International Trauma Life Support

eighth edition
International Trauma Life Support

for Emergency Care Providers
Trauma in
Pregnancy
CHAPTER 19
International Trauma Life Support for Emergency Care Providers, Eighth Edition
John Campbell • Alabama Chapter, American College of Emergency Physicians
Trauma in Pregnancy
Copyright © 2016 by Pearson Education, Inc.

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Objectives
• Understand the dual goals in managing

the pregnant trauma patient
• Describe the physiologic changes
associated with pregnancy
• Understand the pregnant trauma
patient’s response to hypovolemia
• Describe the types of injuries most
commonly associated with the pregnant
trauma patient
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Objectives
• Describe the initial assessment and

management of the pregnant trauma
patient
• Discuss trauma prevention in
pregnancy

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Trauma in Pregnancy
• Unique challenges
– Vulnerability of pregnant trauma patient
– Potential injuries to unborn child
• Dual roles
– Provide care to mother
– Provide care to fetus

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Trauma in Pregnancy
• Leading cause of morbidity and

mortality
– 6–20% of pregnancies experience some
trauma
 1 in 12 injured experience significant trauma
– Major causes
 Motor-vehicle collisions  Penetrating injuries
 Falls  Burns
 Abuse and domestic  Suicide
violence  Homicide
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Factors Affecting
Fetal Mortality and Morbidity
• Hypoxia
• Infection
• Drug effects
• Pre-term delivery

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Pregnant Patient
• Increased risk for trauma

– Fainting spells, hyperventilation, excess
fatigue commonly associated with early
pregnancy
– Balance and coordination affected by
changes throughout pregnancy

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Fetal Development

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Viability Assessment

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Physiologic Changes

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Physiologic Changes
• Respiratory system
– Diaphragm elevated due to uterine size
– Decreased thoracic volume
– Relative alkalosis
– Predisposed to hyperventilation

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Physiologic Changes
• Anemia in pregnancy
• Absolute anemia
• Decreased gastric mobility

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Vital Signs in Pregnancy
• Do not mistake normal vital signs of

pregnancy for signs of shock
– Normal pulse: 10–15 beats faster
– Blood pressure: 10–15 mmHg lower
– 30–35% blood loss (1500 cc)
before significant blood pressure change
• Be alert to all signs of shock
– Frequent ITLS Ongoing Exams

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Response to Hypovolemia
• Vasoconstriction and tachycardia

– Reduction of uterine blood flow by 20–
30%
– Fetal heart rate and blood flow decrease
– Fetus becomes hypoxemic
• High-flow oxygen is essential
– Maternal shock has 80% fetal mortality
rate

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Trauma in Pregnancy
• ITLS Primary and Secondary Surveys

• Optimize maternal and fetal outcome
– High-flow oxygen rapidly administered
 Fetal hypoxia occurs before maternal hypoxia
– Fluid administration must be prompt
 Fluid volume needed is greater
– Frequent Ongoing Exams
 Mortality of fetus related to maternal treatment
 Optimal care of the fetus is appropriate
treatment of the mother
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Supine Hypotension
• Venous return decreases 30% in supine

position with 20-week or larger uterus
compressing the inferior vena cava
– Acute maternal hypotension
– Syncope
– Fetal bradycardia

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Supine Hypotension
• Transport position
– Elevate right hip 4–6 inches (10–15 cm)
with towel
– If SMR and backboard needed, tilt or
rotate backboard 15–30° to patient’s
left
– Manually displace
uterus to left

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Supine Hypotension
• Transport position
– Better stabilized
with vacuum
backboard
– More comfortable
than standard
backboard

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Relatively minor abdominal
trauma can cause fetal death
Maternal death is most

common cause of fetal death

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Types of Trauma
• Motor-vehicle collisions
• Penetrating injuries
• Domestic violence
• Falls
• Burns

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Motor-Vehicle Collisions
• 65–75% of pregnancy-related trauma

– <1% injured when minor vehicle
damage
– Seatbelts significantly decrease
mortality
 Have not shown any increase in uterine
injury

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Motor-Vehicle Collisions
• Maternal death • Fetal injury

– Head injury – Fetal distress
 Most common – Fetal death
– Uncontrolled – Placental abruption
hemorrhage – Uterine rupture
 Second most
common – Pre-term labor
 Assess pelvis

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Abdominal Trauma
• Physiologic changes
– Decreased sensitivity
 Gradual stretching
 Hormonal changes
 Uterus very vascular
• Clinical presentation
– Guarding, rigidity, rebound response
absent
 Abdominal trauma requires ED evaluation

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Penetrating Injuries
• Gunshot wounds and stabbings

– Entry below fundus
 Uterus absorbs force, protects maternal
organs
 High fetal mortality rate: 40–70%
 Lower maternal mortality rate: 4–10%
– Entry above fundus
 Bowel injury due to displacement

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Domestic Violence
• 10% experience abuse during

pregnancy
• Occurrence increases in 2nd and 3rd
trimester
– Proximal and midline injuries
 Face and neck most common
– Low birth weight
– Abused by spouse or boyfriend:
70–85% (U.S.)

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Falls
• Injury from falls

– Increase with progression of pregnancy
 Center of gravity altered
– Proportionate to force and body part
impacted
– Pelvic injuries
 Placental separation
 Fetal fractures

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Burns
• Fluid volume needed increases

– Mortality and morbidity
 Maternal mortality same as non-pregnant
 Fetal mortality increases with >20% BSA
 CO exposure increases risk to fetus
– Pregnant women with CO poisoning should be
transported to hyperbaric center if available

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FAST Exam
• No exposure to radiation
• Rapid assessment
• Assess both mother and fetus

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Trauma Prevention
• Proper seatbelt use

• Report domestic violence
• Counseling for domestic violence
• Patient education
– Multiple changes associated with
pregnancy
 Physiological, anatomical, emotional

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Summary
• Trauma in pregnancy
– Knowledge of physiological changes
 Hypotension and hemorrhage easily
overlooked
– Rapid evaluation and interventions to
stabilize
 Aggressive oxygen administration
 Aggressive fluid resuscitation
– Prevent supine hypotension
• Fetal care depends on maternal care

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eighth edition

International Trauma Life Support

Copyright © 2016 by Pearson Education, Inc.

• Understand the dual goals in managing

• Describe the initial assessment and

Copyright © 2016 by Pearson Education, Inc.

Copyright © 2016 by Pearson Education, Inc.

• Leading cause of morbidity and

Copyright © 2016 by Pearson Education, Inc.

• Increased risk for trauma

Copyright © 2016 by Pearson Education, Inc.

Copyright © 2016 by Pearson Education, Inc.

Copyright © 2016 by Pearson Education, Inc.

Copyright © 2016 by Pearson Education, Inc.

Copyright © 2016 by Pearson Education, Inc.

Copyright © 2016 by Pearson Education, Inc.

• Do not mistake normal vital signs of

Copyright © 2016 by Pearson Education, Inc.

• Vasoconstriction and tachycardia

Copyright © 2016 by Pearson Education, Inc.

• ITLS Primary and Secondary Surveys

• Venous return decreases 30% in supine

Copyright © 2016 by Pearson Education, Inc.

Copyright © 2016 by Pearson Education, Inc.

Copyright © 2016 by Pearson Education, Inc.

Maternal death is most

Copyright © 2016 by Pearson Education, Inc.

Copyright © 2016 by Pearson Education, Inc.

• 65–75% of pregnancy-related trauma

Copyright © 2016 by Pearson Education, Inc.

• Maternal death • Fetal injury

Copyright © 2016 by Pearson Education, Inc.

Copyright © 2016 by Pearson Education, Inc.

• Gunshot wounds and stabbings

Copyright © 2016 by Pearson Education, Inc.

• 10% experience abuse during

Copyright © 2016 by Pearson Education, Inc.

• Injury from falls

Copyright © 2016 by Pearson Education, Inc.

• Fluid volume needed increases

Copyright © 2016 by Pearson Education, Inc.

Copyright © 2016 by Pearson Education, Inc.

• Proper seatbelt use

Copyright © 2016 by Pearson Education, Inc.

Copyright © 2016 by Pearson Education, Inc.

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