Beyond The Basics: Trauma During Pregnancy

Instead of a single patient with a normal physiological response to the injuries sustained, you have two patients with special needs.


CONTINUING EDUCATION FROM EMS

     This CE activity is approved by EMS Magazine, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS), for 1.5 CEUs.

To take the corresponding test to this article online visit www.rapidce.com.

     OBJECTIVES

  • Review epidemiology of trauma in pregnant women
  • Discuss anatomic changes during pregnancy
  • Review management of the pregnant trauma patient

     Pregnant patients who are involved in trauma pose a special challenge to EMS. Instead of a single patient with a normal physiological response to the injuries sustained, you have two patients with special needs depending on you: the mother and her unborn fetus. Whether the trauma is minor or severe, it will require you to understand and apply your knowledge of the pregnant patient to your assessment and emergency care.

EPIDEMIOLOGY

     Trauma occurs in approximately 6%–7% of all pregnancies and is the leading cause of death for pregnant women. The morbidity and mortality associated with these patients depends on the mechanism of injury, gestational age of the fetus and severity of the trauma.

     Motor vehicle collisions account for more than half of all injuries sustained by pregnant trauma patients. One factor that can directly influence a pregnant patient's outcome when involved in a motor vehicle collision is the use of proper restraints. In order to be properly restrained, a pregnant woman should wear her lap belt placed snugly against her pelvis beneath her abdomen and should utilize the shoulder restraint between her breasts. Properly restrained pregnant women are half as likely to experience vaginal bleeding or give birth after a motor vehicle collision as women who are unrestrained. Fetal death resulting from a motor vehicle collision is three to four times more likely to occur if the mother is unrestrained. The severity of the collision can affect both the maternal and fetal outcome, even if the patient is properly secured. Maternal death is the primary cause of fetal death following a motor vehicle collision.

     Falls are another common mechanism of injury during pregnancy. Pregnant women, especially after their 20th week, are prone to falling, because their pelvic ligaments are loosened, their abdomen is protruding and their center of gravity changes. The incidence of injury is often associated with how the patient falls and the force of the fall. About 2% of pregnant women sustain repeated blows to the abdomen because they fall more than once. Women who fall are at risk for premature uterine contractions that could result in delivery.

     Pregnant women, especially teenagers, are susceptible to physical abuse that can result in various injuries, usually involving the abdomen and genitalia. Domestic violence carries a high risk of morbidity for the pregnant patient and fetus. Approximately 4% to 17% of all pregnant females will experience physical abuse, although most cases of abuse go unreported. Most often, the perpetrator of physical abuse is the patient's husband or boyfriend. Sixty-four percent of previously abused women report an increase in attacks when they are pregnant.

     Gunshot wounds and stab wounds are the most frequent causes of penetrating trauma to this population. Penetrating trauma to the abdomen alone accounts for approximately 36% of overall maternal mortality. Because the woman's abdominal organs are pushed upward by the growing uterus, she is highly susceptible to bowel, hepatic or splenic injuries resulting from penetrating trauma to the upper abdomen; however, if the injury is lower, it poses fewer visceral injuries to the mother, who is shielded by the uterus, but poses significantly higher risks to the developing fetus. Penetrating trauma directly to the uterus has a 67% fetal death rate.

ANATOMIC AND PHYSIOLOGIC CHANGES
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