Emergency Medicine Book

Traumatic Injury

  • Blunt Trauma in Pregnancy

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Blunt Trauma in Pregnancy

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  1. See Also
    1. Trauma Evaluation
  2. Causes
    1. Motor vehicle accident (42%)
    2. Falls (34%)
    3. Direct blunt abdominal trauma (18%)
    4. Physical abuse
  3. History
    1. See Trauma History
  4. Examination
    1. See Trauma Primary Survey
    2. See Trauma Secondary Survey
  5. Labs
    1. See Diagnostic Testing in Trauma
    2. Initial
      1. Complete Blood Count
      2. Blood Type and Rh Factor
    3. Additional studies in severe injury
      1. Coagulation Factors
      2. Chemistry panel
      3. Arterial Blood Gas
    4. Unnecessary tests
      1. Kleihauer-Betke test is not indicated
  6. Radiology
    1. Standard XRays
      1. Complete critical XRays as in non-pregnant patients
      2. Radiation exposure for plain film XRays is low
        1. Risk of fetal adverse effects low if rads <5
        2. Low risk if gestational age >15 weeks
    2. Obstetric Ultrasound
      1. Indications
        1. Distinguishes maternal and Fetal Heart Rates
        2. Confirms live fetus
        3. Identifies placental location
        4. Establishes gestational age
        5. Determines amniotic fluid index
      2. Misses most Placental Abruptions
        1. Tests sensitivity for abruption: 20-50%
  7. Specific risk areas for injury in pregnancy
    1. Abdominal injury risk increases
      1. Uterine injury (e.g. Placental Abruption)
        1. Placenta susceptible to shearing forces
          1. Rapid acceleration or deceleration
        2. Highest risk in third trimester
          1. Thin-walled uterus
          2. Decreased amniotic fluid
          3. Engaged fetal head inside pelvis
      2. Bladder injury
      3. Stomach often full due to delayed emptying
        1. Aspiration risk in trauma and surgery
    2. Pelvic Fractures associated with high morbidity
      1. Bladder injury
      2. Injury to urethra
      3. Retroperitoneal bleeding
      4. Fetal skull Fracture (42% mortality rate)
  8. High risk indicators for 24 hours intense monitoring
    1. Vaginal Bleeding
    2. Spontaneous Rupture of Membranes
    3. Fetal heart tone abnormality
    4. Uterine contractions for >4 hours
      1. Consider Placental Abruption (8/hour for 4 hours)
        1. Pearlman (1990) Am J Obstet Gynecol 162:1502
      2. Occasional contractions are common after trauma
        1. Usually <3-7 contractions per hour
        2. Contractions usually resolve within 4 hours
        3. Avoid Tocolytics (delays abruption diagnosis)
    5. Uterine tenderness
    6. Abdominal Pain
    7. High risk injury
      1. Pedestrian struck by motor vehicle
      2. High speed motor vehicle accident
  9. Management: Maternal Stabilization (Primary Survey)
    1. See ABC Management
    2. See Trauma Primary Survey
    3. Oxygen supplementation
    4. Intravenous fluids (lactated ringers or normal saline)
      1. Consider pRBC transfusion if significant blood loss
    5. Decrease uterine compression of great vessels
      1. Position patient in lateral decubitus position or
      2. Deflect uterus laterally
  10. Management: Maternal Secondary survey
    1. See Trauma Secondary Survey
    2. Treat non-obstetrical injuries as needed
    3. Administer RhoGAM if Rh negative
      1. Kleihauer-Betke test is not indicated
      2. Administer one full dose in all Rh negative patients
        1. Administer regardless of gestational age
        2. Administer in all but minor extremity trauma
  11. Management: Fetus
    1. Document Fetal Heart Tones
      1. No fetal Resuscitation if Fetal Heart Tones absent
        1. Morris (1996) Ann Surg 223:481
    2. Determine gestational age (as accurately as possible)
      1. Gestational age >20-24 weeks: See below
      2. Gestational age <20-24 weeks or EFW < 500 grams
        1. No Resuscitation of fetus
    3. Monitoring of >20-24 week gestation
      1. Consider Obstetric Ultrasound (see radiology above)
      2. Efficacy of monitoring
        1. Abnormal findings poorly predict fetal outcome
          1. Poor sensitivity and Specificity
        2. Normal: Reassuring for home discharge
          1. Negative Predictive Value: 100%
        3. References
          1. Shah (1998) J Trauma 45:83
      3. Protocol: Observe for signs of Placental Abruption
        1. Contraction indications for delivery
          1. Consider if 8 or more per hour for >4 hours
          2. Avoid Tocolytics after trauma
            1. May delay Placental Abruption diagnosis
        2. Fetal heart tone indications for delivery
          1. Fetal Bradycardia
          2. Late Decelerations
      4. High risk: 24 hours of monitoring
        1. See high risk indicators above
      5. Low risk: 4 hour electronic fetal monitoring
        1. Indications for discharge
        2. If negative, then see precautions below
  12. Disposition: Discharge
    1. RhoGAM in nearly all Rh Negative patients
      1. See maternal secondary survey above
    2. Indications for discharge
      1. Contraction resolution
      2. Fetal Heart Tones reassuring
      3. No signs of Rupture of Membranes
      4. No uterine tenderness
      5. No Vaginal Bleeding
    3. Indications to return to labor and delivery
      1. Vaginal Bleeding
      2. Decreased fetal movement
      3. Rupture of Membranes
      4. Persistent uterine contractions
      5. Abdominal Pain
  13. Prevention of injury in pregnancy
    1. See Seat Belt Use in Pregnancy
  14. References
    1. Murphy (2000) ALSO, F:1-20
    2. Baerga-Varela (2000) Mayo Clin Proc 75:1243
    3. Grossman (2004) Am Fam Physician 70:1303

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