Be Prepared to Manage Severely Injured Pregnant Women
After surgery—or when the woman does not need surgery and is considered stable enough to undergo observation—continuous monitoring of the viable fetus, with a longer-term view, should be done using external monitoring of fetal heart rate and uterine monitoring for signs of preterm labor. Frequent uterine contractions should be followed closely, and cervical dilatation should be evaluated.
The ob.gyn. becomes the primary provider when a viable fetus shows signs of fetal compromise that necessitate delivery, or when uterine rupture occurs, in which case urgent intervention is necessary for the mother.
Many studies have attempted to address the question of how long trauma patients should be monitored, and many guidelines have been proposed. In general, we can conclude that 12 hours of observation is adequate for stable patients who are not contracting and have reassuring fetal tracings and no signs of bleeding.
On the other hand, patients who are contracting, who have a nonreassuring fetal tracing, or who have had any form of vaginal bleeding should be observed for a minimum of 24 hours. The more severe the injury to the mother, the more likely there is to be an injury to the fetus, and the higher the risk that a placental abruption or other serious complication may surface.
If a patient is discharged after observation, regardless of the severity of trauma, she must be given precautions regarding any changes in fetal movement or the development of abdominal pain, vaginal bleeding, or fluid loss. Any one of these changes should prompt her to return for evaluation immediately.
The Kleihauer-Betke test may be useful in evaluating the degree of fetal-maternal hemorrhage and the amount of Rh immune globulin that may be needed in the Rh-negative mother. In general, Rh-negative mothers who are involved in trauma should be given a single dose of Rh immune globulin unless it is known that the fetus is Rh negative.
Cardiac arrest is sometimes the tragic outcome for a posttrauma victim. Maternal resuscitation should be undertaken immediately. If maternal resuscitation is not thought likely to be effective, and the fetus is considered viable, the best outcome for fetal survival occurs if delivery can be accomplished within approximately 5 minutes from arrest. Beyond this time, there is diminishing return for fetal survival.
Organized, rapid assessment and intervention hold the key to the best outcomes for the pregnant patient involved in a trauma. Following the rules of trauma resuscitation (those ABCs) provides the best chance of successful treatment of the mother, which in turn provides the best chance of a favorable fetal outcome.
Motor vehicle accidents are the leading cause of trauma and death in women of childbearing age. Courtesy Dr. Hugh Mighty
One situation in which the ob.gyn. becomes the primary provider is when delivery is necessary. Courtesy Dr. Hugh Mighty
Trauma in Pregnancy
High-risk obstetrics by its very nature involves a wide spectrum of diseases and events that complicate pregnancies and preclude or prevent their normal progression. Sometimes, high-risk obstetrics involves physical trauma that is inflicted externally upon an otherwise normal pregnancy.
Physical trauma is, in fact, one of the leading causes of morbidity and mortality during pregnancy. It has been estimated that physical trauma complicates approximately 1 in every 12 pregnancies—a staggering figure and one that we may not fully appreciate or think about often enough.
According to the American College of Obstetricians and Gynecologists, approximately two-thirds of all trauma during pregnancy in industrialized nations results from motor vehicle crashes.
Women not only are more likely to be involved in automobile accidents than are male drivers; they also are increasingly more likely to be victims of violence. In 1994, women were about six times more likely than men to be victims of violence—a significant increase from more than a decade before, when women were half as likely as men to be victims of violence.
Trauma in pregnant women has to be dealt with by a variety of specialists. Very often, these patients will present to emergency departments or urgent care centers, and will have to be seen by emergency physicians, surgeons, or general practitioners. This is a challenging situation and one that presents unusual challenges for obstetric staff.
Especially as the number of patients with traumatic injuries and complications increases, it is important that we review some of the key types of presentations and complications of trauma in pregnancy, and discuss how we may best develop therapeutic algorithms for dealing with them.
It is in this light that we have invited Dr. Hugh E. Mighty, chairman of the department of obstetrics, gynecology, and reproductive sciences at the University of Maryland, Baltimore, to discuss the management of seriously injured pregnant women.
