TRAUMA AND PREGNANCY

Trauma and/or accidental injury complicates 6-7% of all pregnancies. T he management protocols for trauma in pregnancy are based largely on c ase reports and small series. The purposes of this study were to: desc ribe the demographics of pregnant trauma patients at a tertiary care c enter and a large community hospital; identify variables predictive of fetal outcome including an examination of Kleihauer-Betke and nonstre ss testing; and recommend an evaluation and management protocol after trauma based on empirical data rather than anecdotal reports. Data fro m pregnancies complicated by trauma from July 1987 through October 199 3 were retrospectively reviewed. Statistical analysis included Chi-squ are and Kruskall-Wallis testing. There were 476 medical records availa ble for review. Of the trauma cases, 54.6% were motor vehicle accident s, 22.3% were domestic abuse and assaults, 21.8% were associated with falls, and 1.3% were secondary to burns, puncture wounds, or animal bi tes. Mean maternal age was 24 years, 49.9% were Caucasian, and 43% wer e primigravid. Mean gestational age at occurrence of trauma was 25.9 w eeks and mean gestational age of delivery was 37.9 weeks. Domestic abu se occurred most frequently before 18 weeks, falls between 20-30 weeks ' gestation, and motor vehicle accidents occurred with equal frequency throughout gestation. Uterine contractions occurred in 39.8% of patie nts and as often as every 1 to 5 min in 18% of patients. Preterm labor occurred in 11.4%, preterm delivery in 25%, and abruptions in 1.58% o f the trauma population. Fetal heart rate monitoring was abnormal in 3 % of cases. Twenty-seven perinatal deaths were noted and in 14 pregnan cies the deaths were related to trauma. Eight of these perinatal death s were associated with motor vehicle accidents, four with domestic vio lence, and two with falls. The only preventable perinatal deaths were a twin pregnancy transferred with nonreassuring fetal heart tones. Ear ly warning symptoms of vaginal bleeding, uterine contractions, and/or abdominal and/or uterine tenderness were not predictive of either pret erm delivery or adverse pregnancy outcome, sensitivity 52%, specificit y 48%. Abnormal monitoring and positive Kleihauer-Betke tests were als o not predictive of adverse pregnancy outcome. However, there were no adverse outcomes directly related to trauma when monitoring was normal and early warning symptoms were absent (negative predictive value 100 %). Two hundred eighty-nine Kleihauer-Betke tests were performed and o nly one affected management. Repetitive monitoring over several days d id not uncover any patients whose heart rate tracings evolved from nor mal to abnormal monitoring. Given our findings that prolonged monitori ng was not helpful in management of pregnant trauma patients, we suppo rt the recommendation that initial external fetal monitoring be perfor med for 4 hr, and, if reassuring, the patient may be sent home with pr ecautions. We also recommend an Kh-immunoglobulin work-up for all Rh-n egative pregnant trauma patients, but do not recommend Kleihauer-Betke testing for Rh-positive women. Given the frequency with which trauma affects pregnancy and the difficulty encountered with identifying vari ables predictive of pregnancy outcome, there may be great benefits of incorporating trauma prevention into routine prenatal care.