Trauma pregnant woman is a particular type of patient to treat. Many fetal deaths are caused by traumatic incidents. It seems not common, however, trauma in pregnancy affects 7% of all pregnancies.
At the first place as cause of traumas there is the vehicle accident, while at the second place we have the intimate partner violence, which a paramedic should never exclude.
The question now is, how can we look after our 2 patients? What are the procedures?
Supposing that a young woman, in her second trimester of pregnancy, experiences a motor vehicle collision. She was not wearing a seatbelt. She arrives in the ED brought by basic life support crew, who have immobilised her on a spine board. She is diaphoretic, tachypnoiec and appears grey. She is alert but anxious, complaining of chest and abdominal pain. Initial vitals are: Sats 82% on room air, HR 120 BPM, BP 80/60.
Let us see what are the single steps:
1. Evaluate mother’s condition.
Treat her like any other traumatic patient. The first thing to be sure of is the nature of her pain and evaluate her injuries.
2. Resuscitate the mother first!
The concept is: if the mother is ok, so is her baby. Regardless the gestational age of the fetus, your focus must be her. Improving her oxygenation and perfusion will improve fetal oxygenation and perfusion
3. A pregnant trauma patient is physiologically and anatomically difficult to intubate. It requests well skilled and prepared team.
4. Bear in mind that fetal loss is higher when there is a maternal shock. You must identify the cause of the shock and treat. In particular a pregnant woman has an increasing circulating blood volume, that means that she loses more of her blood volume to manifest hypotension than if she were not pregnant.
5. Pregnant women were excluded from trials studying the efficacy of Tranexamic acid (TXA) in trauma patients. It classified as a category B drug in pregnancy, meaning that no animal studies have shown adverse outcomes with its use, but no human studies exist. TXA crosses the placenta. Despite the lack of published research, TXA may be of benefit in bleeding, seriously injured pregnant patients.
Remember to perform manual uterine displacement in all pregnant trauma patients over 20 weeks gestation.
Another caution to take is avoiding vasopressors wherever possible because they are associated with worse outcomes. In the specific case, they usually produce vasoconstriction of the placental bed, increasing the risk of fetal hypoxia.
6. Tilt the patient left lateral before starting resuscitation manouvers. The most usual way is keeping her supine, and then displace the uterus off the IVC, by pulling it from the left or pushing it to the right. In case this manouver should last for long time, it could be easier pushing the uterus from the right side instead pulling to the left.
7. Injured pregnant women should never be denied adequate analgesia.