Excellent maternal resuscitation is the best treatment for the fetus
While fetal radiation exposure is an important consideration – this needs to be balanced with investigations which are in the best interests of the mother
Even seemingly minor mechanisms (eg: fall from standing, low speed RTC) can cause placental abruption and significant blood loss
The altered anatomy and physiology in pregnancy can conceal clues to potentially life-threatening injuries
Early involvement of the gynaecology/obstetric and neonatology teams is essential especially if potentially viable or suspicion of complication.
Consult local policy regarding the gestational cut-off for gynae vs obstetric review, usually around 20/40 gestational age, which can be estimated by a fundal height above the umbilicus (below umbilicus likely <20/40), or by using or USS to measure the fetal head biparietal diameter, >6cm is likely to be viable
Any history of post traumatic PV bleeding or amniotic fluid loss, abdominal pain/contractions
Anti-D must be administered to rhesus negative pregnant trauma patients (even with minor trauma). Kleihauer test allows dose titration.
Domestic violence is an important cause of trauma in pregnancy
Important additional features on history
Mechanism of injury
If in RTC, type of restraint and where placed in relation to uterus
Lap belts worn over high the uterus increases the risk of placental abruption
Consider domestic violence as a cause of the injuries
Initial treatment considerations
Due to a decreased respiratory reserve, hypoxia can develop more rapidly. Place supplemental oxygen early
Intubation can be more challenging due to rapid desaturation, airway oedema, breast enlargement, and increased gastric pressures leading to aspiration risk
In later pregnancy, the diaphragm will be elevated due to uterine displacement. Therefore, if an intercostal catheter is to be placed, it should be done in the 3rd or 4th intercostal space.
Left lateral uterine displacement is an essential element in the resuscitation of the pregnant woman (>20/40) by relieving pressure off the aorto-caval vessels. This can be achieved by
Manual displacement by an assistant
30 degree wedge under patient’s right side (tilt patient to left)
Pregnancy is a relatively hypervolaemic state, so significant blood loss can occur before usual clinical signs (hypotension, tachycardia) are apparent
However: note that a mild tachycardia and a lower BP are normal vital signs, especially in later pregnancy (as well as a dilutional anaemia)
Placental abruption can occur even with minor injury and can result in significant blood loss (>2-4 litres) and fetal demise. It is usually heralded by abdominal pain, uterine firmness and PV bleeding but can be asymptomatic. Uterine rupture is usually caused by higher force mechanisms and can also result in major haemorrhage.
If cardiac arrest occurs, early consideration of a resuscitative caesarean section is essential if the gestation is >20/40 (note that even if the fetus not viable, relief of aortocaval pressure can result in improved maternal circulation). Ideally this should be performed within 5 minutes after the onset of cardiac arrest.
standard trauma blood tests
if rhesus negative, perform a Kleihauer test in order to ascertain the amount of anti-D to administer
if >26 weeks, CTG monitoring should be performed for at least 4 hours even if the trauma is seemingly minor in order to detect placental abruption (as well as the onset of labour)
24-26/40 CTG can be difficult to interpret so prolonged fetal heart beat auscultation is recommended, involve midwifery
major trauma patients with significant injuries should have all imaging performed as indicated , including CT. CT is the most sensitive imaging for placental abruption. Even with multi-regional CT the radiation dose is below that at which observable fetal effects have been recorded.
in patients that are less severely injured, other imaging modalities may be appropriate in the first instance eg: MRI, USS, plain xrays
decisions should be made in conjunction with surgery and radiology
fetal shielding should be used where appropriate eg: for CXR, and decreased radiation doses utilised if possible
The sensitivity of a FAST scan is similar to non-pregnant patients, though there may be higher rate of false positives due to misinterpretation of amniotic fluid as free fluid.