Initial evaluation and management of pregnant women with major trauma
- Sarah J Kilpatrick, MD, PhD
Sarah J Kilpatrick, MD, PhD
- Chair, Department of Obstetrics and Gynecology
- Cedars-Sinai Health Center
- Section Editors
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Scott Manaker, MD, PhD
Scott Manaker, MD, PhD
- Section Editor — Critical Care
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Maria E Moreira, MD
Maria E Moreira, MD
- Section Editor — Adult Trauma
- Associate Professor, Department of Emergency Medicine
- University of Colorado Denver School of Medicine
- Residency Program Director
- Denver Health Residency in Emergency Medicine
Motor vehicle accidents and domestic/intimate partner violence account for most cases of maternal major trauma, while falls, burns, homicide, suicide, penetrating trauma, and toxic exposure account for the majority of the remainder [1-3]. Evaluation of the pregnant patient with major trauma presents unique challenges since the presence of a fetus means two patients are potentially at risk, both of whom require evaluation and management.
In the pregnant woman, compression of the abdomen from a fall, intentional violence, or a low-speed motor vehicle crash can be considered major trauma. Issues specific to the pregnant major trauma patient will be discussed here. Issues related to management of trauma in the nonpregnant population are reviewed separately. (See "Initial management of trauma in adults".)
A 2013 systematic review of studies on trauma in pregnancy reported the following estimates of trauma incidence/prevalence by subtype of trauma :
●Domestic violence: 8307/100,000 live births
●Motor vehicle crash: 207/100,000 live birthsTo continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Kuo C, Jamieson DJ, McPheeters ML, et al. Injury hospitalizations of pregnant women in the United States, 2002. Am J Obstet Gynecol 2007; 196:161.e1.
- Weiss HB, Songer TJ, Fabio A. Fetal deaths related to maternal injury. JAMA 2001; 286:1863.
- Mendez-Figueroa H, Dahlke JD, Vrees RA, Rouse DJ. Trauma in pregnancy: an updated systematic review. Am J Obstet Gynecol 2013; 209:1.
- Awwad JT, Azar GB, Seoud MA, et al. High-velocity penetrating wounds of the gravid uterus: review of 16 years of civil war. Obstet Gynecol 1994; 83:259.
- Stone IK. Trauma in the obstetric patient. Obstet Gynecol Clin North Am 1999; 26:459.
- Pearlman MD, Tintinalli JE, Lorenz RP. Blunt trauma during pregnancy. N Engl J Med 1990; 323:1609.
- Committee on Trauma of the American College of Surgeons. Advanced Trauma Life Support: Course for Physicians, 5th ed, American College of Surgeons, Chicago, 1993, p. 17.
- Brown HL. Trauma in pregnancy. Obstet Gynecol 2009; 114:147.
- Sperry JL, Minei JP, Frankel HL, et al. Early use of vasopressors after injury: caution before constriction. J Trauma 2008; 64:9.
- Morris S, Stacey M. Resuscitation in pregnancy. BMJ 2003; 327:1277.
- Katz V, Balderston K, DeFreest M. Perimortem cesarean delivery: were our assumptions correct? Am J Obstet Gynecol 2005; 192:1916.
- Katz VL, Dotters DJ, Droegemueller W. Perimortem cesarean delivery. Obstet Gynecol 1986; 68:571.
- Morris JA Jr, Rosenbower TJ, Jurkovich GJ, et al. Infant survival after cesarean section for trauma. Ann Surg 1996; 223:481.
- Weber CE. Postmortem cesarean section: review of the literature and case reports. Am J Obstet Gynecol 1971; 110:158.
- Mann FA, Nathens A, Langer SG, et al. Communicating with the family: the risks of medical radiation to conceptuses in victims of major blunt-force torso trauma. J Trauma 2000; 48:354.
- Nagy KK, Roberts RR, Joseph KT, et al. Experience with over 2500 diagnostic peritoneal lavages. Injury 2000; 31:479.
- Connolly AM, Katz VL, Bash KL, et al. Trauma and pregnancy. Am J Perinatol 1997; 14:331.
- Pearlman MD, Tintinallli JE, Lorenz RP. A prospective controlled study of outcome after trauma during pregnancy. Am J Obstet Gynecol 1990; 162:1502.
- Higgins SD, Garite TJ. Late abruptio placenta in trauma patients: implications for monitoring. Obstet Gynecol 1984; 63:10S.
- Barraco RD, Chiu WC, Clancy TV, et al. Practice management guidelines for the diagnosis and management of injury in the pregnant patient: the EAST Practice Management Guidelines Work Group. J Trauma 2010; 69:211.
- Palmer JD, Sparrow OC. Extradural haematoma following intrauterine trauma. Injury 1994; 25:671.
- Ellestad SC, Shelton S, James AH. Prenatal diagnosis of a trauma-related fetal epidural hematoma. Obstet Gynecol 2004; 104:1298.
- Sadro CT, Zins AM, Debiec K, Robinson J. Case report: lethal fetal head injury and placental abruption in a pregnant trauma patient. Emerg Radiol 2012; 19:175.
- Härtl R, Ko K. In utero skull fracture: case report. J Trauma 1996; 41:549.
- Goodwin TM, Breen MT. Pregnancy outcome and fetomaternal hemorrhage after noncatastrophic trauma. Am J Obstet Gynecol 1990; 162:665.
- El-Kady D, Gilbert WM, Anderson J, et al. Trauma during pregnancy: an analysis of maternal and fetal outcomes in a large population. Am J Obstet Gynecol 2004; 190:1661.
- El Kady D, Gilbert WM, Xing G, Smith LH. Maternal and neonatal outcomes of assaults during pregnancy. Obstet Gynecol 2005; 105:357.
- Rogers FB, Rozycki GS, Osler TM, et al. A multi-institutional study of factors associated with fetal death in injured pregnant patients. Arch Surg 1999; 134:1274.
- Schiff MA, Holt VL. Pregnancy outcomes following hospitalization for motor vehicle crashes in Washington State from 1989 to 2001. Am J Epidemiol 2005; 161:503.
- Esposito TJ. Trauma during pregnancy. Emerg Med Clin North Am 1994; 12:167.
- Kuhlmann RS, Warsof S. Ultrasound of the placenta. Clin Obstet Gynecol 1996; 39:519.
- Manriquez M, Srinivas G, Bollepalli S, et al. Is computed tomography a reliable diagnostic modality in detecting placental injuries in the setting of acute trauma? Am J Obstet Gynecol 2010; 202:611.e1.
- Lavin JP Jr, Miodovnik M. Delayed abruption after maternal trauma as a result of an automobile accident. J Reprod Med 1981; 26:621.
- Dahmus MA, Sibai BM. Blunt abdominal trauma: are there any predictive factors for abruptio placentae or maternal-fetal distress? Am J Obstet Gynecol 1993; 169:1054.
- Muzumdar D, Higgins MJ, Ventureyra EC. Intrauterine penetrating direct fetal head trauma following gunshot injury: a case report and review of the literature. Childs Nerv Syst 2006; 22:398.
- Vaysse C, Mignot F, Benezech JP, Parant O. [Traumatic uterine rupture: a rare complication of motor vehicle accidents during pregnancy. A case report]. J Gynecol Obstet Biol Reprod (Paris) 2007; 36:611.
- Franger AL, Buchsbaum HJ, Peaceman AM. Abdominal gunshot wounds in pregnancy. Am J Obstet Gynecol 1989; 160:1124.
- Sakala EP, Kort DD. Management of stab wounds to the pregnant uterus: a case report and a review of the literature. Obstet Gynecol Surv 1988; 43:319.
- McNabney WK, Smith EI. Penetrating wounds of the gravid uterus. J Trauma 1972; 12:1024.
- Grubb DK. Nonsurgical management of penetrating uterine trauma in pregnancy: a case report. Am J Obstet Gynecol 1992; 166:583.
- Chames MC, Pearlman MD. Trauma during pregnancy: outcomes and clinical management. Clin Obstet Gynecol 2008; 51:398.
- Rose PG, Strohm PL, Zuspan FP. Fetomaternal hemorrhage following trauma. Am J Obstet Gynecol 1985; 153:844.
- Cahill AG, Bastek JA, Stamilio DM, et al. Minor trauma in pregnancy--is the evaluation unwarranted? Am J Obstet Gynecol 2008; 198:208.e1.
- Guo SS, Greenspoon JS, Kahn AM. Management of burn injuries during pregnancy. Burns 2001; 27:394.
- Chang J, Berg CJ, Saltzman LE, Herndon J. Homicide: a leading cause of injury deaths among pregnant and postpartum women in the United States, 1991-1999. Am J Public Health 2005; 95:471.
- Fildes J, Reed L, Jones N, et al. Trauma: the leading cause of maternal death. J Trauma 1992; 32:643.
- Deshpande NA, Kucirka LM, Smith RN, Oxford CM. Pregnant trauma victims experience nearly 2-fold higher mortality compared to their nonpregnant counterparts. Am J Obstet Gynecol 2017.
- Koch AR, Rosenberg D, Geller SE, Illinois Department of Public Health Maternal Mortality Review Committee Working Group. Higher Risk of Homicide Among Pregnant and Postpartum Females Aged 10-29 Years in Illinois, 2002-2011. Obstet Gynecol 2016; 128:440.
- Mehta PK, Bachhuber MA, Hoffman R, Srinivas SK. Deaths From Unintentional Injury, Homicide, and Suicide During or Within 1 Year of Pregnancy in Philadelphia. Am J Public Health 2016; 106:2208.
- Drost TF, Rosemurgy AS, Sherman HF, et al. Major trauma in pregnant women: maternal/fetal outcome. J Trauma 1990; 30:574.
- ACOG. Obstetric aspects of trauma management. ACOG educational bulletin 1998; 251:1.
- Shah KH, Simons RK, Holbrook T, et al. Trauma in pregnancy: maternal and fetal outcomes. J Trauma 1998; 45:83.
- Baerga-Varela Y, Zietlow SP, Bannon MP, et al. Trauma in pregnancy. Mayo Clin Proc 2000; 75:1243.
- Theodorou DA, Velmahos GC, Souter I, et al. Fetal death after trauma in pregnancy. Am Surg 2000; 66:809.
- Aboutanos MB, Aboutanos SZ, Dompkowski D, et al. Significance of motor vehicle crashes and pelvic injury on fetal mortality: a five-year institutional review. J Trauma 2008; 65:616.
- Sperry JL, Casey BM, McIntire DD, et al. Long-term fetal outcomes in pregnant trauma patients. Am J Surg 2006; 192:715.
- Vivian-Taylor J, Roberts CL, Chen JS, Ford JB. Motor vehicle accidents during pregnancy: a population-based study. BJOG 2012; 119:499.
- Klinich KD, Flannagan CA, Rupp JD, et al. Fetal outcome in motor-vehicle crashes: effects of crash characteristics and maternal restraint. Am J Obstet Gynecol 2008; 198:450.e1.
- PREGNANCY-RELATED CHANGES IN PHYSIOLOGY
- INITIAL EVALUATION AND MANAGEMENT OF MAJOR TRAUMA
- General principles
- Airway, breathing, and ventilation
- Cervical spine immobilization
- - Uterine displacement
- - Volume replacement
- - Transfusion
- - Cardiopulmonary resuscitation
- Fetal heart rate
- Neurologic evaluation
- Diagnostic laboratory tests
- Diagnostic imaging
- Diagnostic procedures
- PREGNANCY EVALUATION AND MANAGEMENT AFTER INITIAL MATERNAL STABILIZATION
- Physical examination
- - Determining gestation age
- - Abdominal examination after abdominal trauma
- - Vaginal examination
- Fetal assessment
- - Fetal heart rate monitoring
- - Role of ultrasound examination
- Evaluation and management of obstetric complications
- - Abruptio placentae
- Fetal monitoring
- Maternal management
- - Uterine rupture or penetrating injury
- - Fetomaternal bleeding
- Antenatal corticosteroids for patients at risk for preterm birth
- Management of non-obstetric surgery
- - Anti-D immune globulin
- - Tetanus toxoid
- Overall outcome
- MENTAL HEALTH AND COUNSELING
- SUMMARY AND RECOMMENDATIONS