Treatment of Pregnant Women Involved in Car Accidents
The management of pregnant women involved in car accidents requires immediate assessment for both maternal and fetal injuries, with priorities including maternal stabilization, left lateral uterine displacement to prevent aortocaval compression, and consideration of perimortem cesarean delivery in severe cases. 1
Initial Assessment and Stabilization
- Maternal stabilization always takes priority as fetal survival depends on maternal well-being 1
- Perform systematic trauma assessment with consideration of pregnancy-specific anatomical and physiological changes 1
- For pregnant women beyond 20 weeks gestation, perform left lateral uterine displacement (manually or with a wedge) to relieve aortocaval compression during assessment and resuscitation 1
- Pregnant patients are more prone to hypoxia due to decreased functional residual capacity and increased oxygen demand; prioritize oxygenation and airway management 1
Monitoring and Evaluation
- All pregnant women >20 weeks gestation involved in even minor trauma should receive obstetrical examination by an obstetrician or midwife 1
- For minor trauma, perform 4-24 hours of tocodynamometric monitoring to detect contractions or signs of placental abruption 2
- Consider ultrasonography to evaluate fetal status and rule out placental abruption (high specificity but low sensitivity) 2
- Perform Kleihauer-Betke test after significant trauma to determine degree of fetomaternal hemorrhage, regardless of Rh status 2
Management Based on Trauma Severity
Minor Trauma
- Even minor trauma can result in significant fetal complications; 60-70% of fetal losses occur after minor maternal injuries 2
- Consider administration of anti-D immunoglobulin (50 μg) in Rh-negative patients with minor trauma 1, 3
- Monitor for signs of placental abruption including uterine tenderness, contractions, or vaginal bleeding 1, 2
Major Trauma
- Administer anti-D immunoglobulin to Rh-negative women, with dosage based on estimated fetomaternal hemorrhage 3
- If fetomaternal hemorrhage exceeds 15 mL of red blood cells, calculate additional doses of Rh immune globulin (divide red blood cell volume by 15 mL) 3
- For high-speed accidents (>80 km/h), maintain high suspicion for placental abruption, which is a leading cause of fetal death after trauma 4
Cardiac Arrest Management in Pregnant Trauma Patients
- Provide high-quality CPR with left lateral uterine displacement to relieve aortocaval compression 1
- Position chest compressions slightly higher on the sternum to adjust for elevated diaphragm 1
- If cardiac arrest occurs in a woman with fundal height at or above umbilicus (approximately 20 weeks gestation) and ROSC is not achieved with initial resuscitation:
Special Considerations
- Standard medication dosages for adult resuscitation apply to pregnant patients 1
- Defibrillation can be performed at standard ACLS doses with no modifications needed for pregnancy 1
- For pregnant women who remain comatose after resuscitation from cardiac arrest, targeted temperature management is recommended with continuous fetal monitoring 1
- Recognize that broadside collisions carry higher risk of maternal and fetal complications than frontal collisions 4
Prevention
- Proper seat belt use significantly reduces risk of maternal and fetal injuries 2, 5
- The lap belt should be placed as low as possible under the protuberant portion of the abdomen 2
- The shoulder belt should be positioned between the breasts and over the midportion of the clavicle, off to the side of the uterus 2
Common Pitfalls to Avoid
- Delaying maternal stabilization to focus on fetal assessment 1
- Failing to perform left lateral uterine displacement in pregnant women beyond 20 weeks gestation 1
- Underestimating the significance of minor trauma, which can still result in serious fetal complications 2
- Neglecting to administer anti-D immunoglobulin to Rh-negative women after trauma 1, 3
- Inadequate dosing of anti-D immunoglobulin when significant fetomaternal hemorrhage occurs 3