Trauma in Pregnancy

• Trauma in a pregnant patient should follow the trauma algorithm that is always used. Transfusion, imaging and diagnostic work up should not be changed. Treat the mother first.
• Vaginal, cervical, and rectal examinations should be included in the secondary survey.
• Hemorrhage can be provoked during a digital examination on a patient with placenta previa. A speculum exam is safe to perform.
• Venous return is compromised by fetuses greater than 20 weeks gestational as they compress the IVC. Displaced the uterus by placing the patient in a left lateral position (15-30 degrees)
• Vitals – Signs of active bleeding and hypotension may be delayed due to the increase in blood volume in pregnancy. The pCO2 falls to 30mmHg in the second trimester due to hyperpnea. The diaphragm is elevated. A pCO2 of 40mmHg in late pregnancy is pending badness. Pregnant patients have little pulmonary reserve.
• The FAST should include imaging the uterus for FHR (120-160), movement, dating (fundal height is a good option), looking for blood with in the uterus although many abruption bleeds will not be visualized.
• Additional workup for evidence of fetomaternal hemorrhage, preterm labor, abruption, and ruptured membranes must be included.
• Monitoring of the fetus – A non reassuring fetal tracing may not be apparent until approximately 30% of the placenta is affected. Fetal demise occurs with abruption of approximately 50%.  4 to 6 hours of initial continuous monitoring is needed and 80% of abruption occur in this time. If contractions, vaginal bleeding or an abnormal tracing is present after 4 hours then 24 hours of monitoring is needed.
• All pregnant trauma patient should receive O2, a decrease in pO2 leads to constriction of the uterine arteries.
• The intrauterine cavity can accommodate the patients entire blood volume.
• Abruption can lead to disseminated intravascular coagulation and amniotic fluid embolism.
• There is no evidence that the fetus is harmed by defibrillation.
• Avoid lower extremity lines as administered meds and fluids may be impeded by compression of the IVC.
• Don’t forget the RhoGAM.
• Consider a perimortem C-section (earlier the better and defiantly less than 4 minutes)

Rosen’s 7th ed., ch 34

Oxford CM, Ludmir J. Trauma in pregnancy. Clin Obstet Gynecol. 2009 Dec;52(4):611-29.