Trauma in a Pregnant Patient
You are called to a 28-year-old female, 32 weeks pregnant, who was in a motor vehicle collision. She is complaining of abdominal pain and vaginal bleeding. On arrival, she is anxious, pale, and diaphoretic. Vital signs: BP 90/60, HR 120, RR 24, SpO2 98% on room air. The fetus is active. You note a gravid uterus with tenderness and a small amount of dark blood at the introitus. You have spinal precautions, oxygen, IV access, and a trauma center 15 minutes away.
1. What are your priorities in managing this patient? Explain how pregnancy alters your approach.
Read the worked answer
Priorities:
- Primary survey – airway, breathing, circulation with spinal precautions. Pregnancy does not change the ABCs, but physiological changes (increased blood volume, cardiac output) can mask shock; hypotension is a late sign.
- Positioning – Place the patient in a left lateral tilt (15-30 degrees) to relieve compression of the inferior vena cava by the uterus, improving venous return and cardiac output.
- Oxygenation – Maintain SpO2 ≥95% to ensure fetal oxygenation.
- IV access – Two large-bore IVs, administer isotonic fluids for hypotension; avoid vasopressors if possible.
- Assess for vaginal bleeding – Note amount and character; do not perform digital exam.
- Rapid transport – To a trauma center with obstetrical capabilities.
Rationale: Pregnancy increases plasma volume, so the mother may lose up to 30% blood volume before showing hypotension. Left lateral tilt improves cardiac output. Fetal distress may be the first sign of maternal compromise.
2. What are the potential causes of her vaginal bleeding and abdominal pain? How does this affect your management?
Read the worked answer
Differential:
- Placental abruption: Painful bleeding, uterine tenderness, fetal distress. Common after trauma.
- Placenta previa: Painless bleeding, but here there is pain; however, trauma can cause bleeding.
- Uterine rupture: Rare, but severe pain, fetal distress, shock.
- Vaginal or cervical trauma.
Management implications:
- Do not perform digital vaginal exam – may worsen placenta previa or provoke bleeding.
- Monitor fetal heart rate if equipped; fetal distress indicates maternal shock or abruption.
- Rapid transport for definitive diagnosis and treatment.
Rationale: Abruption is the most common cause of painful bleeding after trauma; it can lead to fetal demise. Previa typically causes painless bleeding. Digital exam is contraindicated. Transport to a facility with obstetric and neonatal capabilities is crucial.