What is the management for a 30-week gestation patient who fell down steps?

Management of a 30-Week Gestation Patient Who Fell Down Steps

A pregnant patient at 30 weeks who has fallen down steps requires immediate evaluation in the emergency room or trauma unit with priority given to maternal stabilization, followed by continuous fetal monitoring for at least 4 hours, and admission for 24 hours if any concerning features develop. 1

Immediate Triage and Initial Assessment

Transfer the patient to the emergency room or trauma unit regardless of apparent injury severity, as this gestational age requires comprehensive maternal and fetal evaluation. 1 At 30 weeks, the fetus is viable (≥23 weeks), but the severity of trauma from a fall down steps is often initially unclear and warrants full trauma evaluation. 1

Primary Survey Priorities

• Assume pregnancy in any reproductive-age female with significant injuries until proven otherwise. 1 At 30 weeks, this is obvious, but the trauma team must immediately recognize the dual-patient nature of the case.

• Position the patient with left lateral tilt or manual uterine displacement to prevent aortocaval compression, which significantly reduces cardiac output and uteroplacental perfusion after mid-pregnancy. 1 Ensure spinal precautions are maintained if using lateral tilt. 1

• Provide supplemental oxygen to maintain maternal saturation >95% to ensure adequate fetal oxygenation. 1

• Establish two large-bore (14-16 gauge) IV lines for potential fluid resuscitation. 1

• Insert a nasogastric tube if the patient is semiconscious or unconscious to prevent aspiration of acidic gastric contents. 1

Maternal Assessment

Immediate Clinical Evaluation

Look specifically for warning signs that indicate serious complications: 2, 3

• Vaginal bleeding (may indicate placental abruption or other complications) 2, 1
• Regular, painful uterine contractions (preterm labor or abruption) 2, 1
• Severe abdominal pain or uterine tenderness (abruption, uterine rupture) 1
• Persistent loss of fluid from vagina (rupture of membranes) 2
• Severe headache, visual disturbances, or right upper quadrant pain (pre-eclampsia/HELLP syndrome) 3
• Measure blood pressure urgently - even modest elevations may cause significant symptoms and indicate pre-eclampsia. 3

Diagnostic Studies

Do not defer or delay indicated radiographic studies, including abdominal CT, due to concerns about fetal radiation exposure. 1 Maternal assessment takes priority, and the radiation risk to the fetus is minimal compared to missing serious maternal injuries.

• Obtain routine trauma labs plus coagulation panel including fibrinogen. 1 Fibrinogen <200 mg/dL is a concerning marker for placental abruption and warrants 24-hour admission. 1

• Perform focused abdominal sonography for trauma (FAST) to detect intraperitoneal bleeding. 1

• Consider abdominal CT as an alternative to diagnostic peritoneal lavage when intra-abdominal bleeding is suspected. 1

• Defer speculum or digital vaginal examination until placenta previa is excluded by ultrasound if vaginal bleeding is present. 1

Fetal Assessment

Continuous Fetal Monitoring

All pregnant trauma patients with viable pregnancy (≥23 weeks) require electronic fetal monitoring for at least 4 hours. 1 At 30 weeks, this is mandatory regardless of apparent injury severity.

Admit for 24-hour observation if ANY of the following adverse factors are present: 1

• Uterine tenderness
• Significant abdominal pain
• Vaginal bleeding
• Sustained contractions (>1 per 10 minutes)
• Rupture of membranes
• Atypical or abnormal fetal heart rate pattern
• High-risk mechanism of injury (falling down steps qualifies)
• Serum fibrinogen <200 mg/dL

Obstetrical Ultrasound

Perform urgent obstetrical ultrasound to: 1

• Confirm gestational age if undetermined and delivery may be needed
• Assess fetal well-being, position, and amniotic fluid
• Evaluate for placental abruption (though ultrasound has poor sensitivity for this diagnosis)

All patients admitted for monitoring >4 hours should have obstetrical ultrasound prior to discharge. 1

Critical Obstetrical Complications to Recognize

Placental Abruption

Do not delay management of suspected placental abruption while awaiting ultrasound confirmation, as ultrasound is not sensitive for this diagnosis. 1 Clinical signs include:

• Vaginal bleeding (may be absent with concealed abruption)
• Abdominal pain and uterine tenderness
• Uterine contractions
• Abnormal fetal heart rate patterns
• Coagulopathy (low fibrinogen)

At 30 weeks with confirmed abruption and fetal distress, immediate delivery is indicated. 3, 4 Neonatal survival at 30 weeks is approximately 92%, with cerebral palsy risk of 6.3%. 5

Preterm Labor

Falls can trigger preterm labor through direct trauma or stress response. 1 Regular uterine contractions warrant urgent obstetrical consultation. 1

If preterm delivery appears imminent within 7 days, administer corticosteroids immediately for fetal lung maturity - do not delay while awaiting definitive diagnosis. 3 At 30 weeks, corticosteroids significantly reduce respiratory distress syndrome (which occurs in 43.8% of infants at this gestational age without steroids). 5

Uterine Rupture

Though rare, traumatic uterine rupture is catastrophic. Suspect with severe abdominal pain, abnormal fetal heart rate, and hemodynamic instability. Urgent obstetrical consultation and likely emergency cesarean delivery are required. 1

Rh Status Management

Administer anti-D immunoglobulin to all Rh-negative pregnant trauma patients. 1 This must be given regardless of apparent injury severity, as even minor trauma can cause fetomaternal hemorrhage.

Perform Kleihauer-Betke test or equivalent to quantify fetomaternal hemorrhage and determine if additional doses of anti-D immunoglobulin are needed beyond the standard 300 mcg dose. 1

Disposition Decisions

Discharge Criteria (After Minimum 4 Hours Monitoring)

Patient may be discharged if ALL of the following are met:

• No adverse factors listed above
• Normal fetal heart rate pattern throughout monitoring period
• No uterine contractions or <1 per 10 minutes
• No vaginal bleeding
• Normal fibrinogen level
• Obstetrical ultrasound completed and reassuring
• Rh immunoglobulin administered if indicated

Admission Criteria

Admit for 24-hour observation if any adverse factors are present. 1 Given that falling down steps is a high-risk mechanism of injury, most patients will meet admission criteria.

Delivery Considerations at 30 Weeks

If maternal or fetal condition deteriorates requiring delivery at 30 weeks: 2, 5

• Neonatal survival is approximately 92% 5
• In-hospital mortality is 8.1% 5
• Respiratory distress syndrome occurs in 43.8% 5
• Cerebral palsy risk at 5 years is 6.3% 5
• Cognitive impairment risk at 5 years is 35.3% 5

Mode of delivery should be determined by standard obstetrical indications. 1 Cesarean section is indicated for fetal distress with irreversible causes (major abruption, cord prolapse with sustained bradycardia) or maternal instability. 4

Common Pitfalls to Avoid

• Do not assume minor trauma means minor risk. Falls during pregnancy alter postural balance and can cause significant complications even without obvious external injury. 6

• Do not discharge after brief evaluation. The minimum 4-hour monitoring period is essential, as placental abruption can manifest hours after initial trauma. 1

• Do not position the patient flat supine. This causes aortocaval compression and reduces uteroplacental perfusion. 1

• Do not withhold indicated imaging. Maternal assessment takes priority, and radiation exposure from necessary studies poses minimal fetal risk. 1

• Do not forget Rh immunoglobulin. This must be administered to all Rh-negative patients regardless of injury severity. 1