Presentation and Clinical Features
- Trauma is a frequent event in pregnancy.
- Initial interventions are aimed at stabilization of mother according to advanced trauma life support protocols.
- After initial survey of the mechanism and extent of injury, establishment of fetal age and fetal heart monitoring is undertaken.
Types of Abdominal Trauma
1) Penetrating Trauma:
- It places the uterus at great risk during the later stages of pregnancy.
- Evaluation and treatment is similar to that in non-pregnant patient with the usual necessity of surgical exploration.
- Amniocentesis may be helpful to establish fetal lung maturity or to detect bacteria or blood.
2) Blunt Trauma:
- It is associated with variety of mechanisms including motor vehicle accidents.
- Intrauterine or retro-placental haemorrhage must be considered, because 20% of cardiac output in pregnancy is delivered to utero-placental unit.
- An Abruption of placenta 1-5% of minor and 40 to 50% of major blunt trauma.
- Focal uterine tenderness, vaginal bleeding, hypertonic contractions, and fetal compromise frequently occur. Disseminated intravascular coagulopathy may occurs in about one-third of abruptions.
- Management of abruptio-placenta depends upon fetal age and degree of placental separation and blood loss as estimated on ultrasound.
- At viability, continuous fetal heart monitoring done. The route of delivery is dictated by both fetal and maternal cardiovascular stability, with immediate C-section undertaken if there is evidence of severe compromise.
Special Consideration of Trauma in Pregnancy:
- Fetal uterine monitoring is a factor in determining fetal distress, abruptio-placenta and pre-term labor due to trauma. These measures are indicated for gestation more than 20 weeks.
- Ultrasound is effective in establishing gestational age, fetal viability, placental state and location.
- In positioning the pregnant patient, one should avoid placing her supine, to optimize venous return.During cardiopulmonary resuscitation, 10 to 20-degree wedge in lateral cubitus position if possible.
- Tetanus prophylaxis should be administered in the same manner and for same indication as for nonpregnant patient.
- Peritoneal lavage, usually by open technique can be used to detect intraperitoneal haemorrhage while avoiding the uterus, which is localized by examination and ultrasonography.
- Radiation in the form of diagnostic studies places the fetus at potential risk of spontaneous abortion, (first several weeks of pregnancy), teratogenesis (Weeks 3 to 12), and growth retardation (> 12 weeks gestation.
- X-Ray studies should be used judiciously but X-Rays that are deemed important for evaluation should not be omitted. Uterine shielding should be employed when possible.
- Peri- or postpartum c- section should be accomplished within 10 minutes of maternal cardiopulmonary arrest to optimize neonatal prognosis and maternal response to resuscitation.
- Isoimmunization must be considered in Rh-negative patient, when fetal maternal haemorrhage is suspected.
