Management
> The management of pregnant women with moderate to severe injuries can be divided into:
> Primary survey
> Resuscitation
> Secondary survey
> Definitive treatment
> Many of the steps will occur simultaneously once the woman is received in the trauma centre or an emergency department
Primary survey
> The primary survey is to identify and treat life threatening conditions
Airway and cervical spine
> Any woman with trauma who is unconscious or has a neck injury above the clavicle should be regarded as having a cervical neck injury until proven otherwise
Breathing
> Oxygen should be administered at rates of at least 10 litres per minute
Circulation and haemorrhage control
> Assess peripheral circulation, skin colour and pulse rate and character
> Control obvious external haemorrhage
> Position woman on her left side with lateral tilt 15˚ to 30˚
> If lateral tilt is not possible because of spinal injuries or other trauma, the uterus should be manually displaced to alleviate aorto caval compression
> Establish intravenous access with at least two large bore 16 gauge cannulae or larger in peripheral veins. Central veins are not the first choice of venous access
> Treat hypovolaemic shock with intravenous fluid or blood as indicated. The assessment of shock in young women is difficult and must not be based on blood pressure (BP). A normal BP does not mean a normal circulation. In shocked young people BP is maintained well until very late and in the pregnant woman mild hypotension is commonly encountered. The pulse rate and its character, peripheral perfusion and skin colour provide a more accurate assessment of the circulation. Sufficient intravenous fluid should be administered to improve these parameters in women with blunt injury. If the woman remains unstable despite ongoing resuscitation operative intervention is indicated.
> An unstable woman must not be taken to the CT scanner
> With penetrating trauma, haemorrhage can only be controlled effectively by surgery. Resuscitation to normal BP results in an increase in mortality (Bickell et al. 1994). Until an operating theatre and surgeon can be organised, IV fluid administration should be limited to that sufficient to maintain a palpable radial pulse
Disability
> Initial neurological assessment using Glasgow coma scale and pupillary response
Exposure and environmental control
> The woman must be undressed to allow for a full physical examination
> The woman must always be kept warm or rarely cooled. Hypothermia is one of the main dangers in trauma contributing to worsening acidosis, coagulopathy and infection
Resuscitation
> Monitor response to initial treatment with pulse rate and peripheral perfusion. Blood pressure can be a distraction; if low it confirms the woman is significantly hypovolaemic but a normal BP does not necessarily imply a normovolaemic, fully resuscitated woman
> Radiology
> The following plain films must be taken
> Chest
> Pelvis
> Lateral C spine
Secondary survey
> A complete physical examination is performed to identify all other injuries. Orogastric tube and urinary catheter are inserted
> Continue to regularly assess maternal pulse, blood pressure, urine output as appropriate
> Obstetric evaluation
> Fundal height
> Uterine tone, contractions, and tenderness
> Fetal heart rate
> Vaginal bleeding or evidence of spontaneous rupture of the membranes
> Pelvic examination
> Cardiotocography for at least 4 hours if 24 weeks or more (see below)
> Abdominal and obstetric ultrasound
> Radiographic imaging (CT scan) as indicated when the woman is stable
> Laboratory investigations for all trauma in pregnancy should include:
> Complete blood picture and coagulation studies
> Group and save
> Biochemistry
> Kleihauer test
> Laboratory investigations for women with moderate to severe trauma in pregnancy:
> Group and cross-match
> Coagulation studies
> Serum electrolytes
> Renal function test
> Serum glucose
> AST and ALT
> Amylase
> Arterial blood gas analysis
> Kleihauer test – quantify with flow cytometry, if the Kleihauer test indicates significant feto-maternal haemorrhage
> Urinalysis
Definitive care
> Ongoing management of any further injuries should be undertaken at FMC. The pregnant woman should be retrieved or transferred to FMC as soon as possible
> In the presence of abdominal trauma (particularly with ultrasound evidence of intra peritoneal fluid), persistent hypotension and tachycardia despite appropriate fluid resuscitation is an indication for immediate midline laparotomy to definitively control intra abdominal bleeding (abruption, uterine rupture, splenic rupture, vascular injury etc)
> The first point of contact is medSTAR (South Australia’s emergency medical retrieval service), telephone 8222-4222.
> MedSTAR will liaise with the Flinders Medical Centre (FMC) Critical and Intensive Care Unit, telephone 8204-5542 and the South Australian obstetrician and paediatrician rostered on call for retrieval to arrange retrieval as required
> If retrieval is required, medSTAR will also notify the on call obstetric registrar at FMC of the impending arrival (as the SA on call obstetrician may not be from FMC). All pregnant women being retrieved by air should be transported to FMC
> If a caesarean section is necessary trauma surgeons should be present to assess and treat any maternal injuries
> Consider venous thromboembolism prophylaxis
> Administer Rh (D) immunoglobulin (625 IU CSL for gestation > 12 weeks) if the woman is Rh negative and has no pre-existent Rh (D) antibodies
> Women suffering trauma in pregnancy should be admitted for fetal assessment if the gestational age is thought to be ≥ 20 weeks
Cardiotocography
> If the gestation is known to be or could be 24 weeks or more, electronic fetal monitoring (EFM) should be continued for a minimum of 4 hours following the initial abdominal trauma
> Maternal trauma may be associated with placental abruption
> In severe maternal trauma, CTG may be important, primarily as a monitor of maternal wellbeing. Placental circulation may be compromised before hypovolaemia is otherwise apparent.
> If the gestational age is unknown, a fundal height at the level of the umbilicus (20 centimetres or more) can be used as a guide until more accurate dating is possible
> Medical review after 4 hours continuous EFM
> If discharge criteria (see below) are not met, intermittent EFM should be continued for 24 hours (at least one 20 minutes trace every 4 hours)
> Indications for more extensive fetal monitoring are:
> Uterine contractions > 1 every 15 minutes
> Uterine tenderness
> Signs of fetal compromise on cardiotocography
> Evidence of vaginal bleeding
> Rupture of the membranes
> Positive Kleihauer test
> Ultrasound suggestive of placental or cord abnormality
> Any evidence of serious maternal injury top |