One of the leading causes of nonobstetrical maternal death in the United States, trauma experienced during pregnancy can cause significant complications for the mother and fetus. This article reviews the most common types of traumatic injury, the physiologic and anatomic changes that occur in pregnancy, and how to approach assessing and caring for a pregnant patient after a trauma.
Types of injury
Pregnant women experience violent trauma more significantly than those who aren't pregnant, which is associated with an increase in mortality. The type of trauma most often seen is blunt trauma—the force of pressure over an area of the body. When this happens to the pregnant abdomen, it can lead to placental abruption, liver or spleen injuries, retroperitoneal hemorrhage, and preterm delivery. Bruises to the abdomen, pelvis, and lower back are often seen.
Trauma severity and higher gestational age increase the risk of emergency cesarean section. When blunt trauma occurs above the fundus, there's a greater likelihood of injuries to a maternal organ. Blunt trauma to the heart and chest can cause significant life-threatening injuries. When there's blunt trauma below the fundus, there's a higher likelihood of injury to the fetus. Penetrating trauma can lead to sudden pregnancy loss due to direct impact to the fetus, placenta, or umbilical cord, causing injury and fetal-maternal hemorrhage.
The top causes of trauma during pregnancy are intimate partner violence (IPV), motor vehicle accidents (MVAs), falls, toxic exposure, and burns.
IPV is the physical, sexual, financial, or emotional abuse inflicted by a partner in an intimate relationship. The rate of IPV increases in pregnancy; it's associated with maternal and fetal morbidity, and is significantly linked to placental abruption. Patients who experience trauma due to IPV have a higher rate of mortality compared with pregnant patients who experience unintentional trauma. Women in IPV relationships can experience a range of violence, including slapping, punching, biting, kicking, spitting, burning, stabbing, strangling, threatening, controlling access to healthcare, preventing the pregnant woman from working, and forcing or coercing sexual activity. Victims of IPV often experience multiple forms of trauma.
MVA injuries can be caused by different mechanisms; however, the number one cause is improper seatbelt use (not using a seatbelt or using it improperly). Lack of seatbelt use is associated with more severe maternal and fetal injuries, placental abruption, preterm labor, and low-birth-weight babies. Other MVA injuries can occur from the steering wheel or dashboard impact.
The incidence of falls during pregnancy increases after 20 weeks' gestation when the fetus and uterus have grown, and there's a softening of ligaments and muscles, which shifts the woman's center of gravity forward and may cause balance issues.
Toxic exposure can be a result of intentional or unintentional poisoning. Intention poisoning typically occurs as a suicide attempt; unintentional poisoning can occur from various environmental exposures, such as the inhalation of solvents, lead, pesticides, air pollutants, mercury, or carbon monoxide. The effects of toxic exposure can result in fetal abnormalities, such as preterm birth, low birth weight, anemia, small for gestational age, physical impairments, and cognitive impairments such as autism; maternal morbidity and death; and fetal death. One of the major risk factors for intentional poisoning is IPV; all women should be screened for IPV, depression, and suicidal ideation.
The overall incidence of significant burns in pregnancy is low; however, burns result in high morbidity and mortality for the mother and fetus. Both maternal and fetal outcomes depend on the severity of the burn (depth and surface area) and the gestational age of the fetus, and fetal survival is highly dependent on maternal survival. Unlike other types of trauma, burns have a complex physiologic effect. There's direct trauma to tissue, and large burns may result in infections and sepsis. Inhalation burns can cause damage to the respiratory tract, resulting in respiratory compromise and arrest.
Physiologic and anatomic changes
During pregnancy, there are normal physiologic and anatomic changes that can be a challenge when caring for pregnant trauma patients. These changes can affect most organs and impact treatment and recovery.
Within the circulatory system, there's an uptake in water retention—as much as 8.5 L in the early term pregnant patient. Most of the increase in volume is due to the placenta and amniotic fluid. However, there's also an increase in maternal blood volume, plasma, and red blood cells. In addition, there's an increase in extracellular fluid and a general underlying edema, mostly seen in the extremities, but occurring throughout the body.
There are also changes to the cardiovascular system. As the pregnancy develops, the woman's heart will shift upward and to the left, rotating so the apex is more lateral. Maternal BP will decrease slightly in early pregnancy and return to prepregnancy levels by term. There's an increase in blood volume, heart rate, stroke volume, and coagulation factors, with a 50% to 80% increase in fibrinogen. There's also a decrease in vascular resistance. Supine position results in the obstruction of venous return from the compression of the inferior vena cava, which increases the risk of deep venous thrombosis.
Respiratory system changes include anatomic changes in the ribcage, with a widening of the subcostal angle, expansion of the chest, and the level of the diaphragm rising as much as 4 cm. There's a 40% to 50% increase in the respiratory rate and a 30% to 50% increase in oxygen demand. Pregnant women develop a state of chronic hyperventilation that causes a normal respiratory alkalosis. Due to an increase in respiration and fetal oxygen demands, it's critical to assess maternal airway patency in cases of trauma. The further along in gestation, the higher the risk of aspiration.
The renal system experiences an increase in sodium retention. As the pregnancy progresses, there's a decrease in bladder capacity and an enlargement of the kidneys due to increased vasculature and dilation of the uterus.
Many pregnant women experience gastrointestinal changes, with a decrease in stomach motility and delayed gastric emptying. This can lead to increased heartburn and appetite. In addition, the woman may experience excessive saliva (ptyalism) and an appetite for nonnutritive substances such as paper (pica). The endocrine system can be involved, leading to a peripheral resistance to insulin and gestational diabetes.
Musculoskeletal system changes include softening of the pelvic ligaments and widening of the symphysis pubis and sacroiliac joints. In addition, there's a progressive inward arch of the lower back (lordosis), displacing the center of gravity forward.
Overall, the immune system is dampened, preventing the rejection of the growing fetus. With an altered immune system, pregnant women are more susceptible to infections and viruses.
In general, there are no normal neurologic changes. Any pregnant woman who's passed 20 weeks' gestation with seizures should be presumed to have preeclampsia/eclampsia and be treated accordingly.
The primary survey starts with the ABCDEs. The secondary survey doesn't start until the primary survey has been completed and these aspects are stabilized. All trauma patients should have a comprehensive systematic trauma assessment at the time they present for care. Special assessments and evaluations should be done for the pregnant patient.
A: The first step in the trauma assessment is stabilizing the airway and cervical spine immobilization. Assess the airway for patency, foreign bodies, and injuries. Assess the patient's speech when speaking with her. Note and monitor any changes in voice or speech patterns. Hoarseness can be a sign of a traumatic injury to the neck or the vocal cords, or it can be an early signal of strangulation or an evolving aortic dissection. Cervical spine immobilization should be done in all multisystem traumas and the patient should remain on cervical spine precautions until cleared clinically or radiographically for any injuries. Due to the changes in pregnancy with an increase in weight, edema, and mucus secretions, ongoing assessment is needed to ensure a patent airway. If the airway is compromised or changes are detected, early intubation may be necessary because failed intubation rates significantly increase in pregnant patients.
B: The breathing assessment is done by inspecting, palpating, and auscultating to determine adequate ventilations. Begin by inspecting for abnormalities, such as a flailed chest, deviated trachea, injuries, and open wounds. Palpate for crepitus, pain, and/or tenderness over the chest. Auscultate lung sounds to determine normal versus abnormal breath sounds. Remember that hyperventilation occurs in pregnancy, so the normal baseline rate will be elevated.
C: Assess the circulatory system to determine level of consciousness, hemodynamic status, and the presence of hemorrhage. Tilt pregnant patients over 20 weeks' gestation onto their left side by 25% to 30% to lift pressure off the vena cava, which will increase venous return to the heart by 20% and improve the patient's coronary perfusion. Pregnant women have an increased volume load, so signs and symptoms of hemorrhage may be delayed. In cases of suspected or obvious hemorrhage, obtain two large-bore I.V.s; pregnant women should receive O negative blood until a crossmatch is performed. Aggressive I.V. fluids may also need to be given to patients with severe burns.
If the patient experiences cardiac arrest, immediately initiate CPR using Basic Life Support and Advanced Cardiac Life Support (ACLS) recommendations. If no return in spontaneous circulation is noted after 3 minutes of ongoing CPR, prepare for a perimortem caesarean section if 20 weeks' gestation or greater. Preparation for a perimortem caesarean section includes administration of betamethasone to strengthen the fetal lungs. Obtain the necessary supplies, such as an incubator, and notify the obstetrician, respiratory therapist, and the neonatal ICU. Per the 2015 American Heart Association ACLS updates, the goal time to begin the perimortem caesarean section is after 5 minutes of continuous CPR. Be aware that the managing trauma physician may consider a perimortem hysterectomy because this has been shown to improve maternal end organ perfusion by more than 25%.
D: The disability aspect of the assessment includes a neurologic exam and pupillary reaction. Conduct a quick neurologic assessment using a common tool, such as the Alert, Voice, Pain, Unresponsive Scale or the Glasgow Coma Scale (GCS). Pregnant patients presenting with seizures should be treated for preeclampsia and eclampsia. Another consideration is strangulation. For the unconscious pregnant patient who isn't seizing and IPV is suspected, conduct a thorough assessment for strangulation.
E: All trauma patients should be completely exposed, allowing for a quick assessment of significant injuries that may need immediate treatment. For cases of IPV, there may be multiple injuries in various stages of healing. If IPV or attempted homicide is suspected, measure all injuries with detailed descriptions and/or photographs for potential forensic and legal purposes. In burn cases, the total body surface area (TBSA) of the burns needs to be calculated. For burns greater than 50% TBSA, the recommended treatment is caesarean section if the woman is in the third trimester and possibly for those in the second trimester. Obtain an obstetrical consultation for women in the first trimester because spontaneous miscarriage can occur.
Initiating the presence of the family during the trauma assessment should be done cautiously if the patient's injury is unexplained or IPV is suspected. IPV is one of the leading causes of trauma in pregnancy and until it can be ruled out, these patients should have safety measures in place to protect them.
A full set of vital signs is essential to monitor for the effectiveness of interventions. Obtaining frequent vital signs allows for the identification of trends that can signal improvement in clinical condition or a potential rapid decline. A sudden decrease in BP or an increase in heart rate greater than 100 beats/minute may signal internal bleeding; a ruptured uterus; or a shock state such as hypovolemic shock, cardiogenic shock, or distributive shock. Consult with the physician for specific hemodynamic target goals. In the absence of hemodynamic target goals, follow the hospital's policy. In the absence of a hospital policy, ensure that the systolic BP remains greater than 100 and less than 140 mm Hg, the diastolic BP remains greater than 60 and less than 90 mm Hg, and the heart rate remains greater than 50 and less than 100 beats/minute. This ensures that the mother has a higher likelihood of circulating an adequate amount of oxygen to organs and tissues, as well as the fetus. A BP measurement of greater than 140/90 mm Hg warrants an obstetrical consult because this may be an early sign of preeclampsia. All pregnant trauma patients should have additional interventions, including lab work, cardiac monitoring, nasogastric tube consideration, oxygenation and ventilation assessment, and pain management (see Testing procedures).
The secondary survey beings with the history of the trauma, followed by obstetrical history, a head-to-toe exam, and diagnostic procedures. See Taking an MVA history for essential questions to ask if your patient has experienced an MVA.
The first step in obtaining an accurate obstetrical history is to determine the gestational age. If the patient is responsive, she may be able to tell you the gestational age or when the baby is due; however, you may need to rely on an ultrasound once the patient is stable. Measuring fundal height is often a quick method to determine gestational age and potential viability. A fundus at the umbilicus is noted to be 20 weeks' gestational age and should be presumed to be viable.
The obstetrical history should also include asking if there were previous single or multiple pregnancies and the outcomes; if there were any complications in previous pregnancies; the last time that the patient felt fetal movement; and if there's been any vaginal discharge, uterine pain, or contractions. If the patient experienced preterm labor in a previous pregnancy, she's at risk for preterm labor precipitated by the trauma.
For the patient who's alert and responsive, determine her gravida and parity information, often referred to as GTPAL:
- G: Gravida, how many times has the patient been pregnant?
- T: Term, how many of the pregnancies reached term gestational age (37 weeks or more)?
- P: Preterm, how many of the pregnancies were preterm (22 to 36.6 weeks)?
- A: Abortion, how many of the pregnancies resulted in a spontaneous miscarriage or a therapeutic abortion?
- L: Living, how many live offspring does the patient currently have?
Pregnant trauma patients, especially those at 20 weeks' gestation or more, should have an immediate consultation with an obstetrician and fetal status should be monitored.
A head-to-toe exam should be done for all pregnant trauma patients. Assess the uterus for injuries, contour, shape, size, and tenderness. An abnormal shape, size, or couture may indicate uterine rupture or hemorrhage; tenderness may indicate blunt trauma or placental abruption. Palpating the uterus using Leopold maneuvers is a method to determine fetal size, position, and movement, which may be essential if labor is suspected. Palpating the abdomen also helps determine if contractions are present. Assess the vagina for injuries, bleeding, or other fluid that may indicate ruptured membranes. If there are concerns for labor or ruptured membranes, a sterile speculum exam or manual exam may need to be conducted.
Assess fetal heart sounds in patients greater than 12 weeks' gestation. Fetal heart rate is a direct indicator of the well-being of the fetus. This can be done using Doppler or ultrasound if there's difficulty assessing fetal heart sounds in patients who are in the first trimester. For patients greater than 20 weeks' gestation with a presumed viable pregnancy, continuous fetal heart monitoring for at least 4 hours should take place. For patients with severe injuries or those who've experienced a significant MVA, continuous fetal heart monitoring should take place for a longer period.
When a pregnant patient has sustained a traumatic injury, many hospitals require that the mother be assigned a primary nurse to provide care for her and a second nurse with specialty training in interpreting fetal heart rate patterns who can identify concerning results, including later decelerations, minimal variability, bradycardia or tachycardia, and contractions on the continuous fetal heart monitor.
All female patients of childbearing age should have a beta human chorionic gonadotropin test to establish whether they're pregnant. Studies have shown that 10% of women who present to the ED and report that there's no way they can be pregnant are found to have a positive pregnancy test. Early detection of a pregnancy will enable healthcare providers to minimize risks to the pregnancy, such as avoiding teratogen medication or radiographic studies. A complete blood cell count should be done to establish hematocrit and hemoglobin levels. It may be necessary to know the platelet count, prothrombin, and partial thromboplastin level in cases of suspected or actual coagulopathies.
Knowing the blood type and Rh status of the pregnant patient is paramount. Patients who are Rh negative should have Rh(D) immune globulin administered in cases where there's extensive maternal trauma, vaginal bleeding, or suspected placental abruption; this should be considered on a case-by-case basis when there's mild trauma. A Kleihauer-Betke test should be conducted to detect the presence of fetal blood in the maternal circulation. This can help indicate the severity of uterine and placental trauma, and the need for Rh(D) immune globulin.
It may be necessary for pregnant patients to have a computed tomography (CT) scan or X-rays to rule out or diagnose injuries. Radiation exposure is often a concern for the pregnant patient and growing fetus. All pregnant patients should have a lead shield placed over their abdomen. In cases where the patient needs an abdominal CT scan, the number of scans should be limited because two or more abdominal CT scans can result in enough radiation exposure to cause fetal abnormalities.
Consequence of trauma
Placental abruption—when the placenta shears away from the uterus—is a serious consequence of trauma in pregnancy and the leading cause of fetal death. The degree of the abruption can vary depending on gestational age, where the placenta was implanted (anterior versus posterior), and the degree of trauma. There can be a significant abruption, or a microscopic abruption can occur in response to the trauma immediately or hours and days later. This can lead to inadequate placental and fetal perfusion, causing fetal distress. Signs of placental abruption include abdominal pain, tenderness or cramping, back pain, vaginal bleeding, frequent uterine contractions, and fetal distress.
Preterm labor—the onset of labor before 37 weeks' gestation—is another complication of trauma in pregnancy. Signs of preterm labor include pelvic, lower abdomen, or lower back pain/pressure; abdominal or vaginal cramps; and ruptured membranes. Having more than six contractions in 1 hour may be indicative of preterm labor and warrants further assessment.
Less common, but more lethal, is the risk of uterine rupture—the tearing of the uterine muscles. This can occur from direct blunt trauma; penetrating trauma from an external object; or penetrating trauma from an internal maternal or fetal part, such as a fractured bone that's penetrating through the uterus. Signs and symptoms may be obvious, such as external trauma, or subtler. The only clinical signs are an expanding abdomen and a decrease in fetal heart rate. Uterine rupture requires immediate emergency cesarean section and often hysterectomy.
Pregnant women who've sustained minor trauma and no injuries will most likely be discharged home. The discharge instructions for all pregnant women should include follow-up with their obstetrician and signs and symptoms of possible complications that can occur.
Instruct the patient on how to count fetal kicks. One easy method is to select a time each night to lie down and place both hands on the abdomen. The patient should feel 10 movements or kick counts within 2 hours. Once she reaches 10 movements, she can stop. If she has gone 2 hours and hasn't reached 10 movements, she should get up, have a cup of water or juice to try to stimulate the fetus, and then lie down again. If she fails to reach 10 movements thereafter, she should call her obstetrician and have an evaluation.
Teach the patient about the signs and symptoms of preterm labor to immediately report to the obstetrician. Pregnant women should be on the alert for cramping or abdominal, suprapubic, or back pain that has a pattern. The uterus may or may not feel hard during the time of pain. Instruct the patient to start counting the pain episodes and if they occur every 10 minutes or more frequently for an hour, she should contact the obstetrician.
Because many preventable trauma-related injuries and complications are associated with improper seatbelt use, instruct the patient on the correct placement. The seatbelt should be placed under the uterus and the shoulder belt should be positioned between the breasts, lateral to the uterus, and over the middle portion of the clavicle. Because many MVAs are associated with substance use, counsel the patient to avoid alcohol or other substances that interfere with the ability to drive and avoid being a passenger when the driver is impaired.
Because IPV is a significant and often escalating issue affecting many pregnant women, information should be provided on available support resources if IPV is suspected. Initiating a social worker consult may be necessary.
Caring for a pregnant trauma patient can be a challenge, but nurses are in a key role to not only provide essential care, but also to identify possible IPV, which can be deadly if left unrecognized.
Taking an MVA history
Ask the following questions if your pregnant patient has been in an MVA:
- What were the dynamics of the accident? How did it take place? Where did it occur? Who was involved?
- What was the patient's location in the vehicle?
- Was there airbag deployment?
- Was the patient wearing a seatbelt and was it on correctly?
- How much damage was there to the vehicle?
- Did unconsciousness occur?
- How long did it take the patient to be extricated from the vehicle?
- Was the patient able to ambulate after the accident?
To determine the patient's gravida and parity information, think GTPAL.
G: Gravida, how many times has the patient been pregnant?
T Term, how many of the pregnancies reached term gestational age (37 weeks or more)?
P: Preterm, how many of the pregnancies were preterm (22 to 36.6 weeks)?
A: Abortion, how many of the pregnancies resulted in a spontaneous miscarriage or a therapeutic abortion?
L: Living, how many live offspring does the patient currently have?
A female patient is brought into the ED via ambulance. Report from the paramedics reveals that a neighbor in the apartment complex found her unconscious at the bottom of a flight of stairs. She remains unconscious, with minimal arousal to painful stimuli. Her left leg has obvious trauma and appears to be fractured. The paramedics have no medical history; the neighbor who found her said that she tends to keep to herself but he thought she may be pregnant. The neighbor also reported that there are always fights going on in the apartment and he doesn't know how she puts up with it. You're the first healthcare professional to assess the patient. You'll need to follow these nursing considerations for caring for an unconscious patient:
- The unconscious patient without a history of events should be considered a trauma patient.
- All patients should be placed in a cervical collar until the presence of cervical spine injuries is determined.
- Assess the patient's ABCs immediately; consider activating the rapid response or trauma team for a GCS score under 8 because early interventions and intubation may be needed.
- Use the primary and secondary trauma survey when assessing the patient.
- Determine gestational age and activate an obstetrical consult early on.
- Undress the patient, which is imperative to determine any unobvious injuries; maintain privacy.
- Use warmed blankets to replace removed clothing.
- Document all injuries, old and new; consider taking pictures if the hospital policy allows.
- Place all clothing in brown paper bags to preserve evidence in case of homicide or attempted homicide.
- Consult with the labor and delivery department, and update them on the case so they can prepare for transfer, emergency cesarean section, and fetal monitoring.
- Inform the security department in case the patient's partner presents due to the risk of IPV based on the neighbor's comments.