Chapter 223 Trauma in Pregnancy
INTRODUCTION
Description: Trauma and violence are the leading causes of death for women of reproductive age and of maternal death from nonobstetric causes. The most common cause of fetal death in automobile accidents is death of the mother. The altered physiologic state of pregnancy and the need to treat two patients simultaneously alters the management of even simple trauma.
ETIOLOGY AND PATHOGENESIS
Causes: Motor vehicle accidents (most common; two thirds of cases in developed countries), falls, direct assault (battering most common; 60% report two or more episodes of physical assault during pregnancy).
CLINICAL CHARACTERISTICS
Signs and Symptoms
• Varies with type of trauma—blunt trauma, trauma associated with covert internal injuries such as retroperitoneal hemorrhage or splenic rupture with bowel injuries less common, penetrating, fetal injury (two thirds)
• Abruptio placenta (1% to 5% of minor trauma, 40% to 50% of major trauma)—vaginal bleeding, uterine tenderness, tetany, or contractions suggest abruption
DIAGNOSTIC APPROACH
Workup and Evaluation
Imaging: As needed for the management of trauma (unchanged by the pregnancy, trauma takes precedence). Ultrasonography for gestational age assessment, placental location, intrauterine death, and others. (Not reliable for assessment of fetal injury.)
Special Tests: Peritoneal lavage under direct vision may be used to evaluate intraperitoneal hemorrhage. Kleihauer-Betke test for fetal–maternal hemorrhage.
