Updated: 5/12/2020

Trauma during Pregnancy

Review Topic
  • Snapshot
    • A 25-year-old G1P0 woman at 36 weeks of gestation presents to the emergency department after a motor vehicle crash. She was wearing her seatbelt when another vehicle crashed into her car's rear-end. The airbag did not deploy, but the patient denies any pain or discomfort. Her blood pressure is 110/80 mmHg, pulse is 115/min, respirations are 24/min, and SaO2 is 96% on RA. Fetal monitoring reveals contractions every 10 minutes the pulse is 165/min. One hour later, the nurse notices that the patient's bedsheet is soaked with blood. Transabdominal and transvaginal ultrasound reveal placenta previa. One liter of normal saline is infused through a large-bore IV, a type and cross sample is obtained, and RhoGAM is prepared as the patient is rushed to the OR for emergent delivery.
  • Introduction
    • Overview
      • trauma during pregnancy is the leading non-obstetric cause of mortality among pregnant women
        • most common causes
          • motor vehicle crash
          • intimate partner violence
          • assaults
          • falls
  • Epidemiology
    • Incidence
      • 1 in 12 pregnant women
    • Risk factors
      • incorrect seat belt use
      • intimate partner violence
    • Pathophysiology
      • traumatic injuries are either unintentional or intentional and classified as either minor or major trauma
        • minor trauma does not involve the abdomen and the patient does not report pain, vaginal bleeding, loss of fluid, or decreased fetal movement
          • 90% of traumatic injuries during pregnancy are minor injuries
      • pregnancy alters maternal physiology and anatomy
        • near term, IVC compression in supine position can decrease cardiac output by 30-40%
        • systolic blood pressure drops 5-15 mmHg in 2nd trimester, increases to normal by term
        • maternal pulse increases 15-20/min by 3rd trimester
        • physiologic macrocytic anemia is present (Hb 10-12 g/dL)
        • leukocyte count increases to high of 20,000/uL
        • blood volume increases in pregnancy up to 50%
          • pregnant woman may lose 35% blood volume without typical signs of shock
  • Presentation
    • Symptoms
      • variable depending on the type of injury
    • Physical exam
      • variable depending on the type of injury
      • fetal heart rate changes may suggest a decrease in uteroplacental circulation from blood loss
  • Imaging
    • Ultrasound
      • indications
        • assess for placental abruption
  • Studies
    • Kleihauer-Betke test
      • indications
        • identification of fetal blood cells to screen for the degree of fetomaternal hemorrhage
          • measures the amount of fetal hemoglobin transferred from a fetus to a mother's bloodstream
        • can inform Rh Ig therapy in Rh-negative patients to prevent Rh disease in future pregnancies
  • Treatment
    • Medical
      • primary survey with resuscitation
        • focus of primary survey is on mother not fetus
        • every female of reproductive age with significant injuries should be considered pregnant in the emergency setting until proven otherwise
        • airway
          • if Glasgow Coma Scale score < 10, consider nasogastric tube to prevent aspiration of acidic gastric content
        • breathing
          • if thoracostomy necessary, tube should be inserted 1 or 2 intercostal spaces higher than usual
        • circulation
          • use left lateral decubitus positioning or hip bolster to alleviate compression of inferior vena cava and increase blood return if blood pressure is low
          • obtain PT/INR, PTT, D-dimer, and fibrinogen
          • consider RhoGAM and O-negative blood until crossmatched blood becomes available
          • if patient enters cardiac arrest, cesarean section should be performed for viable pregnancies (> 23 weeks) as soon as possible to facilitate maternal resuscitation and fetal salvage
      • fetal evaluation
        • obtain obstetric consultation
        • if fetus is > 23 weeks and mother is stabilized, start fetal monitoring
        • evaluate for uterine contractions, placental abruption, or traumatic uterine rupture
        • if vaginal bleeding is present, do NOT perform speculum or digital vaginal exam
          • obtain ultrasound to evaluate for placenta previa
      • secondary survey
        • obtain thorough medication and substance use history, as well as obstetric history
        • radiographic studies needed for maternal evaluation including CT scan should NOT be deferred or delayed due to fetal exposure concerns
        • for penetrating trauma, tetanus vaccination is safe in pregnancy
        • every female trauma patient should be questioned specifically for intimate partner violence
          • asking about abuse is the strongest predictor of disclosure
          • HITS screening tool: How often does your partner...
            • physically Hurt you?
            • Insult you?
            • Threaten you with harm?
            • Scream or curse at you?
          • involve a social worker
          • reassure that the patient is not to blame and that assault is a crime
          • document all evidence of abuse for medicolegal purposes
  • Complications
    • Placental abruption
      • may occur when acceleration-deceleration forces shear the placenta from its implantation site
      • most common cause of fetal death when the mother survives the trauma
      • incidence
        • 35-65% of major injuries
        • 2-4% of minor injuries
    • Exsanguination
      • rupture of the uterus or severe damage to the uterine vessels may cause rapid exsanguination due to significant increases in uterine blood flow
        • uterine rupture complications 0.6% of traumatic injuries in pregnancy
    • Retroperitoneal hemorrhage
      • may be a sequela of pelvic fracture
    • Rupture of amniotic membranes
      • may lead to chorioamnionitis, preterm labor, and umbilical cord prolapse
  • Prognosis
    • 60-70% of fetal losses after trauma are a result of minor traumatic injuries
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