Trauma In Pregnancy

Emerg Med Clin N Am 25 (2007) 861–872

Trauma in Pregnancy
Seric S. Cusick, MDa, Carrie D. Tibbles, MDb,*
a

Department of Emergency Medicine, UC Davis School of Medicine,
PSSB, 4150 V Street, #2100, Sacramento, CA 95817, USA
b
Department of Emergency Medicine, Harvard Affiliated Emergency Medicine Residency,
Beth Israel Deaconess Medical Center, One Deaconess Road,
West Campus ClinicalCenter CC2, Boston, MA 02215, USA

The care of the pregnant trauma patient provides unique challenges and
holds profound implications for both fetal and maternal outcomes. The incidence of trauma in pregnant patients is low, approximately 5% [1], but it is
the leading cause of nonobstetric mortality, and the associated fetal morbidity and mortality increases with the severity of the maternalinjuries.
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 inthe literature pertinent to emergency management.

Incidence
As described previously, trauma represents a significant cause of maternal death despite its relatively low absolute incidence. In a review of 95 maternal deaths, Fildes and colleagues [2] reported 46.3% to be of traumatic
etiology. This rate increases in younger women and those of certain ethnic
and socioeconomic groups. The natureof these traumatic insults has been
reported as 55% motor vehicle collisions, 22% falls, 22% assaults, and
1% burns [3]. Although sampling of certain patient populations yields
higher rates of penetrating trauma and mortality associated with violent
crimes [2], Weiss and colleagues [4] identified motor vehicle collisions as
the leading traumatic cause of fetal death (82%). This study alsonotes

* Corresponding author.
E-mail address: ctibbles@bidmc.harvard.edu (C.D. Tibbles).
0733-8627/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.emc.2007.06.010
emed.theclinics.com

862

CUSICK & TIBBLES

that the causes of maternal and fetal mortality differ, with 11% of all fetal
deaths being independent of maternal death.
Even minor maternal traumamay have immediate and long-term impacts
on fetal well-being, highlighting the need for prevention, appropriate recognition, and multidisciplinary care.
General considerations
Typical prehospital and Advanced Trauma Life Support protocols must
be modified in assessing the pregnant trauma patient because of alterations
in anatomy and physiology. Additionally, the providers must consider theassessment and well being of the second patientdthe fetus. These factors
demand attention most immediately during the initial assessment and
hold implications in the effective resuscitation, diagnosis, and treatment.
The uterus first becomes an intra-abdominal organ at 12 weeks, and as it
enlarges it displaces abdominal contents upwards, reaching the costal margin between 34 and 38 weeks. Thediaphragm may be elevated as much as
4 cm, with accompanying displacement of associated thoracoabdominal
organs, altering interpretation of physical examination and radiographic
findings. In a supine patient, the enlarged uterus compresses the inferior
vena cava, decreasing venous return and potentially causing supine hypotension syndrome.
The maternal cardiopulmonary system displays significantalterations. By
the second trimester, a mild increase in resting heart rate and decrease in systolic blood pressure are accompanied by moderate hypocapnia caused by increased minute ventilation. Multiple factors affect maternal hemodynamics.
Increases in maternal blood volume (by 50%) and relatively smaller increases in red blood cell volume (by 30%) create a physiologic anemia of
pregnancy with...