Trauma in Pregnancy
Jason Vaught
GENERAL PRINCIPLES
Definition
Traumatic injury refers to physical injuries of varying severity; all trauma should be immediately addressed because severity can increase if not addressed.
Traumatic injury resulting in systemic shock often requires immediate and aggressive resuscitative and operative measures to preserve both life and limb (1).
Traumatic injury in pregnancy affects both maternal and fetal well-being and is thought to occur in approximately 1 in 12 pregnancies, with the most common causes being motor vehicular accidents and interpartner violence (2).
Although there are two patients in the parturient trauma patient, maternal resuscitation and safety takes priority.
A multidisciplinary team approach with emergency medicine, trauma surgery, anesthesiology, and interventional radiology should be employed.
There are specific aspects to pregnancy-related trauma, which include the following:
Mitigation of exposure and radiation
Management of pregnancy-related aspects of trauma—rhesus isoimmunization, preterm labor, and placental abruption
Physical Examination
The physical examination is probably the most important aspect of the traumatic physical examination, and it begins in the hospital phase.
Obstetric providers should gain information if possible for incoming trauma, which includes the type of environmental injury that occurred, gestation of pregnancy, and patient compensation if any at all (1).
Primary Survey (Figure 3.8.1)
The primary survey is the initial portion of in-hospital physical examination, and it encompasses the ABCDEs of trauma care. The assessment is as follows:
Airway maintenance with restriction of cervical spine
Breathing and ventilation
Circulation with hemorrhage control
Disability (neurologic status)
Exposure and environment (1)
During the primary survey, life-threatening conditions are identified and treated on priority.
Figure 3.8.1. Trauma survey. (Adapted from American College of Surgeons. ATLS Student Course Manual: Advanced Trauma Life Support. 9th ed. American College of Surgeons; 2012.)
Irrespective of other injuries, the establishment of a protected airway is a priority, and a definitive airway should be instituted if indicated.
Definitive airway management should be instituted for the following:
Traumatic Brain Injury with Glasgow Coma Score (Table 3.8.1) <8
Airway obstruction (secretions, blood, and gastrointestinal [GI] contents)
Hypoxemia not resolved with supplemental oxygen
Airway injury
Our doubt if the patient is unable to maintain airway throughout initial assessment
While assessing airway, the practitioner should also examine, protect, and prevent further injury to the patient’s cervical spine.
After airway maintenance or definitive airway placement has been established, breathing and ventilation are assessed.
In this assessment, there is assessment for paradoxical breathing (flail chest), subcutaneous air (pneumothorax), or diminished breath sounds (mucus plugging, hemothorax).
Often plain radiography is employed to aid in assessment.
Circulation is then assessed, and obvious hemorrhage is treated expeditiously, as hemorrhage is the predominant cause of preventable death after injury (1). Pulse, level of consciousness, and skin perfusion are quick markers of circulation in the trauma patient.
Other clinical markers of circulation and perfusion are urine output and blood pressure.
Large-bore vascular access should be established, and typically this is initially achieved with two peripheral intravenous catheters, and blood studies are obtained.
Usually, these studies include but are not limited to a complete blood count, complete metabolic panel, coagulation panel, lactate, and blood gas.
When peripheral sites are not able to be accessed, central access and/or intraosseous infusion may be performed.
Warm isotonic fluids are usually initially given, followed soon after by blood products if indicated.
For patients in shock from hemorrhage, institutional massive transfusion protocols (MTP) should be administered.
Permissive hypotension (SBP 80-90) or intentional hypotension to reduce ongoing bleeding in severe trauma can also be utilized.
However, MTP and permissive hypotension is a bridge to definitive surgical management.
Disability is the assessment of a rapid neurologic evaluation to establish a level of consciousness.
Usually, this is done with the use of the Glasgow Coma Score (Table 3.8.1).
Exposure also occurs during the primary survey. This requires the patient to be completely disrobed.
During this assessment, clinicians assess for hypothermia and prevent further hypothermia with temperature control in the room and with intravenous fluids.
The primary survey has adjuncts to the physical examination assessment; this includes the following:
Electrocardiographic monitoring
Pulse oximetry
Urinary and gastric catheters
Table 3.8.1 Glasgow Coma Score
1
2
3
4
5
6
Eye opening
None
To pain
To sound
Spontaneous
–
–
Verbal response
None
Incomprehensible
Inappropriate
Confused
Oriented
–
Motor response
None
Extending
Abnormal flexing
Flexing
Localizing
Obeying
Plain film x-ray studies
FAST and eFAST (Table 3.8.2) examination
Secondary Survey (Figure 3.8.1)
The secondary survey is a more detailed and in-depth evaluation of the trauma patient, and it does not begin until the primary survey is complete.
The primary survey is completed when there is improvement and vital signs and hemodynamic stability in the patient.
The secondary survey is a head-to-toe evaluation with a complete history and physical examination. Often, the obstetric evaluation is done during this portion of the trauma evaluation. The practitioners evaluate for the following:
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