Introduction
Trauma affects nearly 8% of pregnant population[1] and is one of the leading causes of pregnancy-related mortality and morbidity.[2] The risk of trauma to mother increases as pregnancy advances, 10%–15% in first trimester and 50%–54% in third trimester.[3] Moreover, there is nearly twofold increase in mortality in pregnant trauma patients as compared with nonpregnant patients.[4]
Managing a pregnant patient with trauma is a challenging task. The clinician has to keep in mind that there are two patients who have to be managed simultaneously mother and the fetus and these two are interrelated. The effect of treatment of the mother is going to affect fetus and the adverse effects on fetus can lead to maternal complications. Moreover pregnancy causes various physiological and anatomical changes in the mother making them a special population to deal with.
The various anatomical and physiological changes that occur during pregnancy and their implications in the management of a parturient with trauma are given in [Tables 1 and 2].[567]
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Table 1: Anatomical changes and implications during major trauma[5]
Table 2: Physiological changes and implications during major trauma
Despite the various physiological changes during pregnancy, the initial management of pregnant patient remains almost similar to nonpregnant population. The best treatment for fetus is the timely optimal resuscitation of the mother. The treatment priorities remain the same. The assessment is divided into primary survey and secondary survey. First is the primary survey and resuscitation of the mother, then assessment of the fetus and then secondary survey of the mother.[5]
Primary Survey and Resuscitation
Any trauma victim of childbearing age must be considered pregnant until proven otherwise. This is important because most of severely injured patient may not be able to communicate or may not be aware of their pregnancy. It is recommended that pregnancy test should be performed in all patients.[5]
Airway and Breathing
The first step in management is adequate airway patency. It should be kept in mind that pregnant patients have difficult airway and difficult intubation than nonpregnant patients.[8] They have mucosal edema, difficult laryngoscopy, and increased capillary engorgement, which leads to increased risk of bleeding during airway manipulation.[8] They have decreased functional residual capacity (FRC) and less oxygen reserve and increased oxygen requirements making them prone for hypoxia. Moreover, the fetus is extremely sensitive to maternal hypoxia. All pregnant patients should receive oxygen to maintain saturation >95%. An early elective planned intubation should be considered than an emergency intubation.
The risk of aspiration of gastric contents also increases in pregnant patients as gastric emptying is delayed and the tone of lower esophageal sphincter is decreased.[9] The precautions to be taken during intubation are included in Table 3.
Table 3: Precautions to be taken during intubation
After intubation, it is important to monitor PCO2 and this should be kept around 30 mmHg. As the minute ventilation increases during the course of pregnancy, PaCO2 decreases. PaCO2 decreases to approx. 30 mmHg by 20 weeks of gestation from 40 mmHg prepregnancy. Care should be taken while inserting a chest tube in pregnant patients. As the diaphragm is pushed up by the gravid uterus, there are chances of chest tube entering abdominal cavity if put in the usual space. Ideally, a chest tube should be placed one to two intercostal space higher than normal patients.[10]
Circulation With Hemorrhage Control
The same principles of management of shock have to be followed as while managing nonpregnant patients. Two large bore cannulae [14–16 G] should be inserted in antecubital veins and 1–2 L of crystalloid rapidly infused. Early type specific blood should be administered. Whole fresh blood may be a good alternative to blood component therapy. The studies done in cases of massive obstetric hemorrhage have revealed that whole blood may be superior to PRBCs in preventing acute tubular necrosis and other complications.[11] In developing countries, readily available fresh warm blood is a good alternative to more expensive blood components.[12] In case of emergency transfusion, O-negative blood should be transfused to prevent Rh sensitization in Rh-negative woman.
The classes of hemorrhagic shock remain the same but few points have to be kept in mind. Pregnant patients can lose a significant amount of blood before becoming tachycardiac or hypotensive. This is because they have already increased intravascular volume.[13] Vasopressors should be avoided and should be used as last resort[14] as vasoactive agents may reduce uteroplacental circulation resulting in fetal hypoxia. One should be very cautious regarding the use of bicarbonate because rapid correction of maternal acidosis with bicarbonate can reduce the compensatory hyperventilation.[15]
Another peculiar feature in pregnant patients is supine hypotension syndrome. There can be up to 30% reduction in cardiac output in pregnant patients after midpregnancy because of compression of vena cava by gravid uterus.[16] If the patient is hypotensive, either she should be placed in left lateral position or uterus be displaced manually to the left side. If the patient is on the spine board, it can be logrolled 4–6 inches to left and a bolster can be kept beneath it.
Disability
As soon as the patient's cardiopulmonary status has been stabilized, a rapid and directed neurological examination should be performed.
Evaluation of Glassgow coma score, pupillary reaction, and lateralizing signs is similar to nonpregnant patients. However, seizures in a pregnant patient should be evaluated carefully. Seizures could be due to head injury or eclampsia. If there is associated hypertension, proteinuria, and peripheral edema, eclampsia is more likely. In this regard, early consultation with neurologist and obstetrician are important. Head computed tomography (CT) scan, if necessary, should be done in all patients. The indications of CT remain the same as in nonpregnant patients. Radiation exposure of the fetus to <5–10 rad causes no significant increase in the risk of congenital malformations, intrauterine growth retardation, or miscarriage.[17] Radiation dose from the CT scan of the head is approx. 0.05rad. While doing CT scan, the abdomen of the mother should be shielded with lead apron.
It is important to note succinylcholine can be safely used when there is an urgent need to secure an airway in the head-injured pregnant trauma victim. The concern regarding increase in ICP with succinylcholine is not significant.[18]
Measures to decrease raised intracranial pressure should be undertaken as in nonpregnant patients. Bolus of mannitol and acute hyperventilation can be safely instituted in cases of acute rise in ICP. Prophylactic anticonvulsant therapy with phenytoin should be administered to prevent seizures as seizures may have deleterious effect on both mother and the fetus.[19] Those patients who require surgical evacuation should be taken for the surgery without delay. Sometimes limited intervention as extraventricular drainage should be done and at other times termination of pregnancy is also done along with intracranial surgery. During the surgery, it is important to monitor the fetal heart rate and uterine contractions.[20]
Exposure
The pregnant patient should be fully exposed and screened for life-threatening injuries. The abdominal examination is critically important to rule out various complications of trauma in pregnancy and to assess the well-being of fetus.
Abdominal Examination and Assessment of the Fetus
Fetal assessment comes after the primary survey is completed and the patient is hemodynamically stabilized.
The abdomen should be inspected for distension and palpated for guarding and rigidity to assess for intraabdominal hemorrhage, perforation of viscus, and uterine rupture. In uterine examination, fundal height, shape, hypertonus, and tenderness should be assessed. Uterine contractions occur in almost 40% of cases of trauma but in 90% cases resolve with time with no adverse fetal effects.[21] Routine tocolytics are not indicated in trauma patients as most of the contractions stop spontaneously and those contractions that are not self-limited are often pathological in origin and are contraindication to tocolytic therapy. The decision to use them should be made by the obstetrician managing the patient.
Contraindications for tocolysis include the following:
- Pathological or suspicious fetal heart rate pattern
- Lethal fetal anomaly
- Intrauterine fetal death
- Suspected chorioamnionitis (clinical signs of infection)
- Severe hypertensive conditions in pregnancy
- Abruption of placenta
- Severe intrauterine growth retardation (IUGR).
Common tocolytics that are used include calciumchannel blockers, magnesium sulfate, and nonsteroidal anti-inflammatory agents.[22]
The two most important complications of pregnancy which need to be ruled out initially and which can lead to fetal demise are placental abruption and uterine rupture.
Placental abruption occurs in 5%–50% of cases.[23] The signs of placental abruption are vaginal bleeding, uterine tenderness, uterine irritability, and tetany. Abruption near term can be managed by urgent vaginal delivery or cesarean section depending on the mothers' vitals, but early abruption is difficult to manage. In early abruption, continuous and vigilant monitoring is required for careful continuation of pregnancy with urgent delivery as irritability increases.[24]
Uterine rupture is rare. It is seen in only 0.6% of all trauma patients. Uterine rupture is suggested by abdominal fetal lie [oblique or transverse] or palpation of fetal parts along with guarding and rigidity. Urgent obstetrical consultation is required in such cases.[25] Management includes urgent laparotomy to control bleeding and resuscitation of patients.
Trauma can lead to twofold increased risk of preterm delivery.[26] Placental abruption, traumatic injury to uterus directly, or premature rupture of membranes can initiate preterm labor. Early neonatology consultation and injection of steroid if the fetus is viable should be considered.
Fetal Monitoring
Fetal heart sounds should be auscultated for fetal assessment. Before 10 weeks of gestation, they can be auscultated with Doppler ultrasound. After 20–24 weeks of gestation, continuous fetal monitoring with tocodynamometer should be done. Normal fetal heart rate is 120–160 beats/minute Fetal bradycardia, tachycardia, repetitive decelerations, and absence of beat to beat variability are signs of impending maternal or fetal decompensation.
The important point to remember is that the fetus may have suffered significant injury with apparently minor maternal injury. With any abnormal fetal heart rate pattern, the maternal vitals should be stabilized. This can be done with supplemental oxygen, intravenous fluids, and left lateral position. Ideally, the fetal monitoring should continue for at least 24 hours following the insult.[27] According to ATLS,[5] patients should be monitored for continuously 6 hours if they have no risk factor for fetal loss. The risk factors that mandate 24-hour extensive monitoring are given in Table 4.
Table 4: Risk factors that mandate 24 h extensive monitoring
Vaginal examination is to be done after ruling out placenta previa by ultrasound scan. Vagina should be examined for bleeding, cervical dilatation and effacement or lacerations, and fetal presentation.
Adjuncts to Primary Survey
SPO2 monitor, ECG tracing, and vitals monitoring should be continued. Obtain a complete blood count, urinalysis, serum electrolyte level, and blood for typing and cross-match. Administer tetanus toxoid (0.5 mL) to all patients. Out of various laboratory values, the important considerations taken into account before interpretation are physiological anemia of pregnancy and hyperfibrogenemia. Normal fibrinogen levels are more than 4 g/L during pregnancy, whereas in nonpregnant patients, the levels are between 1.5 and 4 g/L. Fibrinogen levels <2 g/L suggest disseminated intravascular coagulation in pregnant patients.[28]
The X-rays that should be done during primary survey in major trauma include chest and pelvis X-ray. Sometimes the X-rays are not ordered due to fear of damage to the fetus, but this is not true during all the trimesters pregnancy. It is usually limited to the gestational age <18 weeks.[2930] The highest teratogenic potential of ionizing radiation is during first 5–10 weeks during the period of organogenesis,[31] after 10 till 18 weeks, there can be Central nervous system (CNS) effects and growth retardation. There should be no delay of radiological evaluation for concern about fetal exposure.[32] Radiation carries negligible fetal risk of anomalies after 20-week gestation, especially if cumulative doses are <10 rads (100 mGy). Radiation doses of <5 rads (50 mGy) are not associated with an increase in pregnancy loss or fetal anomalies.[29] Fetal exposure at the time of chest X-ray is minimal (<0.1 mrad); femur exposure 1 mrad and at the time of pelvis X-ray 170 mrad.[22] This can be further reduced by putting an abdominal shield. CT causes more radiation exposure to fetus than X-ray. The area and number of CT cuts should be limited for avoiding more exposure.
Focused abdominal sonography for trauma (FAST) has no harmful effect of radiation and can be used to evaluate intrabdominal hemorrhage and the sensitivity of FAST in detecting intraperitoneal fluid in pregnant patients is close to 83%.[33] Obstetrical ultrasonography should be done along with the FAST in cases of significant maternal injury. Obstetrical USG may assist in assessment of gestational age, location of placenta, fetal cardiac rate, volume of amniotic fluid, or confirmation of fetal death.[34]
Secondary Assessment
Secondary assessment is similar as in nonpregnant patients. It comprises history and secondary survey of the patient. Secondary assessment should not be started unless primary survey and resuscitation is complete, all life-threatening injuries have been managed and patient is stabilized.
History – Brief history is taken which is the same as in nonpregnant patients. The mnemonic AMPLE is used.[5]
- A – History of allergies
- M – Medication
- P – History of past illness
- L – Last meal taken
- E – Events leading to injury.
Apart from this history, one should also take past obstetrical history and the history of current pregnancy. Any leakage of fluid, vaginal bleeding, abdominal pain, and contractions should be enquired.
Secondary survey includes head to toe systematic examination for injuries including perineum examination and pervaginal examination.
Definitive Care
Management of a pregnant trauma patient requires multidisciplinary approach including emergency physicians, trauma surgeons, anesthesiologists, obstetrician, and pediatricians. Timely obstetrician referral should be done while primary survey and resuscitation of the patient. Various fetomaternal complications which are peculiar to pregnant patients should be kept in mind. They are mentioned in Table 5.
Table 5: Various fetomaternal complications peculiar to pregnant patients
Isoimmunization
Fetomaternal bleeding has been reported in 2.6%–30% of pregnant trauma patients.[35] As small as 0.01 mL of Rh-positive blood can sensitize 70% of Rh-negative women which mandates Rh immunoglobulin therapy. Therefore, all Rh-negative pregnant trauma patients should receive Rh immunoglobulin therapy (single dose of 300 mg) within 72 hours of injury[36] with the exception when the injury is far away from the uterus as in extremities, head, etc.
A kleihauer-Betke test has been advocated to detect fetomaternal hemorrhage and to quantify it. A positive test indicates fetomaternal hemorrhage, but a negative test does not exclude it, so it has to be interpreted with caution. Most clinical laboratories will screen 1,000 red blood cells taken from the mother. One fetal cell per 1,000 cells counted corresponds to an fetomaternal hemorrhage (FMH) of 5 mL. If transplacental hemorrhage is more than 30 mL fetal blood, an additional dose of anti-D IgG is required.[34]
If the obstetrician services are not available, pregnant patients should be transferred to a particular center after primary survey and resuscitation are complete and life- and limb-threatening injuries have been ruled out. The fetus is usually considered viable after 23 weeks of gestation, when it has a 50% chance of extraurine survival. Patients can be managed in trauma unit if pregnancy is less than 23 weeks of gestation as fetus is considered nonviable and serious obstetrical complications are uncommon. If period of gestation is >23 weeks, they should be transferred to maternity unit.
Discharge
The patient should be discharged after she fulfills the following discharge criteria.
Discharge criteria
- No signs of fetal compromise
- No uterine activity
- No ruptured membranes
- No vaginal bleeding
- 4 hours of normal electronic fetal monitoring (if viable).
Any patient who is being discharged after adequate time of monitoring should be told about the warning signs (any signs of preterm labor, abdominal pain, vaginal bleeding, or change in fetal movement), so that she can report back.
Perimortem Cesarean Section
It is the cesarean section that is initiated after the CPR has commenced. The data in support of perimortem cesarean section are limited. It is done for two main indications:
- To salvage the mother – if cardiopulmonary resuscitation has not been effective and should be performed within 4 minutes of maternal cardiac arrest.[37] The rationale behind this is improved efficacy of maternal chest compression and resuscitation as aortocaval compression is alleviated after delivery. It should be done only in pregnancies more than 23–24 weeks when the uterus is large enough to cause aortocaval compression[3438]
- To salvage the fetus – if survival of the mother is not possible, but in such cases, judgement has to be made as the fetal compromise may have started well before mothers' hemodynamic instability and the fetus may have suffered prolonged hypoxia.
Conclusion
Trauma remains a major cause of maternal mortality and morbidity. Managing a pregnant trauma victim is a challenging task. Understanding of the various physiological and anatomical changes during pregnancy helps in guiding the management at each step. Timely resuscitation and multidisciplinary approach involving emergency physicians, trauma surgeons, anesthesiologists, and obstetricians can improve the survival.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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