Trauma in Pregnancy

July 1, 2008

Trauma in Pregnancy

Authors: Howard A. Werman, MD, FACEP, Professor of Clinical Emergency Medicine,

The Ohio State University, Medical Director, MedFlight of Ohio; and Robert E. Falcone,
MD, FACS, Clinical Professor of Surgery, The Ohio State University.

Peer reviewer: Dennis Hanlon, MD, FAAEM, Vice Chairman of Emergency Medicine,
Academics, Allegheny General Hospital, Pittsburgh, PA.

Trauma is the leading cause of death for women of child bearing age and for maternal death
during pregnancy. Pregnancy increases a female's risk of physical and sexual abuse,
resulting in significant morbidity and mortality for both the mother and the baby.
Understanding the anatomic and physiologic changes that occur with pregnancy enhance the
management of the pregnant trauma patient, potentially improving outcomes for both the
mother and fetus. The best approach to fetal preservation is careful attention to resuscitation
of the mother.

— The Editor

Introduction

Pregnant females commonly sustain traumatic injuries. As with all other trauma victims, the
priorities in patient assessment remain the same; however, anatomic and physiologic changes
that occur as the result of the developing fetus will alter overall patient assessment. In
addition, after 23 to 24 weeks of gestation there are actually two patients, the mother and the
fetus. Under certain circumstances, independent decisions must be made regarding their care.
As a general principle, excellent care for the mother also provides excellent care to the fetus.
Most injuries require the multidisciplinary care often found in trauma centers. This issue
reviews the pertinent information on the assessment and optimal management of trauma in
pregnancy. An extensive bibliography has been included to allow the reader to pursue this
subject in more depth.

Incidence and Demographics

Trauma is the leading cause of death for females of child-bearing age. It also is the leading
cause of maternal death in pregnancy, accounting for 46% of all deaths; this is far more
common than death from obstetrical causes or complications of medical illness.1-6
The leading causes of maternal trauma are motor vehicle accidents (55%), falls (22%),
assaults (22%), and burns (7%). Physical violence and assault are most common in the first
half of pregnancy, and falls become important in the second and third trimesters.7,8

Maternal trauma also is the leading cause of fetal demise. Fetal death typically is due to
maternal hypotension, hypoxemia, placental abruption, uterine rupture, direct uterine trauma,
disseminated intravascular coagulation, and maternal death.9-18

Fetal loss complicates up to 5% of minor trauma.19,20 Physical findings such as uterine

contractions, vaginal bleeding, and abdominal tenderness have been found to be poor
predictors of preterm delivery and fetal demise; even abnormal fetal monitoring does not
accurately predict fetal loss.21,22 The absence of these findings, however, along with normal
fetal monitoring, has been uniformly predictive of a good outcome.7

Mechanism of Injury

Blunt Trauma. Motor vehicle collisions account for the majority of maternal trauma.7,9,13,23
Specific injuries to the spleen, liver, and retroperitoneum are more common due to the
increased vascularity of these structures.24 The uterus is well protected within the confines of
the pelvis in the first 12 weeks of gestation. As the pregnancy progresses, there is greater risk
to the uterus, placenta, vagina, and fetus. After 12 weeks, the bladder is displaced both
anteriorly and superiorly, making it more prone to injury. Pelvic fractures are a particular
challenge in pregnancy; resulting in up to a 35% fetal loss.4,25

Up to one-third of blunt injuries are related to falls during pregnancy.7,13 It is the second
leading cause of significant trauma in the second and third trimesters. The increase in falls is
at least partially attributable to a change in the center of gravity during pregnancy.
Recognizing this increased risk as the pregnancy progresses, many authorities recommend
high-risk activities be avoided in the last trimester. Dunning and colleagues reported that 27%
of pregnant patients surveyed reported a fall during pregnancy.26 Overall, there is less than a
10% risk of poor maternal or fetal outcome. However, 23% of those patients who were
hospitalized following a fall delivered during that admission.27

Physical Violence and Abuse. In the United States, more than 1 million women are victims
of domestic violence; pregnancy is a factor that increases the likelihood of physical and
sexual abuse. Ten to thirty percent of pregnant females are victims of physical violence, with
a resultant fetal demise of 5%.14,28-30 Common sites of trauma are head, neck, breasts, and
abdomen. Homicide remains the second leading cause of trauma deaths in pregnancy.31
Pregnant women who are abused have both short-term (fetal demise, abruption, pre-term
labor, rupture of membranes, and vaginal bleeding) and long-term (low fetal birth weight,
maternal infections, and maternal drug/alcohol abuse) complications.19,32,33 Risk factors for
abuse include drug and alcohol problems in a partner as well as a change in employment or
less than a high school education. As with other patients who are abused, pregnant women
are typically abused by someone intimately known to them and may be reluctant to report
their abuse for a variety of reasons. One significant clue is a woman who delays prenatal care
until late in pregnancy.34,35 Other signs of potential physical abuse include repeated
emergency department visits, depression, a history that is incompatible with injuries present,
and the persistent presence of the patient's partner. Emergency physicians and trauma
surgeons should be trained to ask appropriate screening questions of all females (including
those who are pregnant) to detect abuse, especially if they appear to demonstrate any of the
high-risk behaviors previously described.19,36 Table 1 provides a sample of appropriate
screening questions.

Penetrating Trauma. Penetrating trauma accounts for 10% of pregnant trauma victims and
is the cause of 24% of maternal deaths.9 Gunshot wounds and stab wounds are the most
common mechanisms of penetrating injury. Six percent of injuries in pregnancy are directly
attributed to firearms.13 A significant number of gunshot wounds are self-inflicted.

As with blunt trauma, the uterus becomes more vulnerable to injury as the pregnancy
progresses. After the middle of the second trimester, the uterus protects much of the maternal
abdominal contents. In a significant percentage of penetrating injuries, the uterus is the only
abdominal organ that sustains injury. Maternal outcome is generally good with penetrating
injuries; however, there is a corresponding high percentage of fetal loss (generally 40-70%)
as the uterus, amniotic fluid, placenta, and fetus absorb most of the energy from penetrating
objects or missiles. Maternal mortality is actually less common in pregnancy when compared
to similar injury in non-pregnant patients. Stab wounds result in maternal injury only with
upper abdominal injuries. Maternal visceral injuries are, thus, less common during
pregnancy, complicating only 19% of cases and carrying a maternal mortality rate of 3.9%.37

Stab wounds to the pregnant abdomen are managed in the usual manner, although there has
been recent emphasis on non-operative management of the patient. The penetrating object
should be stabilized in place until surgical exploration is conducted. Delivery of the fetus is
indicated if there are signs of fetal distress or the uterus must be evacuated to localize and
control the site of bleeding. More conservative methods of managing the fetus are indicated
for fetal death in cases in which maternal injury has been excluded.

Physiology of Pregnancy

An understanding of the unique anatomic and physiologic changes in pregnancy is essential

in caring for the pregnant patient who sustains injury. Virtually every organ system is
impacted by the changing hormonal milieu and the growth of the uterus, placenta, and fetus
as the pregnancy advances.
Major changes occur in the cardiovascular and pulmonary systems during pregnancy. Cardiac
output increases up to 40% above baseline, much of which is diverted to support the
developing fetus. Systemic and pulmonary vascular resistance falls during pregnancy to its
nadir by the 28th week. The baseline blood pressure may drop by as much as 15-20%,
resulting in a 5 to 15 mmHg decline in both systolic and diastolic blood pressure late in the
second trimester. As full term approaches, these pressures begin to return to their normal
values. There is significant remodeling of the cardiac chambers with a thickened left ventricle
and some degree of valvular insufficiency. The heart rate increases during pregnancy; thus, it
is not uncommon to have 10-15% increase in heart rate in the third trimester. A low blood
pressure and elevated pulse in a pregnant patient can mistakenly be interpreted as normal
physiology when in fact there is significant ongoing blood loss.

Blood volume increases by 30-50% during pregnancy; red blood cell mass increases by only
10-15%. This produces a normal physiologic anemia in pregnancy with a normal hematocrit
measured between 32-34%. This is thought to protect the mother from blood loss during
childbirth, which averages 500 mL for vaginal deliveries and 1000 mL for cesarean sections.
When a pregnant trauma patient does exhibit signs of hypovolemic shock, she will have lost a
greater percentage of blood (>30% or more) than the average non-pregnant patient. Maternal
deterioration can proceed rapidly after the loss of 2500 mL of blood.

Other hematologic changes include a normal elevation of the white blood cell count to 12,000
cells/cm3. Serum clotting factors and plasma proteins increase during pregnancy, resulting in
a hypercoagulable state. Fibrinogen levels, as well as the levels of factors VII, VIII, IX, and
X, are all increased during pregnancy, with the rise in fibrinogen most notable. Normal serum
fibrinogen levels in a pregnant patient with trauma may suggest early DIC (disseminated
intravascular coagulation).

Oxygen consumption increases by 60% during pregnancy when compared to 8 and 12

months post-partum.38 There is an accompanying 50% increase in minute ventilation, along
with a decrease in functional residual capacity by 20-25%. This is primarily caused by a 4 cm
elevation of the diaphragm and a 5 to 7 cm widening of the lower chest wall caused by the
gravid uterus. The increased minute ventilation leads to a "normal" paCO2 of 28-30 mmHg in
pregnancy. The net result of these changes is that the pregnant female will have greater
oxygen requirements along with a smaller reserve. As a result, rapid oxygen desaturation can
occur, and these patients will abruptly desaturate during rapid sequence intubation. It should
be noted that the fetus is protected from hyperoxia; supplemental oxygen poses no harm to
the developing fetus. Thus, all pregnant trauma victims should receive oxygen
supplementation. Additionally, the level of 2,3 diphosphoglycerate (DPG) is elevated in
pregnancy, causing a shift in the oxygen dissociation curve and greater release of oxygen to
fetal tissues. Maternal hypocapnea and acidosis also cause a shift in the oxygen dissociation
curve, leading to reduced oxygen delivery due to greater affinity of hemoglobin for oxygen
molecules. Additional findings in pregnancy include an increased arterial pH, decreased
pCO2, decreased serum bicarbonate, and slightly increased paO2 with a measured arterial
blood gas.

The heart rotates to the left from elevation of the diaphragm resulting in both T-wave
inversion and Q waves in the inferior cardiac leads. Echocardiography demonstrates
thickening of the left ventricle along with small pericardial effusions and mild pulmonic and
tricuspid regurgitation.39
Renal blood flow increases by almost 50% in pregnancy. As a result, the normal BUN (blood
urea nitrogen) and creatinine levels are lower in pregnant females. Conversely, a "normal"
BUN and creatinine level in advanced pregnancy may indicate renal dysfunction.
Gastrointestinal motility decreases during pregnancy due to effect of progesterone with
increasing risk of both gastrointestinal reflux and aspiration of gastric contents. There is
resistance to insulin during pregnancy, increasing the likelihood of precipitating a
diabetogenic state.

Uterine blood flow has poor autoregulation and is almost linearly dependent upon maternal
systolic blood pressure. Uterine blood flow increases from 60 mL/min to 600 mL/min (or
10% of cardiac output) as pregnancy progresses. Uterine injury thus can result in significant
blood loss. As a result of early hypotension, the mother's physiologic response is that of self-
preservation. The result is alpha-adrenergic stimulation, whereby uterine blood flow is
sacrificed for maternal systemic blood flow. During periods of hypoxia and hypotension
during trauma, fetal tachycardia, loss of variability, and fetal heart rate deceleration can be
seen. The first signs of distress may not occur until hemorrhage of 1500 to 2000 mL.
Additionally, maternal hyper- or hypocapnea can cause uterine vasoconstriction. This may
lead to fetal hypoxia and acidosis. Even uterine contractions, which commonly occur after
maternal injury, can compromise uterine blood flow.

In the supine position the gravid uterus, which averages 4500 gms at term, can compress the
inferior vena cava. This decreases venous return, with resultant diminished cardiac output by
as much as 30% in the supine position.40 In addition to causing hypotension, the increase in
venous pressure also can increase vascular bleeding from pelvic or lower extremity fractures.

The physiologic changes in pregnancy are summarized in Table 2.

Management of the Pregnant Patient

Prehospital Transport. The priorities in patient management remain the same in the
prehospital environment. A uterine fundus that is palpated midway between the xiphoid and
umbilicus suggests a viable fetus. Ideally, all pregnant trauma victims with a viable fetus
should be transported to a trauma center where committed multidisciplinary services,
including obstetrical resources, are available.41 Other indications for transport to a trauma
center include tachycardia, chest or abdominal pain, loss of consciousness, and third-trimester
gestation.42

Initial Management. The general approach to resuscitation of the pregnant female is to

address the priorities outlined in the American College of Surgeons' Advanced Trauma Life
Support course and attend to the obstetrical issues during the secondary survey when the
mother has been stabilized. Some specific differences, however, are outlined below.

Airway with Spinal Protection. Due to the higher risk of aspiration and the greater likelihood
of hypoxic decompensation in pregnant females, early intubation is recommended. All
pregnant females should be considered a difficult intubation.43,44 Preoxygenation is extremely
important due to the pregnant patient's tendency to desaturate rapidly during rapid sequence
intubation, the preferred technique for intubation. When possible, the most experienced
provider, following the ASA (American Society of Anesthesiologists') Guidelines for the
difficult airway modified for trauma,45,46 should perform the intubation. Awake fiberoptic
intubation may be considered. Supraglottic airway devices can be an effective alternative in
ventilating the pregnant female.47 If the patient cannot be intubated or ventilated, preparations
for surgical cricothyroidotomy should be made.

Neither depolarizing nor non-depolarizing paralytics cross the placental barrier. However,
lower doses of succinylcholine should be selected due to the natural decline in
pseudocholinesterase levels in pregnancy.48 Short-acting induction agents such as thiopental,
propofol, and midazolam are safely used in pregnancy but have significant hemodynamic
effects in trauma patients. Ketamine can be used in patients who are at risk for hypotension
but should be avoided in those with intracranial injuries. Etomidate is a class C drug in
pregnancy but is generally the preferred induction agent at many trauma centers, and is
advocated in at least one review of the anesthetic literature on pregnancy in trauma.49

While observing standard spine precautions, patients beyond 20 weeks gestation should be
transported in the left lateral tilt or decubitus position. Some late third trimester patients may
not tolerate the supine position due to respiratory distress, and these patients will require
reverse Trendelenburg positioning in addition to a left tilt.50 All patients should be on high
flow oxygen as the fetus is less tolerant of hypoxia.

Breathing. Any chest wall or lung injury is poorly tolerated in the later stages of pregnancy
due to altered respiratory function. Chest tube insertion, if required, should be conducted 1-2
interspaces above the normal landmarks for tube thoracostomy because of elevated
diaphragms.

Both the uterus and fetus respond poorly to hypocapnea or hypercapnea and the resultant
acid/base changes. Mild hypocapnea (pCO2 = 27 to 30 mmHg), which may be indicated for
pregnant patients with evidence of acutely elevated intracranial pressure, is tolerated by the
fetus. Positive pressure ventilation with PEEP (positive end-expiratory pressure) is not
contraindicated by pregnancy.
Circulation. The goal of resuscitation is to restore maternal circulation and reduce the effects
of maternal shock. The patient should be placed in the left lateral position to reduce
aortocaval compression by tilting the backboard to the left 15 degrees or manually displacing
the uterus if this was not already done by the pre-hospital personnel.

Tachycardia and hypotension should not simply be attributed to normal physiology and
should be considered potential signs of blood loss. With the increased plasma volume, the
pregnant patient may not display signs of shock until she has lost more than 30% of her blood
volume. Fluid resuscitation with crystalloid and blood products should be aggressive to
optimize uteroplacental perfusion.51

Lactated Ringer's solution may have some practical advantages over normal saline.52,53
Neither colloids nor hypertonic saline have been specifically studied in pregnant patients.
Autotransfusion may risk amniotic fluid contamination and subsequent amniotic fluid
embolism. However, at least one study suggests the risk is low when the cell-saver is used in
conjunction with a leukocyte pore filter.54 Blood products (O-negative) should be
administered as indicated when there is no response to crystalloids. In addition to fluid losses,
other causes of hypotension should be considered, including neurogenic shock and amniotic
fluid embolism.55

Disability. A baseline neurologic examination should be conducted, especially if intubation

and the use of paralytics is considered. The goal is to perform a quick assessment for signs of
intracranial hemorrhage and spinal cord injury. Management of patients with an expanding
intracranial mass or other causes of increased intracranial pressure should proceed as it would
in patients without pregnancy. Hypertonic agents such as mannitol and hypertonic saline
should be used with caution in pregnant patients with traumatic brain injury due to the
theoretical concern over the development of oligohydramnios in the uterus. Seizures in
pregnancy should raise the additional concern of eclampsia.

Management of pregnant patients with spinal cord injuries includes the use of high-dose
steroids as in other settings. Additionally, fluids and dopamine are safe for the initial
management of neurogenic shock, although there is a theoretical concern about
compromising uterine blood flow with higher doses of dopamine.

Exposure/Environment. A complete examination of the patient for signs of injury requires

proper patient exposure. The patient should be carefully log-rolled to assess for injuries on
the back. If the backboard is subsequently removed, the left side of the patient should be
elevated with a pillow or towel roll. As with all other trauma victims, hypothermia is
associated with an increased incidence of coagulopathy and worsening outcome; therefore,
attention to the patient's thermal environment is essential.

Once the primary survey has been completed, a nasogastric tube and Foley catheter may be
inserted. Because of nasal venous engorgement, the risk of epistaxis following nasogastric
insertion should be anticipated. The risk of urinary tract infection also is greater in pregnant
females, so urinary catheters should remain in place only as needed. Tetanus toxoid should be
administered as indicated.

Laboratory and Radiologic Studies. Routine laboratory testing in the trauma victim
depends on the institutional protocols and underlying patient condition. In many trauma
centers, a type and screen, a hemoglobin, urinalysis, and urine pregnancy test (for females of
child bearing age) may be all that are required. Further testing in the pregnant trauma victim
should include a coagulation profile. An arterial blood gas and serum lactate may be
considered due to the association between maternal acidosis and fetal demise. Rh negative
patients should receive anti-D antibody (Rhogam 300 mcg) within the first 72 hours and
additional doses of 300 mcg for every 30 mL of estimated exposure to fetal blood (based on
Kleihauer-Betke results) to prevent isoimmunization.56,57

Standard x-rays should be obtained as needed. Where possible, a protective lead apron should
be used to minimize fetal radiation exposure. Radiation doses of less than 5 rads are not
associated with increased pregnancy loss or fetal abnormalities and no study has
demonstrated increased teratogenicity below 10 rads. Teratogenesis, childhood cancer,
leukemia, mental retardation, and microcephaly become a concern for radiation doses in
excess of 12 to 20 rads.58-61 Common radiation doses for radiographic studies are presented in
Table 3.

The FAST (Focused Assessment with Sonography for Trauma) examination is an excellent
screening tool to quickly assess for intra-abdominal fluid (blood), the possibility of
pregnancy, and fetal viability if one is identified.62-65 The ultrasound is the safest imaging
modality in pregnancy. However, ultrasonography typically provides limited information
regarding the presence or absence of intraperitoneal fluid. A positive FAST examination in an
unstable patient suggests the need for immediate laparotomy; in a stable patient, the
abdominal CT scan should be obtained to determine the need for an operative intervention. In
addition, the diagnostic peritoneal lavage (DPL) can be performed safely using an open
supraumbilical approach for equivocal FAST examinations.66 However, this technique
requires significantly more training than ultrasonography and poses greater risk to the
pregnant patient.

Obstetrical Management
The obstetrical management of the patient begins once the trauma assessment moves into the
secondary examination. Even in the case of relatively minor injuries, any patient with a viable
pregnancy should be seen by an obstetrician, and a period of fetal monitoring, including
ultrasonography and cardiotocography, should be provided.67

Part of the secondary examination should include assessment of the abdomen for tenderness,
uterine tone, contractions, and tenderness. A pelvic examination should be performed using a
sterile speculum to detect any pregnancy-related vaginal bleeding and the presence of
amniotic fluid. Rectal and vaginal examination should be conducted even in the presence of
pelvic fractures. Specific examination also may be conducted to determine cervical
effacement, cervical dilatation, and fetal position.

Fetal monitoring of fetal heart rate and uterine activity should be initiated under appropriate
conditions as early as possible in all pregnant females at more than 24 weeks of gestation.
The fetus may demonstrate signs of distress while the maternal vital signs are adequate. This
may signify under-resuscitation of the mother. Monitoring should be supervised under the
direction of an obstetrician and appropriately-trained obstetrical staff.

In the absence of other significant injuries, most patients can be monitored for a period of 4-6
hours and then safely discharged if there are no signs of fetal distress, premature labor, or
vaginal bleeding. Patients who are discharged under these conditions should be given clear
instructions to return for any signs of preterm labor or placental abruption, including regular
contractions, abdominal pain, or vaginal bleeding. However, any abnormalities noted in the
first 4-6 hours require an extended period of observation for at least 24 hours;
cardiotocographic monitoring also should be continued if the patient requires admission for
other injuries.6,19

Emergency cesarean section may be indicated to control obstetrical bleeding from placental
abruption or uterine rupture. Additionally, it may be required to provide better surgical
exposure for non-obstetrical abdominal injuries. Finally, the procedure may be indicated for
persistent fetal distress if the gestational age is 25 weeks or greater. Emergency cesarean
section under these conditions is associated with a fetal survival rate of 45% and maternal
survival of 72%.68

Special Considerations

Placental Abruption. Placental abruption is the most common obstetrical complication of

blunt trauma and the second most common cause of fetal demise.40,69-71 Placental abruption
occurs in 1-5% of minor trauma and 20-50% of major trauma. Mortality for the mother is less
than 1%, but fetal mortality is 30-60%.71,72

Signs of abruption include uterine tenderness, tetany, vaginal bleeding, and contractions.
Placental abruption does not always present with vaginal bleeding. Abdominal tenderness,
however, is almost uniformly present. Abruption may be complicated by
hypofibrinogenemia, DIC, and hemorrhagic shock. Ultrasound only identifies up to 50% of
acute abruptions.61 Fetal distress is noted in 60% of cases and cardiotocographic monitoring
is the most reliable method of detecting abruption.15,73,74 Cesarean section is performed for
maternal complications and fetal compromise. Vaginal delivery may be performed for a
stable viable fetus and in the absence of maternal complications.
Uterine Rupture. Uterine rupture is uncommon. There is a high association with pelvic
fracture.4 It carries a maternal mortality of only 10% but results in nearly 100% fetal loss.
The patient typically presents with a severe abdominal pain and associated guarding and
rebound, and often complains of shoulder pain. Uterine asymmetry or fetal parts may be
palpated on examination. Signs of shock are common. The diagnosis can be established by
plain radiography, although ultrasound is more commonly employed. Fetal monitoring
reveals fetal tachycardia, decreased beat-to-beat variation, and deceleration with
bradycardia.21 The diagnosis is confirmed and managed by laparotomy.

Uterine Contractions and Premature Labor. Uterine contractions result from

prostaglandins, which are released because of direct uterine trauma. Seventy percent of
contractions following trauma resolve spontaneously. Premature labor with contractions and
evidence of effacement and dilatation occurs in the remainder of patients. Preterm labor is
treated with tocolytic agents and steroids to promote fetal lung development. Tocolytic
therapy should be avoided in cases in which fetal distress or maternal complications mandate
immediate delivery and the fetus is more than 36 weeks or less than 20 weeks.

Magnesium sulfate may be an appropriate tocolytic agent. However, magnesium sulfate is a

smooth muscle relaxant and may exacerbate maternal hypotension. Nifedipine has recently
been gaining popularity.75,76

Maternal Burn Injury. Minor burns rarely have significant consequences for the fetus. For
major burns, fetal outcome directly parallels maternal outcome. Early fetal loss occurs as the
result of fluid loss and maternal hypoperfusion in the first 12 hours. Aggressive fluid
resuscitation is as applicable to the pregnant female as any other burn victim. The rule of
nines is modified by adding 5% for burns over the gravid uterus.

The other major complication of burns in pregnancy is preterm labor. Emergent delivery for
gestational age > 25 weeks may be indicated for patients with major burns and significant
complications.77 Tocolytic therapy may be considered if the burn injury is less than 30
percent body surface area and the gestational age is between 24 and 32 weeks.

Inhalation injuries may produce maternal hypoxia, which has profound consequences for the
fetus. Early intubation should be considered. In addition, fetal hemoglobin has a greater
affinity for carbon monoxide than adult red blood cells. Aggressive management with 100%
supplemental oxygen is warranted. In addition, some sources recommend that all pregnant
females undergo hyperbaric oxygen treatment if there is any exposure to carbon monoxide.78

Electrical injuries also may pose a risk to mother and fetus. Low voltage injuries do not
appear to pose any risk to the developing fetus, although the literature presents conflicting
data.79-81 The role of fetal monitoring in low-voltage exposures is unclear. High-voltage
electrical injuries, particularly when the current path goes from the hand to the feet, increases
the risk of fetal death and complications such as growth retardation, placental abruption, and
spontaneous abortion. Lightning injuries in pregnancy are rare.82

Perimortem Cesarean Section

Post-mortem cesarean sections were commonly performed throughout the 19th century when
maternal mortality was between 2-5%; infant survival was rare. Ritter83 reviewed the
literature and reported on 120 perimortem cesarean sections in which the infant survived.
Katz recommended that perimortem cesarean section should only be considered for mothers
at greater than 24 weeks gestation with loss of vital signs for no more than 4 minutes. For
maximum survival, delivery of the infant was to be accomplished within 5 minutes. This
initial recommendation was made for all cases of cardiopulmonary arrest (including trauma)
in the mother.84 However, a review of this work revealed that at least one normal infant
survived more than 21 minutes of maternal CPR. In a subsequent review, Katz and
colleagues85 found 38 patients who underwent emergency cesarean section within the
appropriate time frame. Thirty-four infants were long-term survivors and 13 mothers
survived. However, of eight cases performed for traumatic arrest, only three infants and no
mothers survived. This was primarily due to the long interval between time of arrest and
cesarean section.

Perimortem cesarean section is performed using a generous vertical incision from the xiphoid
to the pubic and a vertical upper uterine segment incision once the uterus is exposed. This
procedure should immediately be considered in any viable fetus in which cardiopulmonary
arrest occurs in the setting of trauma. Fetal salvage is best if the infant is delivered within 10
minutes and ideally in the first 4-5 minutes of maternal arrest; however, survival has been
reported with episodes of prolonged maternal arrest.83-86 The surgery not only serves to
preserve fetal viability but also evacuates the uterus and reduces aortocaval compression,87-89
and maternal cardiac output will increase by 60-80% of pre-pregnancy levels.86 The FAST
exam can be used to confirm the absence of maternal cardiac activity and the presence of
fetal viability.90

Treatment of cardiac arrest in pregnancy is otherwise not altered. However, chest

compressions may be less effective. Open thoracotomy should be considered for the viable
fetus as well performed open chest compressions may improve fetal survival. It is important
to note that, if performed after an emergent thoracotomy, aortic cross-clamping may worsen
placental and fetal perfusion.

Injury Prevention

Not surprisingly, the single most important intervention in preventing maternal and fetal
injury is the use of restraint systems in motor vehicle operation. Proper use of seatbelts has
been shown to be the best predictor of maternal and fetal outcome in motor vehicle crashes.91
Unfortunately, only 46-66% of pregnant trauma patients have been found to use restraints
during motor vehicle operation.9,14,92 Additionally, a survey-based study of 450 pregnant
women who used seatbelts reported a 73% rate of correct use of seatbelts during pregnancy.
The most common reason for lack of restraint use was patient discomfort (53%), followed by
forgetfulness (37%). Ten percent believed that seatbelts would harm the fetus during a motor
vehicle crash.93 This and other studies support the fact that only about one-third of pregnant
patients report receiving information about proper restraint system use.93-95 On the other
hand, Pearlman and Phillips96 demonstrated that most of those who were educated wore their
seatbelts (83%) and could identify proper placement (77%).

Correct placement should include a shoulder strap between the breasts and the lap belt
positioned across the hips. Placement of the lap belt over the dome of the uterus places the
fetus and uterus at risk of injury97 and premature delivery within 48 hours of injury.98 Airbags
also contribute to safety in the passenger compartment.99 Although studies are
conflicting,69,100 Sims and coworkers99 have shown that there is no increased risk of placental
abruption, preterm labor, fetal injury, or complicated deliveries with airbag deployment.
Improper placement of the seatbelt increases the incidence of maternal hemorrhage from
uterine rupture and a three-fold incidence of fetal death.101,102 One recent study103 determined
that almost half of fetal losses could be prevented by appropriate seatbelt use among pregnant
patients involved in motor vehicle crashes. These data suggest seatbelt education is vital to
appropriate prenatal care.

Summary

Care of the pregnant trauma victim often requires a multi-disciplinary approach found in a
trauma center. The priorities in caring for the pregnant trauma victim remain unchanged.
However, the unique anatomic and physiologic changes associated with pregnancy must be
understood. The best approach to fetal preservation is careful attention to resuscitation of the
mother. When these attempts fail, emergent perimortem cesarean section should be
considered early. Preventive measures such as proper restraint system use and screening for
evidence of domestic violence offer the best approaches to improving maternal and fetal
outcomes in trauma.

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