CHAPTER 37

Trauma in
Pregnancy

PHYSIOLOGIC
CHANGES UNIQUE TO
PREGNANCY
Although the initial assessment and management priorities for
resuscitation of the injured pregnant patient are the same as
those for other traumatized patients
The specific anatomic and physiologic changes that occur
during pregnancy may alter the response to injury and, hence,
necessitate a modified approach to the resuscitation process

SISTEM CARDIOVASKULAR

Plasma volume begins to expand at 10 weeks gestation and

increases by 45% at full-term as compared to pregravid levels

This increase in plasma volume is accompanied by an erythroid

hyperplasia in the bone marrow, resulting in a 15% increase in red
blood cell mass and a physiologic anemia.
During the first trimester, maternal pulse rate increases by about
1015 beats/min and remains elevated until delivery.
Maternal blood pressure decreases during the first trimester,
reaches its lowest level in the second trimester, and then rises
toward pre-pregnancy levels during the final 2 months of gestation.

SISTEM RESPIRASI
As the uterus enlarges, the diaphragm rises about 4 cm and the
diameter of the chest enlarges by 2 cm, increasing the
substernal angle by 50%.
Functional residual capacity (FRC) decreases because of a
decline in expiratory reserve and residual volumes.

SISTEM REPRODUKTIF
By the end of full-term gestation, the weight of the uterus has
increased to 20 times its prepregnancy weight
After the 12th week of pregnancy, the uterus extends out of the
pelvis, rotates slightly to the right, and ascends into the
abdominal cavity to displace the intestines laterally and
superiorly.
Uterine veins may dilate up to 60 times their size in the prepregnant state, allowing for adequate venous drainage to
accommodate the uteroplacental blood flow.

Evaluation of the Fetal

Placental Unit
Evaluation of the state of the pregnancy focuses on the
following:
(a) vaginal bleeding
(b) ruptured membranes (amniotic sac)
(c) a bulging perineum
(d) the presence of contractions
(e) an abnormal fetal heart rate (FHR) and rhythm.

Ultrasonography

High-resolution real-time ultrasonography (US) has proven

valuable for the assessment of fetal age and well-being,
recognition and categorization of fetal abnormalities, and
treatment of disease processes in the unborn patient

Additionally, it is routine to evaluate the fetus for gestational

age, cardiac activity, and movement.

Radiographic Examination
There are three phases of radiation damage related to the
gestational age of the fetus.
39 During preimplantation and early implantation (less than 3
weeks gestational age), exposure to radiation can result in
death of the embryo.
During organogenesis (from 316 weeks gestation), radiation can
damage the developing fetal tube and results in the associated
anomalies of exencephaly, dysraphism, single cerebral ventricle,
hydrocephaly, and the hypoplastic brain syndrome.

In summary, the ACOG Committee recommends the following:

Women should be counseled that x-ray exposure from a single
diagnostic procedure does not result in harmful fetal effects.
Exposure to less than 5 rads is not harmful to the fetus or the
pregnancy.
Concern about possible effects of high-dose ionizing radiation
should not prevent medically indicated diagnostic x-ray
procedures from being performed during pregnancy.
Other imaging procedures not associated with ionizing
radiation, such as US or magnetic resonance imaging, which are
not associated with known adverse fetal effects, should be
utilized when appropriate.
Consultation with an expert in dosimetry calculation may be

MANAGEMENT OF SPECIFIC
INJURIES DURING
PREGNANCY
Thoracic Trauma
The management of thoracic trauma during pregnancy differs
little from the nonpregnant state
Additionally, during placement of thoracostomy tubes in late
pregnancy, the elevated location of the diaphragm must be
considered.

Blunt Abdominal Trauma

The management of abdominal injuries during pregnancy
differs little from the nonpregnant state.
Nonoperative management of injuries to solid organs (liver,
spleen, kidney) has been performed successfully in the gravid
state and should be considered the treatment of choice in stable
patients with these injuries
The basic objectives in the anesthetic management of these
patients include the following:
(a) maternal safety
(b) avoidance of teratogenic drugs
(c) avoidance of intrauterine fetal asphyxia

Pelvic Fractures

The management of a pelvic fracture following blunt trauma

may be particularly challenging during late pregnancy.

Hemorrhage from massively dilated retroperitoneal vessels can

obviously cause hemorrhagic shock.
Operative fixation of unstable pelvic fractures, including
acetabular fractures, has been reported during pregnancy, with
good outcomes for both the mother and the fetus.

Fetal Injuries Following

Blunt Trauma
The fetus is generally well protected from blunt forces by the
pelvic bones (until the third trimester) and by the cushion of
amniotic fluid.
Occasionally, blunt trauma to the fetus may result in fractures
of the extremities or skull, although these usually occur in late
pregnancy, especially when the head is engaged.
Severe blunt trauma occasionally causes rupture of the uterus.
More commonly, blunt abdominal trauma causes separation of
the placenta from the relatively inelastic uterine wall, a
condition termed placental abruption (or abruptio placenta)

 Separation of the placenta from the uterus reduces the area for
fetomaternal exchange of respiratory gases and delivery of
nutrients for the fetus.
The manifestations of placental abruption:
a). Vaginal bleeding (which may be relatively minor)
b). Abdominal pain
c). Uterine tenderness
d). Contractions.

Penetrating Trauma
The maternal death rate from both gunshot wounds and stab
wounds is lower than that of nonpregnant patients likely due to
the fact that the uterus is frequently targeted rather than other
abdominal organs
Death of the mother after abdominal gunshot wounds is similarly
uncommon, as only 2030% have injuries outside of the uterus
If the bullet has penetrated the uterus and the fetus is both
viable and alive, cesarean section should be performed and the
babys injuries addressed surgically, if indicated.

Neurologic Injury During

Pregnancy
Severe injury to the brain was a significant risk factor for
pregnancy loss in the investigation conducted by Ikossi et al.
Maternal hypothalamic and pituitary dysfunction may
accompany catastrophic brain injuries, and replacement of
cortisone, thyroid, and vasopressin hormones may be required.
The care of the pregnant patient with an acute injury to the
spinal cord is challenging, as well.
Finally, patients with an injury to the spinal cord are at risk for
unattended delivery secondary to unrecognized contractions.

Thermal Injuries in
Pregnancy
The maternal outcome of burns during pregnancy is related to the
total body surface area involved as in nonpregnant patients, but fetal
survival depends upon the gestational age, the extent of maternal
injury, and maternal outcome.
There are certain caveats to be considered in burned patient during
pregnancy

1. fluid resuscitation should be particularly vigorous, given the

expanded intravascular volume during normal pregnancy.
2. hypoxia must be avoided, and this may be particularly
challenging in patients with inhalational injury associated with the
burn.

 A burn increases spontaneous uterine activity and it affects

circulatory exchange in the uteroplacental unit due to volume
changes, which can have an adverse effect on the fetus.
Additionally, the use of tocolytic drugs may worsen the
pulmonary complications of inhalation injuries.
For care of the burn wounds, silver sulfadiazine cream should
be used sparingly because of the risk of kernicterus associated
with sulfonamide absorption, whereas pain medications should
be used liberally

Cesarean Section Following

Injury

INJURY PREVENTION DURING

PREGNANCY
These poor outcomes for both the mother and her fetus
associated with even relatively minor trauma highlight the need
for attention to injury prevention during pregnancy, and three
areas of injury prevention deserve specific attention
Prenatal care must include education on the subject of
substance abuse and provide opportunities for treatment for
those women with a history of alcohol abuse.
Abuse during pregnancy has been associated with low fetal birth
weight, low maternal weight gain, maternal infections, anemia,
and maternal alcohol and drug abuse

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