Trauma in Pregnancy

Clinical Expert Series

Continuing medical education is available online at www.greenjournal.org

Trauma in PregnancyHaywood L. Brown, MD

Acute traumatic injury during pregnancy is a significant contributor to maternal and fetalmorbidity and mortality in the United States. Motor vehicle accidents are the leading cause ofinjury-related maternal death, followed by violence and assault. Lack of seat belts or otherrestraints increases the risks of both maternal and fetal morbidity and mortality. The AmericanCollege of Obstetricians and Gynecologists recommends proper seat belt use by all pregnantwomen and screening for domestic abuse. Maternal injury and death from physical abuse isprevalent, and in some communities, homicide is a major cause of pregnancy-associatedmaternal death. Blunt trauma most often occurs as a result of motor vehicle accidents, whereaspenetrating trauma results from gunshots or stabbings. Blunt trauma to the abdomen increasesthe risk for placental abruption, and direct fetal injury is more likely with penetrating trauma.Management strategies in acute maternal trauma must focus on a thorough assessment of themother. A coordinated team effort that includes the obstetrician is essential to ensure optimalmaternal and fetal outcomes. Imaging studies should not be delayed because of concerns of fetalradiation exposure, because the risk is minimal with usual imaging procedures, especially inmid-to-late pregnancy. The obstetrician should serve in a consultative role if nonobstetricsurgical care is required and must also be prepared to intervene on behalf of the mother and thefetus if trauma care is compromised by the pregnancy. Perimortem cesarean delivery should beconsidered early in the resuscitation of a pregnant trauma victim, especially when fetal viabilityis a concern. Once the mother is stabilized in the emergency setting, she should be transportedfor appropriate maternal and fetal observation until both mother and fetus are clear of danger.It is essential that the clinician and staff maintain thorough and accurate documentation andrecording of the chronology of events, the maternal and fetal assessment, and the managementand outcome of the pregnancy.(Obstet Gynecol 2009;114:147–60)

When a pregnant woman is the victim of trau-matic injury, the risk to the mother and the

fetus for morbidity and mortality is a potential conse-quence. The chance of major trauma occurring dur-

ing pregnancy from either accidental or intentionalinjury has gained increasing recognition over the pastseveral decades as a major contributor to maternaland fetal morbidity and mortality.1–3 Trauma is asso-ciated with first-trimester pregnancy loss, prematurebirth from labor or premature rupture of membranes,placental abruption, uterine rupture, and stillbirth.2–4

The risk for adverse outcome is more likely frommajor trauma that might occur due to motor vehicleaccidents. However, pregnancy complications, in-cluding placental abruption, can occur even afterminor trauma to the abdomen as might occur fromfalls, domestic abuse, or seemingly minor accidents.

The unique physiologic changes of pregnancy,particularly on the cardiovascular system, are both anadvantage and disadvantage after acute traumatic

From the Department of Obstetrics and Gynecology, Duke University MedicalCenter, Durham, North Carolina.

Continuing medical education for this article is available at http://links.lww.com/A1266.

Corresponding author: Haywood L. Brown, MD, Professor and Chair, Depart-ment of Obstetrics and Gynecology, Duke University Medical Center, Box 3084,203 Baker House, Durham, NC 27710; e-mail: [email protected].

Financial DisclosureThe author did not report any potential conflicts of interest.

© 2009 by The American College of Obstetricians and Gynecologists. Publishedby Lippincott Williams & Wilkins.ISSN: 0029-7844/09

VOL. 114, NO. 1, JULY 2009 OBSTETRICS & GYNECOLOGY 147

injury. The physiologic increase in blood volume canbe protective after early injury as blood is shunted tovital organs. However, changes in heart rate andblood pressure may lead to failure to recognize orunderestimation of the extent of injury and blood lossduring the initial evaluation of an accident victim.Such miscalculations can further compromise theoutcome for both mother and fetus. The acute resus-citation team must lean toward aggressive volumereplacement in the early stages of management ofmajor trauma to minimize morbidity.

This review will highlight the leading causes fortrauma during pregnancy and the effect of trauma onmaternal and fetal morbidity and mortality. A multi-disciplinary team approach to acute management ofthe mother is essential to the well-being of bothmother and infant. The lack of or inappropriate useof motor vehicle restraints is identified as a signifi-cant contributor to adverse maternal and perinataloutcomes.

BACKGROUNDTrauma-related events are responsible for approxi-mately 1 million deaths annually worldwide,5 and inthe United States they are recognized as leadingcontributors to pregnancy-associated maternal death.1

Major trauma complicates 3–8% of pregnan-cies.6,7 In 2002, approximately 16,900 major andminor injury-related hospitalizations of pregnantwomen occurred in the United States, and a deliveryoccurred in 38% of those hospitalizations.8 For non-delivery hospitalizations, the most common injurytypes, in order, were fractures, dislocations, sprainsand strains, and poisoning. For hospitalizations result-ing in a delivery, the most common injury types weresuperficial injuries, contusions, and crushing injuries.The overall rate of injury hospitalizations of pregnantwomen was 4.1 per 1,000 deliveries.8

There are several likely reasons for a rise in injuryprevalence during pregnancy. In recent years, womenhave remained actively employed throughout preg-nancy and have assumed jobs that are consideredmore hazardous. Another factor is the unfortunatereality that society has become more violent, leadingto women being victims of crime and physical abuse.1

Motor vehicle accidents account for approximately70% of all major traumas during pregnancy and arethe greatest contributor to traumatic maternal andfetal death2 (Box 1). In parts of the United States,however, violence and homicide are leading causesof trauma-related maternal death, especially amongAfrican-American women.1,9,10

The fact that injuries from motor vehicle acci-dents occur frequently during pregnancy should notbe surprising when one considers that female driversare more likely than male drivers to be involved in anautomobile accident per 10 million miles driven.11 Infact, motor vehicle accidents are the leading cause ofdeath in girls and women aged 6 to 29 years, accord-ing to data from the National Highway Traffic SafetyAdministration (NHTSA).12

Fetal deaths can result from direct maternal insta-bility, placental abruption, direct fetal injury, andhemorrhage, or as a consequence of prematurebirth.13,14 The most common cause for fetal loss isplacental injury.15

INTENTIONAL MATERNAL INJURY(VIOLENCE)Intentional injury during pregnancy in the UnitedStates from domestic or physical abuse contributes tomaternal and fetal morbidity and mortality.1,16–19 In areview more than 20 years ago, intimate partnerviolence and battery was reported to occur in 1 ofevery 12 pregnancies in the inner city.16 Intimatepartner violence contributed to 20% of all nonfatalviolent crimes experienced by women in 2001, and1,247 women were killed by an intimate partnerbetween 1976 and 2000.17 In 1999, homicide was thethird leading cause of death from injury (4.99%)behind motor vehicle accidents (19.5%) and suicide(5.5%) for pregnant and nonpregnant women aged15–44 years and the second leading cause of death forwomen aged 15–24 years (9.8%).1,20 Homicide ratesfor African-American women were more than three

BOX 1. LEADING CAUSES OF MATERNALTRAUMATIC INJURY AND DEATH

Motor vehicle accidentsViolence and assault

GunshotsStabbingStrangulation

FallsSuicideToxic exposures

Drug overdosePoisoning

BurnsDrowning

148 Brown Trauma in Pregnancy OBSTETRICS & GYNECOLOGY

times higher than that for white women.21 The homi-cide was most often from gunfire (57.6%) followed bystabbings (17.8%), strangulation (13.9%), or battery(7.8%).1

Depression during pregnancy and postpartumhas contributed to the higher number of suicide-related maternal mortalities as a contribution to preg-nancy-related injury deaths.1,22–24 Clinicians must re-main mindful to screen all pregnant and postpartumwomen for depression to diminish the adverse conse-quences of depressive illness, including suicide andattempted suicide. Women attempt suicide threetimes more frequently than men, and for women ofreproductive age, suicide is the fourth-leading causeof female mortality.25 Despite the stresses and psy-chiatric comorbidities during pregnancy, pregnantwomen have a lower risk for successful suicide thanwomen of child-bearing age who are not preg-nant.26,27 Attempted suicide during pregnancy hasbeen estimated to be 0.4 per 1,000 pregnancies,with the best predictor for women at risk forattempting suicide being substance abuse.28 Com-mon methods of self-inflicted attempted suicideare drug overdose and poisoning with a corrosivesubstance.9,28

There are a number of screening tools that canidentify women at risk for depression, and clini-cians should be encouraged to use these toolsliberally in all clinical settings. For example, theEdinburgh Postnatal Depression Scale is a 10-itemself-report depression scale, widely used to screenfor postpartum depression, and has been validatedfor antenatal use.29

BLUNT TRAUMAThe leading cause of blunt abdominal trauma inpregnancy is motor vehicle accidents. Factors relatedto maternal and fetal outcome include gestational ageat the time of injury and severity and mechanism ofinjury.

In the first and early second trimester, the preg-nant uterus is mostly a pelvic rather than an abdom-inal organ. At 13–14 weeks of gestation, the uterus hasreached just above the pubic symphysis and is lesslikely to have direct injury because it is protected bythe bony pelvis. Pregnancy loss in the first trimestercannot usually be attributed to direct uterine injurybut more so from maternal hypovolemia and hypo-tension leading to hypoperfusion of the uterus and thedeveloping fetus. Beyond 20 weeks of gestation, theenlarged uterus compresses the aorta and inferiorvena cava when the mother is supine, leading to

decreased venous return and uterine perfusion. De-creased uterine perfusion is more pronounced insituations of maternal hypotension.

Placental AbruptionClinically evident placental abruption occurs in up to40% of severe blunt abdominal trauma and in 3% ofminor trauma with direct uterine force.3,4,30–32 Whenplacental abruption occurs, depending on the sever-ity, there is a compromise in fetal oxygen transfer,leading to signs of fetal distress and fetal death. Themechanism for placental abruption is related to thedifference between tissue properties of the elasticmyometrium and inelastic placenta. The placentaabruption is caused by shearing forces at the placen-tal–uterine interface. Because amniotic fluid is non-compressible, impact against the uterine wall resultsin amniotic fluid displacement and uterine distension.Even non–severely injured pregnant women are atincreased risk for placental abruption.3,4,33,34 Abrup-tion may occur immediately after abdominal impactor be delayed for several hours after the traumaepisode.35

Uterine RuptureIn some instances, blunt trauma can be so severe itresults in uterine rupture. Uterine rupture occurs inless than 1% of pregnant trauma victims but has anobvious grave prognosis for the fetus and the mot-her.3,36,37 As the uterus becomes an abdominal organ,the risk of direct uterine trauma and rupture increa-ses. The increase in uterine vascularity and blood flowthat comes with advancing pregnancy makes serioushemorrhage more likely if the uterus is injured anduterine vasculature is disrupted.38,39 The extent ofuterine damage and damage to adjacent organs can-not be predicted by clinical presentation and will notbe apparent until exploratory surgery is performed.However, surgeons must be prepared to act quickly toavoid the consequences of severe hemorrhage andcoagulation complications. If the uterus is severelydamaged and cannot be repaired expeditiously, thenhysterectomy is appropriate to prevent further dete-rioration in the woman’s condition and maternalmorbidity and mortality; the fate of the fetus has morethan likely already been determined. Prompt hemo-dynamic resuscitation with fluids and replacement ofblood products diminishes the potential for bleedingcomplications from disseminated intravascular coagu-lopathy. The greater and more rapid the hemorrhagewithout replacement with blood products, the morelikely the loss of critical clotting factors that arerequired for proper coagulation. The typical symp-

VOL. 114, NO. 1, JULY 2009 Brown Trauma in Pregnancy 149

toms of uterine rupture (lower abdominal pain) maybe masked by the extent of the abdominal injuriesand overall maternal discomfort from those injuries.Furthermore, there may be bleeding from other or-gans (liver and spleen) rather than or in addition tothe damaged uterus.

Direct Fetal InjuryBlunt abdominal trauma to the abdomen or pelvis canresult in direct fetal trauma, fractures, hemorrhage,and death. Direct fetal injury complicates less than 1%of pregnancies with blunt trauma.40,41 Direct fetalinjury is rare because of protection by the uterus andamniotic fluid. The risks to the fetus are greatest inmid-to-late gestation. Prenatal diagnosis of fetal injurywas demonstrated in a case of direct abdominaltrauma from physical abuse resulting in fetal headtrauma, intracranial hemorrhage, and fetal demise42

(Figs. 1 and 2). With the fetal head in the maternalpelvis at or near term, there is a risk for fetal skullfracture and brain injury with maternal pelvicfractures.

Pelvic FracturesPelvic fractures are a common accidental injury.Leggon et al43 reported on a total of 101 cases ofpelvic or acetabular fractures in pregnant womenfrom 1932 to 2000. This report identified three mech-anisms of injury: motor vehicle accidents (73%), falls(14%), and pedestrian struck by a car (13%). Mecha-nism of injury and injury severity were related tomortality rates. The overall fetal mortality rate inpelvic and acetabular fractures was 35% comparedwith 9% maternal mortality43 (Fig. 3).

Pregnancy and Restraint UseBecause of reasonable evidence that restraint usereduces both maternal and fetal morbidity and mor-tality, ACOG recommends seat belt use in pregnantwomen to reduce both maternal and fetal morbidityand mortality.5,44

Seatbelt RestraintsEducation on the proper use of restraints should be astandard component of all prenatal care programs.The use of three-point seatbelt restraints during preg-nancy is highly recommended. The National High-way Transportation Safety Administration recom-mends that pregnant women wear their seatbelts withthe shoulder harness portion positioned over thecollarbone between the woman’s breasts, and the lapbelt portion under the pregnant abdomen as low aspossible on the hips and across the upper thighs andnot above or over the abdomen (Fig. 4).

In 2000, a survey evaluating the practice andknowledge of car seatbelt use in pregnancy indicated

Fig. 1. The arrow points to a magnetic resonance imageshowing fetal suture separation and intracranial hemor-rhage as a result of blunt abdominal trauma from domesticabuse. From Ellestad S, Shelton S, James AH. Prenataldiagnosis of a trauma-related fetal epidural hematoma.Obstet Gynecol 2004:104;1298–300.Brown. Trauma in Pregnancy. Obstet Gynecol 2009.

Fig. 2. The arrow points to an empty fetal calvarium fromliquefaction of the brain as a result of severe intracranialhemorrhage from blunt abdominal trauma.Brown. Trauma in Pregnancy. Obstet Gynecol 2009.


that many women were ignorant of the correct usageof seatbelts, their positioning, and the legal require-ments for seatbelts.45 Placement of the lap belt overthe dome of the uterus increases pressure transmis-sion and the risk of uterine injury during a significantcrash. Restraint use has a benefit in protecting boththe mother and fetus from morbidity and mortality.46

Unfortunately, restraint use during pregnancy is in-consistent. Restraint use may be lower among ethnic

minorities.47 In a recent report from Duke UniversityMedical Center, the relative risk for perinatal deathwith lack of restraint use was 5.2:1 (Luley T, BrownHL, Fitzpatrick FB, Hocker M. Trauma during preg-nancy: restraint use and perinatal outcome after mo-tor vehicle accidents. Obstet Gynecol 2008;111:1S).

Crash severity and the proper use of seatbelts isthe primary predictor of maternal and fetal out-come.4,8 Ejection from the vehicle and head traumacorrelates with poor maternal and fetal outcome.

AirbagsAirbags have been shown to be life saving in severeautomobile crashes. Airbags detonate with more than1,200 lb of force at speeds that can exceed 230 mph.Airbag systems were developed for males averaging 5ft. 8 in. and weighing 180 lb and were only tested tobe sure they met their needs. Segui-Gomez et al48

reported that for female drivers, airbags create a netprotective effect only when a vehicle’s speed exceeds52 km/h to 62 km/h (32 mph to 38 mph), and at lowerspeeds, the potential for injury from airbags out-weighs the benefits. This included all female drivers,not just the shorter ones defined in NHTSA’s endan-gered group (Segui-Gomez M, Levy J, Graham J.Airbag safety and distance of the driver from thesteering wheel [letter]. N Engl J Med 1998;339:132–3).48 The NHTSA’s new criteria for “advanced airbags” will require manufacturers to make supplemen-tal restraint systems and airbags that are safe forchildren and women as well as for the standard-sized

Fig. 3. The arrow points to a pelvic fracture before (A) andafter (B) fixation in a pregnancy in late third trimesterresulting in fetal death.Brown. Trauma in Pregnancy. Obstet Gynecol 2009.

A B

Fig. 4. A. Improper use of lap seatbelt in pregnancyshowing placement across the abdominal dome. B. Properuse of lap seatbelt appropriately placed below the abdom-inal dome. Illustration: John Yanson.Brown. Trauma in Pregnancy. Obstet Gynecol 2009.


male. These supplemental restraints and airbag sys-tems will be developed to meet the final implemen-tation deadline of the year 2012.

There is no clear evidence that the effect of airbagdeployment during the third trimester of pregnancyincreases the risk for maternal or fetal injury. Minormaternal injuries from airbag impact and contacthave been reported.49 In a review of 30 womeninvolved in motor vehicle accidents with airbag de-ployment, a higher risk for placental abruption wasnot found.50 Although the risk of fetal injury fromairbag deployment in the late third trimester istheoretical, the benefits to maternal survival shouldweigh against any recommendation or idea on thepart of the driver to disable airbags during preg-nancy. According to recommendations by theNHTSA, the breast bone of the pregnant womanriding in front of an airbag should be at least 10inches away from the dashboard or steering wheel,and the seat should be moved back as the pregnantabdomen grows.

PENETRATING TRAUMAPenetrating trauma is typically the result of gunshotand stabbing injuries. These women are either by-standers or victims of violent events. Maternal mor-tality risk with penetrating trauma is more favorablethan with blunt trauma injury because nonreproduc-tive viscera are provided some protection by thegravid uterus, which absorbs the projectile objects.5

The enlarged uterus protects the bowel from injurywith lower abdominal stab wounds and shot gunblasts. The upper abdomen is the most common siteof stab wounds during pregnancy, leading to bowelinjury secondary to upward displacement of thebowel by the gravid uterus.51 However, the extent ofinjury with single gunshots is dependent on a numberof additional factors including type of firearm, sizeand velocity of the bullet, distance from the victim,and anatomic region of penetration and deflection.Although maternal outcomes are often more favor-able with penetrating injuries, fetal injury and prog-nosis are poorer if the uterus is the main organ ofabsorption of the stabbing or gunshots.5 Fetal death isdependent upon the amount of placental or umbilicalcord disruption. Fetal death has been reported to beas high as 71% with gunshot injuries52 and 42% withstabbings.53

Pregnant women with gunshot wounds to theabdomen should typically undergo exploratory sur-gery with debridement of damaged tissues. Stabwounds to the abdomen should be managed in a

manner similar to the nonpregnant patient if intraab-dominal injury is suspected. It is important to remem-ber that tetanus prophylaxis is recommended for theappropriate candidates, particularly victims of pene-trating injuries from gunshots and stabbings. Bowelinjury with spillage of intestinal contents increases therisk for peritonitis and pregnancy loss from infection.Irrigation and antibiotics are important, just as withthe nonpregnant individual with bowel damage.

MANAGEMENT OF PREGNANT TRAUMAVICTIMSPrehospital and Emergency EvaluationThe primary goal of initial management is a thoroughevaluation and stabilization of the pregnant traumavictim. Most emergency management teams (EMT)who arrive on the scene of an accident are familiarwith the designated trauma units equipped to dealwith cases of severe trauma, including helicoptermedical evacuation to the appropriate level traumacenter. If the patient is transported to a facility closerto the scene because the EMT’s initial assessmentdictates that disposition to improve chances of sur-vival, this team and the facility accepting the victimwill need to make the acute management decisions inthe best interest of the woman; stabilize if possibleand then evacuate to a appropriate level traumacenter. In any case, there should be a coordinatedteam approach with emergency, trauma, obstetric,and neonatal care providers. The clinical team shouldbe mobilized as soon as an emergency facility isnotified that a pregnant trauma victim is being trans-ported for emergency care. This coordinated effort isessential to both maternal and fetal survival. Preg-nancy should never delay the decision to intubate thewoman, especially if there is likelihood that surgicalintervention will become necessary. As a result of thevulnerability of the fetus to hypoxia, every attemptshould be made to avoid hypotension, and all preg-nant trauma victims should be provided with supple-mental oxygen even if intubation is not required.

Military anti-shock trousers (MAST)—also knownas a MAST suit or pneumatic antishock garment(PASG)—is a one-piece inflatable device that has beenused to support blood pressure in hypotensive traumapatients during transport to the hospital. The use ofMAST and PASG is restricted to qualified emergencymedical personnel as an adjunct in the managementof hemorrhagic shock using manufacturer recommen-dations. The MAST suit can be placed over clothingand bandages. It is unclear how often MAST suits areused in current practice. They are a class III interven-


tion in trauma victims, and current indications for theMAST suit are 1) splinting and control of pelvicfractures with continuing hemorrhage and 2) intraab-dominal trauma with severe hypovolemia in patientswho are en route to the operating room or anotherfacility.54 The MAST suits are potentially harmful topregnant women in the second and third trimesterand are relatively contraindicated in pregnancy otherthan for a ruptured ectopic pregnancy.55 The emer-gency management team must be aware to inflateonly the leg compartments and not the abdominalsection of MAST if used while transporting a pregnantwoman whose pregnancy has progressed beyond midgestation, because inflation of the abdominal com-partment of the MAST/PASG can compromise utero-placental blood flow.55 The use of MAST is based onblood pressure readings and not MAST pressure.Indication for urgent use and inflation of MASTincludes signs of severe hemorrhagic shock (ie, un-consciousness, systolic blood pressure less than 80mm Hg, and absent or weak radial pulses). The legcompartments should be inflated to 50 mm Hg ini-tially, and then the patient should be reassessed. Ifshock persists, the legs’ pressures should be furtherinflated until the Velcro (Velcro Industries B.V.,Manchester, NH) crackles. If there is further deterio-ration of shock in the mother, then abdominal infla-tion may be warranted by order and direction of aphysician or other qualified medical personnel as thepatient is being transported until Velcro on the ab-dominal compartment crackles. Deflation should oc-cur in the hospital only after intravenous lines aresecure and transfusion and definitive intervention hasbegun to stop the hemorrhage.

Other principles of transport and initial emer-gency evaluation include avoiding supine hypoten-sion from inferior vena cava compression by thegravid uterus. This can be accomplished by tilting thewoman to the left by 15 degrees or by placing a rolledtowel beneath the spinal board.

Laboratory and Imaging in the PregnantTrauma PatientThe initial laboratory assessment should include de-termination of a complete blood count, urinalysis,electrolytes and glucose, blood typing and crossmatching, Rh determination, coagulation profile, andtoxicology screening. Gross or microscopic hematuriasuggests pelvic (fractures) injuries (Fig. 5).

Maternal mortality from motor vehicle accidentsis primarily related to head trauma and intraabdomi-nal hemorrhage. Hemorrhagic shock was a consistentfeature in the mortality of 103 pregnant women with

blunt trauma reviewed by Rothenberger et al31 in1978. The obstetrician can provide expertise in thecardiovascular, anatomic, and other physiologicchanges of pregnancy that can affect prognosis for themother and fetus. Anatomic and physiologic changesin pregnancy can mask maternal injury and aresomewhat protective of the major effects of traumaand hemorrhage. When evaluating the pregnantwoman, the emergency team must appreciate thephysiologic changes that accompany normal preg-nancy. During pregnancy, the blood pressure de-creases during the early-to-mid second trimester andremains decreased as the woman enters the thirdtrimester. Systolic blood pressure decreases approxi-mately 2–4 mm Hg, whereas the diastolic bloodpressure decreases by 5–15 mm Hg, and maternalheart rate increases by 10–15 beats per minute withadvancing gestation. The evaluating team must bealert not to be misled by these normal physiologicpregnancy changes, because hypotension and tachy-cardia may suggest a more profound hypovolemia inthe woman with trauma. By the time there aresignificant changes in vital signs, critical blood lossmay be more pronounced compared with the non-pregnant state. In the healthy pregnant woman withphysiologic hypervolemia of pregnancy, the usualsigns of hemorrhage may not become evident at restuntil 15–20% (approximately 1,200 mL) of the totalblood volume has been lost (Box 2).

Volume resuscitation can be complicated by theaorta–caval compression of the enlarged uterus andsupine positioning in the second and third trimester.Therefore, left lateral displacement or tilting shouldbe performed on women beyond mid gestation (24weeks). This maneuver partially relieves the compres-sive effect of the uterus on the vena cava, which canreduce the women’s cardiac output up to 30%.56 The50% increase in blood volume that occurs in preg-nancy can falsely mask significant hemorrhage bysuggesting a more stable hemodynamic status thanactual. Volume resuscitation with crystalloid (Ringer’slactate) will need to be increased by as much as 50%of that for nonpregnant women because of the in-creased plasma volume of pregnancy.

The Obstetric AssessmentThe obstetric team can also provide the surgicalexpertise if an emergency hysterotomy is necessary tofacilitate maternal resuscitation in the event of aperimorbid maternal presentation. The initial priori-ties and principles for maternal resuscitation, includ-ing oxygen and fluid management, should be the


same as for the nonpregnant accident or traumavictim.

Once stabilized in the emergency setting, theobstetrics team can turn their attention to a morethorough physical and obstetric (pelvic) examination.The abdomen should be inspected for ecchymosesand possible seatbelt injury in cases of motor vehiclecrashes. A thorough physical examination shouldlook for old and new ecchymoses and bruises over theentire body. This is important if there is a possibilitythat injuries are related to interpersonal violence. Avaginal speculum examination should be performed,especially if there is vaginal bleeding or hematuriaand pelvic fractures are suspected. The vaginal exam-ination can detect bleeding, rupture of membranes,and vaginal lacerations that can occur if there hasbeen a pelvic fracture. An ultrasonographic examina-tion should be performed early in the assessment todocument fetal heart status and viability and fetal

gestational age and presentation. Ultrasonography isuseful in detecting free peritoneal fluid or maternalhemorrhage and placental abruption. Although therehas been significant improvement in ultrasonographicimaging technology over the past two decades, thesensitivity for the diagnosis of abruption has notgreatly improved.57,58 Ultrasonographic diagnosis ofplacental abruption is challenging in the immediateevaluation period. However, when a clot is visualizedon ultrasonography, the positive predictive value foran abruption at delivery is high, indicating that thevolume of clot under the placenta is large enough tobe visible ultrasonographically.58

Radiologic Evaluation in PregnancyMaternal radiologic studies (X-rays, magnetic reso-nance imaging, and computed tomography) shouldnot be deferred over concerns for the fetus if they arerequired for adequate maternal assessment. Various

Major trauma after20 weeks of

gestation

Gestational age,fetal movement,bleeding, ruptureof membranes,

pain/ contractions

Clinical historyassessment

Examination

Seatbelt use:Proper or improper

Violence

Yes No

Social services

Abdomen Bimanual (optional)

Pelvic

Inspect for seatbelt injury,

ecchymoses(old)*

Palpate for contractions or

tenderness

Perform ultrasonography

to check fetal viability

Examine with vaginal speculum

for bleeding, laceration, bone

fragments

Laboratory/Studies

Imaging Blood Urinalysis Coagulation profile

Toxicologyscreening andblood alcohol

testing

Kleihauer-Betke testing†

Prothrombin time, partial

thromboplastintime, possibly

fibrinogen? D-dimer for abruption

Complete bloodcount,

electrolytes, and glucose levels

Blood typing and Rh group,cross-matching

X-ray, MRI asappropriate to

area of concern

Abdominalultrasound

Fetal assessment

Intraperitoneal bleeding

Fig. 5. Clinical assessment of the pregnant trauma patient more than 20 weeks of gestation. MRI, magnetic resonanceimaging. * Old ecchymoses—suggestive of domestic abuse; † detects maternal–fetal hemorrhage and allows calculation ofimmune globulin (RhoGAM, Ortho-Clinical Diagnostics, Inc., Rochester, NY) dosing in Rh-negative women (immuneglobulin 300 micrograms covers up to 15 mL of red cells bleed).Brown. Trauma in Pregnancy. Obstet Gynecol 2009.


diagnostic radiologic procedures pose minimal radia-tion exposure and limited theoretical risk. Accordingto the American College of Radiologists, no singlediagnostic procedure provides a radiation dose signif-icant enough to threaten the well-being of the devel-oping embryo or fetus, especially in mid-to-late preg-nancy.59 Adverse effects are not expected at criticalperiods of development unless the dose exceeds the50–100 mGy range (1 mGy�0.1 rad). Animal studiesindicate malformation risk at a threshold of approxi-mately 100 mGy during the most vulnerable period ofembryonic development.60–63 The highest dose ofradiation occurs with computed tomography, whichexposes the viable fetus to approximately 20–50 mGywith maximal imaging. Magnetic resonance imagingand ultrasonography have not been associated withadverse fetal effects. There is no evidence of terato-genic effects with gadolinium administration.64

Exploratory Laparotomy and SurgicalProcedures in PregnancyIf nonobstetric surgery is required, attention toadequate maternal oxygenation, volume, and uter-ine perfusion should provide an environment toprevent fetal hypoxia. Surgical decisions must bebased on the type of injury and clinical assessmentof the status of the mother and fetus. Diagnosticperitoneal lavage can be performed safely in alltrimesters using an open direct visualization tech-nique through a supraumbilical incision65 or underultrasound guidance at a point above the umbilicusand avoiding the pregnant uterus. If chest tubeplacement is required, the chest should be entered1 or 2 interspaces higher than usual becauseof elevation of the diaphragm with advancingpregnancy.

The surgical team should never let the enlargeduterus compromise or be an obstacle to adequatesurgical exploration in the evaluation and manage-ment of nonobstetric maternal injuries. However,exploratory laparotomy is not an automatic indicationfor hysterotomy and delivery of the fetus. In cases ofknown fetal death, vaginal delivery after exploratorysurgery is an appropriate option unless there is obvi-ous uterine injury or a placental abruption withcoagulopathy. If there is significant potential for co-agulopathy such as from a placental abruption, it maybe prudent and beneficial from the perspective ofmaternal morbidity and while the mother is under thecurrent anesthetic to proceed to evacuation of theuterus with or without fetal viability to optimizematernal management in the postsurgical period.Placental abruption can promote the release of tissuethromboplastins into the maternal circulation leadingto coagulopathy. Coagulopathy further complicatesthe hemorrhagic picture and leads to more compli-cated perioperative management and possible adultrespiratory distress syndrome.

Fetal heart monitoring should be performedperiodically throughout surgery in the viable fetusby using a sterile cover over an ultrasound orDoppler transducer. If there is a concern about thefetal status during surgery for nonobstetric indica-tions or there is evidence of uterine trauma orpenetration of the uterus, the obstetric team mustremain on alert and be prepared to perform acesarean delivery if the fetus is beyond 24 weeks ofgestation. If the uterus is injured from penetratingtrauma, a cesarean plus hysterectomy may berequired.

BOX 2. MATERNAL PHYSIOLOGICADAPTATIONS TO BLOOD LOSS

Mild blood loss 20–25% of blood volume(1,200–1,500 mL)

Tachycardia (95–105 beats per minute [bpm])Vasoconstriction—cold, pale extremitiesMean arterial pressure drops by 10–15% (70–75

mm Hg)

Moderate blood loss of 25–35% of blood volume(1,500–2,000 mL)

Tissue hypoxiaTachycardia (105–120 bpm)RestlessnessMean arterial pressure drop of 25–30% (50–60

mm Hg)Oliguria (less than .5 mL/kg of actual weight)

Severe blood loss—more than 30% of bloodvolume or more than 2,000 mL

Hemorrhagic shockTissue hypoxiaTachycardia (more than 120 bpm)Hypotension (mean arterial pressure less than 50

mm Hg)Altered consciousnessAnuriaDisseminated intravascular coagulation


Maternal and Fetal Observation and ObstetricManagementIt is not uncommon for the pregnant woman who hassurvived exploratory abdominal surgery with an in-tact pregnancy to experience uterine contractions orpreterm labor postoperatively after recovery fromanesthesia. Unless she requires surgical intensive carefor nonobstetric injuries, postoperative care can bestbe accomplished in a labor and delivery setting thatcan manage both maternal and fetal monitoring andintervene on behalf of the fetus if necessary. In casesof preterm labor without placental abruption, bleed-ing, or a compromised fetus, labor suppression withindomethacin, magnesium sulfate, or other agents canbe administrated using a standard protocol. The useof betamimetics (terbutaline; Brethine, Novartis Phar-maceutical Corp., East Hanover, NJ) should beavoided due the undesired maternal cardiovascularside effects of these drugs (tachycardia and hypo-tension), which can mask worsening signs andsymptoms of undiagnosed hemorrhage. Progres-sion of cervical dilation and preterm labor despitethe use of tocolytics may indicate other causes ofpreterm labor, such as asymptomatic placental ab-ruption or chorioamnionitis.

Once stabilized, the woman not requiring nonob-stetric surgery should be transported to the appropriateunit for additional maternal and fetal monitoring, de-pending on the maternal condition and gestational age.If she is beyond 20 weeks of gestation and is stable, theobservation usually occurs in the labor and deliveryenvironment (Fig. 6). Monitoring for uterine contrac-tions and fetal well-being with standard obstetric moni-toring should occur until the team is comfortable thatmaternal and fetal well-being has been achieved. Amajor concern for the obstetric team is placental abrup-tion, which is usually manifested shortly after abdominalinjury. Delayed placental abruption is unlikely if con-traction frequency is less than every 10 minutes withnormal fetal heart rate activity over a 4–6 hour period ofobservation. Recommended minimal time for monitor-ing is at least 4 hours from the trauma event.5,34 Ofcourse, monitoring should be continued if there isevidence of uterine tenderness, contractions or irritabil-ity, abnormal fetal heart activity, or vaginal bleeding. Ifthere is evidence of deteriorating fetal status, delivery isindicated even though placental abruption is not clini-cally evident (Fig. 7).

Fetal–maternal hemorrhage can be a complica-tion of maternal trauma, leading to fetal anemia,

Trauma after 20–24weeks of gestation Labor and Delivery

Laboratorystudies

Toxicologyscreening andblood alcohol

testing

Prothrombin time, partial

thromboplastintime, fibrinogen

Admit for observation

Ultrasound forfetal evaluation

Complete bloodcount

Blood typing andRh group

Kleihauer-Betketesting*

Maternal and fetalmonitoring

Contractions/bleeding

No contractions/bleeding

Continue maternal and fetal

assessment forplacental

abruption andmaternal–fetal

well-being until stable

Observe for up to24 hours

Discharge if stable

Discharge home

Observe, withmonitoring, for

4 hours

Fig. 6. Labor and Delivery observation after maternal trauma. * Detects maternal–fetal hemorrhage and allows calculationof immune globulin (RhoGAM, Ortho-Clinical Diagnostics, Inc., Rochester, NY) dosing in Rh-negative women (immuneglobulin 300 micrograms covers up to 15 mL of red cells bleed).Brown. Trauma in Pregnancy. Obstet Gynecol 2009.


hypoxia, and fetal death. Fetal–maternal hemorrhageis more likely to occur in women with anteriorplacenta location than in other positions.2 Although aKleihauer-Betke test for fetal–maternal hemorrhagehas become a standard maternal assessment for bluntabdominal trauma victims, there is little evidence thatthis testing predicts adverse immediate fetal or neo-natal outcome from fetal hemorrhage.66 Significantfetal hemorrhage to predict fetal jeopardy is likely tobe accompanied by abnormal fetal heart findingssuch as tachycardia, loss of fetal heart variability, orsinusoidal fetal heart rate patterns (Fig. 8). TheKleihauer-Betke test may be most helpful in Rh-negative women to determine the amount of Rhimmune globulin to be given to prevent maternalisoimmunization. When the gestational age is lessthan 20 weeks, 300 micrograms of Rh immune glob-ulin should be sufficient to cover a fetal–maternalbleed, because the expected fetal blood volume is notlikely to exceed that covered with a standard 300-microgram Rh-immune globulin dose. However, it isnot unreasonable to provide Rh-immune globulinwithin 72 hours to all nonsensitized Rh-negativepregnant women who experience abdominal traumairrespective of Kleihauer-Betke status.

Prognostic Implications of Cardiac Arrest andPerimortem CesareanManagement of cardiac arrest in the pregnant womanat mid pregnancy and beyond presents a challenge for

Fig. 7. Tracing showing late type fetal heart rate decelera-tions at 27 weeks of gestation in a woman with a placentalabruption after an automobile accident. A. Two late typedecelerations (arrows). B. One prolonged late type decel-eration (arrow).Brown. Trauma in Pregnancy. Obstet Gynecol 2009.

Fig. 8. Tracing showing sinusoidal pattern in a woman withfetal–maternal hemorrhage at 30 weeks of gestation afterautomobile accident. Infant was severely anemic at birth.Brown. Trauma in Pregnancy. Obstet Gynecol 2009.


the management team. The pregnant uterus andplacenta serves as a major shunt, which makes car-diopulmonary resuscitation (CPR) less effective inincreasing cardiac output and vital organ perfusion.The use of left lateral tilt typically recommended toreduce the effects of aortocaval compression compro-mises CPR compression forces and reduces the effi-cacy of chest compressions.

Perimortem cesarean should be consideredearly in the resuscitation of the trauma victim,especially when fetal viability is a concern and thepregnancy has extended beyond 24 weeks of ges-tation. Emergency cesarean delivery aids in mater-nal resuscitation and perfusion by eliminating theaortocaval compression produced by the graviduterus.67 Evacuation of the uterus by cesareanshould be strongly considered before resorting toopen cardiac massage in the resuscitation efforts.Thoracotomy and open chest massage can result inimproved cardiac output.

The chance of maternal survival after cardiacarrest even with vigorous resuscitation efforts is sig-nificantly diminished compared with the nonpreg-nant state. Proper CPR provides only a maximum of30% of normal cardiac output, and fetal anoxia ismore likely after maternal cardiac arrest, even withideal CPR efforts. The decision to proceed to peri-mortem cesarean should be immediate and decisiveafter maternal cardiac arrest if there is any hope ofsaving an intact neonate. In a review by Clark et al68

of maternal cardiac arrest with amniotic fluid embo-lism, intact neonatal survival was linked to timing ofcesarean after maternal cardiac arrest. Sixty-sevenpercent of neonates had intact survival if deliveredbefore 15 minutes, whereas only 40% had intactsurvival when delivery was delayed between 16 and25 minutes after maternal arrest.69 The cesareanshould be performed through a midline abdominalincision from xiphoid to the pubis through all layersof the abdominal wall and through a midline verticaluterine incision through the upper segment of theuterus. If an anterior placenta is encountered it isappropriate to cut through the placenta to reach thefetus as soon as possible. The cesarean deliveryimproves the chances of intact neonatal survival,especially in the third trimester. Fetal outcome fromperimortem cesarean delivery as measured by intactsurvival is best if delivery is accomplished within 5minutes of maternal arrest.69 Once the neonate isdelivered maternal resuscitation efforts can be contin-ued more aggressively.

Medical–Legal Implication After MaternalTraumaClinicians are likely to have to offer a medical opinionon the outcome of pregnancy if litigation is broughtafter a motor vehicle accident or assault. In fact, moreoften than not this is the rule rather than the exceptionif the outcome is significant maternal or fetal morbid-ity or mortality.

The findings on initial and subsequent examina-tion and monitoring status of the mother and fetusmust be carefully and accurately documented, be-cause these records will likely be revisited if legalaction is pursued. Hence, the evaluation and therecommendation for monitoring of the mother andthe fetus for up to 4 hours after an accident or injuryis not only necessary for the critical assessment ofmaternal and fetal well-being, but also to have com-plete documentation of maternal and fetal statusduring the period of observation and management.For example, documentation of the timing of anemergency cesarean delivery for placental abrup-tion within a few hours after a motor vehicleaccident has strong correlation to that accident. Incontrast, an episode of preterm labor and deliveryseveral weeks removed from an event is unlikely tohave a relationship to the acute event, particularly ifa through maternal and fetal assessment over theperiod of observation was normal. It is importantfor all clinicians and staff to make careful chrono-logic charting of findings, whether in the emergencydepartment, operating room, or the obstetric observa-tion unit (Box 3).

CONCLUSIONSBoth maternal and fetal morbidity and mortality arereduced when the multidisciplinary treatment team ismobilized to provide coordinated care for the preg-nant trauma victim. The obstetrician is an essentialmember of this multidisciplinary team for the initialassessment, stabilization, and subsequent manage-ment. The fact that the trauma victim is pregnantshould not interfere with or deter the appropriateand thorough evaluation of injuries, including byuse of appropriate imaging studies. The obstetricianmust be prepared to intervene on behalf of themother, especially where fetal survival is in ques-tion. Pregnant women must be educated on theproper use of restraints. Screening for domesticabuse and depression are essential components ofquality prenatal care.


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BOX 3. EMERGENCY MANAGEMENTSTRATEGIES FOR THE PREGNANTTRAUMA VICTIM

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2. Avoid supine hypotension and supply oxygento the mother to decrease risk for fetal hypoxia.

3. Obtain appropriate laboratory and imagingstudies based on the needs of the mother, anddo not postpone imaging studies because of fetalconcerns.

4. Monitor maternal vital signs and fetal heart ratefrequently during the maternal observation pe-riod.

5. Be prepared for an emergency cesarean deliv-ery if the gestational age is older than 24 weeksand the maternal condition, fetal condition, orboth deteriorates.


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