mild abd trauma in pregnancy

Discussion in 'Emergency Medicine' started by GiJoe, Dec 1, 2008.

  1. GiJoe

    GiJoe Senior Member
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    so i had this 16 week pregnant restrained lady driver involved ina soft mvc, was rearended at a stop sign, slow speed. no injuries sustained. went home, started to have some lower abd cramping. NO vag bleeding.

    what my attd and i wanted to do was a quick bedside u/s check urine and then send home...but what had crossed my mind was checking an rh and getting a formal u/s (i dont know about most of you but i dont know how to identify sub chorionic hemmorrage or placental hematoma, etc), mainly b/c if there is a hx of trauma, and pt is rh neg, don't we need to rule these things out? or are there some of you that routinely give rhogam to rh neg women without vaginal bleeding but with a hx of trauma?
     
  2. WilcoWorld

    WilcoWorld Senior Member
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    I would give RhoGam if RH neg, because it's safe,and because fetal maternal hemorrhage occurs in up to 30% of traumas during pregnancy, and the amount of blood required to cause sensitization is lower than is detectable on the KB test. The US is +/-. You might pick something up, and it's safe, so that's a plus. However a neg US doesn't rule out abruptio or other pregnancy related injuries and diagnosing these conditions before fetal viability is of arguable utility, so that's a minus.
     
  3. Seaglass

    Seaglass Quantum Member
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    Yes on the Rh, no on the US - if she's miscarrying there is nothing you can do -- the baby is not viable. New cramping should make you wonder about other lower abdominal trauma.
     
  4. Apollyon

    Apollyon Screw the GST
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    Low speed rear-ended female 36w gravid. Moderate to severe low back pain. I got plain films, which were negative, and sent her up to Ob. 30 minutes later, to the OR for delivery for an abruption.

    Low-speed MVCs are notorious for abruption, and it goes up the higher the speed. Even on the preg females before viability, they get medically cleared and go to Ob for observation.
     
  5. beriberi

    beriberi Senior Member
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    Careful about waiting for medical clearance to send upstairs. I would want these women on a monitor (viable fetus, history of abdominal trauma) as soon as possible. If it looks normal, you can continue your work-up, abnormal and OB-GYN, ED, Trauma Surg consult on what the next step is.

    We had one of these in our ED (as a resident) who took a few hours getting cleared (I wasn't involved, but I think there were some neck and extremeties filmed). When the patient (who was a big ball of whiny--"nothing" was wrong with her) got upstairs-- no fetal heart beat, loss of full term fetus. Yikes.

    Having said that, I agree with the +Rhogam, -US for the 16 weeker. What are you going to do with the results?
     
  6. Seaglass

    Seaglass Quantum Member
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    Regarding toco/continuous FHT in the ED - I have tried to do this on numerous occasions in two level 1 high volume EDs and all you get are blank stares and confusion. Has anyone else had more success with this?
     
  7. Jarabacoa

    Jarabacoa non carborundum ilegitemi
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    Possibly, get her a D/C faster? I guess you wouldn't want to send someone home with a dead fetus to rot away inside her. Very early abortions usually don't need surgery, but after first trimester, they tend to do D/Cs.

    Katz Gynecology says:
    "Recommendations for surgical versus medical management should be based partially on the size of the intrauterine contents. Many 9- to 10-week pregnancies by gestational age may be only 6 to 8 weeks by size, after ultrasound evaluation. A pregnancy of 11 or more weeks' gestation that presents as a missed or incomplete miscarriage is best handled surgically, because of the increased bleeding. Practitioners skilled in sur-gical uterine evacuation may perform dilation and evacuation up to 20 weeks."
     
  8. Old_Mil

    Old_Mil Senior Member
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    I have a lot to learn about medicine...that having been said, this I've learned - never do what you can get away with. Only do what you'd feel comfortable talking about on the witness stand.

    So when this woman has a spontaneous abortion at 20 weeks - for reasons that may be totally unrelated to this accident - and she sues the hospital for $5 million, what are you going to say about your ultrasound credentials in court?

    Never forget that there is an entire industry out there dedicated to making you pay for mistakes...even if they are perfectly accurate medical decisions which can be plausibly misinterpreted as mistakes.
     
  9. Jarabacoa

    Jarabacoa non carborundum ilegitemi
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    A lot of abruptions aren't seen on ultrasound. A small abruption is going to be exceedingly subtle on exam, if not impossible to see. I think that a formal scan with a better machine, by the person with the most experience is in order. I agree about the medicolegal pitfalls here.

    How does it change your management? I'm no Ob-Gyn, but I think a women is more likely to f/u with her Ob-Gyn if she knows she's got an abruption. She is more likely to follow bed-rest.

    As far as fetal monitoring in viable pregnancies, there is an interesting article:

    Minor trauma in pregnancy--is the evaluation unwarranted?
    American Journal of Obstetrics and Gynecology - Volume 198, Issue 2 (February 2008) - Copyright © 2008 Mosby, Inc.

    I don't think that this article will change my management. I'm still going to call the OB and ask them to monitor and dispo the viable minor abdominal trauma pregnancies.
     
  10. turtle md

    turtle md Hardware Included
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    We were lucky at my last job. If we couldn't get the pt to OB due to ED w/u, we would get OB to the pt in the ED (at least a nurse from OB who could monitor).
     

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