This document discusses trauma in pregnancy and provides key information. It notes that trauma poses unique challenges due to the need to care for both the mother and unborn child. Physiological changes in pregnancy like increased risk of fainting and changes to vital signs can affect trauma assessment and treatment. Aggressive oxygen and fluid administration are critical to optimize outcomes for both. Proper positioning is also needed to prevent supine hypotension in pregnant patients. Motor vehicle collisions are a leading cause of trauma-related injuries or deaths among pregnant women.

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Trauma in Pregnancy

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Overview
Dual goals in managing pregnant trauma
Physiological changes of pregnancy
• Response to hypovolemia
Types of injuries most commonly associated
Initial assessment and management
Trauma prevention in pregnancy
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Trauma in Pregnancy
Unique challenges
• Vulnerability of pregnant trauma patient
• Potential injuries to unborn child
Dual roles
• Provide care to mother
• Provide care to fetus
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Pregnant Patient
Increased risk for trauma
• Fainting spells, hyperventilation, excess
fatigue commonly associated with early
pregnancy
• Balance and coordination affected by
changes throughout pregnancy
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Trauma in Pregnancy
Leading cause of morbidity and mortality
• 6–7% of pregnancies experience some trauma
 1 in 12 injured experience significant trauma
• Major causes
 Motor-vehicle collisions
 Falls
 Abuse and domestic violence
 Penetrating injuries
 Burns
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Fetal Development
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Viability Assessment
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Physiologic Changes
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Physiologic Changes
Respiratory system
• Diaphragm elevated due to uterine size
• Decreased thoracic volume
• Predisposed to hyperventilation
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Vital Signs in Pregnancy
Do not mistake normal vital signs
for signs of shock.
• Normal pulse: 10–15 beats faster
• Blood pressure: 10–15 mmHg lower
• 30–35% blood loss
before significant blood pressure change
Be alert to all signs of shock.
• Frequent Ongoing Exams
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Response to Hypovolemia
Vasoconstriction and tachycardia
• Reduction of uterine blood flow by 20–30%
• Fetal heart rate and blood flow decreases
• Fetus becomes hypoxemic
High-flow oxygen is essential.
• Maternal shock has 80% fetal mortality rate
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Trauma in Pregnancy
Primary and Secondary Surveys
Optimize maternal and fetal outcome
• High-flow oxygen rapidly administered
 Fetal hypoxia occurs before maternal hypoxia
• Fluid administration must be prompt
 Fluid volume needed is greater
• Frequent Ongoing Exams
 Mortality of fetus related to maternal treatment
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Supine Hypotension
Venous return decreases 30% in supine
position with 20-week or larger uterus.
• Acute hypotension
• Syncope
• Fetal bradycardia
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Supine Hypotension
Transport position
• Tilt or rotate backboard 20–30o to patient’s left
• Elevate right hip 4–6 inches with towel
 Manually displace uterus to left
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Supine Hypotension
Transport position
• Better stabilized
with vacuum backboard
• More comfortable
than standard backboard
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Relatively minor abdominal trauma
can cause fetal death.
Maternal death is most common cause
of fetal death.
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Pregnant Trauma Arrest
Treated same as for other victims
• Defibrillation settings are same
• Fluid volume needed increases
 4 liters normal saline rapid infusion during transport
If mother unsalvageable:
• Continue CPR
• Notify hospital of possible cesarean section
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Types of Trauma
Motor-vehicle collisions
Penetrating injuries
Domestic violence
Falls
Burns
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Motor-Vehicle Collisions
65–75% of pregnancy-related trauma
• <1% injured when minor vehicle damage
• Seatbelts significantly decrease mortality
 Has not shown any increase in uterine injury
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Motor-Vehicle Collisions
Maternal death
 Head injury
• Most common
 Uncontrolled
hemorrhage
• Second most common
• Assess pelvis
Fetal injury
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 Fetal distress
 Fetal death
 Placental
abruption
 Uterine rupture
 Preterm labor

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Abdominal Trauma
Physiologic changes
• Decreased sensitivity
 Gradual stretching
 Hormonal changes
 Uterus very vascular
Clinical presentation
• Guarding, rigidity, rebound response absent
 Abdominal trauma requires ED evaluation
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Penetrating Injuries
Gunshot wounds and stabbings
• Entry below fundus
 Uterus absorbs force, protects maternal
organs
 High fetal mortality rate: 40–70%
 Lower maternal mortality rate: 4–10%
• Entry above fundus
 Bowel injury due to displacement
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Domestic Violence
10% experience abuse during pregnancy
• Proximal and midline injuries
 Face and neck most common
• Low birth weight
• Abused by spouse or boyfriend: The incidence of
violence in pregnancy may range from 4 to 17
percent (in Canada)
http://www.womensweb.ca/violence/dv/pregnan
cy.php
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Falls
Injury from falls
• Increase with progression of pregnancy
 Center of gravity altered
• Proportionate to force and body part impacted
• Pelvic injuries
 Placental separation
 Fetal fractures
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Burns
Fluid volume needed increases
• Mortality and morbidity
Maternal mortality same as non-
pregnant
Fetal mortality increases with >20%
BSA
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Trauma Prevention
Proper seat-belt use
Report domestic violence
Counseling for domestic violence
Patient education
• Multiple changes associated with pregnancy
 Physiological, anatomical, emotional
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Summary
Trauma in Pregnancy
• Knowledge of physiological changes
 Hypotension and hemorrhage easily overlooked
• Rapid evaluation and interventions to stabilize
 Aggressive oxygen administration
 Aggressive fluid resuscitation
• Prevent supine hypotension
Fetal care depends on maternal care.
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Discussion
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