A 42-year-old primigravida, 30 weeks gestation, is admitted with abdominal trauma and hypotension, following a motor vehicle crash, to the Emergency Department of a hospital without an obstetric service.
Outline the management issues specific to the care of this patient.
In addition to management by a trauma team following EMST principles, this case requires additional early obstetric, neonatal and anaesthetic input. The operating theatre needs to be alerted to the possibility of the need for emergency Caesarian section. In an elderly primigravida this is likely to be a ‘precious’ pregnancy.
Other specific management issues include:
High flow oxygen to avoid maternal and fetal distress. Reduced respiratory reserve with decreased FRC. Potential for relative difficulty in intubation
Maternal compensation for blood loss is at the expense of utero-placental blood flow. Left lateral tilt to avoid aorto-caval compression.
Transfusion should be Rhesus compatible and immunoglobulin should be given if she is Rhesus negative because of the immunological effects of minor feto-maternal haemorrhage.
Physiological anaemia of pregnancy
Minimise exposure to radiation – ultra-sound alternatives may be preferable. (DPL contra-indicated).
Retroperitoneal haemorrhage, placental abruption or fetal distress may occur and premature labour may be precipitated.
If pelvic fractures present, pelvic binders may not be suitable. Regular fetal monitoring is required.
Bereavement issues in the event of an adverse fetal outcome
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.). Specific features of severe multi-trauma in pregnancy can also be found on the page dedicated to this topic.
Issues to consider in investigations and the secondary survey
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.