Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 12 n Trauma in Pregnancy and Intimate Partner Violence
A B C
n FIGURE 12-6 Abruptio placentae. A. In abruptio placentae, the placenta detaches from the uterus. B. Axial and C. Coronal sections of the
abdomen and pelvis, demonstrating abruptio placentae.
In most cases of abruptio placentae and uterine
rupture, the patient reports abdominal pain or
cramping. Signs of hypovolemia can accompany each
of these injuries.
Initial fetal heart tones can be auscultated with
Doppler ultrasound by 10 weeks of gestation. Perform
continuous fetal monitoring with a tocodynamometer
beyond 20 to 24 weeks of gestation. Patients with
no risk factors for fetal loss should have continuous
monitoring for 6 hours, whereas patients with risk
factors for fetal loss or placental abruption should be
monitored for 24 hours. The risk factors are maternal
heart rate > 110, an Injury Severity Score (ISS) > 9,
evidence of placental abruption, fetal heart rate > 160
or < 120, ejection during a motor vehicle crash, and
motorcycle or pedestrian collisions.
Adjuncts to Primary Survey with
Resuscitation
Mother
If possible, the patient should be monitored on her left
side after physical examination. Monitor the patient’s
fluid status to maintain the relative hypervolemia
required in pregnancy, as well as pulse oximetry and
arterial blood gas determinations. Recognize that
maternal bicarbonate normally is low during pregnancy
to compensate for respiratory alkalosis.
Fetus
Obtain obstetrical consultation, since fetal distress can
occur at any time and without warning. Fetal heart rate
is a sensitive indicator of both maternal blood volume
status and fetal well-being. Fetal heart tones should
be monitored in every injured pregnant woman. The
normal range for fetal heart rate is 120 to 160 beats
per minute. An abnormal fetal heart rate, repetitive
decelerations, absence of accelerations or beat-to-beat
variability, and frequent uterine activity can be signs of
impending maternal and/or fetal decompensation (e.g.,
hypoxia and/or acidosis) and should prompt immediate
obstetrical consultation. If obstetrical services are not
available, arrange transfer to a trauma center with
obstetrical capability.
Perform any indicated radiographic studies because
the benefits certainly outweigh the potential risk to
the fetus.
Secondary Survey
During the maternal secondary survey, follow the
same pattern as for nonpregnant patients, as outlined
in Chapter 1: Initial Assessment and Management.
Indications for abdominal computed tomography,
focused assessment with sonography for trauma
(FAST), and diagnostic peritoneal lavage (DPL) are
also the same. However, if DPL is performed, place the
catheter above the umbilicus using the open technique.
Be alert to the presence of uterine contractions, which
suggest early labor, and tetanic contractions, which
suggest placental abruption.
Evaluation of the perineum includes a formal pelvic
examination, ideally performed by a clinician skilled
in obstetrical care. The presence of amniotic fluid
in the vagina, evidenced by a pH of greater than 4.5,
suggests ruptured chorioamniotic membranes. Note
the cervical effacement and dilation, fetal presentation,
and relationship of the fetal presenting part to the
ischial spines.
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