Trauma in pregnancy: A narrative review of the current literature - 03/06/24

Doi : 10.1016/j.ajem.2024.04.029

Michael D. April, MD, DPhil ^a,^b , Brit Long, MD ^c,^{^⁎}
^a Uniformed Services University of the Health Sciences, Bethesda, MD, USA
^b 14th Field Hospital, Fort Stewart, GA, USA
^c Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA

^⁎Corresponding author at: 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234.3551 Roger Brooke DrFort Sam HoustonTX78234

Abstract

Introduction

Trauma accounts for nearly half of all deaths of pregnant women. Pregnant women have distinct physiologic and anatomic characteristics which complicate their management following major trauma.

Objective

This paper comprises a narrative review of the most recent literature informing the management of pregnant trauma patients.

Discussion

The incidence of trauma during pregnancy is 6–8%. The focus of clinical assessment must be on the mother, starting with the primary survey. During airway management, clinicians should consider early intubation if necessary and utilize gastric tubes to minimize the risk of aspiration. Pregnant women experience progesterone-mediated hyperventilation, and normal PaCO2 levels may portend imminent respiratory failure. Clinicians should utilize left lateral tilt in hypotensive pregnant women to displace the uterus off the inferior vena cava. Ultrasonography is an attractive imaging modality for pregnant women which is specific for ruling in intraabdominal hemorrhage but not sufficiently sensitive to exclude this diagnosis. Clinicians should not hesitate to order computed tomography imaging in unstable patients if there is diagnostic ambiguity. Cardiotocographic monitoring simultaneously assesses uterine contractions and fetal heart rate and should last at least 4 h for pregnant women following even minor abdominal trauma if their fetus has achieved viable gestational age (approximately 24 weeks). In the event of cardiac arrest, peri-mortem cesarean section may improve outcomes for the mother and fetus alike. Unique specific complications include uterine rupture and placental abruption, which require emergent resuscitation and obstetrics consultation for definitive management. Emergency clinicians should maintain a low threshold for transfer to a tertiary care center given correlations between even isolated and relatively minor traumatic injuries with adverse fetal and maternal outcomes.

Conclusions

Trauma is a common cause of morbidity and mortality in pregnant women. Emergency clinicians must understand the evaluation and management of pregnant trauma patients.

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Keywords : Pregnancy, Trauma, Resuscitation, Placental abruption, Uterine rupture, Neonatal, Fetus