-disciplinary team approach – early obstetric assistance, monitoring and follow up.
  • Do not withhold treatments/ investigations in the pregnant patient, if they are in the best interests of the mother.
  • Remember the anatomical and physiological changes of pregnancy.
  • Check Rhesus status.
  • Continuous CTG for at least 6 hours post presentation for pregnancies ≥24 weeks gestation.[iv]

The best outcome for the foetus is dependent upon optimal management of the mother.

Here is a bedside tool developed by the American College of Emergency Physicians encompassing the key management guidelines for managing the pregnant trauma patient.[v]

Further References and Resources

[i] American Congress on Obstetricians and Gynaecologists - Guidelines for Diagnostic Imaging During Pregnancy and Lactation

[ii] Jeejeebhoy FM, Zelop CM, Windrim R, Carvalho JCA, Dorian P, Morrison LJ. Management of cardiac arrest in pregnancy: a systematic review. Resuscitation. 2011; 82(7):801-809.

[iii] Brown S, Mozurkewich E. Trauma during pregnancy. Obstetrics and Gynaecology Clinics of North America. 2013; 40(1):47.

[iv] Eastern Association for the Surgery of Trauma. Pregnant Patient, Diagnosis and Management of Injury. J. Trauma. 69 (1): 211-4, July 2010

Trauma in Pregnancy - Clinical Guideline from Queensland Health

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