In the emergency department of a small rural hospital you see a 36/40 lady, Mrs. Janice Cook, who was involved in a motor vehicle crash. She was the front seat passenger with seatbelt on while her husband was driving. She is conscious and able to sit at up and talk to you. She has her antenatal notes with her. Her antenatal check up has been normal so far, including 18/40 scan. Her BG is O negative.YOUR TASK IS TO:• Take a further history• Examine the patient• Arrange for appropriate investigations• Discuss your findings an management with the examinerHOPC: Whilst driving along a country road in wet weather the car lost grip and it slammed into a power pole on the side of the road although fortunately they were not going at a high speed and nobody seemed to be seriously injured. Janice had no loss of consciousness, no pain, no bleeding and she felt her baby moving and kicking as usual. However she is very worried about her baby!
PHx. + FHx.: unremarkable
SHx: married school teacher, 2 children and 3rd pregnancy, non smoker, no alcohol, NKA, no medication.
EXAMINATION: Although in this patient the examination will be unremarkable, it is important to consider the following:
Abdominal pain and/or tenderness in pregnant trauma patients raises the difficult question of whether the signs and symptoms are obstetric or nonobstetric in origin. After the first trimester of pregnancy, the most common confusing obstetric diagnoses are preterm labor and abruptio placentae. Unfortunately, these complications may be the consequence of maternal trauma, rather than the cause of the abdominal pain and tenderness.
The differentiation between nonobstetric and obstetric causes is critical to management. The single most effective aid in diagnosis is an experienced obstetrician who has conducted a detailed history and physical examination. Subsequently, the results of serial pelvic examinations, electronic fetal monitoring, and ultrasonographic examinations are important in the diagnosis and management.
Primary (ABC!) and secondary trauma surveys should be performed as per usual, as the haemodynamic and ventilatory well-being of the patient are the most important factors in determining the fetus' outcome in a injured pregnant patient. The secondary survey should also include the following:
Abdominal examination
Inspect for ecchymoses, ( bleeding in subcutaneous tissue) especially across the lower abdomen, which may indicate a possible seatbelt injury.
Palpate for uterine contractions or tenderness.
Fetal heart tones can be assessed with Doppler examination or ultrasonography.
Rebound tenderness and guarding may be less apparent in advanced gestation, making clinical diagnosis of haemoperitoneum potentially less reliable because peritoneal stretching in the third trimester decreases the density of afferent pain fibers, thereby muting peritoneal signs.
Sterile speculum examination before bimanual examination
Perform these in the absence of vaginal bleeding.
Test the fluid for pH and ferning. A pH of 7 indicates amniotic fluid. Vaginal secretions are more acidic, with a pH around 5.
Examine for vaginal lacerations, which may signify an open pelvic fracture.
Look for bone fragments in the vagina, which signify an open pelvic fracture.
Bimanual examination
In general, the obstetrician should perform this examination.
It should be performed in a setting where emergency cesarean delivery can be performed.
INVESTIGATIONS:
• FBE, U+E’s, glucose
• blood group (if not known) and X-match
• urinalysis
• coagulation studies
• Kleihauer test: this test (an acid elution test in which adult haemoglobin is eliminated while fetal haemoglobin is resistant and hence stains) is used to detect fetal-to-maternal haemorrhage and the amount of fetal blood cells in the maternal circulation and then a prophylactic injection of anti-D gammaglobulin should be given!
• Toxicology screening
• Some obstetricians advocate use of D-dimer testing to help in determining the course of action for placental abruption.
• Radiologic examinations should not be deferred because of the presence of the fetus. The acquisition of an anteroposterior pelvic radiograph delivers a 0.16 mega ray (mGy) dose to the fetus, while typical dose from CT scanning of the pelvis is approximately 20-50 mGy.
As a general rule, abdominal CT should be avoided in early pregnancy because other diagnostic modalities, such as ultrasonography and diagnostic peritoneal lavage, are acceptable alternatives. CT does, however, allow for better visualization of retroperitoneal and intrauterine injuries. Head and chest CT may be used when indicated because the amount of radiation is much less and because few, if any, alternative diagnostic modalities exist.
• Cardiotocographic monitoring:
All pregnant trauma victims of 20-24 weeks of gestational age or greater should be placed on a fetal monitor. Fetal distress may be the first sign of maternal haemodynamic compromise because the mother will maintain her vital signs by shunting blood away from the relatively low-resistance uterus. A minimum of 4 hours of monitoring is suggested, even after minor abdominal or flank trauma, to identify patients that might experience placental abruption. This is because clinical signs and symptoms of abruption, such as vaginal bleeding, abdominal pain and tenderness, and uterine tenderness, are often absent.
• Monitoring for 24 hours is suggested with major trauma or signs of obstetric decompensation, such as persistent uterine contractions, vaginal bleeding, premature rupture of the membranes, or fetal heart rate tracing that causes concern.
• Ultrasonography has less than 50% sensitivity in diagnosing placental abruption because the density of a fresh clot of blood behind the placenta is the same as the placenta itself. However, the obstetric ultrasonogram should confirm gestational age and fetal and placental position.
DIAGNOSIS:
The pregnant trauma patient presents a unique challenge because care must be provided for two patients—the mother and the fetus. Anatomic and physiologic changes in pregnancy can mask or mimic injury, making diagnosis of trauma-related problems difficult. Care of pregnant trauma patients with severe injuries often requires a multidisciplinary approach involving an emergency clinician, trauma surgeon, obstetrician, and neonatologist.
MANAGEMENT:
Patients who have minor trauma and who are at less than 20 weeks' gestation do not require specific intervention or monitoring. All pregnant women beyond 20-24 weeks' gestation who have direct or indirect abdominal trauma should undergo at least 4 hours of cardiotocographic monitoring. Resuscitation of the more serious trauma patient must focus on the mother because the most common cause of fetal death is maternal shock or death. It is important to remember that the mother will maintain her vital signs at the expense of the fetus. Because plasma volume is increased 50% and the mother is able to shunt blood away from the uterus, maternal shock may not manifest itself until maternal blood loss exceeds 30%. During the initial ABC assessment, the fetus is addressed only during evaluation of circulation.
If the patient is more than 20-24 weeks' pregnant, the patient should be tilted 15° to the left. Alternatively, one person may be designated to manually displace the uterus to the left. If the patient does not require spinal immobilization, then she can be asked to assume the left lateral decubitus position.
Airway and breathing
All pregnant trauma patients should receive supplemental oxygen because the fetus is extremely sensitive to hypoxia and because the oxygen reserve is significantly diminished in the pregnant patient.
In general, pregnancy does not affect the decision to intubate, although the risk of aspiration is increased (decreased gastric tone, delayed gastric emptying, and cephalad displacement of intra-abdominal organs).
Circulation
It is extremely important to maintain adequate maternal blood volume as a first step in fetal resuscitation. A decrease in maternal blood pressure may result in a decrease in uterine blood flow, even without uterine artery vasoconstriction.
Resuscitate the patient with warmed crystalloid administered through large-bore catheters placed for intravenous lines because the relative hypervolaemia of pregnancy allows for a 30-35% loss of blood volume before hypotension develops.
Rule out occult sources of bleeding because maternal blood flow is maintained at the expense of fetal blood flow.
If blood is needed on an emergency basis, use Rh-negative blood unless the patient's Rh status is known.
Consultations
The pregnant patient with serious traumatic injury requires a multidisciplinary team, which includes an obstetrician, trauma surgeon, and neonatologist.
Medication
The goal of therapy is to prevent immune response to Rh-negative fetus after trauma.
Immune serum
Suppresses immune response of nonsensitized Rh(D)–negative mothers who are exposed to Rh(D)–positive blood from the fetus, resulting from a fetomaternal haemorrhage, abdominal trauma, amniocentesis, abortion, full-term delivery, or transfusion accident.
Rh(D) immune globulin:
Administered if the patient is Rh-negative, unless the father also is Rh-negative. Suppresses the immune response of nonsensitized Rh-negative mothers after delivery of Rh-positive infant. Prevents sensitization to Rh(D) factor. Prevents erythroblastosis fetalis in subsequent pregnancy.
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