Practice Management Guidelines for the Diagnosis and Management of Injury in the Pregnant Patient: The EAST Practice Management Guidelines Work Group

Abstract

Trauma during pregnancy has presented very unique challenges over the centuries. From the first report of Ambrose Pare of a gunshot wound to the uterus in the 1600s to the present, there have existed controversies and inconsistencies in diagnosis, management, prognostics, and outcome. Anxiety is heightened by the addition of another, smaller patient. Trauma affects 7% of all pregnancies and requires admission in 4 of 1000 pregnancies. The incidence increases with advancing gestational age. Just over half of trauma during pregnancy occurs in the third trimester. Motor vehicle crashes comprise 50% of these traumas, and falls and assaults account for 22% each. These data were considered to be underestimates because many injured pregnant patients are not seen at trauma centers. Trauma during pregnancy is the leading cause of nonobstetric death and has an overall 6% to 7% maternal mortality. Fetal mortality has been quoted as high as 61% in major trauma and 80% if maternal shock is present. The anatomy and physiology of pregnancy make diagnosis and treatment difficult.

Pregnancy and trauma: analysis of 139 cases

“…However, trauma management in the gravida has been a continuous problem for centuries (2). Trauma is reported to be seen in 3-7% of all pregnancies and 0.4% of these are reported to need hospitalization (2, 3).…”

“…Level 2 studies indicate that fetal heart monitorization should be carried out for at least 6 hours in a pregnant woman with a gestational age of over 20 weeks. Monitorization should be continued in cases of uterine contractions, vaginal bleeding, abnormal fetal heart rate pattern, uterine tenderness, severe maternal injury and rupture of amniotic membranes (2). Level 3 studies indicate that the fetus should be evaluated in the early period and optimum resuscitation of the mother according to advanced trauma life support should be obtained (2).…”

“…Monitorization should be continued in cases of uterine contractions, vaginal bleeding, abnormal fetal heart rate pattern, uterine tenderness, severe maternal injury and rupture of amniotic membranes (2). Level 3 studies indicate that the fetus should be evaluated in the early period and optimum resuscitation of the mother according to advanced trauma life support should be obtained (2). Oxygenation should certainly be provided due to the harmful effects of hypoxemia on the fetus, even when there is no need for maternal intubation (6).…”

“…Although fetal mortality and morbidity increase in parallel with the severity of maternal injury, sometimes severe fetal injury may occur even with mild traumas, and trauma may lead to intrauterine fetal demise, abortions, preterm deliveryor ablatio placentae (1)(2)(3)(4). The approach to pregnant trauma patients is still a problem for health care providers due to the physiologic and anatomic changes in pregnancy, drugs that are considered to negatively affect the fetus and anxiety about radiologic tests (4,5).…”

Trauma in pregnancy – A brief review

“…Mostly foetomaternal haemmorage is contained to less than 30 ml of blood. Additional dosing may then be supplemented by Kleihauer-Betke test [42]. Rh antigen develops by 6 th week gestation age [43].…”