CONDITIONS IN L ATE PREGNANC YObstetric and Gynaecological Emergencies 387Trauma in late pregnancy
Treatment priorities for trauma in a pregnant patient are the same as for the
non-pregnant patient. The best treatment for the fetus is to rapidly stabilize the
mother.
MANAGEMENT1 Follow the immediate management guidelines as for multiple injuries (see p.
218), but note the following additional considerations:
(i) Tilt the supine, third trimester patient laterally using a wedge
or pillow under the right hip, and manually displace the gravid
uterus upwards and to the left to minimize impaired venous
return from inferior vena caval compression.
(ii) Protect the airway from the increased risk of gastric regurgitation
and pulmonary aspiration.
(iii) Larger amounts of blood may be lost before obvious signs of
hypovolaemia such as tachycardia, hypotension and tachypnoea
occur, as both maternal blood volume and cardiac output
increase in pregnancy
(a) common mistakes are to fail to recognize shock despite
normal vital signs, and to then fail to treat aggressively with
crystalloids and blood.
(iv) Observe and monitor every pregnant woman with a potentially
viable fetus of >24 weeks gestation with cardiotocography
(CTG) for at least 6 h, looking particularly for evidence of
placental abruption with fetal distress and frequent uterine
contractions
(a) fetal distress occurs readily without signs of maternal shock,
as blood is shunted preferentially away from the uterus to
maintain the maternal circulation following blood loss.
(v) Also arrange an abdominal ultrasound to evaluate both the
mother and the fetus. It is highly sensitive for detecting free
intraperitoneal fluid (blood) following blunt trauma.
(vi) Retroperitoneal bleeding with pelvic fracture after blunt trauma
may be massive from the engorged pelvic veins.
2 Assess the fetus during the secondary survey after initial resuscitation of the
mother.
(i) Examine fundal height, uterine tenderness, fetal movement, fetal
heart rate and strength of contractions.
(ii) Use a fetal stethoscope, Doppler ultrasound or cardiotocograph
to assess the fetal heart rate. Fetal distress is indicated by:
(a) bradycardia <110 beats/min (normal 120–160 beats/min)