Rosen & Barkin's 5-Minute Emergency Medicine Consult (572 page)

• Direct therapy to the mother with no delays due to pregnancy:
  
  • Manage airway and resuscitate as indicated
    
• Cardiac, pulse oximetry, and cardiotocographic monitoring
  
• Tilt patient or board 15–30° to the left (or manually displace uterus to the left)
  

• Lactated Ringer preferred for IV fluids:
  
  • Large volumes of normal saline may induce hyperchloremic acidosis
    
• Replace estimated blood loss in a 3:1 ratio:
  
  • O-negative packed red blood cells if type-specific blood is not available
    
• In cases of severe hemorrhage transfusion of fresh frozen plasma, platelets and packed RBC at 1:1:1 ratio lowers the rate of coagulopathy and may improve survival
  
• Resort to transfusions after 1 L of estimated blood loss or if hypovolemia persists after 2 L of crystalloid
  
• Nasogastric tube decompression (higher risk of aspiration in pregnancy)
  
• Foley catheterization to assess urinary output
  
• Tube thoracostomy:
  
  • Use a higher intercostal space to avoid diaphragm
    
• Rapid sequence intubation:
  
  • Safe and preferred method
    
  • Avoid aspiration and deoxygenation
    
• If diagnostic peritoneal lavage is necessary, use supraumbilical open technique
  
• Use tocolytic therapy only for hemodynamically stable patients:
  
  • Contraindicated if cervix dilated >4 cm or if FMH and abruption have not been reasonably ruled out
    
  • Use tocolytics only when >8 contractions/hr have lasted >4 hr
    
• A perimortem cesarean delivery may be attempted within 4–5 min of cardiopulmonary arrest. See Cesarean Section, Emergency.
  
• In minor trauma after week 20, fetal and maternal monitoring is best done in the labor and delivery area
  
• If burns are >50% BSA + fetus in the 2nd or 3rd trimester consider delivery
  
• RhoGAM in all Rh-negative women (within 72 hr):
  
  • 50 μg IM in women <12 wk pregnant
    
  • 300 μg IM in women >12 wk pregnant
    
• 24 hr recheck for ongoing FMH:
  
  • Repeat Rh immune globulin if needed (if FMH >30 mL)
    
• Tocolytics: Magnesium sulfate 4 g IV
  
• Avoid aspirin, hypnotics, nonsteroidals, vasopressors when possible
  

FOLLOW-UP

• Vaginal bleeding or amniotic fluid leakage
  
• Fetomaternal hemorrhage
  
• Abdominal pain
  
• Uterine contractions
  
• Evidence of fetal distress
  
• Abruption placenta
  
• Hemoperitoneum or visceral or solid-organ injury
  
• Fetal survival begins at week 24 (9.9%):
  
  • Survival becomes significant after week 26 (54.7%)
    

• All the following criteria must be met:
  
  • No uterine contractions for >4 hr of tocodynamometry
    
  • No evidence of fetal distress
    
  • No vaginal bleeding or amniotic fluid leakage
    
  • No abdominal pain or tenderness
    
  • Timely obstetric follow-up
    
• Specific instructions to return if any of the above symptoms occur
  
• Discharge only in consultation with obstetrics.
  

A pregnant trauma patient being discharged after appropriate evaluation and observation needs prompt follow-up with obstetrician.

• Minor trauma can lead to maternal and/or fetal death
  
• Stabilization of the mother is 1st priority
  
• Maternal stress may not occur until 1,500–2,000 mL of blood loss
  

• Chames MC, Pearlman MD. Trauma during pregnancy: Outcomes and clinical management.
  Clin Obstet Gynecol
  . 2008;51:398–408.
  
• Cusick SS, Tibbles CD. Trauma in pregnancy.
  Emerg Med Clin North Am
  . 2007;25:861–872.
  
• Dunning K, Lemasters G, Bhattcharya A. A major public health issue: The high incidence of falls during pregnancy.
  Matern Child Health J.
  2010;14:720–725.
  
• Hill CC, Pickinpaugh J. Trauma and surgical emergencies in the obstetric patient.
  Surg Clin North Am
  . 2008;88:421–440.
  
• Maghsoudi H, Kianvar H. Burns in pregnancy.
  Burns.
  2006;32:246–250.
  
• Mendez-Figueroa H, Dahlke JD, Vrees RA, et al. Trauma in pregnancy: An updated review.
  Am J Obstet Gynecol
  . 2013;209(1):1–10.
  
• Muench MV, Canterino JC. Trauma in pregnancy.
  Obstet Clin North Am
  . 2007;34:555–583.
  
• Schiff MA. Pregnancy outcomes following hospitalisation for a fall in Washington state from 1987 to 2004.
  BJOG
  . 2008;115:,1648–1654.
  
• Wiencrot A, Nannini A, Manning SE, et al. Neonatal outcomes and mental illness, substance abuse, and intentional injury during pregnancy.
  Matern Child Health J
  . 2012;16:979–988.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Cesarean Section, Emergency
  
• Placental Abruption
  

CODES

• 641.20 Premature separation of placenta, unspecified as to episode of care or not applicable
  
• 656.00 Fetal-maternal hemorrhage, unspecified as to episode of care or not applicable
  
• 665.90 Unspecified obstetrical trauma, unspecified as to episode of care or not applicable
  

BASICS

• Pregnancy is not a disease process but rather a physiologic state. It involves severe metabolic stresses on the mother to facilitate the growth and development of the fetus.
  
• All women of reproductive age with abdominal pain are considered pregnant until proven otherwise even with history of sterilization.
  
• The changes in pregnancy occur from the production of large amounts of placental hormones:
  
  • Placental progesterone and estrogen
    

• Range for menarche in US is 11–15 yr old
  
• Pregnant adolescents who present to the ED may be either unaware of the pregnancy or reluctant to admit it:
  
  • Assume pregnancy in adolescents, regardless of the chief complaint
    
  • Pediatric pregnancies have an increased risk of obstructive labor
    

• Preceding signs and symptoms can be explained by elevations in various hormone levels or changes in anatomy that are a function of the progression of the pregnancy.
  
• Placental human chorionic gonadotropin (hCG):
  
  • Prevents the normal involution of the corpus luteum at the end of the menstrual cycle
    
  • Causes the corpus luteum to secrete even larger quantities of estrogen and progesterone
    
  • Elevated hCG levels are responsible for nausea and vomiting.
    
• Placental progesterone:
  
  • Causes decidual cells in the endometrium to develop and provide nutrition for the early embryo
    
  • Decreases contractility of the gravid uterus and risk of spontaneous abortion
    
  • Helps estrogen prepare the breasts for lactation
    
• Placental estrogen:
  
  • Responsible for enlargement of uterus, breasts, and mammary ducts
    
  • Enlargement of female external genitalia, relaxation of pelvic ligaments, symphysis pubis, and sacroiliac joints
    

DIAGNOSIS

The diagnosis of pregnancy and some of its potential complications focus on 3 diagnostic tools:

• History and physical exam
  
• Hormonal assays
  
• Ultrasonography
  

• Amenorrhea accompanied by nausea and vomiting in a sexually active woman
  
• Amenorrhea:
  
  • Most common cause of secondary amenorrhea in a woman of reproductive age is pregnancy
    
• Nausea and vomiting (morning sickness)
  
• Breast tenderness (mastodynia)
  
• Urinary frequency
  
• Headache
  
• Low back pain
  
• Pica
  
• Edema of feet and ankles
  
• Weight gain
  
• Easy fatigability, generalized malaise
  
• Increase in abdominal girth
  
• Constipation
  
• Heartburn
  
• Excessive eructation
  
• Skin darkening