A 27-year-old woman who is 32 weeks pregnant is an unrestrained driver involved in a T-bone collision with damage to the driver’s door at moderate speed. She is extricated from her vehicle by paramedics, and she arrives at the emergency department (ED) alert but in distress. She has a scalp laceration, deformities on her left arm and left leg, and ecchymosis over her left flank.

Which of the following statements is correct regarding trauma in patients who are in their third trimester of pregnancy?

 Computed tomography (CT) is contraindicated.
 In late pregnancy, PaCO2 is elevated and fibrinogen is low, leading to a misdiagnosis of respiratory failure and disseminated intravascular coagulation.
 Vaginal pH > 4.5 indicates an amniotic fluid leak.
 Fetal assessment occurs during the secondary survey.

Correct Answer:

Vaginal pH > 4.5 indicates an amniotic fluid leak.

Educational Objective:

Outline management principles for a trauma patient who is pregnant.

Key Point:

The basic resuscitation priorities and interventions after trauma are the same in pregnant and nonpregnant patients, with several important points to consider: pelvic examination is required for all pregnant women because it yields critical information about fetal risk; a vaginal pH > 4.5 indicates rupture of the chorioamniotic membranes; blood suggests placental abruption (blood is present in 70% of placental abruption after trauma); dilation and effacement suggest impending labor.

Explanation:

Fetal survival after trauma in pregnancy depends on maternal stability. The most common cause of fetal death in trauma is maternal shock, so the primary survey and resuscitation of a pregnant patient with trauma proceeds the same as in any other scenario with the addition of shifting the second or third trimester uterus off the vena cava, and monitoring fetal heart tones. Maternal blood pressure and heart rate may remain normal for a longer period than in nonpregnant patients after trauma (due to extra fluid volume of pregnancy), leading to a situation where the mother appears stable while the fetus is in severe distress. Hence, fetal vital signs are a more sensitive indicator of distress than maternal vital signs.

The pelvic exam is performed during the secondary survey to search for signs of amniotic fluid leak (vaginal pH > 4.5), placental abruption (blood in vault), or impending delivery (effacement, dilation). Obstetrics should be consulted early because fetal distress can occur unpredictably, necessitating an emergency C-section.

Placental abruption is the second leading cause of fetal death after trauma. If there is no blood in the vault, either an ultrasound (less sensitive) or CT scan (more sensitive) should be performed to assure that this diagnosis is not missed. Most patients with placental abruption after trauma will also experience uterine irritability with contractions triggered even just by the normal abdominal exam. Repeat vaginal examinations should be avoided.

Radiological studies should be performed according to the same protocols as in nonpregnant patients because fetal risk of death from missed injuries is greater than fetal risk from radiation exposure.

During pregnancy, PaCO2 and HCO3 are low (compensated respiratory alkalosis), meaning that a NOMAL PaCO2 indicates a problem, but a low HCO3 does NOT necessarily indicate hypovolemic shock. A fibrinogen level should always be ordered in pregnant patients. Towards the end of pregnancy, the fibrinogen nearly doubles; therefore, a normal fibrinogen level may indicate significant disseminated intravascular coagulation (DIC).

Pearl: Late in pregnancy, surprisingly minor trauma is sufficient to cause placental abruption.

Reference:

American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual. 10th ed., 2018.

It's important to know, Med-Challenger courses require NO exam building labor on your part - unlike other board review QBanks. Our courses come with pre-built, exam-mapped, adaptive self-assessments so there's no set up required - you can just dive in. However, we also include custom build tools, so if you DO want to build something special - you can.

Build custom exams that dynamically issue selected content based on your specifications and create a personal review solution that fits your study preferences and lifestyle.

Select from light and dark themes and customize your experience within your account profile.

Review completed work, batch claim CME credits, and produce printable CME certificate PDFs. Review, reproduce & email CME certificates anytime.

Our program director suite also includes custom question authoring, custom assignment creation, scheduling and more.

Med-Challenger provides you with key statistics and robust analytics to create an efficient and effective learning strategy - and predict outcomes.

Quickly see what's complete and what's left to review.

See how you're performing and improve your knowledge in problem areas.

See the likelihood of you passing your exam at any time.