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BACKGROUND

KEY QUESTIONS

  • What are the most common obstetric (OB) traumas, their the management considerations, and the impact on pregnancy?

  • What should the initial evaluation of an OB trauma include?

  • What is the most appropriate type of imaging to obtain, and how should patients be counseled about the risks involved?

CASE 50-1

A 26-y.o. G2P1001 at 35 and 3/7 weeks gestation presents to the ED after a high-impact motor vehicle collision (MVC). As per EMS, the patient was a restrained driver of a car traveling 50 mph on the highway when a car rear-ended her as she came to an abrupt stop. The airbag deployed, and the patient's abdomen was hit by it. She did not hit her head or lose consciousness. She is brought in by ambulance to the trauma room stable; however, she is mildly tachycardic and reports severe abdominal pain.

Upon arrival, the OB and Trauma teams are present. She is cleared by the primary survey. A FAST scan shows minimal blood in the right upper quadrant. History is taken and is unremarkable. Physical exam shows moderate amount of bright red blood at the perineum and patient's abdomen is severely tender. FHR tracing (FHRT) is Category I however, on tocometry the patient is contracting every minute.

Trauma in pregnancy is a relatively common occurrence, affecting 1 in 12 pregnancies. It is broadly divided into blunt and penetrating injury, which can vary widely in both severity and mechanism. The most common mechanism of blunt injury is motor vehicle collisions (MVCs), followed by falls and assaults. Penetrating injuries, such as gunshot and stab wounds, are much less common than blunt injuries. Approximately 1% to 4% of pregnant women will be hospitalized due to traumatic injury; it is the leading cause of nonobstetrical maternal death. Homicide and suicide attempts are infrequent in pregnancy. Overall, the most common mechanisms of injury for maternal and fetal mortalities are MVCs (73%), followed by falls (14%) and automobile-pedestrian collisions (13%). Fortunately, the overall maternal mortality rates after trauma are relatively low (< 3.8%). However, factors such as the need for a cesarean delivery soon after trauma, penetrating trauma, and lack of restraint use during an MVC all increase the mortality risk to both mother and fetus. In addition, head injuries, a low Glasgow Coma Scale (GCS), a high Injury Severity Score (ISS), internal injuries, and shock on admission are associated with worse maternal outcomes and increased fetal loss.

FALLS

Approximately 1 in 4 women will fall at least once during pregnancy, and the incidence of injury from such falls is 48.9 per 100,000 live births from falls. Physiologic changes that occur with pregnancy, such as increased joint laxity, weight gain, and postural changes, increase the risk of falls. Dynamic postural stability decreases with pregnancy, especially during the third trimester; 79% of pregnant women hospitalized after a fall were in their third trimester. Among such women, lower-extremity fractures were the most commonly associated injury, followed by contusions and sprains. The majority of falls occur indoors, and 39% involve falling down stairs. Exercise during pregnancy contributes an overall injury incidence of 4.1 cases per 1000 exercise hours, the majority of which involve falls. Falls also may occur at the workplace, with one study reporting that 6.3% of all employed pregnant workers fell ...

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