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.

(b)       Please discuss the timing and nature of any investigations that you would perform.

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College Answer

Consider:   Immediate:   blood   for   group   (consider   Rhesus   isoimmunisation),  cross   match, electrolytes, full blood examination and coagulation profile.   Xrays of chest and cervical spine (&/or pelvis), delaying other Xrays until stable.
Early: abdominal ultrasound (FAST, uterus and foetal heart rate), CTG
Once stable: abdominal CT, thoracic and lumbar spine films (if can’t clear clinically in view of distractors). DPL probably not of additional help, unless other investigations unavailable.

 

Discussion

This question is about immediate bloods, and the investigations which form part of the secondary survey. How are these different in a pregnant patient? A generic approach to the pregnant trauma patient is discussed in Question 3 from the first paper of 2007.

 

The usual barrage of blood tests remains unchanged.

FBC, EUC, CMP LFT coags and crossmatch get sent away just as they would in any trauma patient, but the savvy candidate will mention the need for Rh blood grouping to prevent Rh isoimmunisation (where the mother is Rh negative and the foetus is Rh positive). An administration of anti-Rh IVIG can mop up any Rh-positive foetal erythrocytes which might have haemorrhaged into the maternal circulation, preventing the mother from developing her own anti-Rh antibodies (and thus preventing the haemolytic disease of the newborn).

 

An abdominal ultrasound (FAST) is still performed, with additional focus on the uterus; uterine rupture or placental abruption need to be detected early.

 

Foetal welfare can be monitored by CTG, and the O&G specialist should be invited to perfrom their own focused ultrasound to investigate the pregnancy.

 

Though radiation exposure is undesirable, it is tolerated (particularly in late term pregnancy) because organogenesis has already taken place, and because the risk from ionising radiation exposure is minute in comparison to the risk of missed injuries and haemorrhage.

 

 

References

References

 

Kuczkowski, K. M. "Trauma during pregnancy: a situation pregnant with danger." Acta Anaesthesiol Belg 56.1 (2005): 13-18. 

 

Oxford, Corrina M., and Jonathan Ludmir. "Trauma in pregnancy." Clinical obstetrics and gynecology 52.4 (2009): 611-629.

 

Goodwin, Hillary, James F. Holmes, and David H. Wisner. "Abdominal ultrasound examination in pregnant blunt trauma patients." Journal of Trauma-Injury, Infection, and Critical Care 50.4 (2001): 689-694.