What is the appropriate ER workup for a pregnant woman in her 3rd trimester who has experienced an assault and fall?

From the Guidelines

The appropriate ER workup for a pregnant woman in her 3rd trimester who has experienced an assault and fall should prioritize both maternal and fetal well-being, with a focus on identifying potential complications such as placental abruption, preterm labor, and fetal distress. The initial assessment should include vital signs, physical examination focusing on trauma-related injuries, and evaluation for vaginal bleeding or fluid leakage, as recommended by the American College of Radiology 1. Fetal monitoring with electronic fetal heart rate monitoring should be initiated promptly and continued for at least 4-6 hours, even if the initial assessment appears normal.

Some key considerations in the ER workup include:

• Laboratory tests such as complete blood count, blood type and Rh status, coagulation profile, and urinalysis to check for hematuria or proteinuria
• Imaging studies, including focused abdominal ultrasound to assess fetal heart rate, placental integrity, and amniotic fluid volume, as well as transvaginal US to evaluate the cervix and potential placental abruption 1
• Administration of Rh immunoglobulin (RhoGAM) 300 mcg IM if the mother is Rh-negative to prevent alloimmunization
• Observation for at least 4-6 hours, with extended monitoring or admission if there are concerning findings such as contractions, decreased fetal movement, or signs of placental abruption

It is essential to note that the outcome of pregnancies with trauma in the second and third trimesters depends on the precise etiology of the injury, and imaging, particularly with ultrasound (US), is the mainstay for making accurate diagnoses and for emergent guidance of management 1. The patient's care should be individualized, taking into account the severity of the trauma, the presence of any complications, and the patient's overall health status.

From the Research

ER Workup for Pregnant Women in 3rd Trimester After Assault and Fall

• The primary survey for a pregnant woman in her 3rd trimester who has experienced an assault and fall should include consideration of the patient as pregnant until proven otherwise by a definitive pregnancy test or ultrasound scan 2.
• A nasogastric tube should be inserted in a semiconscious or unconscious injured pregnant woman to prevent aspiration of acidic gastric content, and oxygen supplementation should be given to maintain maternal oxygen saturation > 95% to ensure adequate fetal oxygenation 2.
• Two large bore intravenous lines should be placed in a seriously injured pregnant woman, and vasopressors should be used only for intractable hypotension that is unresponsive to fluid resuscitation due to their adverse effect on uteroplacental perfusion 2.

Fetal Assessment and Monitoring

• All pregnant trauma patients with a viable pregnancy (≥ 23 weeks) should undergo electronic fetal monitoring for at least 4 hours 2.
• Pregnant trauma patients (≥ 23 weeks) with adverse factors, including uterine tenderness, significant abdominal pain, vaginal bleeding, sustained contractions, rupture of the membranes, atypical or abnormal fetal heart rate pattern, high-risk mechanism of injury, or serum fibrinogen < 200 mg/dL, should be admitted for observation for 24 hours 2.
• Fetal ultrasound and external fetal monitoring are more useful in detecting fetal or pregnancy-associated complications after blunt injury than the Kleihauer-Betke test 3.

Special Considerations

• The abdominal portion of military anti-shock trousers should not be inflated on a pregnant woman because this may reduce placental perfusion 2.
• Transfer or transport to a maternity facility is advocated when injuries are neither life- nor limb-threatening and the fetus is viable (≥ 23 weeks), and to the emergency room when the fetus is under 23 weeks' gestational age or considered to be non-viable 2.
• Every woman who sustains trauma should be questioned specifically about domestic or intimate partner violence 2.

Trauma Severity and Outcome

• Trauma during pregnancy is associated with both immediate and long-term adverse pregnancy outcomes, including preterm labor, placental abruption, and perinatal morbidity 4.
• Increased trauma severity (ISS ≥ 5) and the need for laparotomy during the trauma hospitalization are independently associated with long-term adverse pregnancy outcome 4.
• Women who experience trauma should be followed more closely throughout pregnancy 4.