Blunt Trauma in Pregnancy

Blunt Trauma in Pregnancy
AUTOMOBILE ACCIDENTS

Trauma affects 6-7% of pregnancies in the U.S. 60 - 67% related to automobile accidents.

Fetal mortality after maternal blunt trauma is 34 - 38%. The two major causes of fetal death after maternal blunt trauma are: Maternal shock/death, and placental abruption.

The pregnant trauma patient presents a unique challenge because care must be provided for two patients, the mother and the fetus. It is vital that the nurse know and understand the anatomical and physiological changes that occur during pregnancy. She must be aware of these changes, and how they can mask or mimic injury, and very importantly that fetal distress or loss can occur even when the mother has incurred no abdominal injuries.

Regardless of the apparent severity of injury in blunt trauma, all pregnant women should be evaluated in a medical setting.

Only viable fetuses are monitored, because no obstetric intervention will alter the outcome of a pre-viable fetus. Determination of fetal viability is subject to institutional variation: an estimated gestational age of 20 - 26 weeks and an estimated fetal weight of 500g. Are commonly used thresholds of viability. Therefore, patients who have minor trauma and who are at less than 20 weeks gestation do not require specific intervention or monitoring. All pregnant women beyond 20 weeks’ gestation should undergo a minimum of 4 - 24 hours, and in some cases as long as 48 hours of monitoring. Fetal distress may be the first sign of maternal hemodynamic compromise and fetal distress, and to identify possible placenta abruption.

Resuscitation of the more serious trauma patient must focus on the mother because the most common cause of fetal death is maternal shock or death. It is important to remember that the mother will maintain her vital signs at the expense of the fetus. Because plasma volume is increased by 50% and the mother is able to shunt blood away from the uterus, maternal shock may not manifest itself until maternal blood loss exceeds 30%.

Initial ABC assessment:

Airway and breathing: All pregnant trauma patients should receive supplemental oxygen, because the fetus is extremely sensitive to hypoxia and because the oxygen reserve is significantly diminished in the pregnant patient.

Because the heavy uterus may compress the great vessels when a pregnant women is supine, causing a decrease...

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...revention is key to increasing maternal and fetal survival.

Although motor vehicle crashes are responsible for most severe maternal injuries and fetal losses form trauma, pregnant women have low rates of seat belt use. Proper seat belt use is the most significant modifiable factor in decreasing maternal and fetal injury and mortality after motor vehicle crashes. Seat belt-restrained women who are in motor vehicle crashes have the same fetal mortality rate as women who are not in motor vehicle crashes, but unrestrained women who are in crashes are 2.8 times more likely to lose their fetuses.

Prenatal care must include three-point seat belt instruction. The lap belt should be placed under the gravid abdomen, snugly over the thighs, with the shoulder harness off to the side of the uterus, between the breasts and over the midline of the clavicle. Seat belts placed directly over the uterus can cause fetal injury, pregnant patients should be instructed to seek care immediately after any blunt trauma..
REFERENCES:

Introduction to Maternity & Pediatric Nursing, Fourth Edition; Gloria Leifer, MA, Copyright 2003, Elsevier Science (USA).

http://www.aafp.org

http://www.med.umich.edu