Abdominal ultrasound examination in pregnant blunt trauma patients

CETARS/CAR Practice Guideline on Imaging the Pregnant Trauma Patient

Imaging of pregnant patients who sustained trauma often causes fear and confusion among patients, their families, and health care professionals regarding the potential for detrimental effects from radiation exposure to the fetus. Unnecessary delays or potentially harmful avoidance of the justified imaging studies may result from this understandable anxiety. This guideline was developed by the Canadian Emergency, Trauma and Acute Care Radiology Society (CETARS) and the Canadian Association of Radiologists (CAR) Working Group on Imaging the Pregnant Trauma Patient, informed by a literature review as well as multidisciplinary expert panel opinions and discussions. The working group included academic subspecialty radiologists, a trauma team leader, an emergency physician, and an obstetriciangynaecologist/maternal fetal medicine specialist, who were brought together to provide updated, evidence-based recommendations for the imaging of pregnant trauma patients, including patient safety aspects (eg, radiation and contrast concerns) and counselling, initial imaging in maternal trauma, specific considerations for the use of fluoroscopy, angiography, and magnetic resonance imaging. The guideline strives to achieve clarity and prevent added anxiety in an already stressful situation of injury to a pregnant patient, who should not be imaged differently.

Traumatic uterine rupture: A rare complication of vehicle accidents

The rupture of the gravid uterus is a rare complication of trauma. It is reported in less than one percent of pregnant women who are victims of road accidents. The authors report the case of a 26-year-old nulliparous patient presented with a uterine rupture resulting in fetal death at 32 weeks of gestation following a nonpenetrating abdominal trauma in a road traffic accident. An extreme emergency operation and abdominal laparotomy confirmed the imaging findings and led to conservative treatment of the uterus and a splenectomy.

Initial Imaging of Pregnant Patients in the Trauma Bay-Discussion and Review of Presentations at a Level-1 Trauma Centre

Trauma is the leading non-obstetric cause of maternal and fetal mortality and affects an estimated 5-7% of all pregnancies. Pregnant women, thankfully, are a small subset of patients presenting in the trauma bay, but they do have distinctive physiologic and anatomic changes. These increase the risk of certain traumatic injuries, and the gravid uterus can both be the primary site of injury and mask other injuries. The primary focus of the initial management of the pregnant trauma patient should be that of maternal stabilization and treatment since it directly affects the fetal outcome. Diagnostic imaging plays a pivotal role in initial traumatic injury assessment and should not deviate from normal routine in the pregnant patient. Radiographs and focused assessment with sonography in the trauma bay will direct the use of contrast-enhanced computed tomography (CT), which remains the cornerstone to evaluate the potential presence of further management-altering injuries. A thorough understanding of its risks and benefits is paramount, especially in the pregnant patient. However, like any other trauma patient, if evaluation for injury with CT is indicated, it should not be denied to a pregnant trauma patient due to fear of radiation exposure.

Motor Vehicle Accident during Pregnancy with Two Lifes at Risk: A Case Report

Introduction:

Major trauma is the leading non-pregnancy-related cause of maternal and fetal deaths. In particular, traffic accidents account for the majority of accident causes and present the highest mortality for the mother and fetus. Seat belt use has reduced mortality rates for both the mother and the unborn child, however, certain potential patterns of injury occur due to the restraining mechanical forces of the worn seat belts on the body. Since life-threatening injuries in pregnancy are nevertheless rare, trauma care of pregnant women continues to be an exceptional situation and a particularly stressful situation for the attending physicians, including the fact that two lives are potentially at stake.

Case Report:

In this article, we report on a patient in the 37th week of pregnancy who was involved in a high-speed trauma as a front passenger of a car. Initially awake as well as responsive and hemodynamically stable, the patient’s condition deteriorated on the way to the emergency room (ER). On arrival in the ER, according to the Advanced Trauma Life Support concept, interdisciplinary consensus had to be reached between the departments involved regarding further diagnostic and therapeutic procedures. With the knowledge of the special anatomical and physiological changes in the context of pregnancy, both the mother and the child could be stabilized in order to subsequently gain further important information about the present injury pattern during the performed diagnostics and finally to be able to adequately treat the trauma sequelae.

Conclusion:

Because the care of traumatic life-threatening injuries in pregnancy is rare overall, it poses a special challenge for the attending trauma team in the ER. In order to avert the fatal fate of both the mother and the unborn child, a structured, symptom and patient-oriented interdisciplinary approach is indispensable, especially in these exceptional situations, in order to achieve the best possible outcome for those affected.

Imaging during pregnancy: What the radiologist needs to know

During the last decades, there has been a growing demand for medical imaging in gravid women. Imaging of the pregnant woman is challenging as it involves both the mother and the fetus and, consequently, several medical, ethical, or legal considerations are likely to be raised. Theoretically, all currently available imaging modalities may be used for the evaluation of the pregnant woman; however, in practice, confusion regarding the safety of the fetus often results in unnecessary avoidance of useful diagnostic tests, especially those involving ionizing radiation. This review article is focused on the current safety guidelines and considerations regarding the use of different imaging modalities in the pregnant population; also presented is an imaging work-up for the most common medical conditions of pregnant women, with emphasis on fetal and maternal safety.

Use of point-of-care ultrasound to diagnose spontaneous rupture of fibroid in pregnancy

Background: Complications of fibroids in pregnancy are well known, including postpartum hemorrhage, labor dystocia, and cesarean delivery. Outside of pregnancy and labor, the rare occurrence of spontaneous fibroid rupture has been documented. Case: The current case report involves a woman who presented with acute abdominal pain in the third trimester of pregnancy and was found to have spontaneous rupture of a fibroid before the onset of labor. Her initial presentation, diagnosis through use of point-of-care ultrasound, acute surgical management, and postoperative course are described. Conclusion: When assessing acute abdominal pain in a pregnant patient, fibroid rupture should be considered despite the absence of prior uterine surgery. Bedside point-of-care ultrasonography is a useful tool for assessment of abdominal pain in the third trimester of pregnancy.

Guidance for Evaluation and Management of Blunt Abdominal Trauma in Pregnancy

Blunt abdominal trauma is the leading type of traumatic injury in pregnancy, with motor vehicle crashes, falls, and assault being the most common etiologies. Several adverse outcomes can occur in pregnancy, including placental abruption, preterm labor and preterm delivery, uterine rupture, and pelvic fracture. Understanding and integration of key anatomic and physiologic changes in pregnancy are key when evaluating a pregnant trauma patient. Pregnant women should be managed in a medical center with the ability to provide adequate care to both trauma patients-the pregnant woman and fetus. Multiple clinical providers are usually involved in the care of pregnant trauma patients, but obstetric providers should play a central role in the evaluation and management of a pregnant trauma patient given their unique training, knowledge, and clinical skills. An algorithm for management of trauma in pregnancy should be used at all sites caring for pregnant women. An alignment of policies within each system optimizes appropriate triage, integration of care, management, and monitoring of pregnant trauma patients and their fetuses. Ensuring effective protocols for prehospital and hospital treatment, as well as thorough training of involved health care providers, is essential in ensuring that optimal care is provided.

Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis

Objectives

Performing an extended Focused Assessment with Sonography in Trauma (eFAST) exam is common practice in the initial assessment of trauma patients. The objective of this study was to systematically review the published literature on diagnostic accuracy of all components of the eFAST exam.

Methods

We searched Medline and Embase from inception through October 2018, for diagnostic studies examining the sensitivity and specificity of the eFAST exam. After removal of duplicates, 767 records remained for screening, of which 119 underwent full text review. Meta-DiSc™ software was used to create pooled sensitivities and specificities for included studies. Study quality was assessed using the Quality in Prognostic Studies (QUADAS-2) tool.

Results

Seventy-five studies representing 24,350 patients satisfied our selection criteria. Studies were published between 1989 and 2017. Pooled sensitivities and specificities were calculated for the detection of pneumothorax (69% and 99% respectively), pericardial effusion (91% and 94% respectively), and intra-abdominal free fluid (74% and 98% respectively). Sub-group analysis was completed for detection of intra-abdominal free fluid in hypotensive (sensitivity 74% and specificity 95%), adult normotensive (sensitivity 76% and specificity 98%) and pediatric patients (sensitivity 71% and specificity 95%).

Conclusions

Our systematic review and meta-analysis suggests that e-FAST is a useful bedside tool for ruling in pneumothorax, pericardial effusion, and intra-abdominal free fluid in the trauma setting. Its usefulness as a rule-out tool is not supported by these results.

The Pregnant Trauma Patient

Trauma is the leading non-obstetric cause of maternal death. Optimal management of the pregnant trauma patient requires a multidisciplinary approach. The anaesthetist and critical care physician play a pivotal role in the entire continuum of fetomaternal care, from initial assessment, resuscitation and intraoperative management, to postoperative care that often involves critical care support and patient transfer. Primary goals are aggressive resuscitation of the mother and maintenance of uteroplacental perfusion and fetal oxygenation by the avoidance of hypoxia, hypotension, hypocapnia, acidosis and hypothermia. Recognizing and understanding the mechanisms of injury, the factors that may predict fetal outcome, and the pathophysiological changes that can result from trauma, will allow early identification and treatment of fetomaternal injury. This in turn should improve morbidity and mortality. A framework for the acute care of the pregnant trauma patient is presented.

Care of Traumatic Conditions in an Observation Unit

Patients presenting to the emergency department with certain traumatic conditions can be managed in observation units. The evidence base supporting the use of observation units to manage injured patients is smaller than the evidence base supporting the management of medical conditions in observation units. The conditions that are eligible for management in an observation unit are not limited to those described in this article, and investigators should continue to identify types of conditions that may benefit from this type of health care delivery.

Trauma in pregnancy: anatomical and physiological considerations

Management of a pregnant trauma victim is a relatively rare but stressful event, not least due to the need to consider two patients. Initial management by a trauma team should follow a structured approach applicable to all trauma patients, combined with knowledge of the specific problems encountered in pregnancy. This review outlines important anatomical and physiological changes that occur during pregnancy and their relevance to initial assessment and treatment. It discusses the epidemiology of trauma in pregnancy, the presentation and manage ment of specific problems and the methods of fetal assessment.

A 10-year restrospective evaluation of ultrasound in pregnant abdominal trauma patients

The pregnant abdominal trauma patient presents a unique diagnostic challenge. This study aimed to evaluate the accuracy of abdominal sonography for the detection of clinically important injuries in pregnant abdominal trauma patients. A retrospective review was performed of a trauma center database from 2001 to 2011. Medical records were reviewed to determine initial abdominal imaging test results and clinical course. Sensitivity, specificity, positive predictive value, and negative predictive value of ultrasound for detection of traumatic injury were calculated. Of 19,128 patients with suspected abdominal trauma, 385 (2 %) were pregnant. Of these, 372 (97 %) received ultrasound as the initial abdominal imaging test. All 13 pregnant patients who did not receive ultrasound received abdominal CT. Seven pregnant patients underwent both ultrasound and CT. Seven ultrasound examinations were positive, leading to one therapeutic Cesarean section and one laparotomy. One ultrasound was considered false positive (no injury was seen on subsequent CT). There were 365 negative ultrasound examinations. Of these, 364 were true negative (no abdominal injury subsequently found). One ultrasound was considered false negative (a large fetal subchorionic hemorrhage seen on subsequent dedicated obstetrical ultrasound). Sensitivity and positive predictive value were 85.7 %. Specificity and negative predictive value were 99.7 %. Abdominal sonography is an effective and sufficient imaging examination in pregnant abdominal trauma patients. When performed as part of the initial assessment using an abbreviated trauma protocol with brief modifications for pregnancy, ultrasound minimizes diagnostic delay, obviates radiation risk, and provides high sensitivity for injury in the pregnant population.

Guidelines for the Management of a Pregnant Trauma Patient

OBJECTIVE

Physical trauma affects 1 in 12 pregnant women and has a major impact on maternal mortality and morbidity and on pregnancy outcome. A multidisciplinary approach is warranted to optimize outcome for both the mother and her fetus. The aim of this document is to provide the obstetric care provider with an evidence-based systematic approach to the pregnant trauma patient.

OUTCOMES

Significant health and economic outcomes considered in comparing alternative practices.

EVIDENCE

Published literature was retrieved through searches of Medline, CINAHL, and The Cochrane Library from October 2007 to September 2013 using appropriate controlled vocabulary (e.g., pregnancy, Cesarean section, hypotension, domestic violence, shock) and key words (e.g., trauma, perimortem Cesarean, Kleihauer-Betke, supine hypotension, electrical shock). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English between January 1968 and September 2013. Searches were updated on a regular basis and incorporated in the guideline to February 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

This guideline is expected to facilitate optimal and uniform care for pregnancies complicated by trauma. Summary Statement Specific traumatic injuries At this time, there is insufficient evidence to support the practice of disabling air bags for pregnant women. (III) Recommendations Primary survey 1. Every female of reproductive age with significant injuries should be considered pregnant until proven otherwise by a definitive pregnancy test or ultrasound scan. (III-C) 2. A nasogastric tube should be inserted in a semiconscious or unconscious injured pregnant woman to prevent aspiration of acidic gastric content. (III-C) 3. Oxygen supplementation should be given to maintain maternal oxygen saturation > 95% to ensure adequate fetal oxygenation. (II-1B) 4. If needed, a thoracostomy tube should be inserted in an injured pregnant woman 1 or 2 intercostal spaces higher than usual. (III-C) 5. Two large bore (14 to 16 gauge) intravenous lines should be placed in a seriously injured pregnant woman. (III-C) 6. Because of their adverse effect on uteroplacental perfusion, vasopressors in pregnant women should be used only for intractable hypotension that is unresponsive to fluid resuscitation. (II-3B) 7. After mid-pregnancy, the gravid uterus should be moved off the inferior vena cava to increase venous return and cardiac output in the acutely injured pregnant woman. This may be achieved by manual displacement of the uterus or left lateral tilt. Care should be taken to secure the spinal cord when using left lateral tilt. (II-1B) 8. To avoid rhesus D (Rh) alloimmunization in Rh-negative mothers, O-negative blood should be transfused when needed until cross-matched blood becomes available. (I-A) 9. The abdominal portion of military anti-shock trousers should not be inflated on a pregnant woman because this may reduce placental perfusion. (II-3B) Transfer to health care facility 10. Transfer or transport to a maternity facility (triage of a labour and delivery unit) is advocated when injuries are neither life- nor limb-threatening and the fetus is viable (≥ 23 weeks), and to the emergency room when the fetus is under 23 weeks' gestational age or considered to be non-viable. When the injury is major, the patient should be transferred or transported to the trauma unit or emergency room, regardless of gestational age. (III-B) 11. When the severity of injury is undetermined or when the gestational age is uncertain, the patient should be evaluated in the trauma unit or emergency room to rule out major injuries. (III-C) Evaluation of a pregnant trauma patient in the emergency room 12. In cases of major trauma, the assessment, stabilization, and care of the pregnant women is the first priority; then, if the fetus is viable (≥ 23 weeks), fetal heart rate auscultation and fetal monitoring can be initiated and an obstetrical consultation obtained as soon as feasible. (II-3B) 13. In pregnant women with a viable fetus (≥ 23 weeks) and suspected uterine contractions, placental abruption, or traumatic uterine rupture, urgent obstetrical consultation is recommended. (II-3B) 14. In cases of vaginal bleeding at or after 23 weeks, speculum or digital vaginal examination should be deferred until placenta previa is excluded by a prior or current ultrasound scan. (III-C) Adjunctive tests for maternal assessment 15. Radiographic studies indicated for maternal evaluation including abdominal computed tomography should not be deferred or delayed due to concerns regarding fetal exposure to radiation. (II-2B) 16. Use of gadolinium-based contrast agents can be considered when maternal benefit outweighs potential fetal risks. (III-C) 17. In addition to the routine blood tests, a pregnant trauma patient should have a coagulation panel including fibrinogen. (III-C) 18. Focused abdominal sonography for trauma should be considered for detection of intraperitoneal bleeding in pregnant trauma patients. (II-3B) 19. Abdominal computed tomography may be considered as an alternative to diagnostic peritoneal lavage or open lavage when intra-abdominal bleeding is suspected. (III-C) Fetal assessment 20. All pregnant trauma patients with a viable pregnancy (≥ 23 weeks) should undergo electronic fetal monitoring for at least 4 hours. (II-3B) 21. Pregnant trauma patients (≥ 23 weeks) with adverse factors including uterine tenderness, significant abdominal pain, vaginal bleeding, sustained contractions (> 1/10 min), rupture of the membranes, atypical or abnormal fetal heart rate pattern, high risk mechanism of injury, or serum fibrinogen < 200 mg/dL should be admitted for observation for 24 hours. (III-B) 22. Anti-D immunoglobulin should be given to all rhesus D-negative pregnant trauma patients. (III-B) 23. In Rh-negative pregnant trauma patients, quantification of maternal-fetal hemorrhage by tests such as Kleihauer-Betke should be done to determine the need for additional doses of anti-D immunoglobulin. (III-B) 24. An urgent obstetrical ultrasound scan should be undertaken when the gestational age is undetermined and need for delivery is anticipated. (III-C) 25. All pregnant trauma patients with a viable pregnancy who are admitted for fetal monitoring for greater than 4 hours should have an obstetrical ultrasound prior to discharge from hospital. (III-C) 26. Fetal well-being should be carefully documented in cases involving violence, especially for legal purposes. (III-C) Obstetrical complications of trauma 27. Management of suspected placental abruption should not be delayed pending confirmation by ultrasonography as ultrasound is not a sensitive tool for its diagnosis. (II-3D) Specific traumatic injuries 28. Tetanus vaccination is safe in pregnancy and should be given when indicated. (II-3B) 29. Every woman who sustains trauma should be questioned specifically about domestic or intimate partner violence. (II-3B) 30. During prenatal visits, the caregiver should emphasize the importance of wearing seatbelts properly at all times. (II-2B) Perimortem Caesarean section 31. A Caesarean section should be performed for viable pregnancies (≥ 23 weeks) no later than 4 minutes (when possible) following maternal cardiac arrest to aid with maternal resuscitation and fetal salvage. (III-B).

Accuracy of emergency physicians using ultrasound measurement of crown-rump length to estimate gestational age in pregnant females

STUDY OBJECTIVE

The objective of this study is to evaluate the accuracy of emergency providers (EPs) of various levels of training in determination of gestational age (GA) in pregnant patients using bedside ultrasound measurement of crown-rump length (CRL).

METHODS

We conducted a prospective, cross-sectional, observational study of patients in obstetrical care at an urban county hospital. We enrolled a convenience sample of women at 6 to 14 weeks gestation as estimated by last menstrual period. Emergency providers used ultrasound to measure the CRL. Repeat CRL measurements were performed by either an obstetrical ultrasound technician or senior obstetrician and used as the criterion standard for true GA (TGA).

RESULTS

One hundred five patients were evaluated by 20 providers of various levels of training. The average time required to complete the CRL measurement was 85 seconds. When CRL measurements performed by EPs were compared with the TGAs, the average correlation was 0.935 (0.911-0.959). Using standard accepted variance for CRL measurements at different GAs according to the obstetrics literature (±3 days for 42-70 days and ±5 days for 70-90 days), correlation between EP ultrasound and measured TGA was 0.947 (0.927-0.967).

CONCLUSIONS

Emergency providers can quickly and accurately determine GA in first-trimester pregnancies using bedside ultrasound to calculate the CRL. Emergency providers should consider using ultrasound to calculate the CRL in patients with first-trimester bleeding or pain because this estimated GA may serve as a valuable data point for the future care of that pregnancy.

Trauma in the obstetrical patient

Trauma complicates approximately 6-7% of all pregnancies and is associated with significant maternal and fetal morbidity and mortality. While the majority of trauma is minor, it is minor trauma that contributes to the majority of fetal mortality. Since virtually every organ system is affected anatomically and physiologically by pregnancy, it is important for healthcare providers who care for trauma victims to be aware of these changes. While assessment and resuscitation considers the existence of two patients, stabilization of the mother takes priority. Diagnostic and radiologic procedures should be used as indicated, with fetal exposure to radiation limited as much as possible. Management of the pregnant trauma victim requires a multidisciplinary approach in order to optimize outcome for mother and fetus. This review discusses the epidemiology, assessment and treatment of pregnant trauma patients and reviews areas where prevention efforts may be focused.

Imaging the pregnant patient for nonobstetric conditions: algorithms and radiation dose considerations

Use of diagnostic imaging studies for evaluation of pregnant patients with medical conditions not related to pregnancy poses a persistent and recurring dilemma. Although a theoretical risk of carcinogenesis exists, there are no known risks for development of congenital malformations or mental retardation in a fetus exposed to ionizing radiation at the levels typically used for diagnostic imaging. An understanding of the effects of ionizing radiation on the fetus at different gestational stages and the estimated exposure dose received by the fetus from various imaging modalities facilitates appropriate choices for diagnostic imaging of pregnant patients with nonobstetric conditions. Other aspects of imaging besides radiation (ie, contrast agents) also carry potential for fetal injury and must be taken into consideration. Imaging algorithms based on a review of the current literature have been developed for specific nonobstetric conditions: pulmonary embolism, acute appendicitis, urolithiasis, biliary disease, and trauma. Imaging modalities that do not use ionizing radiation (ie, ultrasonography and magnetic resonance imaging) are preferred for pregnant patients. If ionizing radiation is used, one must adhere to the principle of using a dose that is as low as reasonably achievable after a discussion of risks versus benefits with the patient.

Trauma in pregnancy

The care of the pregnant trauma patient provides unique challenges and holds profound implications for both fetal and maternal outcomes. The management of these patients is influenced by unique anatomic and physiologic changes, increased concern for deleterious radiation and medication exposures, and the need for multidisciplinary care. This article reviews the critical features necessary in the assessment, diagnosis, treatment, and disposition of pregnant trauma patients with a focus on recent developments reported in the literature as pertinent to emergency management.

Initial trauma management in advanced pregnancy

The principles enshrined in existing trauma resuscitation protocols for treating nonpregnant trauma victims should also be applied to the pregnant patient. In addition, left tilt of the pregnant patient (or the back board) and supplement oxygen are mandatory. The patient should be treated by a multidisciplinary team, preferably in a trauma center. Early intubation is recommended, but should be performed, where possible, by an experienced physician. The physician should be aware of the different physiologic and laboratory values in normal pregnancy. Fetal monitoring is important to assess both fetal and maternal welfare. Imaging examinations, where indicated, should not be delayed. Even minor maternal trauma, especially if caused by interpersonal violence, might cause fetal loss.

Surgical gastrointestinal disorders during pregnancy

All gastrointestinal (GI) disorders can present during pregnancy, and in fact 0.2% to 1.0% of all pregnant women require non-obstetrical general surgery. All of the clinical decision-making skills of the experienced surgeon must come into play in order to make the correct therapeutic decisions when evaluating the pregnant patient with a GI disorder that potentially requires surgery. While in general the principles of diagnosing and treating a pregnant woman with an acute surgical abdominal problem remain the same as those governing the treatment of the non-pregnant patient, some important differences are present and can pose problems. As a general rule the condition of the mother should always take priority because proper treatment of surgical diseases in the mother will usually benefit the fetus as well as the mother.

Trauma during pregnancy

Trauma is the leading nonobstetrical cause of maternal death. The effect of trauma on the pregnant woman and unborn fetus can be devastating. The major causes of maternal injury are blunt trauma, penetrating trauma, burns, falls, and assaults. There are specific changes associated with pregnancy that are important for the clinician to consider when providing care to these patients. Initial management of traumatic injuries during pregnancy is essential for maternal and fetal well-being. This review outlines common causes of maternal trauma, the initial assessment of the pregnant trauma patient, and ongoing care for the pregnant trauma patient and unborn fetus.

Orthopaedic trauma in the pregnant patient

Trauma affects up to 8% of pregnancies and is the leading cause of death among pregnant women in the United States. A pregnancy test is mandated for all females of childbearing age who are involved in trauma. Orthopaedic trauma in the pregnant patient is managed similarly to that for all trauma patients. Initial resuscitation efforts should focus on the pregnant patient because stable patient vital signs provide the best chance for fetal survival. In the stable patient, fetal assessment and a pelvic examination are mandatory. Radiographs as well as abdominal ultrasound of the patient and fetal ultrasound are useful. No known biologic risks are associated with magnetic resonance imaging, and no specific fetal abnormalities have been linked with standard low-intensity magnetic resonance imaging. Emergency surgery can be safely performed in most pregnant patients. Avoiding patient hypotension and using left lateral decubitus positioning increase the likelihood of success for the patient and fetus. An experienced multidisciplinary team consisting of an obstetrician, perinatologist, orthopaedic surgeon, anesthesiologist, radiologist, and nursing staff will optimize the treatment of both the pregnant patient and her fetus.

Trauma in pregnancy

OBJECTIVE

The objective of this article was to review the existing standards of practice regarding trauma which occurs during pregnancy.

DESIGN

The design of this study was to review the available data from the surgical and obstetrical literature regarding trauma during pregnancy. The design was also to incorporate the contemporary recommendations from the trauma resuscitation courses relating to trauma during pregnancy.

RESULTS

Trauma occurs in 5% of pregnancies. A fetus is not considered to be viable until week 25. Motor vehicle accidents account for more than 50% of all trauma during pregnancy, with 82% of fetal deaths occurring during these automobile accidents. With life threatening trauma a 50% fetal loss rate exists. As anatomy, physiology, and even laboratory findings change during pregnancy, the clinician must consider both patients, the mother and fetus. Following blunt trauma abruption of the placenta is the more common cause of fetus loss. Anterior abdominal penetrating trauma almost never fails to injury the uterus and fetus in the last half of pregnancy. Preventive strategies exist in the areas of social violence, automobile restraints and use of alcohol and drugs by the mother. Perimortem caesarian section is rarely successful.

CONCLUSIONS

Trauma during pregnancy is uncommon, but with increasing trauma severity leads to increased fetal loss. Preventive strategies exist and when admitted monitoring standards should be followed.

Screening sonography in pregnant patients with blunt abdominal trauma

OBJECTIVE

The purpose of this study was to evaluate the accuracy of screening sonography for the detection of clinically significant abdominal injury in pregnant patients with blunt trauma.

METHODS

We retrospectively reviewed the records of 5173 patients with blunt abdominal trauma who underwent screening sonography. Pregnant patients were identified, and the prospective sonographic interpretations were compared with surgical findings, computed tomography (CT), subsequent sonography, cystography, and the clinical course.

RESULTS

Of 1567 female patients with trauma, 947 were of reproductive age and, 102 (11%) of these 947 were pregnant. One patient was excluded because a truth standard was not available. Five (5%) of these 101 patients were found to have injuries at surgery. These injuries involved the placenta (2 injuries), spleen (2 injuries), liver (1 injury), and kidney (1 injury); all required surgery. Initial sonographic findings were positive in 4 of 5 patients with injuries. The missed injury was a placental injury detected 15 hours after screening sonography because of fetal bradycardia. After screening sonography, 6 patients underwent additional abdominal imaging: CT (3 patients), cystography (1 patient), and additional sonography (2 patients). Of 101 patients, 95 (94%) required no additional tests, and 97 (96%) required no test involving ionizing radiation. No pregnant patient underwent diagnostic peritoneal lavage. Sensitivity was 80% (95% confidence interval, 28%-100%), and specificity was 100% (96 of 96; 95% confidence interval, 96%-100%) for detecting major abdominal injury.

CONCLUSIONS

Sonography is an effective screening examination that can obviate more hazardous tests such as CT, cystography, and peritoneal lavage in most pregnant patients with trauma requiring objective evaluation of the abdomen.

Blunt Abdominal Injury in the Pregnant Patient: Detection with US

PURPOSE

To determine the accuracy of ultrasonography (US) for the detection of blunt intraabdominal injury in pregnant patients and to compare differences between pregnant and nonpregnant patients of childbearing age.

MATERIALS AND METHODS

A retrospective review of results of all consecutive emergency blunt trauma US examinations performed at a level I trauma center from January 1995 to June 2002 was conducted. Data on demographics, free fluid location, and patient outcome were collected. Injuries were determined on the basis of results of computed tomography and/or laparotomy. The Student t test was used to detect differences between continuous variables, and chi(2) analysis was used to evaluate differences between proportions.

RESULTS

A total of 2319 US examinations for blunt trauma were performed in girls and women between the ages of 10 and 50 years. There were 328 pregnant patients, 23 of whom had intraabdominal injury. The mean age of the pregnant patients was 24.7 years +/- 6.1 (standard deviation) (age range, 14-42 years). In pregnant patients, the sensitivity of US was 61% (14 of 23 patients), the specificity was 94.4% (288 of 305 patients), and the accuracy was 92.1% (302 of 328 patients). Pregnant patients were significantly more likely to have sustained injuries from assault (odds ratio: 2.6, P < .001). The most common pattern of free fluid accumulation detected at US in pregnant patients was that of fluid in the left and right upper quadrants and pelvis (n = 4, 29%); the second most common pattern was one of isolated pelvic fluid (n = 3, 21%).

CONCLUSION

For detection of intraabdominal injury, US was less sensitive in pregnant patients than in nonpregnant patients but was highly specific in both subgroups. The sensitivity of US was highest in pregnant patients during the first trimester.

Management of general surgical problems in the pregnant patient

BACKGROUND

General surgeons are frequently consulted for nonobstetrical surgical problems in pregnant women, as up to 2% of pregnancies are complicated by such problems. Concerns over the increased morbidity for both the pregnant patient and the fetus are unique to this population.

DATA SOURCES

A review of the English language literature surrounding nonobstetrical surgical issues was collected through a Medline search and review of relevant society and academy papers.

CONCLUSIONS

This manuscript offers a review of current information regarding aspects of surgical care in the pregnant patient. Areas discussed include anesthesiology, radiology, laparoscopy, and specific common and uncommon surgical diseases found in the pregnant patient.

Management of trauma during pregnancy

BACKGROUND

Pregnancy may confuse the management of a trauma patient. The present retrospective review was conducted in order to develop guidelines for the management of such a patient.

METHODS

A retrospective review of case notes was undertaken using a trauma database to evaluate the management of pregnant trauma patients. A review of the English language literature was also carried out.

RESULTS

Between July of 1994 and July of 2002, 34/25 206 (0.13%) of patients on the database were pregnant at the time of injury. The vast majority (27/34; 79%) suffered no obstetric complication. Obstetric complications included four pregnancies complicated by preterm labour but not preterm delivery, one placental abruption and one second trimester pregnancy loss. There was one maternal death with an 8 week gestation fetus viable at time of maternal death and one fetal death with maternal survival.

CONCLUSION

The findings are in keeping with those of other published series. Priority in the management of a pregnant patient who has sustained major trauma must always be maternal stabilization. After stabilization, an assessment of obstetric complications should be a part of the secondary survey. Fetal heart rate monitoring should be used to assess the fetus in pregnancies > or =22 weeks gestation. Active intervention, such as Caesarian section, can be considered if fetal compromise is found.

Imaging modalities in obstetrics and gynecology

The practicing emergency physician often encounters diagnostic dilemmas involving the choice of the most appropriate radiologic study to evaluate patients in the emergency department. In addition, the uncertainty of potentially harmful fetal effects of radiation in the pregnant patient may add unnecessary delay and concern in the workup of obstetric emergencies. An emergency physician's in-depth understanding of the strengths, limitations, and potentially harmful effects of radiologic studies allows the safest and most appropriate studies to be ordered for the gynecologic and obstetric population. With the explosion of interest and growing level of expertise in focused emergency department ultrasonography during the last decade, the practicing emergency physician should add this skill to his or her armamentarium in the future. Many emergency physicians are already comfortable in using radiologic technologies in their daily practice and have discovered how quickly vital and specific information can be obtained.

Trauma in pregnancy

The anatomic and physiologic changes make treatment of the pregnant trauma patient complex. The fetus is the challenge, because, in pregnancy, trauma has little effect on maternal morbidity and mortality. Aggressive resuscitation of the mother, in general, is the best management for the fetus, because fetal outcome is directly related to maternal outcome. Recent literature has attempted, with little success, to identify factors that may predict poor fetal outcomes. Cardiotocographic monitoring should be initiated as soon as possible in the emergency department to evaluate fetal well-being. Other key points include: Maternal blood pressure and respiratory rate return to baseline as pregnancy approaches term. Initial fetal health may be the best indicator of maternal health. Inferior vena cava compression in the supine patient may cause significant hypotension. Maternal acidosis may be predictive of fetal outcome. Kleihauer-Betke testing is not necessary in the emergency department. Early ultrasonographic evaluation can identify free intraperitoneal fluid and assess fetal health. Necessary radiographs should not be withheld at any period of gestation. Radiation beyond 20 weeks' gestation is safe. Patients with viable gestations require at least 4 hours of CTM monitoring after even minor trauma.