Trauma in Pregnancy

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Chapter 223 Trauma in Pregnancy

INTRODUCTION

Description: Trauma and violence are the leading causes of death for women of reproductive age and of maternal death from nonobstetric causes. The most common cause of fetal death in automobile accidents is death of the mother. The altered physiologic state of pregnancy and the need to treat two patients simultaneously alters the management of even simple trauma.
Prevalence: One of 12 pregnancies.
Predominant Age: Reproductive.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Motor vehicle accidents (most common; two thirds of cases in developed countries), falls, direct assault (battering most common; 60% report two or more episodes of physical assault during pregnancy).
Risk Factors: Failure to use a safety restraint while driving, abusive relationship, low socioeconomic status, drug or alcohol use and abuse.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Varies with type of trauma—blunt trauma, trauma associated with covert internal injuries such as retroperitoneal hemorrhage or splenic rupture with bowel injuries less common, penetrating, fetal injury (two thirds)
• Abruptio placenta (1% to 5% of minor trauma, 40% to 50% of major trauma)—vaginal bleeding, uterine tenderness, tetany, or contractions suggest abruption
• Uterine rupture (0.6%) as the result of substantial force to the abdomen
• Direct fetal injury rare in blunt trauma
• Because of increased blood volume during pregnancy, signs of blood loss may be delayed

DIAGNOSTIC APPROACH

Differential Diagnosis

Based on type of trauma and organs potentially involved.

Associated Conditions: Rh isoimmunization.

Workup and Evaluation

Laboratory: Based on normal management of trauma.
Imaging: As needed for the management of trauma (unchanged by the pregnancy, trauma takes precedence). Ultrasonography for gestational age assessment, placental location, intrauterine death, and others. (Not reliable for assessment of fetal injury.)
Special Tests: Peritoneal lavage under direct vision may be used to evaluate intraperitoneal hemorrhage. Kleihauer-Betke test for fetal–maternal hemorrhage.
Diagnostic Procedures: History, physical examination, imaging studies, and exploratory surgery when indicated.

Pathologic Findings

Based on the nature of the trauma.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Rapid assessment and stabilization (e.g., administration of fluids and oxygen, cardiac and fetal heart rate monitoring based on gestational age), assessment of status (blood pressure, oxygen saturation, urinary output). Tetanus prophylaxis should be provided as needed.
Specific Measures: The uterus should be displaced leftward, off the vena cava. All penetrating abdominal injuries must be explored surgically. The decision to deliver the fetus surgically must be based on gestational age, fetal and maternal injuries, and the risk of death of the fetus if left in utero. Prophylaxis for Rh isoimmunization should be given if fetal–maternal hemorrhage is likely.
Diet: Nothing by mouth until the patient has been fully evaluated.
Activity: Bed rest until the patient has been fully evaluated.
Patient Education: American College of Obstetricians and Gynecologists Patient Education Pamphlet AP018 (Car Safety for You and Your Baby), AP055 (Travel During Pregnancy), AP083 (Domestic Violence).

Drug(s) of Choice

Based on injuries sustained. D immunoglobulin 300 μg IM for each 30 mL of fetal blood thought to have been transfused to the mother (for Rh-incompatibility prophylaxis).
Precautions: Tocolytics should only be administered after abruption has been ruled out because medication side effects such as tachycardia may confuse the clinical picture. Vasopressors should be withheld until appropriate fluid resuscitation has been given.

FOLLOW-UP

Patient Monitoring: Aggressive monitoring as appropriate for the trauma sustained, fetal heart rate monitoring.
Prevention/Avoidance: The incidence and severity of injuries can be reduced by the appropriate use of automobile safety restraints. The greatest injuries are seen when a pregnant woman is not using safety restraints during an automobile accident; injury is not usually caused by the restraints. (Approximately 45% of pregnant women use safety restraints while driving.) Lap belts should be worn low over the hips, and shoulder restraints should rest comfortably between the breasts. The use of approved infant seats to transport the newborn home and for all subsequent travel must also be encouraged in the strongest terms.
Possible Complications: Based on injuries sustained.
Expected Outcome: Based on trauma sustained; maternal generally good, fetal mortality 50% to 75% for penetrating injuries involving the uterus.

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MISCELLANEOUS

ICD-9-CM Code: 760.5.

REFERENCES

Level II

Einarson A, Bailey B, Inocencion G, et al. Accidental electric shock in pregnancy: a prospective cohort study. Am J Obstet Gynecol. 1997;176:678.

Fildes J, Reed L, Jones N, et al. Trauma: the leading cause of maternal death. J Trauma. 1992;32:643.

Helton AS, McFarlane J, Anderson ET. Battered and pregnant: a prevalence study. Am J Public Health. 1987;77:1337.

Kissinger DP, Rozycki GS, Morris JAJr, et al. Trauma in pregnancy. Predicting pregnancy outcome. Arch Surg. 1991;126:1079.

Morris JAJr, Rosenbower TJ, Jurkovich GJ, et al. Infant survival after cesarean section for trauma. Ann Surg. 1996;223:481.

Pearlman MD, Tintinalli JE, Lorenz RP. A prospective controlled study of outcome after trauma during pregnancy. Am J Obstet Gynecol. 1990;162:1502.

Stewart DE, Cecutti A. Physical abuse in pregnancy. Can Med Assoc J. 1993;149:1257.

Level III

Agnoli FL, Deutchman ME. Trauma in pregnancy. J Fam Pract. 1993;37:588.

American College of Obstetricians and Gynecologists. Obstetric aspects of trauma management. ACOG Educational Bulletin 251. Washington, DC: ACOG, 1998.

American College of Obstetricians and Gynecologists. Air travel during pregnancy. ACOG Committee Opinion 264. Obstet Gynecol. 2001;98:1187.

American College of Obstetricians and Gynecologists. Exercise during pregnancy and the postpartum period. ACOG Committee Opinion 267. Obstet Gynecol. 2002;99:171.

American College of Obstetricians and Gynecologists. Guidelines for diagnostic imaging during pregnancy. ACOG Committee Opinion 299. Obstet Gynecol. 2004;104:647.

Archer T. The pregnant trauma patient. J Trauma. 2007;62:S110.

Coleman MT, Trianfo VA, Rund DA. Nonobstetric emergencies in pregnancy: trauma and surgical conditions. Am J Obstet Gynecol. 1997;177:497.

Edwards RK, Ripley DL, Davis JD, et al. Surgery in the pregnant patient. Curr Probl Surg. 2001;38:213.

Harrison SD, Nghiem HV, Shy K. Uterine rupture with fetal death following blunt trauma. AJR Am J Roentgenol. 1995;165:1452.

Hendey GW, Votey SR. Injuries in restrained motor vehicle accident victims. Ann Emerg Med. 1994;24:77.

Kettel LM, Branch DW, Scott JR. Occult placental abruption after maternal trauma. Obstet Gynecol. 1988;71:449.

Mattox KL, Goetzl L. Trauma in pregnancy. Crit Care Med. 2005;33:S385.

Nash P, Driscoll P. ABC of major trauma. Trauma in pregnancy. BMJ. 1990;301:974.

Pearlman MD, Tintinalli JE, Lorenz RP. Blunt trauma during pregnancy. N Engl J Med. 1990;323:1609.

Vaizey CJ, Jacobson MJ, Cross FW. Trauma in pregnancy. Br J Surg. 1994;81:1406.

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