Trauma In Pregnancy


MECHANISMS
 

SYMPTOMS/EXAM

DIAGNOSIS

Limited Bedside Transvaginal Ultrasound in ED
Correlation of Gestational Age, b-HCG level, and TVUS findings
 Gestational age  B-HCG (mIU/ml)  TVUS findings
 4.5-5 weeks  <1,000  Gestational sac
 5 weeks  1,000-2,000  Gestational sac + DDS*
 5-6 weeks  >2,000  Yolk sac** (+/- fetal pole)
 6 weeks  10,000-20,000  Embryo with cardiac activity
 7 weeks  >20,000  Embryonic torso/head
 

 

 


**DDS = double *DDS = double decidual sign
**First definitive evidence of IUP

Tips:

  • B-HCG of 1,500 is considered the discriminatory zone, i.e. minimum quantitative level of HCG at which intrauterine pregnancy should be seen by ultrasound. 
  • Abnormal gestation or embryonic demise if:
    • Gestational sac > 10 mm without a yolk sac
    • Gestational sac > 18 mm without a fetal pole
    • Fetal pole > 5 mm without cardiac activity
  • If the B-HCG is > 1500 and no GS is seen
    • Ectopic pregnancy
    • Completed abortion
  • If the B-HCG is < 1500 and the uterus is empty
    • Early normal pregnancy
    • Ectopic pregnancy
    • Completed abortion
  • Serial B-HCG value in 48 hours
    • Live IUP: doubles
    • Completed abortion: decreases
    • Ectopic pregnancy: stable or small rise

TREATMENT

Secondary Survey
Check for fetal heart tone

Fetal heart tone ABSENT

Fetal heart tone PRESENT
   ↓
Maternal treatment only;

No fetal resuscitation

Estimate gestational age (history, fundal height, Leopold’s maneuvers, ultrasonography)

< 20 weeks of gestation

> 20 Weeks of Gestation
Document fetal heart tone

No fetal resuscitation
    Electronic fetal monitoring x4 hrs
• Vaginal bleeding
• SROM
• FH tone abnormality
• Uterine contractions for > 4 hrs
• High-risk mechanism of injury
• Uterine tenderness
• Abdominal pain
• Maternal anesthesia
YES  →
EFM for 24 hours, intervene if needed for NRFHR tracing.

 
NO  → D/C monitoring and discharge to home, return to L&D if:
• Vaginal bleeding
• Decreased fetal movement
• Loss of fluid vaginally
• Repetitive uterine contractions
• Abdominal pain or tenderness

 

 

Clinical Pearls:
  • Consider abuse in injured pregnant patients, particularly those with abdominal injury who report a fall.
  • Fetal viability:
    • 24 weeks gestation, dome of uterus above umbilicus
  • A PCO2 of 40 mmHg during the latter half of pregnancy suggests hypoventilation