Trauma during pregnancy

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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:

 

  1. 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.
  2. Ultrasound is effective in establishing gestational age, fetal viability, placental state and location.
  3. 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.
  4. Tetanus prophylaxis should be administered in the same manner and for same indication as for nonpregnant patient.
  5. Peritoneal lavage, usually by open technique can be used to detect intraperitoneal haemorrhage while avoiding the uterus, which is localized by examination and ultrasonography.
  6. 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.
  7. 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.
  8. Peri- or postpartum c- section should be accomplished within 10 minutes of maternal cardiopulmonary arrest to optimize neonatal prognosis and maternal response to resuscitation.
  9. Isoimmunization must be considered in Rh-negative patient, when fetal maternal haemorrhage is suspected.