(left picture courtesy of Michael Lovelace, right upper picture courtesy... Lewis, right lower picture courtesy of Elisabeth Abel)

(left picture courtesy of Michael Lovelace, right upper picture courtesy of Leslie
Lewis, right lower picture courtesy of Elisabeth Abel)
•Consider the possibility of pregnancy in women aged 10 to 50.
•Injury may be intentional or non-intentional. MVCs and falls most common;
homicides and suicides account for 1/3 to ½ of all fatalities.
•Fetal mortality is 80 % with maternal shock, so early, aggressive treatment of
mom is the key to survival.
•The 1st indication of maternal hypovolemia will be seen in an abnormal fetal
heart rate. Remember that the uterus is not considered and vital organ and in
an hemorrhagic state the blood will be diverted away from the placenta to
support the mother hemodynamically.
•Subsequent slides review each system—don’t talk in detail about each
one as they will be discussed on following slides.
•Assessment, diagnostics, and management all are impacted by the anatomic
and physiologic changes that occur during pregnancy. It is important to know
what is normal that will assist in correctly assessing and treating the pregnant
trauma patient.
• Due to these normal anatomic and physiologic changes identification of
injuries can be missed. Do not assume all is well as long as the maternal vital
signs are stable.
•(picture courtesy of Leslie Lewis)
•The capillaries of the upper respiratory passages become engorged during
pregnancy, increasing susceptibility to nasal bleeding. If a nasal approach is
required, transport personnel should use an endotracheal tube 1 to 1.5 cm
smaller than would normally be selected
•Because the diaphragm is pushed upwards by the growing uterus, lung
volume decreases. During the second half of pregnancy, the diaphragm rises
about 4 cm, severely limiting respiratory reserve and making the pregnant
mother especially vulnerable to the effects of acute lung injury and less
tolerant of hypoxia.
•Minute ventilation increases primarily because of an increase in tidal volume
caused by increased progesterone levels during pregnancy. Hypocapnea
(PaCO2 under 30mmHg) and a respiratory alkalosis are therefore common
in late pregnancy. Accordingly, a PaCO2 of 35 to 40 mmHg may indicate
impending respiratory failure in these patients. The forced vital capacity
fluctuates slightly during pregnancy due to equal and opposite changes in
inspiratory capacity (which increases) and residual volume (which decreases).
•Total body oxygen consumption is increased by 15 percent in pregnancy,
primarily due to the increased needs of the uterus, fetus, and placenta.
Coupled with an up to 20% decrease in functional residual capacity, apneic
pregnant patients desaturate about 2.5 times more rapidly than non-pregnant
•(picture courtesy of Tracy Meyer)
•Blood volume increases steadily throughout pregnancy and plateaus at 34
weeks gestation with a total increase of up to 50%. This is a result of
increases in plasma volume as well as in the cellular components.
•After the 10th week of pregnancy, cardiac output can be increased by 1.0 to
1.5 L/minute due to an increase in plasma volume and a decrease in vascular
resistance of the uterus and placenta.
•Heart rate increases gradually by 10 to 15 beats/minute throughout
pregnancy, reaching a maximum rate by the third semester.
•Blood pressure declines by five to 15 mm Hg during the second trimester,
before returning to near-normal levels at term.
•Because of the increased intravascular volume, the pregnant patient can lose
a significant amount of blood, 1200 to 1500 ml, before tachycardia,
hypotension, and other signs of hypovolemia occur. This amount of blood loss
will cause a 10 to 20 percent decrease in uterine blood flow, as uterine artery
vasoconstriction is one of the first responses to maternal blood loss. Thus, the
fetus may be in distress and the placenta underperfused while the mother’s
condition and vital signs appear stable.
•With maternal blood loss fetal fetal distress precedes change in maternal vital
•(unknown source, looking for new picture)
•When a woman in her second half of pregnancy lies supine, the uterus
compresses her inferior vena cava and impairs blood return to the heart. This
situation can lead to a 20% decrease in cardiac output and is responsible for
the supine hypotensive syndrome seen in 20% of women after 20 weeks
•Although very basic, a commonly forgotten remedy for hypotension in the
pregnant patient is displacement of the uterus to the left, most easily
accomplished by having the patient lie in the left lateral recumbent position.
•In the case of the trauma patient who requires spinal immobilization, tilting the
backboard with towels or a blanket under the hip or manually pulling the uterus
to the left will adequately displace the uterus off the inferior vena cava.
•Manual displacement will hurt!
•(picture courtesy of Karen Snider/Elisabeth Ables)
•The gravid uterus increases to 1200 g from its normal size of 60-80 g.
• The uterus remains an intrapelvic organ until approximately the 12th week of
gestation. It is thick walled and well- protected. The primary risk of trauma is
abortion and isoimmunization.
• By 20 weeks, the uterus is at the umbilicus and now an extrapelvic organ.
Additional risk from trauma include amniotic fluid embolism and abruptio
• At 34 to 36 weeks, it reaches the costal margin. Amniotic fluid volume
decreases with fetal growth thus providing less protection. The uterus is now
thin-walled providing less protection making the fetus more susceptible to
trauma. In late pregnancy, injuries that would normally involve the abdominal
organs may now affect the bladder, uterus, fetus, and placenta.
• Uterine blood flow increases from 60 ml/min to 600ml/min. The circulating
blood volume of a pregnant patient circulates through the uterus in less than
10 minutes increasing the risk of exsanguination and hemorrhage.
• Anatomic alterations in the maternal thoracic cavity include elevation of the
diaphragm by as much as 4 cm. Tension pneumothorax may develop more
quickly due to the elevated diaphragm and pulmonary hyperventilation. The
maternal heart is also elevated and rotated forward to the left. This is reflected
in the 12 lead ECG tracing as a left axis deviation, flattened or inverted T
waves, and prominent Q waves in lead III.
•These changes alter the usual landmarks for some common trauma
procedures. If a chest tube is to be placed in a pregnant patient, enter the
•In preparation for birth, increased progesterone levels cause relaxation of the
ligaments supporting the pelvic joints.
•The symphysis pubis widens and the sacroiliac joint spaces increase causing
changes in the pregnant women’s center of gravity.
•These changes not only cause instability of the pelvis but also make
interpretation of pelvic radiographs more difficult. (Symphysis pubis widens
from 4mm to 8mm).
•(picture from previous version)
•Increased levels of progesterone and estrogen inhibit gastrointestinal motility
during pregnancy, as does physical pressure from the enlarging uterus.
•This physiological ileus, coupled with decreased competency of the
gastroesophageal sphincter, increases the potential for aspiration.
•Pregnant trauma patients, should be assumed to have a full stomach. Early
insertion of a gastric tube may protect the patient from aspiration.
•The glomerular filtration rate is increased. In addition to an increased urine
volume, certain renal function test results may be altered. Serum creatinine
and serum urea nitrogen will decrease to one half of normal pre-pregnancy
levels. Normal changes that occur during pregnancy must be recognized in
order to prevent misinterpretation of test results.
•Red and white blood cell production, as well as that of some clotting factors,
increases in pregnancy It is not unusual to see white blood cell counts of
15,000/mm3 during pregnancy and up to 25,000/mm3 during labor.
•This physiologic anemia is due to a delusional effect of plasma volume
increasing by 50% but red blood cell volume increasing by only 18-30%. Thus,
the average hematocrit in a pregnant patient is 32-34%.
•Because of the decreased erythrocyte to plasma ratio, a decreased oxygen
carrying capacity of the blood also exists and must be taken into account when
resuscitating the pregnant trauma patient. Supplemental high flow oxygen and
early blood administration should be considered early in the resuscitation
•(picture from previous version)
•In both blunt and penetrating trauma, fetal mortality generally exceeds
maternal death.
•The uterus and amniotic fluid act as an anatomic shield to protect the fetus
from injury. In advanced stages of pregnancy, fetal injury and death can occur
with direct injury to the abdomen from maternal contact with the steering wheel
or dashboard, improper placement of the lap portion of the seat belt, or a direct
abdominal blow from a blunt object. Indirect fetal injury can occur from rapid
deceleration or compression, contracoup forces, or shearing effects.
•Abruptio placenta is common following blunt abdominal trauma. Pelvic
fractures late in pregnancy are associated with fetal skull fractures due to the
position of the fetal head within the pelvic ring. Bladder rupture is also an
associated occurrence with pelvic fractures.
•Maternal morbidity and mortality from penetrating injuries to the gravid
abdomen is generally low. The fetus, however, is more susceptible and
generally does not fare as well.
•Domestic violence occurs in up to 17% of women during pregnancy (see
Appendix H).
•(picture courtesy of Karen Snider/Elisabeth Able)
•Initial management of the pregnant trauma patient should not differ from that
of the non-gravid patient with the exception of patient positioning. Although
this simple intervention is basic to obstetrical practitioners, it is sometimes
overlooked by transport team members. Prehospital providers should
transport women pregnant greater than 20 weeks estimated gestational age
(EGA) in a lateral decubitus position to displace the gravid uterus off the
inferior vena cava and prevent supine hypotension.
•As with any trauma resuscitation, the goals of initial management are
securing and maintaining an airway, ensuring breathing, and maintaining
circulation. For optimal outcome of mother and fetus, assess and resuscitate
the mother first, then assess the fetus before conducting a secondary survey
of the mother. The fetus should be assessed by performing an abdominal
exam to include auscultation of fetal heart tones, fetal activity, and for the
presence of maternal vaginal bleeding.
•(picture courtesy of Tracy Meyer)
•Waiting until respiratory failure is evident by ABG unnecessarily places the
fetus at risk for hypoxia. All pregnant women need to be preoxygenated prior
to intubation due to a decreased functional residual capacity that predisposes
them to much more rapid desaturation during the procedure.
•Oxygen consumption increases by 15% by the third trimester. Sixty seconds
of apnea results in a decreased PaO2 of 29% in pregnant patients, compared
with 11% in non-pregnant patients. A longer period of preoxygenation is
required (as long as three minutes or more if clinically appropriate) to
equilibrate oxygen levels across the placenta to the fetus.
•Rapid sequence intubation can be safely performed in pregnant patients, but
medication dosages may need to be adjusted. Etomidate and ketamine are
safe to use in pregnancy, but the ketamine dose is reduced. Succinylcholine
and rocuronium, both of which are safe for use in pregnant patients, have
relatively longer durations of action when given to pregnant patients in doses
appropriate for RSI, and the onset of action is quicker when compared with
non-pregnant patients.
•Pregnant women are at an increased risk for gastric reflux. Ensure cricoid
pressure during the endotracheal intubation. Prompt insertion of a gastric tube
should also be completed after intubation.
•In late pregnancy, chest tube insertion should be performed at the 3rd to 4th
intercostal space.
•(picture from previous version)
•It is important to remember: apparently normal vital signs in a pregnant
trauma patient are a poor indicator of fetal well being and that 80% of pregnant
females who survive hemorrhagic shock will experience fetal death.
•Because of the mother’s expanded intravascular volume, maternal
tachycardia and hypotension occur late in shock, often only after a 30% to
35% blood volume loss. An abrupt decrease in maternal intravascular volume
results in a profound increase in uterine vascular resistance resulting in a
reduction in fetal oxygenation despite normal maternal vital signs.
•The pregnant woman will require more fluid resuscitation than the nonpregnant trauma patient in order to maintain an adequate circulating blood
volume. With hemorrhage, otherwise healthy pregnant patients may lose
1200-1500 ml of their blood volume before exhibiting signs and symptoms of
hypovolemia. In shock states, the placenta is a non-essential organ.
•Monitoring of CVP response to fluid challenges may be valuable in
maintaining the relative hypervolemia required in pregnancy.
•If a pericardiocentesis is required, the pericardial needle puncture should be
above the fundal level, particularly after it reaches the height of the xiphoid
near the 36th week of pregnancy.
•If a pregnant patient develops seizures following an injury it may be difficult to
ascertain if the seizures are secondary to a head injury or a complication of
late pregnancy called eclampsia.
•Signs and symptoms of a closed head injury include hypertension, alteration
in level of consciousness, pupillary changes, and bradycardia.
•Signs and symptoms of eclampsia that are not typically found in trauma
patients are hyperreflexia, proteinuria, and peripheral edema.
•Hypertension is not a normal finding in any pregnant patient.
•Magnesium sulfate may be required for treatment of eclampsia.
•(picture from previous version)
•A thorough abdominal exam should be performed, assessing for pain,
tenderness, rigidity, guarding, and easily palpable fetal parts that may indicate
uterine rupture.
•Abruptio placentae may be suggested by vaginal bleeding (70% of the cases),
uterine tenderness, frequent uterine contractions, uterine tetany, or uterine
• Fetal heart tones can be ausculatated with a doppler ultrasound at 10 weeks.
External fetal monitoring by cardiotocographic monitoring at 22-24 weeks
gestation. If it is not available during transport, the FHR should, at a minimum,
be monitored by doppler no less than every 15 minutes. Document fetal
movement and any contractions. An abnormal fetal heart rate over 160 or
under 120 beats per minute is a very sensitive indicator of fetal distress,
hypoxia, and maternal volume status.
•Fetal monitoring should be initiated to trend changes in fetal heart rate as well
as variability, decelerations, and absence of accelerations. Variability is the
beat-to-beat irregularity of the fetal heart rate; it is the single most important
factor in predicting fetal well being. Decreased variability may be precipitated
by fetal hypoxia, as a hypoxic fetus with metabolic acidosis is unable to
accelerate the heart rate. Decelerations can occur with contractions or with
cord compression. Decelerations will be noted on the EFM with contractions
as the blood is restricted to the placenta. The infant has no reserve and
becomes bradycardic due to the acidosis and placental insufficiency. Late
decelerations always mean there is placental insufficiency. Signs of fetal
decompensation include back-to-back decelerations, loss of variability, lack of
spontaneous accelerations, tachycardia, and subtle decelerations.
•As soon as the primary assessment and management of both mother and
fetus are complete, the woman’s health and prenatal history should be
ascertained, along with information surrounding the present injury. The
maternal secondary survey should follow the same pattern as in the nonpregnant patient. Remember that the goal should be rapid transport to a
tertiary care center that can care for both mother and fetus.
•Evaluate the uterine contour, palpate for any uterine tenderness, and note the
presence of any contractions. The stretched peritoneum from the gravid
uterus causes decreased sensitivity of the nerve endings making the physical
exam much less reliable. Visual inspection of the perineum and vagina for
evidence of bulging, crowning, presentation of fetal parts, bleeding, and
amniotic fluid should be completed.
•Fundal height should be measured in centimeters from the symphysis to the
fundus. The fundal height roughly correlates to the gestation of the pregnancy
in weeks. A quick estimation of gestational age is the centimeter
measurement along the midline from the symphysis pubis to the fundus, which
approximates the gestational age in weeks. At 20 weeks gestation the fundus
is usually at the level of the umbilicus.
(no copyright issues, ok to use, Leslie Lewis)
•Almost 9/10 cases of trauma in pregnancy are minor.
•Even with minor trauma the pregnant woman should be questioned about
seat belt use and placement, loss of consciousness, abdominal pain, vaginal
bleeding, premature rupture of the membranes, and fetal activity.
•Minor trauma to flank/abdomen warrants a minimum of 4 hours of monitoring
to include fetal monitoring.
•Eighty percent of all pregnant women who present to the hospital in
hemorrhagic shock survive but have an adverse fetal outcome.
•(x-ray from previous version)
Next slides will cover these topics. Don’t discuss in detail here.
•The most common obstetric problem caused by trauma is uterine
contractions. Evaluate strength of contractions: feel tip of nose = mild; feel
chin = moderate; forehead = strong.
•Preterm labor should be suspected if the patient has contractions 10 minutes
apart or less for a period of 1 hour or longer.
•Tocolytics should be given only after uteroplacental injury has been ruled out
and after fluid resuscitation and oxygenation has been provided.
•Preparation for an imminent delivery and the resuscitation of a potentially
distressed infant is imperative if contractions continue without resolution.
•(picture courtesy of Karen Snider/Elisabeth Able)
•Abruptio placentae is placental separation from the uterus. This as an
obstetrical life-threatening emergency.
•The best indicators of placental separation are clinical assessment.
•Signs and symptoms: vaginal bleeding, uterine tenderness and irritability,
leakage of amniotic fluid, maternal hypotension, a uterus larger than normal for
gestational age, and a change in FHR.
•Thirty percent of abruptions following trauma may not exhibit vaginal bleeding.
Abruptio placentae can occur for up to 72 hours after even minor trauma.
•In most cases of uterine rupture or abruptio placentae, the patient will
complain of abdominal pain or cramping.
•Disseminated intravascular clotting (DIC) can occur. If this occurs,
replacement of fibrinogen, fresh frozen plasma and platelets must be
administered immediately. Definitive treatment is uterine evacuation.
•(illustration courtesy of Karen Snider)
•Suggestive mechanism: direct blow, perforation, or compression injury, or
when previous uterine surgery, including Cesarean section has taken place.
•S/Sx: abdominal tenderness, guarding, rigidity, or rebound tenderness,
especially if there is profound shock. Also, abnormal fetal lie, easy palpation of
extrauterine fetal parts, and inability to palpate readily the uterine fundus.
•In order to save the mother, immediate laparotomy needs to be performed.
Maternal mortality from uterine rupture is approximately 10% while fetal
mortality exceeds 70%.
•(picture from previous version)
•If the pregnant woman reports release of vaginal fluid or if fluid is observed in
the vagina, rupture of membranes should be suspected and should prompt
additional evaluation. The use of nitrazine paper can be a quick and reliable
test to check for ruptured membranes. Amniotic fluid is alkaline and will have
a pH of 7.0 to 7.5 as indicated by a blue color on the nitrazine paper. Vaginal
fluid is more acidic and has a pH of 5.0, which will change the color of the
nitrazine paper to red.
•Fetal-maternal hemorrhage affects 8 to 30% of all pregnant trauma patients.
In cases of Rh incompatibility, the fetus is Rh positive and Mom Rh negative. If
some fetal red blood cells leak into the maternal circulation system, the mother
may produce antibodies to the Rh D factor (Rh sensitization). This
isoimmunization produces a hemolytic anemia in the fetus. To prevent this,
immunoglobulin therapy should be instituted within 72 hours of injury
•Limited data exists to support prehospital peri-mortem C-sections.
•The C-section must be performed within four minutes of maternal loss of
pulses, and the infant must be delivered by the fifth minute.
•Fetal survival depends upon the age of the fetus and time without oxygen or
maternal circulation. Longer down times are associated with an increased
incidence of neurological sequelae.
•Of the over 200 successful cases of peri-mortem C-sections, reported in the
literature, there was no fetal survival when the gestational age was less than
26 weeks.
(no copyright issues, ok to use, Leslie Lewis)
Maternal survival is key. Pregnancy does not change priorities!
(picture courtesy of Michel Wolford Hall)