You are called to see a 39 year old female driver in the Emergency Department who has been brought in by ambulance after a motor vehicle crash (head on collision). She is eight months pregnant (first pregnancy), and is complaining of abdominal pain.

(a)      Please outline your initial management of this patient.

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College Answer

The additional complicating factor of pregnancy expands the differential diagnosis, and requires additional investigation and monitoring, and complicates the performance of many interventions. Standard ACLS/EMST management of the initial presentation should be performed.   

Primary survey: [airway {and cervical spine}, breathing, circulation, disability and exposure] with high flow oxygen and standard monitoring. Standard resuscitation and initial Xrays should be performed with a lead apron covering the abdomen whenever possible.

Secondary survey: Abdominal examination is even less reliable than usual, and concern about foetal well-being and the possibility of abruption should be considered.  Uterine rupture is rare without previous uterine surgery.  Early consultation should occur with an obstetrician, and Cardio-Toco-Graphic monitoring should be implemented. Focused Abdominal Sonography in Trauma is still reliable, and abdominal CT scan is not contraindicated, and may help in the diagnosis of abruption.

Discussion

This question forms a part of the "manage this pregnant trauma patient" spectrum of fellowship questions. For a general reference, one is directed to Question 3 from the first paper of 2007 (Outline the special considerations involved in the care of a pregnant patient involved in multi-trauma.). Question 6 from the first paper of 2000 also touches on the ways in which physiological changes in pregancy affect the scenario of trauma. Specific features of the cardiorespiratory changes in pregnancy can also be found on the page dedicated to this topic

In brief, one should recall the following issues:

  • The airway is more difficult to control.
  • There is an increased risk of aspiration
  • The respiratory function is impaired by decreased FRC;
    • One needs to insert thei chest drains higher, so as to avoid the pushed-up diaphragms
  • When setting up the ventilator, one needs to keep in mind that the PaCO2 is supposed to be 30mmHg in late pregnancy.
  • The total blood volume has expanded, the cardiac output is high, and thus signs of shock will develop late.
  • Vena cava compression means the patient needs to be positioned at a 30° tilt
  • Pelvic binders are inappropriate
  • Pelvic fractures may threaten the near-term foetus
  • Placental abruption may result in massive haemorrhage and needs to be excluded early in the primary survey
    • foetal heart rate monitoring is essential
  • Retroperitoneal haemorrhage from dilated pelvic veins can be difficult to assess without ultrasound (but FAST is still effective)
  • A vaginal examination needs to be performed, looking for amniotic fluid (a pH of 7.0-7.5 will confirm this - the normal vaginal pH is much lower than this)
  • Rhesus-negative mothers need to receive IV immunoglobulin at least within 48 hours of the trauma
  • Transfusion needs to be Rh compatible
  • Antibiotic choices are limited; tetracyclines and fluoroquinolones are to be avoided
  • The pregnant trauma patient is in an even more hypercoagulable state than the normal trauma patient, and thus requires special attention to DVT prophylaxis

References

References

Oh's Intensive Care manual: Chapter 64   (pp. 684) General  obstetric  emergencies by Winnie  TP  Wan  and  Tony  Gin

 

Soar, Jasmeet, et al. "European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution." Resuscitation 81.10 (2010): 1400-1433.

 

Mattox, Kenneth L., and Laura Goetzl. "Trauma in pregnancy." Critical care medicine 33.10 (2005): S385-S389.

 

DROST, THOMAS F., et al. "Major trauma in pregnant women: maternal/fetal outcome." Journal of Trauma-Injury, Infection, and Critical Care 30.5 (1990): 574-578.