246 A. Khanna et al.

Flow Chart: Initial assessment and management of the pregnant trauma patient
Principles of care for the pregnant trauma patient
Follow ATLS guidelines
First priority is to treat the woman
Multidisciplinary team that includes an obstetrician is essential
Contact neonatal team early if birth imminent/likely
Recognise anatomical and physiological changes of pregnancy
Clear, coordinated and frequent communication essential
Generally, medications, treatment and procedures as for non-pregnant patient
Refer pregnant women with major trauma to a trauma centre
< 20 weeks gestation: to the nearest trauma centre
20 weeks gestation: to a trauma centre with obstetric services
Thoroughly assess all pregnant women even after minor trauma

Initial stabilisation

As indicated for all trauma patients

Follow ATLS guidelines
Early ETT intubation
Initiate early obstetric consultation
Contact QCC (1300 799 127) to Airway Yes Pre-oxygenation
expedite transport & identify compromise? Consider cricoid pressure
receiving facility as required Consider smaller ETT
Insert orogastric tube
Additionally for pregnancy
No
Position (tilt or wedge):
Left lateral 15-30 (right side
up) or
Manual displacement of uterus
Place wedge under spinal
board if necessary High-flow Oxygen 100%
Routinely administer Oxygen Respiratory Yes Consider tube thoracostomy in
therapy compromise? 3rd or 4th rib space if
Large-bore IV access pneumothorax or haemothorax
Volume resuscitation (Crystalloid
infusion)

Cardiac arrest
No
Follow ATLS guidelines
Defibrillate as for non-pregnant
patient
Advanced cardiac life support Control obvious haemorrhage
drugs as indicated for non- 2 x large-bore IV access
pregnant patients Recognise occult bleeding
Perimortem CS if: Commence Crystalloid infusion
20 weeks gestation Assess response
Haemodynamic Yes
No response to effective CPR Avoid volumes > 2 L
after 4 minutes compromise?
FAST
Abbreviations Consider Massive Transfusion
ATLS: Advanced Trauma Life Support Protocol (MTP) activation
CPR: Cardiopulmonary Resuscitation No Rapid transfer to OT
CS: Caesarean section
ETT: Endotracheael tube
FAST: Focused Abdominal Proceed to flowchart:
Sonography for Trauma Secondary assessment and
IV: Intravenous
OT: Operating Theatre management of pregnant trauma
QCC: Queensland Emergency patient
Medical Coordination Centre
>: Greater than
: Greater than or equal to
Queensland Clinical Guideline: Trauma in pregnancy. Guideline No: MN14.31-V1-R19
Secondary Survey ine tone, contractions, rigidity, tenderness, and
palpable fetal parts. The gravid abdomen may be
The secondary survey consists of obtaining a relatively insensate to peritoneal irritation.
complete history, including an obstetrical
history, performing a physical examination, and Estimation of Gestational Age
evaluat- ing and monitoring the fetus. The Gestational age can be estimated by measuring
obstetrical history is important because the fundal height and the vertical distance in the
identification of comorbid factors may alter midline from the symphysis pubis to the top of
management decisions the fundus in centimeters. The top of the fundus
is marked to evaluate the possibility of con-
cealed abruption as noted by increasing fundal
Obstetric History height.

The obstetrical history should include the date of
the last menstruation, expected date of delivery
and any problems or complications of the current
and previous pregnancies, prenatal care, and his-
tory of vaginal bleeding.
Physical Examination
The findings of the physical examination in the
pregnant woman with blunt trauma are not reli-
able in predicting adverse obstetric outcomes.
Head-to-toe examination as for nonpregnant
trauma patients is done. Abdomen is inspected
for ecchymosis or asymmetry.
Compared with nonpregnant persons, preg-
nant women have a higher incidence of serious
abdominal injury but a lower incidence of chest
and head injuries. Maternal pelvic fractures, par-
ticularly in late pregnancy, are associated with
bladder injury, urethral injury, retroperitoneal
bleeding, and fetal skull fracture. After 12 weeks
of gestation, the maternal uterus and bladder are
no longer exclusively pelvic organs and are more
susceptible to direct injury.
Skull fracture is the most common direct fetal
injury, with a mortality rate of 42 %. Altered
mental status or severe head injury after trauma
in a pregnant woman is associated with
increased adverse fetal outcomes.
In cases of motor vehicle accident, incorrect
positioning of the seat belt across the gravid
uterus may cause marked bruising of the abdo-
men, increase the risk of placental abruption, and
increase the risk of uterine rupture. Assess uter-
Fetal Heart Rate Monitoring
Normal FHR 110160 bpm. FHR can be
assessed using standard stethoscope from about
20 weeks and Doppler from about 12 weeks.
Maternal and FHR should be differentiated as
maternal tachy- cardia may cause confusion.
For gestations greater than 24 weeks (major
trauma), continuous cardiotocography (CTG)
should be initiated as soon as possible. It has a
good sensitivity for immediate adverse outcome.
It detects uterine irritability and abnormal fetal
heart rate patterns. Abnormal CTG may be the
only indication of injury or compromise to the
fetus. Persistent fetal bradycardia more than
5 min, loss of baseline variability or recurrent
complex variable, or late decelerations indicate
fetal compromise. Sinusoidal trace indicates fetal
anemia.
Physiological control of FHR and resultant
CTG trace interpretation differs in the preterm
fetus compared to the term fetus, especially at
gestations less than 28 weeks. Four hours of con-
tinuous monitoring is sufficient in the absence of
vaginal bleeding and abdominal pain, uterine
contractions more frequent than 1 in 10 min, and
non-reassuring fetal heart rate tracing. Additional
monitoring up to 24 h is warranted with any evi-
dence of more frequent uterine contractions,
non- reassuring fetal heart testing, vaginal
bleeding, significant uterine tenderness or
irritability, seri- ous maternal injury, or rupture
of the amniotic membranes
Staff and equipment should be moved to the
womans location rather than transporting a
women to an obstetric unit for monitoring.
Pelvic/Vaginal Examination beam (and not if it interferes with imaging). It is

In case of major trauma, a rectal examination

should be performed to assess for spinal cord
damage or local trauma. Sterile speculum vaginal
examination should be performed as clinically
indicated. Evaluation for ruptured membranes,
vaginal bleed- ing, cord prolapse, cervical
effacement, and dilation in labor and fetal
presentation should be done. Vaginal bleeding
may indicate preterm labor, abrup- tion, pelvic
fracture, or uterine rupture. Urinary catheter
insertion may be done if required.

Diagnostic Imaging

The fetus is most vulnerable to radiation during

the first 15 weeks of gestation. The risks of
radia- tion to the fetus are small compared with
the risk of missed or delayed diagnosis of
trauma. Increased risks to the embryo or fetus
have not been observed for intellectual
disability, birth defects, growth restriction,
neurobehavioral effects, impaired school
performance, convulsive disorders, or embryonic
or fetal death below an effective dose of 100
millisievert (mSv) [5].
Although iodinated contrast agents cross the
placenta and may be taken up by the fetal
thyroid, no cases of fetal goiter or abnormal
neonatal thy- roid function have been reported in
connection with in utero contrast exposure.
Gadolinium used in MRI has known teratogenic
effects on animals and is not recommended
unless benefits clearly outweigh the risks.
X-ray examinations of the extremities, head,
and skull, mammography, and computerized
tomography (CT) examinations of the head and
neck can be undertaken on pregnant or possibly
pregnant women without concern. Other X-ray
examinations may also be undertaken if the radi-
ation dose to the embryo or fetus is likely to be
less than 1 mSv [5].
Risk benefit ratio should be assessed where a
pro- cedure on a pregnant woman may result in a
radia- tion dose of more than 1 mSv to an embryo
or fetus.
Personal protective equipment, (e.g., lead
gown) is advised for pregnant women only when
the position of the uterus is in the direct X-ray
preferable to perform a single CT scan with lavage is not indicated.
iodinated contrast rather than perform multiple
suboptimal studies without contrast. Information
and counseling to women exposed to radiation
during diagnosis and care should be done.

Ultrasound

Ultrasound (US) can assess solid organ injury,

intraperitoneal fluid, gestational age, FHR, fetal
activity, fetal presentation, extent of fetal injury,
placental location, amniotic fluid volume, and
bio- physical profile. US is not a reliable
indicator of recent placental abruption. FAST
(focused assess- ment with sonography for
trauma) scan is as accu- rate as in nonpregnant
patients for intra-abdominal free fluid. Formal
obstetric US following FAST should be done if
required. It helps identify intra- abdominal fluid,
thus increasing the index of sus- picion for an
intraperitoneal hemorrhage.

CT Scan

Another imaging modality that may be indicated

during evaluation of a trauma patient during
preg- nancy is computed tomography (CT),
which gen- erally exposes the fetus to 3.5 rad.
Although a CT scan is indicated in cases where
its benefits to the mother outweigh its associated
fetal risks, proper counseling, when possible,
remains warranted.

Open Peritoneal Lavage

Open peritoneal lavage may be necessary if an

intra- peritoneal hemorrhage is suspected on the
basis of abdominal signs or symptoms suggestive
of intra- peritoneal bleeding, altered sensorium,
unexplained shock, major thoracic injuries, and
multiple major orthopedic injuries. Open peritoneal
lavage, usually periumbilical, with sharp dissection
and opening of the anterior abdominal peritoneum
under direct vision is the preferred technique in
pregnancy as this is less likely to injure the uterus
or other organs com- pared with blind needle
insertion. It is important to emphasize that, if
intraperitoneal bleeding is clini- cally evident, a
Flow Chart: Secondary assessment and management of the pregnant trauma patient

Secondary survey
As for non-pregnant patient AND
Consult obstetric team
Maintain high index of suspicion for occult
shock and abdominal injury
Maintain position (tilt or wedge) left lateral
15-30 (right side up) or Gestation Yes or uncertain
Manual displacement of uterus > 24 weeks?
Wedge spinal board if required
Obtain obstetric history CTG
Gestation No Application and
Estimated date of delivery interpretation by
Pregnancy complications experienced obstetric
Physical examination team member
Assess uterus Interpret with caution
Tone, rigidity, tenderness at < 28 weeks
Contractions Monitor uterine activity
Estimate gestational age
Maternal or
Fundal height Yes
fetal
US
compromise?
If uncertain (i.e. severe trauma, no prior
US or lack of accurate records)
presume viability No
Assess and record FHR
Stethoscope or
Doppler Consider discharge criteria
Obstetric team consulted/agree for
Consider - especially for major trauma discharge
Rectal examination Reassuring maternal status
Pelvic exam (obstetric team) No vaginal loss/bleeding
Sterile speculum Normal CTG/FHR (minimum 4
Assess for rupture of membranes, hours CTG)
vaginal bleeding, cervical effacement Interpret CTG with caution at
and dilation, cord prolapse, fetal < 28 weeks
presentation No contractions
Imaging Blood results reviewed
FAST ultrasound Rh immunoglobulin given if
Formal obstetric ultrasound required
Other radiographs Social worker referral offered
Blood tests
Standard trauma bloods
Group and Antibody screen
Kleihauer Test if Rh D negative and all
women if major trauma (EDTA tube) Yes Discharge No
Consider Coag Profile (major trauma) criteria
If Rh D negative and 12 weeks met?
gestation, administer Rh D
Admit
immunoglobulin (but do not delay definitive
care to do so) Assess for:
Placental abruption
Abbreviations
Feto-maternal
haemorrhage
CS: Caesarean section Discharge
CTG: Cardiotocograph Uterine rupture
Advise to seek medical advice if:
DIC: Disseminated intravascular Preterm labour
coagulopathy Signs of preterm labour DIC
FAST: Focused Abdominal
Sonography for trauma
Abdominal pain Continuous CTG if
FHR: Fetal heart rate Vaginal bleeding or discharge > 24 weeks gestation
US: Ultrasound scan Change in fetal movements Intervene as appropriate
<: Less than Advise to inform usual maternity
>: Greater than Consider emergency CS
: Greater than or equal to care provider of trauma event

Queensland Clinical Guideline: Trauma in pregnancy. Guideline No: MN14.31-V1-R19