What should be done if a 37-week pregnant woman falls on her stomach?

Immediate Medical Evaluation Required After Abdominal Fall at 37 Weeks

A 37-week pregnant woman who falls on her stomach requires immediate medical evaluation with continuous fetal monitoring for at least 4 hours, regardless of whether she feels symptoms, as serious complications like placental abruption can occur without obvious signs. 1, 2

Initial Assessment and Monitoring

Immediate Actions

• Transfer to labor and delivery unit or emergency department immediately for evaluation, as even seemingly minor abdominal trauma can result in adverse fetal and maternal outcomes 1, 2
• Begin continuous electronic fetal heart rate monitoring for a minimum of 4 hours to detect signs of fetal distress or placental abruption [1, @20@]
• Assess maternal vital signs with particular attention to blood pressure (≥140/90 mmHg) to exclude preeclampsia, which can be triggered by trauma and requires immediate delivery at 37 weeks 3, 4

Critical Warning Signs Requiring Extended Monitoring

The following findings mandate 24-hour hospital admission and observation rather than discharge after 4 hours 1:

• Uterine tenderness or significant abdominal pain 1
• Vaginal bleeding of any amount 1
• Sustained uterine contractions (>1 per 10 minutes) 1
• Rupture of membranes or persistent fluid leakage 5, 1
• Atypical or abnormal fetal heart rate patterns 1
• Serum fibrinogen <200 mg/dL (indicating possible placental abruption) 1

Maternal Evaluation

Physical Examination Priorities

• Assess for signs of internal hemorrhage including hypotension, tachycardia, or altered mental status 1, 2
• Examine abdomen for tenderness, rigidity, or uterine contractions 1, 6
• Perform speculum examination only after ultrasound excludes placenta previa if vaginal bleeding is present 1
• Check for signs of severe preeclampsia including severe headache, visual disturbances, or right upper quadrant pain 3, 4

Laboratory and Imaging Studies

• Obtain complete blood count, coagulation panel including fibrinogen, liver enzymes, and creatinine [1, @17@]
• Do not delay indicated radiographic studies including CT imaging due to fetal radiation concerns—maternal benefit outweighs theoretical fetal risks 1
• Perform focused abdominal sonography for trauma (FAST) to detect intraperitoneal bleeding, though negative results do not exclude injury 1, 2
• Obtain obstetrical ultrasound to assess fetal well-being, amniotic fluid volume, and placental location before discharge 1

Fetal Assessment

Monitoring Duration and Interpretation

• Continue cardiotocographic monitoring for at least 4 hours even if the patient appears asymptomatic 1, 2
• Ultrasound is not sensitive for diagnosing placental abruption—do not delay management if clinical suspicion exists based on vaginal bleeding, abdominal pain, or abnormal fetal heart rate patterns 1
• Extend monitoring beyond 4 hours if any concerning features develop during observation 1

Rh Status Management

• Administer anti-D immunoglobulin (RhoGAM) to all Rh-negative pregnant women after trauma [1, @22@]
• Perform Kleihauer-Betke test or equivalent to quantify maternal-fetal hemorrhage and determine need for additional anti-D immunoglobulin doses [1, @23@]

Life-Threatening Complications

Placental Abruption

• Most dangerous complication following abdominal trauma, occurring in 1-5% of minor trauma and up to 50% of major trauma cases 2, 6
• Classic triad: vaginal bleeding, abdominal pain, and uterine contractions—but all three may not be present 6
• Falling fibrinogen levels (<200 mg/dL) suggest significant abruption 1
• Requires urgent obstetrical consultation and likely immediate delivery at 37 weeks 1, 6

Uterine Rupture

• Rare but catastrophic complication presenting with severe abdominal pain, vaginal bleeding, loss of fetal heart tones, and maternal shock 2, 6
• Requires emergency cesarean delivery and surgical repair 2, 6

Common Pitfalls to Avoid

• Never assume the patient is fine based on lack of immediate symptoms—placental abruption can develop hours after trauma 1, 2
• Do not discharge before 4 hours of monitoring even if initial assessment appears reassuring 1
• Do not rely on ultrasound to exclude placental abruption—clinical judgment and monitoring are more sensitive 1
• Do not withhold necessary CT imaging due to radiation concerns when maternal assessment requires it 1
• At 37 weeks gestation, immediate delivery is indicated if preeclampsia is diagnosed, regardless of severity 7, 3

Disposition Decision Algorithm

Discharge after 4 hours if ALL of the following are met 1:

• No uterine contractions or <1 per 10 minutes
• No vaginal bleeding
• No abdominal tenderness
• Reassuring fetal heart rate pattern throughout monitoring
• Normal maternal vital signs
• Normal fibrinogen level
• Rh immunoglobulin administered if indicated

Admit for 24-hour observation if ANY concerning feature present 1

Proceed to immediate delivery if 7, 1:

• Placental abruption confirmed or strongly suspected
• Uterine rupture
• Non-reassuring fetal status
• Preeclampsia diagnosed (at 37 weeks, immediate delivery indicated)
• Maternal hemodynamic instability