Pocket ObGyn – Trauma in Pregnancy

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Pocket ObGyn – Trauma in Pregnancy
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Epidemiology (Int J Gynaecol Obstet 1999;64:87; Obstet Gynecol 2009;114:147)

  • Leading cause of nonobstetric mat death during Complicates 3–8% of pregnancies; 2/3 from motor vehicle collisions.
  • Up to 20% of pregnant women are victims of Preg alone is an independent risk factor for DV (Am J Obstet Gynecol 1991;164:1491).
  • Outcomes directly related to GA & severity/mech of injury
  • 40–50% fetal loss rate w/ life-threatening mat trauma (eg, mat shock, head injury leading to coma, emergency laparotomy for mat indications) (Obstet Gynecol Clin North Am 1991;18:371).
  • 1–5% fetal loss w/ nonlife-threatening injuries, but b/c more common, >50% of fetal losses occur w/ minor trauma
  • Blunt trauma: Placental abruption (40% sev cases, 3% nonsevere cases), direct fetal injury (<1%), uterine rupture (<1%), mat shock, mat death
  • Penetrating trauma: Gunshot wounds or stab wounds; fetal prog generally worse than mat prog
  • Pelvic fractures: Fetal mortality rate 35%; may result in signif retroperitoneal Not an absolute contraindication for vaginal delivery.

Clinical Manifestations & Physical Exam (Obstet Gynecol 2009;114:147)

  • Placental abruption: Vaginal bleeding, uterine tenderness, abdominal pain, back pain, fetal distress, high-frequency uterine contractions, uterine hypertonus, decreased fetal movement, or even fetal
  • Primary survey: Note that pregnant women can lose a signif amt of bld before tachy & HoTN occur due to their increased intravascular
  • Abd: Ecchymoses (new & old), seat belt injury, penetrating abdominal injuries, palpate for contractions or tenderness
  • Speculum: Bleeding, rupture of membranes, vaginal lacerations, pelvic bone fragments

Diagnostic Workup/Studies (Obstet Gynecol 2009;114:147)

  • US: Fetal cardiac activity, fetal GA & presentation, free peritoneal fluid or mat Consider FAST to assess for free fluid in perihepatic, perisplenic, pelvic, & pericardial areas.
  • Radiologic eval: Should not be deferred if req for mat assessment

Initial Management (ACOG 1998)

  • Mat: Supplemental O2; 2 large bore IVs; early IV fluid resusc in ratio 3:1 based on bldloss; left lateral uterine displacement after 20 w (if spinal injury suspected, manual displacement or a wedge under a backboard ok); labs – CBC, type & screen, coags, & hold Kleihauer–Betke & RhoGAM for Rh-negative moms.
  • Once mother stabilized, proceed w/ fetal assessment:

GA <24 w0d: Document FHR by Doppler or real time US; tocometer if high con- cern for abruption by Hx or physical exam

GA >24 w0d: 4–6 h continuous fetal monitoring (includes FHR & tocodynamome- try). If >6 contractions in an hour or sev injury ® prolonged monitoring for 24 h. Nonreactive NST ® further eval (BPP or prolonged fetal monitoring).

  • In setting of mat cardiopulmonary arrest, delivery by C/S if >4 min has Improves mat resusc by decreasing uterine compression of venous return.

 

<24 h since trauma
>24 h since trauma
Peritoneal lavage, ± Exploratory laparotomy Trauma surgery, neonatology,

pediatric surgery notified/available

Figure 2.1 Management of trauma in pregnancy

 

 

 

 

 

 

 

 

From ACOG PB#252; Am J Obstet Gynecol 1990;162:1502; Am J Obstet Gynecol 2004;190:1661; Am J Obstet Gynecol

2004;190:1461; UNC SOM OB Algorithms 2004; ATLS Course Manual 2008.

See Abbreviations

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