Trauma In Pregnancy
General Points
Best chance of fetal survival is to ensure maternal survival; lap belt should be as low as possible, shoulder
belt to side, and between breasts
Epidemiology
Maternal shock associated with 80% fetal mortality; fetal death in 1-2% (usually due to placental
abruption / direct trauma); incidence of trauma in pregnancy 7%; blunt most common
Worse prognosis if: maternal age <20yrs / >35yrs, gestation <28/40
Even if discharged home,  risk of placental abruption, LBW, DVT
Complications
Maternal: pelvic # (can usually still deliver PV); amniotic fluid embolism
Obstetric: placental abruption (may be delayed 24-48hrs after trauma), uterine rupture, fetomaternal
haemorrhage (in 8-30% cases  rhesus sensitisation of mother, neonatal anaemia, fetal cardiac
arrhythmias, fetal death); placenta / cord laceration, premature rupture of membranes, premature
labour, direct fetal injury
Assessment
Premature labour may go unnoticed, especially if intubated + paralysed or altered LOC; fetal compromise
may be occuring, even if asymptomatic
Examination: PV usually inappropriate in ED (done by O+G – look for trauma to genital tract, cervical
dilation, fetal presentation and station, test for amniotic fluid); assess lie, fetal heart rate, fundal
height, tenderness, fetal movement, fetal position; PR and urinalysis
Investigation
Bloods: rhesus statusl coag for DIC
Kleihauer if: major injury, Rh negative at risk of massive haemorrhage (not required if <16/40)
XR: request XR’s on clinical grounds; use shield; no  risk to fetus if radiation <0.1Gy and >20/40 (ie.
Pelvis, chest, C spine OK)
CTG: do ASAP; will diagnose placental abruption; do for at least 4hrs
USS: do after significant trauma even if examination normal; free fluid may be from uterine rupture;
assess gestational age, placental position, fetal wellbeing, amniotic fluid volume; 40-50% sensitivity for
placental abruption (CTG better)
CT: accurate, non-invasive; time consuming, exposure 0.05-0.1Gy
DPL: high sensitivity, low specificity; misses retroperitoneal injuries; safe and accurate in pregnancy via
open technique
Management
Avoid compression of IVC (left side, especially if >20/40), involve O+G early, Caesarian section if fetal
distress not responding to maternal resus
ABC: may be difficult intubation secondary to aspiration risk / breast enlargement / C spine; high flow
O2; C spine immobilisation with wedges under spinal board; remember signs of shock occur late due to
 plasma volume; aggressive IV fluids
Secondary survey: obstetric exam occurs here; NG tube to  risk of aspiration; IDC to allow better
assessment of uterus; treat DIC
Rhesus: anti-D if Rh – mother
Premature labour: give tocolytics (eg. IV salbutamol, MgSO4)
Penetrating injury: do laparotomy
Indications for post-mortem Caesarian section: >24/40 + sudden maternal death without obvious fetal
injury + rapid delivery possible
If immediate, 70% survival with good outcome; if within 10mins, 15% survival with poor outcome; if
within 20mins, 2% survival with very poor outcome
TVUS:
Empty gestational sac +
Empty gestational sac +
USS
Investigation
In Fetal
Demise
No cardiac activity
+
No yolk sac
No fetal pole
+
+
diameter <20mm = inconclusive  do follow up
gestational sac diameter >15mm (7/40)
OR >21mm (8/40)
(90% specificity)
gestational sac diameter >9-16mm
OR CRL >5-6mm (non-viable)
gestational sac diameter >10-13mm
gestational sac diameter >18-20mm (non-viable)
If beta-hCG above discriminatory zone (>2000) and no IUP, or mass in ovary / tube = likely ectopic (90%
PPV)
If beta-hCG >6500 and no fetal heart seen on USS = 80% chance of miscarriage
If beta-hCG below discriminatory zone (<2000) and inconclusive scan = pregnancy unknown location 
48hr follow up (serial beta-hCG’s or repeat USS)
Management
If unstable: ?cervical shock  resus, IV fluids, atropine 600mcg IV if bradycardic (to max 3mg), speculum
ASAP; can consider uterine compression, vaginal packs, compression of abdominal aorta, urinary
catheter, ergometrine / oxytocin
Empathy; pan when toileting
Rh prophylaxis – early pregnancy bleeding, singleton, <13/40  250iu IM
early pregnancy bleeding, multipleton, >13/40  625iu IM
Chance of Rh- mother developing antibodies to Rh+ child is <20% regardless (ie. 15%) of whether antiD is
given; Kleihaur done to quantify fetomaternal haemorrhage and thus work out amount to give; of
mother’s serum has detectable anti-D antibodies at 24-48hrs then correct dose has been given; if given
after 3-10/7, still has some effect; 1ml protects against 6mls of fetal blood; 85% Caucasians are Rh +ive;
antiD decreases risk from 1% to 0.3%
Complete: conservative management
Incomplete / inevitable: women’s preference
1) ERPOC –  infection risk, cervical trauma, uterine perforation, intrauterine adhesions
2) Medical – misoprostol 600mcg PO (PGE1 analogue  uterotonic; used in MTOP, miscarriage,
induction of labour; stable, low cost, easy to give, patient acceptance; contraindications:
previous uterine surgery ( risk of uterine rupture)
3) Watch and wait – longer duration of PV bleeding and pain,  need for blood transfusion
Discharge with Early Pregnancy Clinic referral if: bleeding not severe, easy hospital access, good
discharge advice (come back if deterioration, avoid sex and tampax if threatened), cervical os closed,
>6/40 with IUP on scan
USS before discharge if: can’t get to EPAC <72hrs, high maternal anxiety and in-hours, >6/40 with no IUP
on USS
Refer gynaecology if: ?ectopic (unilateral pain, severe, pain, PMH ectopic / tubal surgery / PID), ?actively
miscarrying (heavy bleeding / products / USS evidence of miscarriage), unwell, non-viable fetus on USS