Learning objectives
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Describe the basic principles of trauma management in pregnancy.
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Demonstrate how to triage trauma patients to guide management.
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List signs of trauma-related placental abruption.
Trauma in pregnancy is the main cause of maternal death due to nonobstetrical etiologies. Trauma-associated placental abruption is a major contributor to perinatal death.
Common Causes of Trauma in Pregnancy
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Domestic violence
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Motor vehicle crashes
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Falls
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Homicide
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Suicide
Obstetrical Complications of Trauma
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Preterm labor
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Premature rupture of membranes
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Uterine rupture
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Spontaneous abortion
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Intrauterine fetal demise
Defining Trauma Severity
The severity of trauma is directly related to maternal and fetal outcomes. However, because minor trauma is more common, 60%–70% of fetal losses are due to minor trauma.
Defining features of “major trauma” are as follows:
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Unstable vital signs
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Altered consciousness
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Trauma involving the abdomen
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Rapid compression, deceleration, or shearing forces
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Trauma that results in vaginal bleeding, abdominal pain, and/or decreased fetal movements
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Trauma that results in more than minor bruising, lacerations, or contusions
General Principles of Trauma Management in Pregnancy
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Maintain a multidisciplinary approach and good communication among team members
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Every healthcare facility should be prepared for initial evaluation, stabilization, and care of the pregnant patient
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Transportation to the ideal trauma care center should be considered depending on risk–benefit ratio and the specific trauma circumstances
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Maternal health is the primary goal in the management of trauma in pregnancy. Interventions for fetal benefit should be only carried out after stabilization of the mother
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Advanced trauma life support (ATLS) and advanced cardiac life support (ACLS) guidelines should be followed
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Perimortem cesarean delivery should be performed for any pregnancies greater than 20 weeks if maternal cardiac arrest lasts for greater than 4 minutes. Do not delay delivery because of operating room transportation, abdomen sterilization, or confirmation of fetal viability
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No diagnostic or therapeutic interventions should be withheld because of the concern for potential undesired fetal effects
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Imaging
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Computed tomography (CT) scan may be useful in the diagnosis of placental abruption and/or uterine rupture. Fig. 28.1 shows CT findings in a patient with complete uterine avulsion and fetal demise secondary to motor vehicle accident
Fig. 28.1 (A) Coronal CT reconstruction, demonstrating a fetus outside of the uterine cavity and a “discontinuous uterus” suggesting uterine rupture. (B) Transverse CT demonstrates a fetus outside of the uterine cavity and a “discontinuous skull” suggesting fetal cranial injury. (C) Laparotomy, confirming uterine avulsion; The uterus and the cervix are separated, as consequence of the trauma. The fetus was in the abdomen at delivery. - •
The typical CT scan radiation dose is not associated with adverse outcomes
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Focused assessment with sonography for trauma (F.A.S.T) is an efficient method for detection of intraabdominal free fluid and organ injuries; it consists in the assessment of free fluid in four areas: right and left upper quadrants, suprapubic, and subxiphoid areas
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Hemorrhage control
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Intracavitary hemorrhage may require activation of massive transfusion protocols. A suggested approach is a 1:1:1 replacement of fresh frozen plasma, platelets, and packed red blood cells
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Cryoprecipitate and prothrombin complex concentrate may be necessary
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Topical hemostatic agents are considered safe to use during pregnancy
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Tranexamic acid use seems safe for the fetus but has an unclear effect on maternal mortality
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Sepsis is a risk for admitted patient with major trauma, burns, and penetrating injuries
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These fetal interventions can follow or be undertaken simultaneously with maternal stabilization:
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Leftward uterine displacement
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Volume replacement
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Oxygen administration
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Cesarean delivery
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Trauma-Related Placental Abruption
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Abruption is a clinical diagnosis
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Trauma patients may develop “concealed” abruption without vaginal bleeding
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Cardiotocography has a high negative predictive value for placental abruption
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Continuous fetal monitoring allows timely identification of fetal distress that requires delivery (see Fig. 28.2 )
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