Emergency Department Management

Upon arrival in the emergency department, the prehospital resuscitative measures already undertaken should be reviewed and continued as appropriate. Since maternal stability and survival offer the best chance for fetal well-being, initial efforts must be directed toward the adequate resuscitation of the mother. No critical interventions or diagnostic procedures should be withheld from the treatment of pregnant trauma patients out of concerns for potential adverse fetal consequences. A trauma surgeon and obstetrician should be involved early in the evaluation and management of a significantly traumatized pregnant patient.

The initial sequence of trauma resuscitation is unchanged in the emergency treatment of an injured pregnant patient. The patient is kept in the left lateral decubitus position to the extent possible to minimize vena caval compression. Securing the airway and ensuring the adequacy of ventilation in addition to the administration of supplemental oxygenation are of primary concern. Gastric tube decompression must be performed early, since delayed stomach emptying makes the possibility of aspiration a particular concern during pregnancy. Sources of hemorrhage should be identified and controlled, because maternal blood loss and hypovolemia occur at the expense of fetal hypoperfusion. Adequate large-bore vascular access is essential, and crystalloid infusions may need to be adjusted upward by as much as 50 percent to account for the additional plasma volumes in pregnancy.48 The use of vasopressor agents poses a risk of impaired uterine perfusion and should not be initiated until adequate volume replacement has been administered. Their use should not be restricted, however, if required for maternal resuscitation. Initial laboratory studies include complete blood counts, blood typing, and Rh status, as well as coagulation profiles to determine the possibility of DIC. Low serum bicarbonate levels have been shown to be associated with adverse fetal outcomes, and routine determination of the levels may be of predictive value. 2 After the primary trauma survey, an organized and methodical secondary system survey must be performed to ensure the identification of all potential injuries.

Attention should next be turned to the gravid abdomen. Gestational age can be assessed rapidly by palpating uterine fundal height. At week 20 of gestation, the fundus may be palpated at or about the level of the umbilicus. The abdomen and uterus should be examined for evidence of injury as well as palpated for uterine tenderness or contractions. If abdominal or pelvic trauma is suspected, a sterile pelvic examination is indicated to inspect for injuries of the lower genital tract, vaginal bleeding, or rupture of amniotic membranes. Fluid in the vaginal canal with pH of 7 is suggestive of amniotic fluid, whereas a pH of 5 is consistent with vaginal secretions. A branchlike pattern upon drying of vaginal fluid on a microscopy slide or "ferning" is also diagnostic of amniotic fluid.

The Kleihauer-Betke assay is an acid elution technique that differentially stains fetal and maternal red blood cells based on differences in hemoglobin and may be performed on maternal blood to quantify the degree of fetal-maternal hemorrhage in Rh-negative gravidas. The sensitivity of the typical laboratory Kleihauer-Betke test is generally incapable of detecting small quantities of transfused fetal blood. Thus, administration of one prophylactic dose of Rh immune globulin (RhoGAM) is indicated with all Rh-negative pregnant trauma patients beyond 12 weeks of gestation who are evaluated for abdominal injury. One 300-pg dose of RhoGAM protects against 30 mL of fetal blood. The use of the Kleihauer-Betke test may be helpful in identifying greater amounts of fetal-maternal inadvertent transfusion and determining the need for additional doses of immune globulin. Its utility, however, as a predictor of fetal morbidity or adverse pregnancy outcome has not been demonstrated.19.!2 Tetanus prophylaxis has no deleterious fetal effects and should be routinely administered as indicated following trauma.

The indications for emergent laparotomy remain unchanged in the evaluation of pregnant trauma patients. Similarly, diagnostic peritoneal lavage (DPL) and abdominopelvic computed tomography (CT) scan remain valid modalities for the evaluation of intraabdominal injuries from acute trauma. DPL should be performed with an open, supraumbilical technique in patients with evidence of a gravid uterus. The fetus appears to tolerate surgery and anesthesia well if adequate oxygenation and uterine perfusion are maintained.6 The performance of emergent DPL and surgery have not been shown to have an association with fetal loss, and these procedures should not be withheld out of concern for fetal compromise when indicated in trauma.2 Additionally, a recent large multi-institutional retrospective review has shown that emergent cesarean delivery results in a fetal survival rate as high as 75 percent when gestation is at or longer than 26 weeks, fetal heart tones are present on admission, and the procedure is performed at the earliest indication of fetal distress. 3

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