Electronic fetal heart and uterine monitoring in pregnant trauma patients after 20 weeks gestation may detect placental abruption. Multiple studies have shown that placental abruption was not seen if less than 6 contractions per hour over a 4-hour period of observation, and no uterine tenderness.

Eclamptic Seizures (Acute or Impending). If eclampsia is a concern in the trauma patient, it is best treated with magnesium sulfate.¹⁵

Tetanus Booster. If indicated, tetanus or tetanus-diphtheria booster is safe to administer.¹⁶

Antibiotics. Usual antibiotics for open wounds are generally safe for pregnant women; e.g., ceftriaxone or, if cephalosporin allergic, clindamycin.

Anesthesia. There are no problems with local anesthesia.

Analgesia.¹⁷ Acute trauma pain control with narcotics can be given in any trimester as required to provide comfort to the injured mother. Communicate doses and times to OB so the effect on the fetus can be anticipated if delivered while medications are in the system.

Rh immune globulin (RhIG): 40% of trauma victims will have fetal-maternal bleed. All Rh-negative trauma victims should be considered for 1 vial of RhIG (300 ug IM), which will provide complete protection for most of these patients. Even with negative Kleihauer-Betke (KB) test, these patients may become sensitized, as the test may not have adequate sensitivity to detect very small quantities of fetal blood. It should be given as soon as possible, and within 72 hours of the accident.

The use of additional RhIG should be discussed with an OB consultant and is based on initial and serial KB tests.¹⁸

Vaginal Bleeding¹⁹

Vaginal bleeding indicates a potentially fatal condition, although timely and proper treatment can prevent adverse outcomes. Massive, continuing vaginal bleeding may require emergency Cesarean delivery. Treat heavy vaginal bleeding as you would for hypovolemic shock. Arrange transfer if appropriate and condition allows.

When vaginal bleeding is not severe enough to require immediate C-section but occurs in the late 2nd trimester or 3rd trimester, rule out placental abruption. Diagnosis is supported by the presence of abdominal pain and tenderness, uterine contractions, or fetal heart rate abnormalities. Although an ultrasound exam may show retro-placental clot if an abruption occurs, a normal ultrasound exam does not exclude the diagnosis. If vaginal bleeding is associated with placenta previa, as established by ultrasound, the patient needs to be hospitalized.

Fetal Death

If the mother’s condition is stable, Cesarean delivery is not required in the event of fetal death. Method and timing of delivery can be planned with the OB consultant. If a laparotomy will be performed anyway, the OB should be notified immediately. Cesarean delivery is probably still not indicated, but might be if it is critical to prevent labor or vaginal delivery (e.g., pelvic fractures) or to control bleeding from uterine injury. An obstetrician should make these decisions.