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CME

Trauma in Pregnancy - Emergency Management

General Information

General_InformationGeneral Information

Background

  • Traumatic injury in a pregnant patient
  • Considered as 2 independent patients after 24 weeks gestation
  • Potential trauma and obstetrics (OB) emergency
  • Tip: consider pregnancy in any female patient with trauma of childbearing age

Anatomy and physiology

  • Cardiovascular1
    • Cardiac output increases 40%
    • Heart rate increases 10%-15%
    • Blood pressure decreases 15%-20% late in the second trimester
    • Blood volume increases 30%-50%
    • Cellular components of blood increase 10%-15%
    • Physiologic anemia develops
    • Hypovolemic shock occurs with greater percentage of blood loss
    • Injuries to the spleen, liver, and retroperitoneum are more common because of increased vascularity
    • Hypercoagulable state develops
  • Pulmonary1
    • Diaphragm displaced 4 cm superiorly
    • Hyperventilation develops with respiratory rates increased by 40%-50%
    • Arterial blood gas (ABG) shows increased pH, decreased partial pressure of carbon dioxide (pCO2), decreased bicarbonate, decreased partial pressure of oxygen (paO2)
    • Greater oxygen requirement
    • Smaller reserve
    • Oxygen disassociation curve shifts to increase oxygen delivery to fetus
  • Renal1
    • Blood flow increases
    • Ureteral obstruction can develop in the third trimester
    • Blood urea nitrogen/creatinine (BUN/Cr) decrease
  • Gastrointestinal1
    • Delayed gastric emptying
    • Motility decreases
    • Organs protected by gravid uterus
  • Liver1
    • Increased fibrinogen and coagulation factor production
    • Decrease in protein S
  • Endocrinology
    • Increased insulin resistance
  • Pelvic1
    • Uterus protected in the first trimester
    • Uterine blood flow depends on the maternal systolic blood pressure
    • Uterus can compress the inferior vena cava (IVC)/aorta
    • Bladder is displaced anteriorly and superiorly after the first trimester
  • TIP: remember that pregnancy effects almost all organ systems in the body1,2
    Table 1. Physiologic Changes in Pregnancy - Vital Sign and Laboratory Changes
    ParameterChange In Pregnancy Comment
    Blood pressureDown5-15 mm HgLate second trimester
    Heart rateUp10%-15%Third trimester
    Respiratory rateUp  
    WBCUp5,000-15,000 cells/mm3N/A
    HemoglobinDown10-14 g/dLFrom increased plasma volume
    pHUp7.4-7.47N/A
    PO2Up101-104 mm HgN/A
    PCO2Down25-30 mm HgN/A
    HCO3Down18-21 mEq/LN/A

    Abbreviations: HCO3,
    bicarbonate; PCO2, partial pressure of
    carbon dioxide; N/A, not available; PO2,
    partial pressure of oxygen; WBC, white blood
    cell.

Etiology

  • Assault is the most common cause of trauma during pregnancy3
  • Falls increase in the second and third trimester due to change in center of gravity3
    • 1 in 4 women experience a fall during pregnancy3
    Table 2. Estimated Incidence of Type of Trauma per Pregnancy Occurrence
    Type of TraumaPercentage of Incident Occurrence
    Domestic violence8%
    MVA0.2%
    Falls0.04%
    Penetrating 0.0033%
    Homicide0.0029%
    Suicide0.002%
    Burns0.00017%

    Abbreviation: MVA, motor vehicle
    accident.

Epidemiology

  • Trauma occurs during 1 in 12 pregnancies4
  • Trauma is the leading cause of death for females of child-bearing age5
  • Trauma is the leading nonobstetric (non-OB) cause of maternal death in pregnancy2
  • Fetal loss complicates 5% of minor trauma6
  • 90% of trauma in pregnancy is minor; 60%-70% of fetal loss is the result of minor trauma7

References

References

General references used

  1. Pearce C, Martin SR. Trauma and Considerations Unique to Pregnancy. Obstet Gynecol Clin North Am. 2016 Dec;43(4):791-808
  2. Shah AJ, Kilcline BA. Trauma in pregnancy. Emerg Med Clin North Am. 2003 Aug;21(3):615-29
  3. Mendez-Figueroa H, Dahlke JD, Vrees RA, Rouse DJ. Trauma in pregnancy: an updated systematic review. Am J Obstet Gynecol. 2013 Jul;209(1):1-10
  4. Hill CC, Pickinpaugh J. Trauma and surgical emergencies in the obstetric patient. Surg Clin North Am. 2008 Apr;88(2):421-40
  5. Heron, M. Deaths: Leading Causes for 2008. National Vital Statistics Report. 2008 PDF
  6. Mattox KL, Goetzl L. Trauma in pregnancy. Crit Care Med. 2005 Oct;33(10 Suppl):S385-9
  7. Murphy NJ, Quinlan JD. Trauma in pregnancy: assessment, management, and prevention. Am Fam Physician. 2014 Nov 15;90(10):717-22
  8. American College of Surgeons (ACS) Committee on Trauma. Advanced Trauma Life Support Manual, 10th ed. Chicago, IL: ACS; 2018
  9. Maghsoudi H, Samnia R, Garadaghi A, Kianvar H. Burns in pregnancy. Burns. 2006 Mar;32(2):246-50
  10. Einav S, Sela HY, Weiniger CF. Management and outcomes of trauma during pregnancy. Anesthesiol Clin. 2013 Mar;31(1):141-56
  11. Harrison BP, Crystal CS. Imaging modalities in obstetrics and gynecology. Emerg Med Clin North Am. 2003 Aug;21(3):711-35
  12. Sela HY, Weiniger CF, Hersch M, Smueloff A, Laufer N, Einav S. The pregnant motor vehicle accident casualty: adherence to basic workup and admission guidelines. Ann Surg. 2011 Aug;254(2):346-52
  13. Meroz Y, Elchalal U, Ginosar Y. Initial trauma management in advanced pregnancy. Anesthesiol Clin. 2007 Mar;25(1):117-29
  14. Raja AS, Zabbo CP. Trauma in pregnancy. Emerg Med Clin North Am. 2012 Nov;30(4):937-48
  15. American College of Obstetricians and Gynecologists (ACOG). ACOG educational bulletin. Obstetric aspects of trauma management. Number 251, September 1998 (replaces Number 151, January 1991, and Number 161, November 1991). American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. 1999 Jan;64(1):87-94
  16. Advanced Life Support in Obstetrics Provider Syllabus. Leawood, KS: American Academy of Family Physicians; 2010
  17. Mirza FG, Devine PC, Gaddipati S. Trauma in pregnancy: a systematic approach. Am J Perinatol. 2010 Aug;27(7):579-86
  18. Weinberg L, Steele RG, Pugh R, Higgins S, Herbert M, Story D. The pregnant trauma patient. Anaesth Intensive Care. 2005 Apr;33(2):167-80

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How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T910335, Trauma in Pregnancy - Emergency Management; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T910335. Registration and login required.

Published by EBSCO Information Services. Copyright © 2020, EBSCO Information Services. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission.

EBSCO Information Services accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional.

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