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Care of the Pregnant Trauma Patient

Navdeep Samra, MD¹ and Jaideep Sandhu, MBBS, MPH²

¹ LSU Health, Shreveport, LA, USA

² City of Hope National Medical Center, Duarte, CA, USA

What is the leading cause of trauma in pregnant women?
1. Motor vehicle collisions
2. Intimate partner violence
3. Falls
4. Poisoning/overdoses
5. Penetrating trauma
MVC is the leading mechanism of maternal injury, which causes non‐obstetric maternal deaths. MVC is one of the prominent causes of fetal and maternal mortality. It is estimated that maternal and fetal mortality rates are 3.7 and 1.4 per 10 000 pregnancies, respectively. Prevention strategies such as usage of proper seat belt reduces the risk of adverse outcomes for both mother and fetus.

Answer: A

Weiss HB, Sauber‐Schatz EK, Cook LJ. The epidemiology of pregnancy‐associated emergency department injury visits and their impact on birth outcomes. Accid Anal Prev. 2008; 40(3):1088–1095.

Mendez‐Figueroa H, Dahlke JD, Vrees RA, Rouse DJ. Trauma in pregnancy: an updated systematic review. Am J Obstet Gynecol. 2013; 209(1):1–10.
A physician was educating a pregnant woman about trauma in pregnancy. At the end of the counseling session, she posed a question about if she is at increased risk for falls related trauma. The risk for fall in pregnancy increases the most during:
1. 1^st, 2^nd, and 3^rd months of pregnancy
2. 6^th, 7^th, 8^th months of pregnancy
3. 9^th month of pregnancy
4. Equal throughout the pregnancy
5. Pregnancy does not increase the risk of fall
Falls are one of the leading cause of injury during the pregnancy, second in number to motor vehicle crashes. Falls during the pregnancy can lead to multiple injuries with varying severity: sprains, fractures, head injury, abruptio placentae, rupture of uterus and membranes, and sometimes fetal or maternal death. Almost 2/3 (61%) of the fall occur during 6^th through 8^th gestational months. The anatomical and physiologic changes that occur during the pregnancy increases the risk for falls. The center of gravity shifts forward with the fetus and the hormonal changes causes loosening of joints causes hypermobility, putting the stability of pregnant women at risk of fall. Furthermore, studies show that there is an increase in postural sway during second and third trimesters, adding further instability to the pregnant women.

Answer: B

Dunning K, LeMasters G, Bhattacharya A. A major public health issue: the high incidence of falls during pregnancy. Matern Child Health J. 2010; 14(5):720–725.

Harland KK, Saftlas AF, Yankowitz J, Peek‐Asa C. Risk factors for maternal injuries in a population‐based sample of pregnant women. J Womens Health. 2014; 23(12):1033–1038.
A 24‐year‐old woman was involved in a minor motor vehicle accident. A pregnancy test was performed and she was at 27 weeks of gestation. The patient was wearing a seat belt when the car slipped into the telephone pole. Her blood pressure is 112/83 mm Hg, pulse 116 beats/min, respiration 23 breaths/min, and SaO₂ is 96%. Emergency physician completed the primary assessment. After completing the primary assessment (ABC), what is the next best step?
1. Wait and watch for any hemodynamic changes
2. Transfer the patient to the radiology department for a CT imaging
3. Place an indwelling urinary catheter and reassess the patient after 6 hours
4. Initiate fetal heart monitoring
5. Call obstetric consultation
While noting the vital signs in the event of trauma to the pregnant woman, it is helpful to keep in mind that the heart rate increases in the pregnancy by 15%. Typical signs of hypovolemic shock, tachycardia, and hypotension can be masked by normal physiologic changes in the pregnancy. Signs of hypovolemic shocks can appear late in pregnant trauma patients due to increased plasma volume. Maternal perfusion and vital signs are preserved in the pregnant trauma patient at the expense of uteroplacental perfusion. It is not uncommon in the pregnant trauma patients to note significant loss of blood without any signs of hemodynamic instability, which in turn may have already reduced uteroplacental perfusion. Therefore, in the pregnant patients who are ≥ 23 weeks of gestation age, fetal heart monitoring should be initiated as earlytas possible. Abnormal or atypical fetal heart rate pattern may be the first indicator of significant blood loss or maternal hypovolemia, which is putting fetus at elevated risk of shock.

Answer: D

Jain V, Chari R, Maslovitz S, et al. Guidelines for the management of a pregnant trauma patient. J Obstet Gynaecol Can. 2015; 37(6):553–574.

Murphy NJ, Quinlan JD. Trauma in pregnancy: assessment, management, and prevention. Am Fam Physician. 2014; 90(10):717–722.
A 26‐year‐old G1P0 woman at 35 weeks of pregnancy was in an MVC. She was wearing her seatbelt when a truck hit her car from the back. Her blood pressure is 109/70 mm Hg, pulse 120 beats/min, respirations are 28 breaths/min, and SaO₂ is 92%. One liter of normal saline is given through large‐bore IV. Fetal heart monitoring is initiated and the nurse asks if you want the Kleihauer‐Betke test ordered. What is Kleihauer‐Betke test used for?
1. The presence of disseminated intravascular coagulopathy (DIC)
2. Assessing fetal maturity
3. Identifying Rh status of the mother
4. Identifying fetal blood group
5. Identifying fetal blood cells in the maternal circulation
The Kleihauer‐Betke (KB) test is conducted on the maternal blood to determine the amount of fetal hemoglobin (HgF) in the maternal circulation that may have leaked due to the break in placental barrier. Multiple reasons can lead to this placental disruption, including trauma. Trauma is a leading cause of pregnancy‐associated maternal deaths in America. When fetomaternal hemorrhage occurs, HgF get mixed with maternal blood, which in turn triggers maternal immune system. Activation of maternal immune system can lead to isoimmunization if the mother is RhD negative and fetus blood type is RhD positive. RhoGAM is indicated to prevent isoimmunization (formation of Anti‐RhD antibodies).

RhoGAM (rho(d) immune globulin) is used to prevent antibodies from forming when a mother has Rh‐negative blood and the fetus is Rh‐positive or presumed to be positive, therefore answers A, B, C, and D are incorrect.

A single 300 microgram dose contains sufficient anti‐D to suppress the immune response to 15 mL of D‐positive red cells (or 30 mL fetal D‐positive whole blood). A single 50 microgram dose contains sufficient anti‐D to suppress the immune response to 2.5 mL of D‐positive red cells (or 5 mL fetal whole blood).

Fetomaternal bleeding has been reported in 2.6–30% of pregnant trauma patients.

Answer: E

Murphy NJ, Quinlan JD. Trauma in pregnancy: assessment, management, and prevention. Am Fam Physician. 2014; 90(10):717–722.

Krywko DM, Yarrarapu SNS, Shunkwiler SM. Kleihauer Betke Test. StatPearls . Treasure Island (FL), 2020.

Muench MV, Baschat AA, Reddy UM, et al. Kleihauer‐betke testing is important in all cases of maternal trauma. J Trauma. 2004; 57(5):1094–1098.

Committee on practice bulletins‐obstetrics. Practice bulletin no. 181: Prevention of Rh D alloimmunization. Obstet Gynecol 2017; 130:e57. Reaffirmed 2019.

Wylie BJ, D’Alton ME. Fetomaternal hemorrhage. Obstet Gynecol 2010; 115:1039.
A 27‐year‐old G1P0 woman at 34 weeks of gestation was involved in a MVC. Her blood pressure is 95/65 mm Hg, pulse125 beats/min, respirations are 28 breaths/min, equal bilaterally, and SaO₂ is 92%. Her Glasgow Coma Scale score is 10. IV access was obtained. What is the next best step?
1. Transfer the patient to the radiology for CT imaging
2. Call obstetric consultation
3. Chest X ray
4. Tilt the backboard or use left lateral decubitus positioning
5. Observe as hypotension could be transient
After the primary assessment (ABC), the next best step is to use left lateral decubitus positioning. Patient is hypotensive on primary survey and a quick and the relatively easy maneuver can be attempted to treat the abnormality found in the primary survey. This is done to reduce inferior vena cava compression by the uterus and increase venous return to the heart when the blood pressure is low. Aortocaval compression is also called supine hypotension. This pathophysiologic state is usually seen after 20 weeks of gestation when patient is placed straight supine position. The uterus compresses the inferior vena cava and impede the blood flow from lower extremities to the central circulation thereby cause hypotension in pregnant patients. Subsequently, this compression and resulting hypotension limit the blood flow to the placenta and increases the risk of both morbidity and mortality to both mother and fetus. Physiologic changes in pregnancy results in peripheral vasodilation, which is mediated through endothelium‐dependent factors and vasodilatory prostaglandins (PGI2); 25–30% decrease in systemic vascular resistance is attributed to peripheral vasodilation, which is compensated by increase in cardiac output. It is stated that turning the pregnant woman from lateral position to the supine may lead to the reduction of cardiac output by 25%, which in turn decrease the blood flow of the uterus and interfere in placental perfusion, thereby compromise the health status of the fetus. Transferring a patient to the CT scan would not be appropriate in a hypotensive patient (choice A). Obtaining a consultation may be useful, but it is not the next step (choice B). The chest X‐ray is also a high priority, but one should do what is known (treating hypotension) before looking for the unknown to treat (Choice C). Observing a hypotensive patient is obviously incorrect (choice E).

Answer: D

Krywko DM, King KC. Aortocaval Compression Syndrome. StatPearls . Treasure Island (FL), 2020.

Kinsella SM, Lohmann G. Supine hypotensive syndrome. Obstet Gynecol. 1994; 83(5):774–788.

Soma‐Pillay P, Nelson‐Piercy C, Tolppanen H, Mebazaa A. Physiological changes in pregnancy. Cardiovasc J Afr. 2016; 27(2):89–94. doi:10.5830/CVJA‐2016‐021.
A 19‐year‐old G2P1 woman came to her obstetrician’s office to discuss end her pregnancy at the gestational age of 29 weeks. She has not initiated prenatal care until now. Her gestational weight gain is inadequate. Her vitals are within normal limits. Physical exam shows injuries at her back and breasts at different stages of healing. The physician screened the patient for intimate partner violence. What are the most significant risk factor for intimate partner violence in pregnant woman?
1. Young age, poverty, and relationship status‐single
2. High educational level and employment
3. Relationship status – married and employment
4. High socioeconomic status
5. Planned pregnancy
Intimate Partner Violence (IPV) is a serious public health challenge, which results in adverse health outcomes for both mother and fetus. It is potentially a preventable problem. Data shows that 3–9% of women experience IPV during the pregnancy. Literature indicates that there are well‐known risk factors, which are associated with high rates of abuse; these risk factors includes poverty, young age, single relationship status, low educational level, and minority race. IPV can lead to multiple negative outcomes, which include low weight gain, 1st/2nd trimester bleeding, preterm birth, hemorrhage, uterine rupture, hospitalization, and death. Placenta abruption, which contributes to 12% of all perinatal deaths, is also linked to IPV. Physical violence such as blunt force to abdomen by their partner is one of the top leading cause on list of pregnancy trauma. The types of violence can be physical, sexual, psychological, emotional, spiritual, cultural, verbal, and even financial.

Answer: A

Alhusen JL, Ray E, Sharps P, Bullock L. Intimate partner violence during pregnancy: maternal and neonatal outcomes. J Womens Health (Larchmt). 2015; 24(1):100–106.

Leone JM, Lane SD, Koumans EH, et al. Effects of intimate partner violence on pregnancy trauma and placental abruption. J Womens Health (Larchmt). 2010; 19(8):1501–1509.

Centers for Disease Control and Prevention (2020). Risk Factors for Intimate Partner Violence Perpetration. https://www.cdc.gov/violenceprevention/intimatepartnerviolence/riskprotectivefactors.html (accesses 27 July 2021).
A 29‐year‐old who is 32 weeks pregnant was involved in an MVC. Her blood pressure is 85/60 mm Hg, pulse 120 beats/min, and SaO₂ was 93%. You are concerned about hemorrhagic shock. Hemorrhagic shock may also lead to:
1. Fetal bradycardia
2. Fetal demise
3. Pituitary insufficiency
4. Late or variable decelerations on fetal heart rate monitoring
5. All of the above
Hemorrhagic shock contributes to approximately 40% of total trauma mortality. Traumatic hemorrhagic shock accounts for about 6–7% of total deaths in pregnancy. Hypotension, as marked below ≤90 mm Hg, is commonly used to identify patients who are experiencing hemorrhagic shock. Hemorrhagic shock in pregnancy may lead to fetal bradycardia, fetal demise, and pituitary insufficiency. Shock index was found to be highly associated with early blood product transfusions compared to systolic blood pressure in injured pregnant trauma patients. Shock index is calculated by dividing your heart rate by your systolic blood pressure. While this may seem difficult to calculate during a crisis, a simple rule of thumb is that if your heart rate is greater than your systolic blood pressure, your shock index is greater than 1. Shock index of greater than 1 has been associated with the need for blood transfusions, higher injury severity, and need for intervention.

Answer: E

Jenkins PC, Stokes SM, Fakoyeho S, Bell TM, Zarzaur BL. Clinical indicators of hemorrhagic shock in pregnancy. Trauma Surg Acute Care Open. 2017; 2(1):e000112.

Joseph B, Haider AA, Pandit V, et al. Impact of hemorrhagic shock on pituitary function. J Am Coll Surg. 2015; 221(2):502–508.

Pillarisetty LS, Bragg BN. Late Decelerations. StatPearls . Treasure Island (FL), 2020.

A 24‐year‐old who was 20 weeks pregnant fell down a flight of stairs. She has left chest pain and her breathing is splinted. You ordered a chest X‐ray. What is radiation dose of chest X‐ray?

0.001 mSv
0.1 mSv
1.5 mSv
2.0 mSv
7 mSv

The approximate effective radiation dose for chest X‐ray is 0.1 mSv. The approximate radiation dose for extremity (hand, foot, etc.) X‐ray and chest CT is 0.001 mSv and 7 mSv, respectively.

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