What is the management approach for a 37-week pregnant patient who has fallen and is experiencing pain?

Management of a 37-Week Pregnant Patient Who Fell and Has Pain

A 37-week pregnant patient who has fallen requires immediate assessment for placental abruption and preeclampsia, with continuous fetal monitoring for at least 4 hours and 24-hour admission if any adverse factors are present. 1, 2

Immediate Triage Assessment

Maternal vital signs and warning symptoms must be evaluated urgently:

• Measure blood pressure immediately to exclude hypertensive disorders, as preeclampsia can present at term and requires immediate delivery at ≥37 weeks gestation 3, 4
• Check for vaginal bleeding, which may indicate placental abruption—the most critical obstetrical complication following trauma 1, 2
• Assess for regular, painful uterine contractions and uterine tenderness, as these are warning signs of serious complications 3, 1
• Evaluate for severe abdominal pain or right upper quadrant pain, which may indicate abruption or preeclampsia with severe features 4, 1
• Document mechanism of injury (height of fall, surface landed on, direct abdominal impact) as high-risk mechanisms warrant extended observation 2

Laboratory and Diagnostic Workup

Specific tests are required to identify occult complications:

• Obtain serum fibrinogen level—a level <200 mg/dL is a concerning marker for placental abruption and mandates 24-hour admission 1, 2
• Complete coagulation panel including platelet count, as coagulopathy suggests abruption 2
• Rh status determination for all patients, as anti-D immunoglobulin must be given to Rh-negative patients within 72 hours 2
• Kleihauer-Betke testing for Rh-negative patients to quantify fetomaternal hemorrhage and determine additional anti-D immunoglobulin dosing 2

Fetal Monitoring Protocol

All viable pregnancies (≥23 weeks, but especially at 37 weeks) require electronic fetal monitoring:

• Initiate continuous fetal heart rate monitoring for at least 4 hours following trauma 1, 2, 5
• Monitor for uterine contractions, as frequent contractions (>1 per 10 minutes) indicate need for extended observation 2
• Perform obstetrical ultrasound to assess fetal well-being, amniotic fluid volume, and placental location before discharge 2

Admission Criteria (24-Hour Observation Required)

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

• Uterine tenderness or significant abdominal pain 1, 2
• Vaginal bleeding of any amount 1, 2
• Sustained uterine contractions (>1 per 10 minutes) 1, 2
• Rupture of membranes or persistent fluid leakage 3, 2
• Atypical or abnormal fetal heart rate pattern 1, 2
• High-risk mechanism of injury 1, 2
• Serum fibrinogen <200 mg/dL 1, 2

Management of Placental Abruption (If Suspected)

Placental abruption is the most dangerous complication and requires immediate action:

• Do not delay management pending ultrasound confirmation, as ultrasound has poor sensitivity for diagnosing abruption 2
• Clinical signs include: vaginal bleeding, abdominal pain with uterine tenderness, frequent contractions, abnormal fetal heart rate patterns, and coagulopathy (low fibrinogen) 1
• Obtain urgent obstetrical consultation and prepare for emergency cesarean delivery if fetal distress or maternal instability develops 1, 2
• At 37 weeks gestation, delivery is indicated regardless of abruption severity given term status 3

Preeclampsia Evaluation

Falls can trigger or unmask preeclampsia, which requires immediate delivery at 37 weeks:

• If blood pressure ≥140/90 mmHg, check for proteinuria and assess for severe features (headache, visual changes, right upper quadrant pain) 3, 4
• If preeclampsia is confirmed at 37 weeks, proceed with delivery regardless of severity, as all cases can rapidly progress to emergencies 3, 4
• Administer magnesium sulfate for seizure prophylaxis if severe features are present (BP ≥160/110 mmHg or symptoms) 3
• Do not assume normal vital signs exclude preeclampsia, as serious organ dysfunction can develop at relatively mild hypertension levels 3, 4

Discharge Criteria (If Monitoring is Reassuring)

Patients may be discharged after 4 hours if ALL of the following are met:

• No vaginal bleeding 2
• No uterine tenderness or significant abdominal pain 2
• Fewer than 1 contraction per 10 minutes 2
• Normal fetal heart rate pattern throughout monitoring 2, 5
• Fibrinogen ≥200 mg/dL 1
• Normal blood pressure (<140/90 mmHg) 3, 4
• Reassuring ultrasound findings 2

Provide discharge instructions to return immediately for: vaginal bleeding, regular contractions, severe abdominal pain, decreased fetal movement, persistent headache, or visual changes 3, 2

Critical Pitfalls to Avoid

• Never assume minor trauma is benign—placental abruption can occur with seemingly minor falls and may present hours after injury 2, 6
• Do not rely on Kleihauer-Betke testing to guide management of Rh-positive patients, as it rarely affects clinical decisions beyond Rh immunoglobulin dosing 2, 5
• Avoid discharging patients before 4 hours of monitoring, as adverse outcomes can evolve during this period 2, 5
• Do not perform digital vaginal examination if vaginal bleeding is present until placenta previa is excluded by ultrasound 2
• Recognize that normal early monitoring does not guarantee safety—repetitive assessment over 24 hours is needed when adverse factors are present 2