Document 6427838

CLINICAL OBSTETRICS AND GYNECOLOGY
Volume 51, Number 2, 398–408
r 2008, Lippincott Williams & Wilkins
Trauma During
Pregnancy: Outcomes
and Clinical
Management
MARK C. CHAMES, MD and MARK D. PEARLMAN, MD
Department of Obstetrics and Gynecology, University of Michigan,
Ann Arbor, Michigan
Abstract: Trauma affects up to 6% to 7% of all
pregnancies, and accounts for up to 46% of maternal
death. Adverse consequences such as preterm labor
and delivery, abruptio, fetomaternal hemorrhage, and
fetal demise may be seen with even apparently minor
degrees of injury. Maternal physiologic considerations are reviewed and a protocol for evaluation and
management of the injured gravida is presented.
Key words: wounds and injuries, pregnancy, trauma
Complications associated with trauma
include not only the more obvious, direct
maternal consequences, but also unique
pregnancy-related complications such as
preterm labor and delivery, abruptio placentae, fetomaternal hemorrhage, the
potential for attendant isoimmunization,
direct fetal injury, and fetal demise.5–9
Such outcomes, particularly abruptio placentae, may be seen even with apparently
minor degrees of injury, and fetal death is
a more common occurrence than maternal death.10–12
Although often overlooked as a complication of pregnancy, trauma affecting the
gravida is a common occurrence. Up to
6% to 7% of pregnancies are affected by
some degree of traumatic injury,1 which is
usually accidental but may include intentional violence. Traditional public health
databases have often failed to include
nonobstetric causes of maternal mortality, but several studies have reported that
when wider criteria are used, trauma is the
leading cause of maternal death, accounting for up to 46% of such cases.2–4
Epidemiology
The most common causes of trauma in
pregnancy are motor vehicle accidents
(49%), falls (25%), assaults (18%), guns
(4%), and burns (1%).13 When looking
solely at injuries resulting in death, the
2 most common injuries are homicide and
motor vehicle accidents, which account
for 36% and 32%, respectively, with the
remainder resulting from drug use, suicide, and other nonspecified causes.3
Correspondence: Mark D. Pearlman, MD, Department
of Obstetrics and Gynecology, University of Michigan,
Ann Arbor, Michigan. E-mail: [email protected]
CLINICAL
398
OBSTETRICS
AND
GYNECOLOGY
/
VOLUME
51
/
NUMBER 2
/
’’
2008
Trauma During Pregnancy
Identified risk factors for trauma in
pregnancy are infrequent, but include
younger age,14 drug use, alcohol use,
and domestic violence.15–17 In particular,
drug and alcohol use appear significant as
risk factors for both trauma and for adverse outcome. Berenson and associates18
found that women who were battered
were more likely to use alcohol, drugs,
and tobacco; and among women who had
minor degrees of trauma in pregnancy,
Holland and colleagues19 reported a 21%
incidence of preterm birth when the drug
screen was positive.
Sometimes, pregnancy itself can be a
risk factor for trauma. Over recent years,
attacks on pregnant women have gained
prominence.20 These attacks are frequently targeted at the gravid abdomen,
with intent to cause fetal injury.21
PHYSIOLOGIC CHANGES
OF PREGNANCY
Crucial to the resuscitation of the pregnant trauma victim is an understanding of
both fetal and maternal physiology, particularly the physiologic response to stress
and hypovolemia. Fundamental differences in the physiologic response to trauma occur during pregnancy, and the
obstetrician’s specific knowledge becomes
an invaluable asset to the team of physicians managing the pregnant trauma
victim in all settings of trauma during
pregnancy. An overview of some of these
changes is found in Table 1.
Fetal Physiology
Several factors are important in determining what impact a traumatic event will
have on pregnancy outcome, including
gestational age, type and severity of
trauma, and the extent of disruption of
normal maternal and fetal physiology.22
In the first week of conception, the nonimplanted embryo is relatively resistant to
noxious stimuli. Even during the first
trimester, the uterus resides safely within
the confines of the bony pelvis and is
399
TABLE 1. Anatomic/Physiologic Changes
of Pregnancy
Cardiovascular
Cardiac output
Blood pressure
Heart rate
Supine positioning
Hematologic
Blood volume
Hemoglobin
increases
Gastrointestinal
Intestines
gestation
Gastric
emptying time
Urinary
Bladder
organ
Ureters
Reproductive
Uterine size
Uterine blood
flow
Increases 1-1.5 L/min
Decreases 5-15 mm
in mid-trimester
Increases 15-20 bpm
May decrease cardiac
output up to 30%
Increases 40%-50%
13-28 wk
Decreases 1-2 g/dL as
plasma volume to a
greater degree than
does RBC mass
Displaced into upper
abdomen in later
Increases
Displaced cephalad
becoming an abdominal
in the second and third
trimesters
Dilated (R>L)
Increases to 36 cm, 1000 g
organ
Increases from 60 to
600 mL/min
largely protected from direct uterine
trauma. However, at any gestational age
after implantation, maternal hypovolemic shock may have a significant impact
on the developing embryo/fetus. Blood
flow to the uterine arteries are normally
maximally vasodilated, thus blood delivery to the uterus is maximal in the normal
physiologic state. Maternal hypovolemia
may result in vasoconstriction in many
vascular beds, including the uterine vasculature. Even without uterine artery vasoconstriction, a decrease in maternal
blood pressure may result in a decrease
in uterine blood flow. These facts underlie
the importance of maintaining adequate
maternal blood volume as a first step in
fetal resuscitation. The third trimester fetus
can adapt to this decrease in uterine blood
flow and oxygen delivery by diverting
400
Chames and Pearlman
blood distribution to the heart, brain, and
adrenal glands.23 Furthermore, because
fetal hemoglobin has a greater affinity for
oxygen than does adult hemoglobin, fetal
oxygen consumption does not decrease
until the delivery of oxygen is reduced by
50%.24
Blunt or penetrating trauma to the
fetus may result in rupture of the amniotic
membranes. In the second trimester, rupture of membranes without reaccumulation of fluid may result in pulmonary
hypoplasia or orthopedic deformity. In
addition, infection may develop with
premature rupture of the membranes at
any gestational age. Injury to the placenta
may result in separation or laceration
leading to fetal anemia, hypoxemia, or
hypovolemia.8,22,25,26
Maternal Anatomic and
Physiologic Changes
Nearly every organ system undergoes
anatomic or physiologic changes during
pregnancy. The description below emphasizes the importance of some of these
changes in managing the trauma victim,
particularly as these differences impact on
the usual practice of managing trauma
victims.
A major concern when caring for trauma victims is internal hemorrhage and
hypovolemia. The sentinel findings of
hypovolemia are changes in vital signs,
typically hypotension and tachycardia.
The practitioner must be aware of the
normal decrease in systemic vascular
resistance resulting in a drop in blood
pressure10–15 and increase in pulse (5 to
10 bpm), particularly in the second trimester. These changes can be attenuated if
the gravida is placed in the supine position
(eg, strapped to a long board with the
spine secured). The resultant potential
decrease in venous return from the lower
extremities can reduce central venous
volume and result in a diminished cardiac
output (up to 28%). Simple manual dis-
placement of the gravid uterus to the left
or placement of a rolled towel under the
backboard (while assuring the spine
remains secure) can alleviate most of this
effect.
Plasma volume increases up to 50% in
the singleton gestation, maximal by 28
weeks. RBC mass increases to a lesser
degree than does plasma volume, resulting in a slight decrease in hemoglobin and
hematocrit during pregnancy. Iron deficiency anemia is also common during
pregnancy, and together with the ‘‘physiologic’’ anemia, it is not infrequent to
see hemoglobin in the 9 to 11 g/dL range.
These hematologic changes have 2 potential implications in the management of the
trauma victim: (1) confusion with anemia
due to active bleeding and hypovolemia,
and (2) blood volume estimates should be
modified upward during fluid resuscitation.
The 2 major pregnancy-induced changes
in the gastrointestinal tract, which have
implications for trauma management are
compartmentalization (ie, cephalad displacement of the bowel), and decreased bowel
motility resulting in increased transit time
of bowel contents. Compartmentalization
protects the bowel during lower abdominal
trauma, but is particularly concerning when
there is penetrating trauma to the upper
abdomen in the latter half of gestation.
Complex injuries to the small bowel can
occur under these circumstances, which
may result in multiple entry and exit
wounds. Decreased gastric motility results
in prolonged gastric emptying time increasing the risk of aspiration. Rebound tenderness and guarding may be less apparent in
advanced gestation, making clinical diagnosis of hemoperitoneum potentially less
reliable; changes that are likely due to
stretching of the abdominal musculature
and peritoneum by the gravid uterus.
Dramatic increases in uterine blood
flow (from 60 to 600 mL/min) may result
in rapid exsanguination if there is avulsion of the uterine vessels or rupture of
Trauma During Pregnancy
the uterus. Retroperitoneal hemorrhage is
also a common complication of pelvic
fracture owing to the tremendous increase
in vascularity resulting from pregnancy.
Enlargement of the uterus makes it susceptible to direct abdominal trauma. Injury to the uterus itself (uterine rupture),
adjacent organs (bladder rupture), or contents of the uterus (abruptio placentae
or direct fetal injury) are possible. While
some occur typically with direct and violent trauma (eg, uterine rupture), others
may occur with minimal maternal trauma
(eg, abruptio placentae). Other changes
that have potential importance in managing pregnant trauma victims are listed in
Table 1.
EFFECTS OF TRAUMA
Maternal Effects of Trauma
Mechanisms of maternal injury may
directly relate to the trauma, or may
develop independently. For example, if a
pregnant woman is in a motor vehicle
accident and suffers a penetrating trauma,
the cause of injury may be apparent,
although the spectrum of injury may be
altered owing to the changes previously
reviewed. Even without visible injury,
however, a sudden deceleration involved
in the accident can create a shearing force
sufficient to tear the placenta away from
the uterine wall resulting in placental
abruption. Abruptio may pose risks for
preterm labor and delivery, cesarean delivery, coagulopathy, massive hemorrhage, and isoimmunization. Notably,
blunt injuries in pregnancy do not appear
to pose higher risk for death than they do
in nonpregnant patients, with most deaths
occurring as the result of either head
injury or hemorrhage.27–29
In a more extreme example, uterine
rupture, although rare, may result from
trauma. This unusual occurrence is estimated to complicate only 0.6% of traumatic injury.30 This complication seems
to occur more often later in pregnancy,
401
and usually results from a direct, highenergy blow to the maternal abdomen.
Risk factors that may play a role,
although not entirely clear in order of
importance, include parity, history of
uterine surgery, and uterine overdistention, such as may be seen with polyhydramnios and multiple gestation.31,32
Outcomes in these cases almost always
include fetal death.
Fetal Effects of Trauma
Most trauma in pregnancy is blunt trauma. In cases of blunt trauma, direct fetal
injury is relatively uncommon because the
maternal soft tissues, uterus, placenta,
and amniotic fluid all tend to absorb
and distribute the energy of the blow. In
such cases, indirect fetal injury, such as
placental abruption and fetomaternal
hemorrhage are more common. Abruptio
results from deformation of the uterine
wall, and the resultant shearing effect on
the underlying placenta.8,33 This complication occurs in approximately 6% of
women with maternal trauma in pregnancy.33
Outcomes such as fetal death and
delivery are important consequences of
trauma. Investigators have found that
injury severity is not universally predictive of these complications, and that
adverse outcomes can be seen even with
relatively minor degrees of injury.33–35
More recently, Theodorou and colleagues,36 in a study of risk factors for such
adverse outcomes, found that moderate
and severe degrees of injury, as indicated
by an Injury Severity Score (ISS) of 9 or
greater, were the lone predictive factors.
They reinforced the earlier findings,
however, because adverse outcomes were
seen even without severe injury, and the
authors concluded that all patients with
injury require close surveillance.36
Although indirect mechanisms of fetal
injury predominate, direct fetal injury
can, in fact, occur and is usually a result
of penetrating injury such as stabbing or
402
Chames and Pearlman
gunshots. For example, 70% of abdominal gunshot wounds in the third trimester
result in fetal injury.37 Although relatively
uncommon, blunt trauma can result in
direct fetal injury. This sort of scenario
is most likely to be seen in a cephalic
presentation with pelvic trauma, probably because the fetal head has less protection, being closely approximated to the
bony pelvis. Such injuries can include
skull fracture and intracerebral hemorrhage.12,38 Other fetal injuries such as
long bone fracture and visceral injuries
have also been described, although they
are very uncommon events.
Fetomaternal Hemorrhage
As mentioned earlier, fetomaternal hemorrhage is a result of trauma that may
pose risks for both current and future
pregnancies. Although a recent study of
151 women who experienced trauma
showed no increase in the rate of fetomaternal hemorrhage above the general
population, finding it in only 2.6% of
patients,39 fetomaternal hemorrhage has
traditionally been reported to occur in up
to 9% to 30% of cases of trauma in
pregnancy, which is about a 4 to 5-fold
increase over the baseline rate.8,11,33,40
One study suggested that fetomaternal
hemorrhage occurs more commonly after
trauma in pregnant women with anteriorly located placentae33 and in patients
who experience uterine tenderness after
trauma. Motor vehicle accidents are a
more frequent cause of this complication
than are other types of trauma.8,33 Severity of injury and gestational age do not
seem to reliably predict fetomaternal hemorrhage, but large transfusions of blood
from the fetal to maternal compartment
are generally seen only in patients with
physical evidence of trauma.8
Fetal consequences of hemorrhage, including anemia, supraventricular tachycardia, and death have been described.
These outcomes, however, are not common, even when fetal blood is detected in
the maternal circulation. Longer-term,
the concern with fetomaternal hemorrhage is the development of isoimmunization in the mother. Fetomaternal
hemorrhage is a particular concern in
Rh-negative women, who are at high risk
for sensitization if the infant is Rh-positive. As such, these women should receive
Rh immune globulin, at least 300 mg
intramuscularly, after trauma. This dose
will provide adequate prophylaxis for
fetomaternal transfusions of up to 30 mL
of fetal whole blood. Unfortunately, a
limited number of patients will have
a hemorrhage in exceed this volume, and
a single dose of Rh immune globulin will
not suffice.8,33
Fetomaternal hemorrhage can be detected and quantified by testing for fetal
cells in the maternal circulation using the
Kleihauer Betke, or acid elution test. This
test can be performed in Rh-negative
women to facilitate dosing of immune
globulin. The importance of the test is
unclear in Rh-positive women, and some
authors do not advocate for its use in
these patients. Muench and associates,41
however, studied 71 women who underwent Kleihauer Betke testing after trauma
and found a strong correlation with risk
for preterm labor and have advocated its
use in all patients.
Evaluation and Management
As the well-being of the fetus is dependent
on that of the mother, the first priority in
the care of the injured gravida is maternal
resuscitation. When performing resuscitation, the ABC’s refer to Airway, Breathing, and Circulation.42 Circulation, in
trauma patients, refers not only to establishment of a heart rate, but also
maintaining intravascular volume by controlling blood loss and replacing crystalloid. It is important to remember that by
the third trimester maternal circulating
blood volume has increased by 50%
above baseline. Consequently, when
Trauma During Pregnancy
calculating replacement, the volume infusion calculations should be increased to a
similar degree.
Another important alteration in the
circulation of the gravida must be considered. Beyond about 20 weeks in singleton
pregnancies (or earlier in multiple gestation), the weight of the gravid uterus can
compress the inferior vena cava, impairing return of blood from the lower extremities and hampering resuscitative
efforts. To overcome this, the uterus
should be deflected laterally (adding a
‘‘D’’ to the ABC’s, indicating deflection).
Uterine deflection is most easily accomplished by placing the patient in the leftlateral decubitus position. In patients in
whom such positioning is not possible,
uterine displacement can be performed
either manually, by applying pressure to
shift the uterus, or by placing a wedge
under the patient’s right side, or under the
right side of the patient’s backboard,
if necessary.
The secondary survey should proceed
as in the nonpregnant patient. The fundal
height should be determined, particularly
if gestational age is unknown, and the
uterus should be examined for tenderness
and contractions. Pelvic examination
should be performed to evaluate for
bleeding, rupture of membranes, and cervical assessment. The fetal heart rate
should be evaluated, and, in women beyond 24 weeks, cardiotocodynamometry
should be instituted. Caution must be
exercised to differentiate maternal from
fetal heart rate, because many pregnant
patients with trauma will be tachycardic
and the 2 heart rates may easily be confused. Simultaneous palpation of the maternal pulse with the use of fetal heart
Doppler will usually assure correct identification of the fetal heart rate. Any
continued confusion can be resolved with
direct visualization of the fetal heart using
ultrasound, or the use of newer fetal
monitors that permit continuous tracing
of both maternal and fetal heart rates.
403
Although radiation exposure in pregnancy is not without risk, this should not
preclude performance of necessary radiographic studies. There is not expected to
be an increase in the risk for fetal loss,
growth restriction, or malformation as
long as the fetal dose of radiation is less
than 5000 mrads. Although there may be
an increase in the risk for childhood leukemia with lower doses of radiation, the
risk of undiagnosed and untreated maternal injury certainly outweighs this risk.43
Indeed, among patients with fractures,
particularly pelvic fractures, there is an
increased frequency of complications for
both the mother and the fetus.44 Identification of such patients is, consequently, of
great importance. The estimated doses of
radiation to the fetus with various radiographic procedures is shown in Table 2.43
Laboratory studies should be performed as medically indicated, including
complete blood count, blood typing, and
antibody screen. Coagulation studies may
be indicated in women in whom abruptio is
suspected or when multisystem trauma
is encountered. Interpretation of laboratory tests should take into account the
physiologic changes normally seen in pregnancy. Finally, the Kleihauer Betke test
can be performed in Rh-negative women,
who should receive an appropriate dose of
TABLE 2. Estimated Fetal Exposure From
Common Radiologic Procedures43
Procedure
Fetal Exposure
Chest x-ray (2 views)
Abdominal film (single view)
Intravenous pyelography
Hip film (single view)
Mammography
Barium enema or small
bowel series
CT scan of head or chest
CT scan of abdomen
and lumbar spine
CT pelvimetry
0.02-0.07 mrad
100 mrad
Z1000 mrad
200 mrad
7-20 mrad
2000-4000 mrad
CT indicates computed tomography.
<1000 mrad
3500 mrad
250 mrad
404
Chames and Pearlman
Rh immune globulin within 72 hours of the
traumatic event. If Kleihauer-Betke testing
is not performed, 300 mcg of Rh immune
globulin should be administered in all Rhnegative women.
In patients beyond 23 to 24 weeks,
tocodynamometry is the most sensitive
predictor of abruptio placentae after trauma, and in combination with electronic
fetal monitoring, facilitates its diagnosis
and treatment. Abruptio begins developing soon after trauma, and evidence of
abruptio usually becomes apparent
shortly after injury. Therefore, monitoring should begin as soon as feasible,
although it should not take precedence
over basic maternal resuscitation. Fetal
heart rate changes to identify include
tachycardia, bradycardia, periodic decelerations, loss of variability, and a sinusoidal pattern. Continuous fetal monitoring
is preferred to intermittent auscultation,
as the latter is limited in its ability to detect
heart rate changes other than tachycardia
and bradycardia. In a prospective study of
fetal heart rate tracing in patients with
traumatic abruptio placentae, the authors
reported that of the 4 cases of fetal distress, 2 may have encountered delay in
diagnosis with intermittent monitoring.33
Uterine activity monitoring, tocodynamometry, plays an important role in the
prediction of abruption, and therefore
plays an important role in the evaluation
and care of these women. Pearlman and
colleagues33 prospectively studied 85
consecutive women with trauma in pregnancy. All patients with 3 or more contractions were monitored for 24 hours. At
that point, patients were discharged if
contractions had stopped and no evidence
fetal compromise, rupture of membranes,
vaginal bleeding, or other serious injury,
had become manifest. They found that all
cases of abruptio showed frequent (>8/h)
contractions in the initial four hours of
electronic fetal monitoring.33
On the basis of these data, 4 hours
of electronic monitoring has become a
widely accepted minimum duration of
monitoring.30 Patients who have fewer
than 1 contraction every 10 minutes during this 4-hour period of monitoring and
who also do not exhibit uterine tenderness, bleeding, fetal distress, or serious
maternal injuries do not seem to be at
risk for adverse pregnancy outcomes
compared with uninjured controls.25,33
Among those women with significant
contractions, the rate of fetal death or
delivery is almost 20%.33
Figure 1 shows the algorithm employed
at the University of Michigan guiding care
of the injured gravida.
Prevention
Strategies targeted at the prevention of
traumatic injury in pregnancy have not
been well studied. This is probably due at
least partially to the fact that an active
gravida will engage in typical day-to-day
activities such as driving, which carry a
degree of risk, but these are activities that
are difficult to curtail in our mobile society. Thus our suggestions with regards
to prevention are limited. First among
these is education. Informing the patient
of risks of trauma may increase awareness
of activities that may particularly place
them at risk. In addition, should injury or
fall occur, a patient who is aware of the
risks is almost certainly more likely to
report to the hospital for evaluation.
Regarding automobile accidents, the
cause of almost half of trauma, specific
recommendations exist regarding the use
of safety belts. The correct use of safety
belts during pregnancy should be encouraged, as patients who are unrestrained are
twice as likely to deliver within 48 hours of
motor vehicle accidents as are restrained
patients.45 Further, when placed incorrectly, safety belts have been reported to
be associated with fetal injury.30 Unfortunately, many patients either do not wear
safety belts or are unable to identify proper placement.46,47 The American College
Trauma During Pregnancy
405
STABILIZATION
ect uterus)
Maintain circulatory volume
Secure cervical spine if head or neck injury suspected
PREHOSPITAL
Activate Trauma Team
Notify OB
COMPLETE EXAM
Control external hemorrhage
Identity/stabilize serious injuries
Examine uterus; Evaluate for rupture (shock, fetal distress or death,
uterine tenderness, peritoneal irritation)
Pelvic exam to identity rupture of membranes or vaginal bleeding
Obtain initial blood work
Document Fetal
Heart Tones
23-24
weeks?
No
Yes
INITIATE FETAL MONITORING
Transfer to labor and delivery unit when stable (where applicable)
Minimum 4 hours monitoring
Provide other definitive treatment (suture lacerations, necessary X-rays)
Consider RhoGAM in Rh-negative women
EVALUATE FOR:
More than four uterine contraction in any 1 hr
Rupture of amniotic membranes
Vaginal bleeding
Serious maternal injury
Significant abdominal/uterine pain
Fetal tachycardia, late decelerations, non-reassuring FHTs
Hospitalize
Continue to monitor for 24 hours
Intervene as appropriate
Yes
Present?
No
Discontinue fetal
monitoring
FIGURE 1. Algorithm used at the University of Michigan guiding care of the
injured gravida.
of Obstetricians and Gynecologists has
emphasized that both the lap belt and
shoulder harness should be worn, with
the lap belt passing below the abdomen
and over the anterior superior iliac spine
and symphysis pubis and the shoulder
harness passing between the patient’s
breasts.30 Patients who receive information regarding this are significantly more
likely to use their safety belts correctly.46
406
Chames and Pearlman
Careful crash analysis has demonstrated
that the proper restraint of pregnant occupants is independently associated with
a lower risk of adverse fetal outcomes
(ie, abruptio placentae, preterm birth,
and stillbirth) in motor vehicle crashes
involving pregnant women.48
The many issues related to domestic
violence during pregnancy have been covered in another chapter and are not covered in-depth here. However, given that
some sort of sexual or physical abuse
affects up to 20% of pregnancies,20 it is
important that physicians screen all
patients for domestic violence. Patients
who are in abusive relationships should
be provided with referrals to appropriate
social support systems and counseled
appropriately regarding the risks of such
violence in pregnancy.
As discussed previously, substance
abuse during pregnancy is associated with
increased risk for traumatic injury.18,19
Patients who are using alcohol or drugs
should be counseled regarding the effects
of such substances on the pregnancy. The
patients should receive referrals to social
work and specialists in addiction disorders.
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