The Pregnant Motor Vehicle Accident Casualty: Adherence to Basic Workup and Admission Guidelines

The Management of Pregnant Trauma Patients: A Narrative Review

Trauma is the leading nonobstetric cause of maternal death and affects 1 in 12 pregnancies in the United States. Adhering to the fundamentals of the advanced trauma life support (ATLS) framework is the most important component of care in this patient population. Understanding the significant physiologic changes of pregnancy, especially with regard to the respiratory, cardiovascular, and hematologic systems, will aid in airway, breathing, and circulation components of resuscitation. In addition to trauma resuscitation, pregnant patients should undergo left uterine displacement, insertion of 2 large bore intravenous lines placed above the level of the diaphragm, careful airway management factoring in physiologic changes of pregnancy, and resuscitation with a balanced ratio of blood products. Early notification of obstetric providers, initiation of secondary assessment for obstetric complications, and fetal assessment should be undertaken as soon as possible but without interference to maternal trauma assessment and management. In general, viable fetuses are monitored by continuous fetal heart rate for at least 4 hours or more if abnormalities are detected. Moreover, fetal distress may be an early sign of maternal deterioration. When indicated, imaging studies should not be limited out of fear for fetal radiation exposure. Resuscitative hysterotomy should be considered in patients approaching 22 to 24 weeks of gestation, who arrive in cardiac arrest or present with profound hemodynamic instability due to hypovolemic shock.

A Retrospective Study of the Proportion of Women at High and Low Risk of Intrauterine Infection Meeting Sepsis Criteria

The Surviving Sepsis Campaign recently recommended that qSOFA not be used as a single parameter for identification of sepsis. Thus, we evaluated the efficacy of SIRS and qSOFA scores in identifying intrauterine infection. This case–control study evaluates SIRS and qSOFA criteria fulfillment in preterm premature rupture of membranes (n = 453)—at high infection risk—versus elective cesarean—at low infection risk (n = 2004); secondary outcomes included intrauterine infection and positive culture rates. At admission, 14.8% of the study group and 4.6% of control met SIRS criteria (p = 0.001), as did 12.5% and 5.5% on post-operation day (POD) 1 (p = 0.001), with no significant differences on POD 0 or 2. Medical records did not suffice for qSOFA calculation. In the study group, more cultures (29.8% versus 1.9%—cervix; 27.4% versus 1.1%—placenta; 7.5% versus 1.7%—blood; p = 0.001—all differences) and positive cultures (5.5% versus 3.0%—urine—p = 0.008; 4.2% versus 0.2%—cervix—p = 0.001; 7.3% versus 0.0%—placenta—p = 0.001; 0.9% versus 0.1%—blood—p = 0.008) were obtained. Overall, 10.6% of the study group and 0.4% of control met the intrauterine infection criteria (p = 0.001). Though a significant difference was noted in SIRS criteria fulfillment in the study group versus control, there was considerable between-group overlap, questioning the utility of SIRS in intrauterine infection diagnosis. Furthermore, the qSOFA scores could not be assessed.

Chest compression of a pregnant woman by a seatbelt might affect fetal outcome, even in minor to moderate frontal vehicle collisions

INTRODUCTION

Pregnant women often suffer from negative fetal outcomes, despite wearing a seatbelt correctly. When restrained vehicle passengers are involved in a frontal collision without suffering from any injuries, the forces they experience are particularly concentrated in the chest because of the seatbelt. We analyzed the biomechanics of chest injuries sustained by restrained pregnant drivers and possible effects of these injuries on the fetus.

MATERIAL AND METHODS

The Maternal Anthropometric Measurement Apparatus dummy, version 2B, representing a pregnant woman at 30 weeks of gestation, was used. Sled tests were performed for recreating frontal impact situations with vector velocity changes at impact speeds of 13, 26, and 40km/h. Overall kinematics of the dummy were examined using high-speed video imaging. Quantitative dummy responses, such as time course of acceleration of the sled and chest, pressure of the belt, and deflection of the chest (right and left) during impact were also measured.

RESULTS

Although collision velocities were different, the distances of forward movement of the dummy were similar (121-129mm) owing to the safety devices. However, maximum deflection of the chest (35.4mm to the left and 15.7mm to the right) was obtained at a 26-km/h collision. Additionally, maximum deflection of 28.7mm to the left and 10.9mm to the right of the chest were obtained at 40km/h.

CONCLUSIONS

Because the uterus enlarges and the fundus reaches the lower part of the rib cage during late pregnancy, we consider that the reason for negative fetal outcomes is partly owing to chest compression and subsequent applied forces on the uterus, even in minor to moderate frontal collisions. This knowledge may be useful for forensic scientists who determine the causes and mechanisms of a fetal death or the offenders' responsibilities for both maternal and fetal outcomes when the mother is involved in a frontal vehicle collision.

Are pregnant women safer in motor vehicle accidents?

OBJECTIVE

Motor vehicle accidents (MVAs) are a major incidental cause of pregnancy-associated maternal deaths in the US. The goal of this research was to evaluate the incidence, risks, and fetal and maternal outcomes of pregnant women involved in MVAs. In addition, we examined the relationship between the injury severity score (ISS) and car seat location in pregnant and non-pregnant women.

METHODS

This involved a retrospective cohort study of female patients who were involved in MVAs and hospitalized between the years 2006 and 2013. Data were collected from the Israeli National Trauma Registry. Severity and outcomes of pregnant and non-pregnant women with blunt trauma were compared.

RESULTS

In this study, 3794 pregnant and 3441 non-pregnant patients aged 18-40 years were analyzed. The majority of pregnant patients were drivers (n=2515, 67%) as opposed to passengers (n=1279, 33%). Pregnant patients had lower ISS than non-pregnant patients (P<0.001). Out of these pregnant patients, 38 (1%) had adverse maternal-fetal pregnancy outcomes, including (1) placental abruption 0.1% and (2) miscarriage (0.2%). One pregnant patient died (0.03%) compared with 32 (0.93%) of the non-pregnant patients (P<0.0001). A significant negative correlation between gestational age and spontaneous abortion was found (P<0.009).

CONCLUSIONS

The severity of injury and the mortality rate of pregnant patients involved in MVAs are significantly lower compared with non-pregnant patients. Pregnant drivers had a significantly lower severity of trauma compared with pregnant passengers.

JOURNAL CLUB: Quantification of Fetal Dose Reduction if Abdominal CT Is Limited to the Top of the Iliac Crests in Pregnant Patients With Trauma

OBJECTIVE

The purposes of this study were to correlate fetal z-axis location within the maternal abdomen on CT with gestational age and estimate fetal dose reduction of a study limited to the abdomen only, with its lower aspect at the top of the iliac crests, compared with full abdominopelvic CT in pregnant trauma patients.

MATERIALS AND METHODS

We performed a study of pregnant patients who underwent CT of the abdomen and pelvis for trauma at a single institution over a 10-year period. The inferior aspect of maternal liver, spleen, gallbladder, pancreas, adrenals, and kidneys was recorded as above or below the iliac crests. The distance from the iliac crest to the top of the fetus or gestational sac was determined. The CT images of the limited and full scanning studies were independently reviewed by two blinded radiologists to identify traumatic injuries. Fetal dose profiles, including both scatter and primary radiation, were computed analytically along the central axis of the patient to estimate fetal dose reduction. Linear regression analysis was performed between gestational age and distance of the fetus to the iliac crests.

RESULTS

Thirty-five patients were included (mean age, 26.2 years). Gestational age ranged from 5 to 38 weeks, with 5, 19, and 11 gestations in the first, second, and third trimesters, respectively. All solid organs were above the iliac crests in all patients. In three of six patients, traumatic findings in the pelvis would have been missed with the limited study. There was high correlation between gestational age and distance of the fetus to the iliac crests (R(2) = 0.84). The mean gestational age at which the top of the fetus was at the iliac crest was 17.3 weeks. Using the limited scanning study, fetuses at 5, 20, and 40 weeks of gestation would receive an estimated 4.3%, 26.2%, and 59.9% of the dose, respectively, compared with the dose for the full scanning study.

CONCLUSION

In pregnant patients in our series with a history of trauma, CT of the abdomen only was an effective technique to reduce fetal radiation exposure compared with full abdomen and pelvis CT.

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).

Adherence to protocol in pregnant trauma patients? A 12-year retrospective study

PURPOSE

We investigated whether the standard (ATLS) trauma protocol was adhered to in cases of suspected multi-traumatized pregnant patients and if serious injuries were overlooked. We hypothesized that radiographic studies would be less frequent in pregnant trauma patients.

METHODS

Forty-eight pregnant trauma patients were received in the observational period from January 2000 until May 2012; median age 30 years (range 16-40) and median stage of pregnancy 22 weeks (range 4-40). A retrospective review of patient files was performed.

RESULTS

Twenty-one percent of the pregnant trauma patients received a full trauma CT (T-CT) scan (head to pelvis), which was significantly lower than the percentage (62 %) of all primarily referred trauma patients in the same period. In the last four years of observation, the use of radiographic studies among pregnant trauma patients increased considerably. Along with this increase in the tendency to use T-CT over time during the observational period, there was also a rise in the median ISS. In addition, radiographic studies of the pelvis and abdominal area were performed only half as frequently as studies of the neck and chest.

CONCLUSIONS

Adherence to the ATLS protocol in pregnant trauma patients was low in relation to radiographic studies but, in spite of this, no known significant injuries were missed. We found that a pelvic fracture seems to be predictive of a high risk of obstetric complications, such as intrauterine death or the need for cesarean section, but we were not able to relate trauma in general to a higher risk of cesarean section or premature birth.

Management and outcomes of trauma during pregnancy

Approximately 1% to 4% of pregnant women are evaluated in emergency/delivery room because of traumatic injury, yet there are few educational strategies targeted toward prevention/management of maternal trauma. Use of illicit drugs and alcohol, domestic abuse, and depression contribute to maternal trauma; thus a high index of suspicion should be maintained when treating injured young women. Treating the mother appropriately is beneficial for both the mother and the fetus. Fetal viability should be assessed after maternal stabilization. Pregnancy-related morbidity occurs in approximately 25% of cases and may include placental abruption, uterine rupture, preterm delivery, and the need for cesarean delivery.