Management of Trauma in the Late Second‑Trimester Pregnancy

Maternal Stabilization

Maternal survival is the primary determinant of fetal survival after traumatic injury; therefore, immediate maternal stabilization is the absolute priority. 1

Administer 100 % oxygen without delay to keep maternal oxygen saturation above 95 %, because pregnant patients have reduced oxygen reserves and increased metabolic demands. 2

Insert two large‑bore (14–16 G) intravenous catheters above the diaphragm to allow rapid fluid and blood product administration. 3
Begin with the patient supine for assessment, then perform manual left uterine displacement to relieve aortocaval compression; at 27 weeks gestation the gravid uterus can reduce cardiac output by roughly 30 %. 1
Aggressive crystalloid resuscitation is indicated when maternal systolic blood pressure falls below 100 mm Hg (or below 80 % of baseline), as hypotension compromises placental perfusion. 3

Initiate continuous electronic fetal heart‑rate monitoring for a minimum of 4–6 hours in any pregnant trauma patient at ≥23 weeks gestation. 4
Extend fetal monitoring to 24 hours when any high‑risk feature is present (e.g., uterine tenderness, vaginal bleeding, sustained contractions >1 per 10 min, rupture of membranes, abnormal fetal heart‑rate pattern, or fibrinogen < 200 mg/dL). 4

If maternal cardiac arrest occurs, prepare for immediate perimortem cesarean delivery; the decision should be made as soon as the arrest is recognized. 1
Perform chest compressions with the hands placed slightly higher on the sternum than in non‑pregnant patients to accommodate the elevated diaphragm. 3
Maintain continuous manual left uterine displacement throughout resuscitation while the patient remains supine. 1
Mobilize the obstetric and surgical team without delay; if return of spontaneous circulation is not achieved within 4 minutes, initiate PMCD at the bedside without transporting the patient to the operating room. 1
Reported outcomes indicate maternal survival possible up to 15 minutes after arrest onset, and neonatal survival when delivery occurs within 30 minutes of the arrest. 1

The American College of Cardiology recommends that all pregnant women beyond 20 weeks gestation who experience trauma require systematic obstetrical examination with fetal heart rate monitoring for at least 4-6 hours, as trauma significantly increases risks of preterm birth, fetal distress, placental abruption, and fetal death 5
After mid-pregnancy, the American Heart Association recommends manually displacing the gravid uterus off the inferior vena cava or using left lateral tilt to increase venous return and cardiac output, which is critical as supine positioning can reduce cardiac output by 30% 6

The American College of Radiology recommends performing all medically indicated radiographic studies, including CT scans, without delay or deferral due to fetal radiation concerns, as the risk-benefit balance strongly favors maternal diagnosis and treatment 7
Fetal radiation exposure from typical trauma CT imaging is well below thresholds for adverse effects (<50 mGy) 7, 8
The American College of Radiology recommends that CT with IV contrast is preferred over non-contrast CT for detecting visceral organ and vascular injuries 9

The American College of Obstetricians and Gynecologists recommends that all pregnant trauma patients ≥23 weeks gestation require continuous electronic fetal monitoring for at least 4-6 hours, even after minor trauma 5
The American College of Obstetricians and Gynecologists recommends extending monitoring to 24 hours if high-risk features are present, such as uterine tenderness, vaginal bleeding, or sustained contractions 5, 6, 9

The American Heart Association recommends performing cesarean section within 4 minutes of maternal cardiac arrest onset in viable pregnancy (≥23 weeks) to aid maternal resuscitation and fetal salvage 6
Maternal survival has been reported up to 15 minutes after cardiac arrest onset, and neonatal survival has been documented with delivery up to 30 minutes after maternal cardiac arrest 6