Guidelines on trauma in pregnancy

Guidelines on trauma in pregnancy have been published by the The Eastern Association for the Surgery of Trauma (EAST):

RECOMMENDATIONS

Level I
There are no level I standards.

Level II

  1. All pregnant women >20-week gestation who suffer trauma should have cardiotocographic monitoring for a minimum of 6 hours. Monitoring should be continued and further evaluation should be carried out if uterine contractions, a nonreassuring fetal heart rate pattern, vaginal bleeding, significant uterine tenderness or irritability, serious maternal injury, or rupture of the amniotic membranes is present.
  2. Kleihauer-Betke analysis should be performed in all pregnant patient > 12 week-gestation.

Level III

  1. The best initial treatment for the fetus is the provision of optimum resuscitation of the mother and the early assessment of the fetus.
  2. All female patients of childbearing age with significant trauma should have a human chorionic gonadotropin (HCG) performed and be shielded for X-rays whenever possible.
  3. Concern about possible effects of high-dose ionizing ra- diation exposure should not prevent medically indicated maternal diagnostic X-ray procedures from being per- formed. During pregnancy, other imaging procedures not associated with ionizing radiation should be considered instead of X-rays when possible.
  4. Exposure <5 rad has not been associated with an increase in fetal anomalies or pregnancy loss and is herein deemed to be safe at any point during the entirety of gestation.
  5. Ultrasonography and magnetic resonance imaging are not associated with known adverse fetal effects. However, until more information is available, magnetic resonance imaging is not recommended for use in the first trimester.
  6. Consultation with a radiologist should be considered for purposes of calculating estimated fetal dose when multiple diagnostic X-rays are performed.
  7. Perimortem cesarean section should be considered in any moribund pregnant woman of ≥24 week gestation.
  8. Delivery in perimortem cesarean sections must occur within 20 minutes of maternal death but should ideally start within 4 minutes of the maternal arrest. Fetal neuro- logic outcome is related to delivery time after maternal death.
  9. Consider keeping the pregnant patient tilted left side down 15 degrees to keep the pregnant uterus off the vena cava and prevent supine hypotension syndrome.
  10. Obstetric consult should be considered in all cases of injury in pregnant patients.

Practice Management Guidelines for the Diagnosis and Management of Injury in the Pregnant Patient: The EAST Practice Management Guidelines Work Group
Journal of Trauma 2010;69(1):211-4
Full text guidelines are available here. They are dated 2005 the recommendations appear to be indistinguishable from those published in the July 2010 issue of Journal of Trauma