Rosen & Barkin's 5-Minute Emergency Medicine Consult (571 page)

• HELLP Syndrome
  
• Hydatidiform Mole
  
• Seizure, Adult
  

CODES

• 642.40 Mild or unspecified pre-eclampsia, unspecified as to episode of care
  
• 642.60 Eclampsia complicating pregnancy, childbirth or the puerperium, unspecified as to episode of care
  
• 642.64 Eclampsia, postpartum condition or complication
  

BASICS

• Fetal and maternal injury after the 1st trimester:
  
  • Increased rate of fetal loss, but not maternal mortality
    
• Likelihood of fetal injury increases with the severity of maternal insult
  
• Physiologic hypervolemia of pregnancy may lead to an underestimation of blood loss:
  
  • Clinical shock may be apparent only after a 30% maternal blood loss
    
• Abdominal findings are less evident in the gravid patient
  
• Minor trauma can also lead to fetal injuries (at least 50% of fetal losses)
  
• An Injury Severity Score >9 is associated with a worse outcome
  
• Less frequent bowel injury
  
• More frequent retroperitoneal hemorrhage due to the engorgement of pelvic organs and veins
  
• Increased morbidity and mortality with pelvic fractures due to pelvic and uterine engorgement
  
• Fetal or uterine trauma includes:
  
  • Placental abruption
    
  • Fetal–maternal hemorrhage (FMH)
    
  • Premature labor
    
  • Uterine contusion or rupture
    
  • Fetal demise
    
  • Premature membrane rupture
    
  • Hypoxemic or anatomic fetal injury (skull fracture)
    
• Abruption occurs in up to 60% of severe trauma and 1–5% of minor injuries:
  
  • Accounts for up to 50% of fetal loss
    
  • May occur with no external bleeding (20%)
    
  • Occurs after 16 wk of gestation
    
  • Can present with abdominal pain, cramping and/or vaginal bleeding
    
  • Hallmark is uterine contractions
    
• Uterine rupture:
  
  • Usually in patients with prior C-section
    
  • Nearly universal mortality
    
  • 10% maternal mortality
    
• Pelvic fracture:
  
  • May be an independent predictor of fetal death
    
  • Fatal insults to fetus can occur in all trimesters
    
  • 10% fetal mortality in patients with minor injuries
    
• FMH occurs in >30% of severe trauma:
  
  • Isoimmunization of Rh-negative mothers (with as little as 0.03 cc of FMH)
    
• Penetrating trauma results in direct injury to fetus, maternal shock, and premature delivery
  
• Falls and slips occur in 1 out of 4 pregnant women and may cause:
  
  • 4.4 fold increase in preterm birth (PTB)
    
  • 8 fold increase in placental abruption
    
  • 2.1 fold increase in fetal distress
    
  • 2.9 fold increase in fetal hypoxia
    
• Burns: If BSA involved is > 40% the maternal and fetal mortality approaches 100%
  
• Intentional trauma and domestic violence (DV) increases the risk for PTB 2.7 fold and low birth weight 5.3 fold
  
• Electrocution is a significant cause of fetal mortality
  

• Trauma occurs in ∼7% of all pregnancies
  
• Most common cause of nonobstetric morbidity and mortality in pregnancy
  
• Rate of fetal loss 3.4–38%
  
• Motor vehicle accidents (MVA; 48–84%)
  
• Domestic violence (DV)
  
• Falls
  
• Direct abdominal trauma
  
• Penetrating (stab or gunshot)
  
• Electrical or burn
  
• Higher rate in younger woman
  
• Substance abuse is a common accompaniment of MVA and DV
  
• Suicide and exposure to toxins
  

DIAGNOSIS

• Mechanism of injury
  
• Last menstrual period
  
• Abdominal pain
  
• Uterine contraction
  
• Vaginal bleeding or leakage of fluid
  
• Previous pregnancies, C-sections
  
• Substance use/abuse
  

• Perform with patient in left lateral recumbent position if possible
  
• Primary survey
  
• Secondary survey
  
• Tertiary survey
  
• Placental abruption:
  
  • Uterine tenderness
    
• Uterine rupture:
  
  • Uterine tenderness and variable shape
    
  • Palpation of fetal body parts
    
• Determine the gestational age (EGA) to assess viability:
  
  • Estimate last menstrual period
    
  • EGA = fundal height (FH; distance from pubic bone to top of uterus in cm after week 16
    
• Vaginal exam to assess for:
  
  • Blood
    
  • Amniotic fluid
    
  • Cervical dilation and effacement
    

• Maintain spinal immobilization
  
• Identify maternal condition 1st:
  
  • Airway management and resuscitate as indicated
    
• Determine the EGA to assess viability:
  
  • EGA = FH after week 16
    
  • Doppler fetal heart tones
    
  • Sonography (may miss small abruptions)
    
• Fetal/maternal monitoring for >4–6 hr:
  
  • Only monitor viable fetuses (typically with an EGA >24 wk)
    
  • Abruption unlikely if no contractions during 1st 4 hr of monitoring
    
  • >8 contractions/hr over 4 hr is associated with adverse outcome
    
  • If >1 contraction every 10 min, there is a 20% incidence of abruption
    
  • The occurrence of bradycardia, poor beat-to-beat variability, or type II “late” deceleration indicates fetal distress
    
  • An abnormal tracing has a 62% sensitivity and 49% specificity for predicting adverse fetal outcomes
    
  • A normal tracing combined with a normal physical exam has a negative predictive value of nearly 100%
    

• CBC, urinalysis
  
• Blood gas and electrolyte panel
  
• Type, Rh, and screening of blood
  
• The Kleihauer–Betke (KB) stain:
  
  • Identifies FMH in vaginal fluid or blood
    
  • Indicated when quantification of FMH is important
    

• Shield the uterus if possible, but obtain necessary maternal radiographs
  
• Inform the mother of the potential risks of radiation exposure
  
• No definite evidence of increased risk for congenital malformation or intrauterine death
  
• Cancer risk is debated
  
• Radiation <1 rad (10 mGy) believed to carry little risk
  
• Increased risk of fetal malformation at 5–10 rad
  
• The radiation exposure is estimated at the following:
  
  • CXR (2 views): Minimal
    
  • Pelvis (anteroposterior): 1 rad
    
  • Cervical spine x-ray: Minimal
    
  • Thoracic spine x-ray: Minimal
    
  • Lumbar spine x-ray: 0.031–4.9 rads
    
  • CT head: <0.05 rads
    
  • CT thorax: 0.01–0.59 rads
    
  • CT abdomen: 2.8–4.6 rads
    
  • CT pelvis: 1.94–5 rads
    
• Ultrasonography:
  
  • Focused assessment with sonography for trauma (FAST) exam
    
  • Evaluate for solid-organ injury or hemoperitoneum
    
  • Fetal heart activity
    
  • Gestational age
    
  • Amount of amniotic fluid (amniotic fluid index)
    
  • Misses 50–80% of placental abruptions
    
• Test vaginal fluid with Nitrazine paper (turns blue) and for ferning
  
  • Likely rupture of membranes and presence of amniotic fluid
    
• With stable penetrating trauma, triple-contrast CT is advocated, particularly with stab wounds
  

As indicated by traumatic injury

Differential diagnosis is broad and should include careful exam for occult traumatic injuries

TREATMENT

• Maintain spinal immobilization
  
• Patients in late 2nd and 3rd trimesters should be transported to a trauma center
  
• Advise trauma center early of pregnancy and EGA to facilitate mobilization of appropriate resources
  
• Place patient (while on backboard) in the left lateral recumbent position to avoid supine hypotension (after 20 wk EGA or earlier in multiple gestations)
  
• Mast suit inflation over the abdomen is contraindicated