Trauma in the Obstetric Patient: A Bedside Tool

Learning Objectives

After reading this article, the physician should be able to:

You Might Also Like

• ACS In the Pregnant Patient
• Sepsis in Pregnancy
• Bedside Biliary Ultrasound

Explore This Issue

ACEP News: Vol 29 – No 07 – July 2010

• Practically apply trauma assessment and management principles to the pregnant patient.
• Understand the physiologic basis for variations of trauma care for the pregnant patient.
• Utilize a practical bedside tool to assist in assessment and management of these patients.
• Utilize the tool to help in establishing emergency department protocols for these patients in their institution.

Trauma is the number one cause of pregnancy-associated maternal deaths in the United States.1 Concerns about the impact of tests and treatments on the unborn fetus can often cause misguided delays and alteration of management.

This article contains a tool (Figure 1: Prenatal Trauma Management) that condenses the key management guidelines allowing the user to make prompt, appropriate decisions.

The tool contains links to corresponding sections of this document for in-depth information. However, it can stand alone, and users might consider posting it in ED trauma rooms as a quick guide and/or loading it onto a hand-held device. There is an on-line version of the table that hyperlinks key portions of the table to the article’s didactic content ­located at www.acep.org/clinical.

Generally, medications, tests, treatments, and procedures required for the mother’s stabilization should not be withheld because of pregnancy. A viable fetus should be promptly placed on continuous monitoring until under the care of an obstetrician.

Because it is often difficult to determine degree of force, significant trauma should be anticipated with any mechanism of injury that is more than very minor. Always evaluate for possible pregnancy-related cause of an accident, e.g., seizure secondary to eclampsia in 3rd trimester patient.

Pregnancy Modifications2

Physiologic Changes

Physiologic changes in pregnancy may affect the type of injury and the mother’s response to trauma. Generally the mother’s physiologic response is to maintain her own survival even if there are resultant adverse effects on the fetus.

Pulse. Increases to average of 80-95 by 3rd trimester. A pulse greater than 100 is still a sensitive marker of shock. Orthostatic vital signs may be a more sensitive indicator of hypovolemia.

Blood Pressure. Decreases to average of 105/60. After 20 weeks, a significant drop in supine BP can occur, usually caused by uterine compression of inferior vena cava. These effects may be relieved by turning the patient to the left lateral recumbent position.

Cardiac Output. Increased.

Blood Volume. Plasma volume increases by 50%, allowing patient to lose 30%-35% of blood volume before a significant drop in blood pressure.