Sunday, November 12, 2017

Management of Injured Obstetric Patient-General Guidelines


Purpose: To update established guidelines for rapid assessment and treatment of critically injured pregnant patients.

Background: Trauma in pregnancy is a leading cause of non-obstetric maternal death. The most common mechanisms of injury are falls, motor vehicle collisions and assaults. Risk factors for trauma include young maternal age (<25), drug or alcohol use, non-white race. Even with relatively minor maternal trauma, fetal distress or hypoxia and death can result. Maternal pattern of injury and physiology is altered by pregnancy and these changes are important to bear in mind, not only at the time of injury but for the duration of the pregnancy. The age of viability for a fetus/neonate is considered 23 weeks with medical advances. Unplanned peri-viable/preterm delivery can result in a poor outcome and decisions to deliver pregnant patients are best made with consultation. Team management in the trauma bay is therefore crucial with clearly defined roles and protocols.

Procedure: To effectively manage pregnant trauma patients, a multidisciplinary approach is key. Maternal and fetal status are reliant upon one another as are decisions regarding mother and fetus. Thus, early recognition of gestational age and fetal status is useful in planning management of the patient.

Mechanism of injury (in order of frequency):
  1. Blunt trauma:
    1. Falls
    2. MVC
    3. assault/DV
  2. Penetrating trauma:
    1. GSW
    2. Stab
Initial management:
  1. If near or >23 weeks gestation, sustaining traumatic injury, activate Trauma Alert
    1. If less than 23 weeks gestation: OB consult prior to disposition for ultrasound confirmation of gestational age, assessment of need for Rhogam and follow up.
  2. Notify OB Charge and Attending
  3. Follow ATLS protocol for primary survey with additional considerations;
    1. For C, Place roll under backboard hip to tilt the right side up 10-15 degrees
    2. Chest XR, pelvic XR and FAST performed during primary survey per UK protocol
    3. OB ultrasound performed by Obstetrics at same time as FAST assess gestational age, fetal heart rate (FHR), and evaluate for obvious signs of trauma (abruption, rupture)
  4. OB to evaluate for fetal viability with US without delay, in conjunction with ABCs of mom
  5. In the case of maternal shock and arrest, if undergoing resuscitative thoracotomy and gestational age is at 23 weeks of gestation, cesarean delivery should be performed simultaneously
  6. In the case of stable or transient maternal response, fetal monitoring should be completed during the secondary survey.
    1. If fetal delivery is indicated, proceed to Main OR for combined case with Trauma Surgery for laparotomy via vertical midline.
    2. If maternal status dictates operative intervention, OB to proceed with trauma to OR for further fetal assessment intraoperatively
    3. If no maternal or fetal indications for surgical intervention, admission to either SGB/trauma or OB based on mechanism of injury, injuries and gestational age
Diagnostic studies:

  1. Labs:
    1. Routine trauma labs
    2. Pregnancy specific labs: Type and screen, Kleihauer-Betke (KB or Fetomaternal hemorrhage), Fibrinogen, PT/INR, aPTT
  2. Radiology:
    1. Avoid duplicating imaging if possible
    2. Shield fetus whenever feasible
    3. See Appendix for estimated fetal exposure for counseling regarding imaging
Posted 11/12/17 (A Bernard/C Talley); Reviewed 9/26/24 (A Bernard)
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