CT scanning appears to be the best noninvasive method for evaluating certain internal injuries. Emergency departments should consider preparing guidelines with trauma specialists for a smooth approach, especially regarding CT abdomen/pelvis. Generally consent is not needed for most ED imaging, including a trauma pan scan (head, c-spine, chest, abdomen/pelvis). However, it is prudent to have a form template prepared jointly by emergency medicine and radiology departments for higher dose CT, if the estimated dose is greater than 5,000 mrad and if contrast agents are used.

MRI.⁷ MRI may be required for certain trauma, such as spinal cord injuries. Generally it is considered safe in pregnancy. Paramagnetic contrast agents have not been studied in pregnant women. Use of these agents in pregnancy should be based on risk-benefit analysis with consultation from appropriate specialists.

Management

This section will not cover overall details of trauma management, but will focus on aspects that are unique to the pregnant trauma victim. Advanced Trauma Life Support principles will generally apply.⁸

Maternal stabilization is the priority. After the mother is stabilized, attention is given to the fetus. Maternal physiologic changes may delay signs of shock. Therefore, close attention to urinary output and fetal heart tracing pattern may give an earlier warning of impending maternal cardiovascular collapse, rather than just monitoring maternal pulse and BP alone.

Position

If possible, place any patient over 24 weeks (or fundus 4 centimeters above the umbilicus) in left lateral decubitus position to avoid hypotension from uterine inferior vena caval compression. Turn the patient to the left side with her back angled 15-30 degrees from left lateral position. If the patient is on a backboard, tilt it leftward; alternatively, the uterus can be displaced to the left by placing a wedge under the right side. A patient with unstable BP and questionable c-spine status, not on a backboard, should be log-rolled with her neck stabilized or the uterus can be displaced to the left. Right lateral decubitus is an acceptable alternative.⁹

Airway, Oxygen and RSI

To avoid fetal hypoxia, use high-flow oxygen.

In compromised respiratory settings, pregnant women have an increased tendency toward rapid development of hypoxemia. Anticipate higher potential for regurgitation of gastric contents and aspiration; thus, antiemetics and NG are strong considerations. Failed intubation is more common in pregnancy because of physiologic and anatomical changes that can lead to difficult intubation including: ¹⁰