General considerations

General considerations

1. Pregnancy must always be suspected in any female trauma patient of childbearing age (see Chapter 32 for management of the pregnant patient). All pregnant women greater than 24 weeks of gestation should have cardiotocographic monitoring for a minimum of 4 to 6 hours.
2. Kleihauer-Betke analysis helps in determining the amount of fetomaternal hemorrhage and should be performed. Volume replacement is preferable to vasopressor administration to support blood pressure. O-negative blood should be transfused in a Rh-negative pregnant patient until cross-matched blood becomes available. Fetomaternal hemorrhage in an Rh-negative patient warrants Rh immunoglobulin therapy.
3. Because the fetus depends on its mother for oxygen, an uninterrupted supply of oxygenated blood must be provided to the fetus at all times. The resuscitation of the fetus thus depends on the optimum resuscitation of the mother. The uterus remains an intrapelvic organ until the 12th week of gestation and reaches the umbilicus by 20 weeks. Compression of the vena cava by the gravid uterus after 20 weeks of gestation reduces venous return to the heart, thereby decreasing cardiac output and exacerbating shock. The pregnant patient should be transported and evaluated with left uterine displacement.
4. If intubation is necessary, a rapid sequence induction is recommended with a smaller-sized endotracheal tube and use of cricoid pressure. Advanced airway equipment (video laryngoscope, fiberoptic bronchoscope) should be readily available in anticipation of a difficult airway. Placement of a nasal or orogastric tube prior to induction of anesthesia should be considered to decompress the patient’s stomach and reduce the risk of aspiration.
5. Although diagnostic irradiation poses a risk to the fetus, necessary radiographic studies should always be obtained. Consultation with a radiologist may be obtained for estimation of the total radiation dose to the fetus if multiple diagnostic imaging studies with ionizing radiation have been obtained.
6. If the amniotic fluid gains access to the intravascular space, it can be a source of amniotic fluid embolism and resultant disseminated intravascular coagulation.