Practice Management Guidelines for the Diagnosis and Management of Injury in the Pregnant PatientBarraco RD, Chiu C, Clancy TV et al (2010) EAST practice management guidelines work group July; 69: 211-214.
Trauma during pregnancy leads to admission in 4/1000 pregnancies. It is a major cause of fetomaternal mortality and the considerable physiological changes in pregnancy present diagnostic and management difficulties, particularly regarding maternal resuscitation. This US review also found much variation in practice in use of ionising radiation.
A literature search was undertaken using relevant search terms, with 76/1600 articles included. Single case reports were excluded. The studies were weighted according to type and methodology. Critique and meta analysis was undertaken by senior obstetricians and trauma surgeons. Recommendations were made regarding duration of monitoring post-trauma, use of Kleihauer technique to quantify fetomaternal haemorrhage, optimising maternal resuscitation, and imaging considerations. The analysis notes a lack of large, prospective studies on topics relating to the pregnant patient experiencing traumatic injury.
The recommendations include: In the absence of any other clinical features CTG monitoring should be maintained for 6 hours in trauma at >20 weeks.
Kleihauer testing should be performed in all patients >12 weeks with use of Rh immunoglobulin. It is noted that the test may also be used in evaluating risk of imminent abruption.
All women of reproductive age presenting with trauma should have hCG assay, with routine shielding from X-rays pending result. Linked to this is fetal exposure data to aid clinicians in minimising exposure in the pregnant patient.
The final recommendation supports ALSO in that perimortem caesarean section should be considered early in a moribund woman who is more than 24 weeks pregnant, to guide the critical and difficult aspects of maternal resuscitation.
This review broadly supports international consensus and UK guidelines and it highlights the need for more data on a variety of parameters regarding pregnant women involved in significant trauma.