Guidelines for Trauma Resuscitation of Pregnant Patients with Estimated Gestational Age > 20 Weeks

• Page HCW OB Trauma Team on Tiger Connect after initial trauma alert
  • OB team notifies trauma team leader upon arrival and waits for clearance to enter bay
• Once patient arrives, shift uterus to left side, or bump under right ride to offload IVC
• Fundus above umbilicus indicates >20 weeks GA
• Proceed with normal trauma algorithm and all stabilization procedures
  • Primary Survey, chest and pelvis X rays, FAST exam, lines and tubes, OR if indicated
• Recommend Low Titer O+ Whole Blood (LTOWB) in critical patients (risk of alloimmunization low vs. benefits of whole blood).  Use pRBC/component therapy in stablepatients
• Once stabilized, OB team cleared to assess fetus
  • OB US – May use trauma US machines, or must bring their own
  • Fetal monitoring – Tocodynamometer and incubator are in T112B, near blanket warmer
  • Pelvic exam
• Pan Scan if indicated
• If emergent C-section required for fetal distress, and maternal FAST negative, may proceed in trauma OR vs. Resus Bay
• C-section cart kept near Trauma OR front desk, incubator in T112B.
• OB nursing must bring all other equipment
• If patient in traumatic arrest, usual ATLS protocol
• Perimortem hysterotomy only to improve resuscitation efforts
• If patient is to remain in Ryder, i.e. trauma admission with fetal monitoring, L&D nurse must remain with patient (trauma nurses don’t do this)
• Only admit to OB if cleared by trauma

Airway:

• Anticipate difficult airway due to edema/weight gain
• RSI meds are safe – Etomidate (0.3mg/kg) and Succinylcholine/Rocuronium (1-1.5mg/kg)
• Greater aspiration risk due to delayed gastric emptying and pressure from gravid uterus

Breathing:

• Place chest tubes higher as diaphragm is displaced cranially
• Maintain Sats>95%, avoid fetal hypoxia

Circulation:

• Shift uterus to left to offload IVC
• Shock may present late due to increased blood volume
• Avoid femoral lines
• Diagnostic peritoneal aspirate should be supra-umbilical
• Increased risk for VTE

Disability

• Seizures – secondary to TBI vs. Pre-eclampsia
• Keppra and TXA are safe

VTE Prophylaxis

• Heparin and Lovenox both safe in pregnancy
• Ppx dose: Lovenox 30mg BID titrated by anti-Xa levels, for >90kg start at 40mg BID
• Pregnancy results in augmented renal clearance —> may need higher doses

Ionizing Radiation

• Average radiation dose is 10-15 mSv for PanScan, average trauma patient cumulative 24h dose is approx. 20mSv
• <50mSv no increased risk to fetus (National Council on Radiation Protection)
• Rec. consultation w/ attending radiologist for interpretation of CT findings in pregnancy

Antibiotics

• Penicillins, cephalosporins, clindamycin, Flagyl & vancomycin all considered safe
• Tetanus vaccine is safe

Pain medication

• Tylenol is drug of choice
• Short term: morphine, fentanyl, Dilaudid are all safe
• Avoid NSAIDs

Sedation

• Fentanyl, Propofol – low dose
• Avoid benzos and ketamine

Feto-maternal Hemorrhage (to be managed by OB)

• Break in placental barrier, mother Rh- and fetus Rh+ causes alloimmunization and maternal anti-Rh antibodies, harm for future pregnancies
• In major trauma, if fetus Rh+ or unknown, RhoGam 300mcg given, covers 30cc fetal blood
• Kleihauer-Betke (KB) Test indicated to determine if more Rhogam needed (“Hgb F by flowcytometry” in Cerner)

Clements TW, Van Gent JM, Menon N, et al. Use of Low-Titer O-Positive Whole Blood in Female Trauma Patients: A Literature Review, Qualitative Multidisciplinary Analysis of Risk/Benefit, and Guidelines for Its Use as a Universal Product in Hemorrhagic Shock. J Am Coll Surg. 2024 Mar 1;238(3):347-357.

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McCollough CH, Schueler BA, Atwell TD, et al. Radiation exposure and pregnancy: when should we be concerned? Radiographics. 2007 Jul-Aug;27(4):909-17.

Duhl AJ, Paidas MJ, Ural SH, et al; Pregnancy and Thrombosis Working Group. Antithrombotic therapy and pregnancy: consensus report and recommendations for prevention and treatment of venous thromboembolism and adverse pregnancy outcomes. Am J Obstet Gynecol. 2007;197(5):457.e1–457.e21.

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Krywko DM, Yarrarapu SNS, Shunkwiler SM. Kleihauer Betke Test. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430876/