Trauma in Pregnancy

Learning objectives

  • Describe the basic principles of trauma management in pregnancy.

  • Demonstrate how to triage trauma patients to guide management.

  • 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

  • Domestic violence

  • Motor vehicle crashes

  • Falls

  • Homicide

  • Suicide

Obstetrical Complications of Trauma

  • Preterm labor

  • Premature rupture of membranes

  • Uterine rupture

  • Spontaneous abortion

  • 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:

  • Unstable vital signs

  • Altered consciousness

  • Trauma involving the abdomen

  • Rapid compression, deceleration, or shearing forces

  • Trauma that results in vaginal bleeding, abdominal pain, and/or decreased fetal movements

  • Trauma that results in more than minor bruising, lacerations, or contusions

General Principles of Trauma Management in Pregnancy

  • Maintain a multidisciplinary approach and good communication among team members

  • Every healthcare facility should be prepared for initial evaluation, stabilization, and care of the pregnant patient

  • Transportation to the ideal trauma care center should be considered depending on risk–benefit ratio and the specific trauma circumstances

  • 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

  • Advanced trauma life support (ATLS) and advanced cardiac life support (ACLS) guidelines should be followed

  • 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

  • No diagnostic or therapeutic interventions should be withheld because of the concern for potential undesired fetal effects

  • Imaging

    • 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

    • 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

  • Hemorrhage control

    • 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

    • Cryoprecipitate and prothrombin complex concentrate may be necessary

    • Topical hemostatic agents are considered safe to use during pregnancy

    • Tranexamic acid use seems safe for the fetus but has an unclear effect on maternal mortality

  • Sepsis is a risk for admitted patient with major trauma, burns, and penetrating injuries

  • These fetal interventions can follow or be undertaken simultaneously with maternal stabilization:

    • Leftward uterine displacement

    • Volume replacement

    • Oxygen administration

    • Cesarean delivery

Trauma-Related Placental Abruption

Apr 6, 2024 | Posted by in OBSTETRICS | Comments Off on Trauma in Pregnancy

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