With trauma and pregnancy, the trauma has two patients to manage—the mother and the unborn fetus. The various things done in dealing with a pregnant trauma patient depends on where she is in the pregnancy, the viability of the fetus and the nature of the injuries.
Overview of Trauma and Pregnancy
Trauma in pregnancy can be caused by accidents and violent acts. Trauma is involved in 5-20 percent of pregnancies. Trauma is the number one cause of death in pregnant women—above pregnancy complications. In one study, trauma caused maternal death in 46 percent of cases, compared to obstetrical issues causing maternal death in 31 percent of cases. A total of 57 percent of deaths were due to homicide, while 9 percent were due to suicide. The percent of maternal deaths were spread out as follows:
• Gunshot injuries—23 percent
• Automobile accidents—21 percent
• Stabbings—14 percent
• Strangulating injuries—14 percent
• Blunt head trauma—9 percent
• Burn injuries—7 percent
• Falls from a height—7 percent
• Toxic exposure—4 percent
• Drowning injuries—2 percent
• Doctor-caused injuries—2 percent
In another study out of the New York Medical Examiner records showed that the following:
• Homicide—63 percent
• Suicide—13 percent
• Motor vehicle accidents—12 percent
• Overdoses—7 percent
A total of 48 percent of the injuries were related to substance abuse.
The first step is to recognize that the patient is pregnant. If the doctor does not recognize the pregnancy, there may be misdiagnosis because the doctor is unaware of the normal physiological adaptation to the pregnant state. Obstetrical states can also confuse or delay the diagnosis of intra-abdominal injury. It is important to know that there are two patients present and to weight the health of the fetus against the mother’s need to have surgery. It is difficult to know the possible risk of fetal injury in the operating room and to balance that with the fetal damage that has already occurred at the time of the trauma. The risk of surgery is greatest in the first and third trimesters.
Blunt Trauma in Pregnancy
Motor vehicle accidents are a common cause of injury due to blunt trauma in pregnancy. A study of 441 women involved in a car accident looked at the severity of the accident and the complications. Minor damage to the vehicle resulted in 3 out of 233 victims had any injury and none had an abruption. When the damage to the motor vehicle was severe, 15 of the 208 women died and 25 of the 193 had significant injury. Fetal death occurred after 12 weeks gestation in 8 percent of cases following severe accidents. First trimester loss could not be explained by an accident. About 3.4 percent of women had placental abruption after a severe accident.
Wearing a three point restraint seat belt actually saved prenatal mortality. The rate of delivery within 48 hours was 2.3 times greater among the unrestrained mothers when compared to restrained mothers.
The pregnant women who has undergone trauma should be observed in a hospital to manage the pregnancy-related and trauma-related injuries. The woman should be transported on her left side and a careful history of the incident should be obtained as well as the degree of obvious injuries.
An IV should be placed and a central venous pressure line (only if severe injury is suspected). Transfusions should be given if there is ongoing blood loss. The doctor should get a complete blood count, electrolytes, urinalysis and a type and cross-match. Intubation should be done on anyone who is unconscious or who has respiratory distress. A Foley and a nasogastric tube should be placed. If the woman is at 24 weeks or more, she should have an external fetal monitor placed. If there are fetal accelerations, this is a positive sign.
Monitor the vital signs on a regular basis. Shock can develop quickly so you need to have an attendant around the patient at all times. The patient should have radiologic studies along with ultrasonography of the fetus and uterus. One should not avoid necessary x-rays just because the patient is pregnant. The sonogram should be able to tell fetal age and the position of the placenta. If there is a partial abruption, this can be seen on the sonogram.
The sonogram can determine the fetal heart rate, along with the fetal monitor. A low fetal heart rate of less than 120 can mean maternal hypoxia, maternal hypovolemia, abruptio placentae, or a rupture of the uterus.
If the pregnancy is greater than 25 weeks, one should consider going to cesarean section for fetal distress if the mother is hemodynamically stable. Fetal monitoring should continue for 24 hours after a major trauma because evidence for fetal distress can show up as long as 24 hours post injury. In minor trauma patients, fetal monitoring can last for just 8 hours as long as there are fewer than 6 contractions per hour.
If intra-abdominal trauma is suspected, there should be a diagnostic peritoneal lavage to assess for bleeding in the abdomen. About a liter of Lactated ringers solution (warmed) should be introduced and about 750 ml should be returned. A positive finding is 100,000 rbcs per cc, the presence of gastrointestinal contents, an amylase level of greater than 175 gm/dL or a leukocyte count of more than 175 cells per cc. The false negative and positive rate is about 5 percent. If the test is negative, there is no need to do a laparotomy as long as there are the presence of bowel sounds and a soft, nontender abdomen.
If there is free air under the abdomen, a positive gastric lavage and abdominal distension that is getting worse along with a falling hct, an exploratory laparotomy needs to be done. Maternal-fetal exchange of blood occurs about 28 percent of the time so a dose of Rhogam is necessary for women who are Rh negative. A large fetal hemorrhage can result in fetal asphyxia, fetal anemia and the possibility of fetal death. An in utero fetal transfusion can be used if the fetus is not mature—between 20-26 weeks’ gestation.
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