Q&A: Abdominal trauma in the third trimester

Women's Health -> Q&A

MBBS(Hons), BaBioMedSc. CSO RAN, DRANZCOG adv, FRANZCOG trainee

This article is 3 years old and may no longer reflect current clinical practice.

For the broader O&G Magazine readership, Q&A seeks balanced answers to those curly-yet-common questions in obstetrics and gynaecology.

How would you assess and manage the patient who presents with abdominal trauma in the third trimester?

Trauma is the leading non-obstetric cause of maternal mortality and morbidity, occurring in 8% of all pregnancies. Motor vehicle accidents (MVA) are the most commonly reported abdominal trauma. Fetal injury resulting from trauma can be classified as direct or indirect (Table 1). Direct trauma can attribute to fractures of the spine and skull, haemorrhage from injury to extremities or intracranial haemorrhage and organ ruptures. Direct trauma can compromise maternal physiology. Indirect trauma in this table is defined as trauma that has occurred secondary to the direct trauma. Fetal compromise can be present without obvious maternal injury

Abdominal trauma needs immediate evaluation to determine the severity of the trauma. Minor trauma accounts for 90% of the trauma presentations and 25% of the fetal deaths from abdominal trauma in third trimester. 10% are considered major with only 2% requiring surgical intervention.

Primary obstetric survey should be conducted on presentation with escalation to consultants as required. All hospitals should have effective triage systems allowing rapid detection of irregular observations with escalation protocols. All staff should understand the physiological changes of pregnancy – cardiovascular, haematologic, respiratory and gastrointestinal – in order to provide a systematic evaluation, as the severity of maternal injury directly relates to fetal compromise.

Always remember there are two patients: maternal and fetal. Remember that maternal resuscitation is paramount and needs to be first priority. A multidisciplinary team approach for primary survey has shown better maternal and fetal outcomes. Rapid maternal resuscitation ultimately reduces risk to the fetus. As pregnancy progresses, the associated physiological changes become more significant and the abdominal anatomy becomes distorted. A patient could lose up to 30% of total volume prior to any signs of shock. Serious maternal injury may indicate the need for perimortem caesarean; if needed this must be acted upon quickly.

Table 1. Causes of third trimester abdominal trauma.

Direct	Indirect (resulting from direct trauma)
Motor vehicle accidents Domestic violence Penetrating trauma Mild blunt trauma Falls Suicide Self harm Burns Toxic exposure Maternal physiological change Aneurysm Ruptured liver or spleen Intercranial or limb injury causing fetal compromise	Placenta abruption, mainly from MVA (Rapid deceleration and incorrect seatbelt use) Preterm labour Uterine rupture (rare: 0.6%)

Management at the primary survey

Management is determined on the mechanism of injury and clinical findings. Primary survey allows immediate management of life-threatening abdominal trauma via resuscitation and surgical intervention as needed.

Once patient stable, secondary survey is mandatory to determine obstetric and non-obstetric injuries, the level of assessment, and investigations needed for further management.

Primary obstetric survey

Perimortem caesarean

DR ABC E TILT

Danger
Response
Airway
Breathing
Circulation
Environment
TILT– left lateral tilt

Uterine displacement as alternative to TILT when cardiac compressions, intubation are required.
?? Perimortem caesarean

Indicated – maternal cardiac arrest.
Gravid uterus above umbilicus or >20 weeks
Up to 30 mins after cardiac arrest commenced.
Lie patient supine – increases effective cardiac compressions.
Removes pressure for IVC/aorta
Decrease preload
Improves lung volume compliance
Reduces maternal oxygen demand
Increased chance of maternal and fetal survival

Secondary survey

Firstly, determine the mechanism of Injury and obtain a full antenatal history followed by a full evaluation of maternal and fetal condition, keeping in mind the differential diagnosis of third trimester abdominal trauma.

Vitals

Blood pressure, pulse, temperature, pain, oxygen saturations, ECG.

Remember to consider the physiological changes of third trimester.

Bloods

FBC, Group and hold, LFT. Coags, kleihauer-Betke,Lipase Coags + ROTEM ( Rapid assessment of clotting) urine.
Positive Keilhauer-Betke indicates fetal-maternal haemorrhage. Remember that anti-D should be given to all Rh-negative mothers in third trimester. Continue regular monitoring.

CTG

It is recommended that a minimum of four hours of CGT monitoring be conducted for all presentations with third trimester abdominal trauma. Placenta abruption can occur over time; therefore, CTG may be indicated up to 24 hours post injury. If CTG is abnormal, consider immediate delivery. If labour has commenced, do not treat with tocolytics. If preterm, treat with Betamethasone, magnesium sulphate. If necessary, transfer to a secondary or tertiary centre

Examination should be done with consent and chaperone if possible.

Abdominal palpation

Look for tenderness, contractions, rigidity, injury. Bruising. Seat belt marks. Always look for evidence of domestic violence.

Speculum

Check for vaginal bleeding, evidence of trauma or sexual assault, determine cervical dilatation and perform high vaginal and low vaginal swabs, wound swabs, amnisure and fetal fibronectin, depending on the clinical scenario.

Vaginal examination

Conduct only when necessary and rarely for preterm presentations. Do not perform unless you have checked ultrasound scans for vasa praevia, placenta praevia.
Vaginal bleeding and/or uterine tenderness can indicate abruption, especially in trauma cases.

Imaging

Ultrasounds, CT scans and MRI should be done as indicated. Informed consent should be sought In acute cases. Imaging should be priority while awaiting lab results. A follow-up ultrasound should be done within two weeks on all trauma obstetric patients needing admission.

Management

Management is determined upon history and examination findings as well as clinical expertise and available resources. If delivery is needed and is not urgent, consider the gestational age. If <34 weeks, give Betamethasone 11.4 IU, 12–24 hours apart, with escalation to consultant, theatre, anaesthetics, paediatrics, ICU, as required. Consider delivery vaginal or LUSCS, consider need for transfer, consider stability of the patient. If delivery is not urgent, determine outpatient verses inpatient management and the timing of future monitoring such as antenatal visits, ultrasounds, repeat bloods and delivery. Remember to escalate as situations change and always document everything.