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On successfully completing this topic, you will be able to:
assess the patient who has sustained abdominal trauma, and recognise the possibility of injury
appreciate the changes in anatomy and physiology that occur in pregnancy, and of how such changes may alter the response to trauma
appreciate the diagnostic procedures available for the investigation of abdominal trauma, and the indications for their use
understand the need for timely resuscitation and treatment, including surgical intervention.
Introduction
Abdominal injuries are a recurring cause of preventable deaths associated with major trauma in the pregnant and nonpregnant woman alike. Abdominal injuries in pregnancy are on the increase, from both accidental and nonaccidental causes. The prompt and accurate assessment of the presence of intra-abdominal injury, and its likely site, can be challenging and the existence of a gravid uterus makes the task more complex.
Obstetricians should become involved early in the management of victims of trauma when pregnancy is obvious or suspected. They need to be familiar with the patterns of abdominal injury in the pregnant and nonpregnant patient, and their degree of priority. They need to be aware, also, of the effects of pregnancy on the response to blood loss, affecting both mother and fetus. The mother, especially in later pregnancy, tolerates blood loss well; the fetus tolerates maternal blood loss very badly and reflects maternal hypovolaemia by demonstrating fetal distress on monitoring.
Specific challenges posed by pregnancy in assessment of the abdomen:
The latest CMACE report (Saving Mothers’ Lives, March 2011) records that between 2006 and 2008, 15 women died from road traffic accidents while still pregnant, and two died within 6 weeks of delivery.1 Of the 15 pregnant women, two were pedestrians hit by motor vehicles. A perimortem caesarean section was carried out for four women in the Emergency Department. The gestations ranged from 24 to 41 weeks, and none of the babies survived.
Injuries may be blunt or penetrating. The vast majority in the UK are of blunt origin, mainly associated with motor vehicle accidents. Deceleration injuries predispose to blunt trauma, with the resulting risk of damage to viscera, including the uterus and its contents. The incidence of violent injuries is increasing, most notably domestic violence (see Chapter 14).
You must be able to identify those patients who require immediate or emergency intervention, either obstetric or surgical. A high index of suspicion is required, and early consultation with other specialties is crucial. Up to 50% of young patients with significant intra-abdominal haemorrhage will have minimal or no signs on initial assessment. Unrecognised or underestimated abdominal injury is still a cause of preventable death.
Trauma to the uterus
In the first trimester, the uterus is protected from injury by its relatively thick wall, as well as by the bony pelvis. Subsequently, it is the uterus that provides some protection to the abdominal contents, and thereby becomes increasingly vulnerable.
Abruption
As pregnancy progresses, the uterine wall becomes thinner. The uterus is elastic but the placenta is not, leading to the risk of trauma-induced abruption as the placenta shears off the uterine wall. What may seem fairly trivial trauma to the uterus may cause significant placental abruption, leading to fetal death, and also possibly leading to disseminated intravascular coagulation in the mother.
Uterine rupture
The possibility of uterine rupture should always be considered. This may be caused in a road traffic accident by blunt trauma from striking the dashboard or steering wheel, or by pressure from an injudiciously placed seat belt. The 2006–08 CMACE report restates its recommendations for the use of seat belts in pregnancy: ‘Above and below the bump – not over it.’ Three-point seat belts should be worn throughout pregnancy, with the lap strap placed as low as possible beneath the ‘bump’, lying across the thighs, with the diagonal shoulder strap above the bump, lying between the breasts. The seat belt should be adjusted to fit as snugly as comfortably possible and, if necessary, the seat should be adjusted to enable the seat belt to be worn properly. Lap belts alone are unsuitable in pregnancy.
Signs of uterine rupture include abdominal tenderness with guarding and rigidity associated with signs of hypovolaemia. The fetal lie may be transverse or oblique, with easily palpable fetal parts and inaudible fetal heart sounds. Management of suspected uterine rupture is operative exploration.
Penetrating injury
Penetrating injury, causing uterine rupture and fetal trauma, may be sustained by knife wounds, gunshot wounds or high-velocity fragments due to a blast. Other abdominal viscera, including bladder, bowel, liver and spleen, are likely to be involved in such circumstances.
Amniotic fluid embolus
Amniotic fluid embolus may occur as a result of uterine trauma. This is particularly important to recognise, in view of its high associated mortality from respiratory compromise as well as from disseminated intravascular coagulation (see Chapter 10).
Consideration of uterine rupture, amniotic fluid embolus and placental abruption may not necessarily occur to members of the trauma team without prompting from an obstetrician.
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