ITLS - International Trauma Life Support Trauma in Pregnancy Questions and Answers — Questions and Answers
Question 1: You are treating a 30-year-old female, 32 weeks pregnant, who was involved in a motor vehicle collision. She is secured to a long backboard. Her initial BP was 110/70 mmHg, but it has now dropped to 90/50 mmHg with an increased heart rate. What is the most appropriate immediate intervention?
- Manually displace the uterus to the left. (Correct answer)
- Administer a 1-liter normal saline bolus.
- Prepare for immediate rapid transport.
- Apply high-flow oxygen via a non-rebreather mask.
Correct answer: Manually displace the uterus to the left.
In a pregnant patient beyond 20 weeks gestation, lying supine can cause the gravid uterus to compress the inferior vena cava, which reduces venous return to the heart and causes hypotension. This is known as supine hypotensive syndrome. [1, 6] The most critical and immediate intervention is to relieve this compression, which can be done by manually displacing the uterus to the left or by tilting the entire backboard 15-30 degrees to the left. [14, 24]
Question 2: Following blunt abdominal trauma in a pregnant patient, which of the following is the most common serious pregnancy-specific complication that can lead to fetal distress or demise?
- Uterine rupture
- Placental abruption (Correct answer)
- Premature rupture of membranes
- Direct fetal injury
Correct answer: Placental abruption
Placental abruption, the premature separation of the placenta from the uterine wall, is the most common cause of fetal death following maternal trauma in which the mother survives. [4, 7] The shearing forces from trauma can cause this separation, disrupting oxygen and nutrient supply to the fetus. [15]
Question 3: Why can a pregnant patient in her third trimester lose a significant amount of blood before showing classic signs of shock, such as a significant drop in blood pressure?
- Uterine compression of the femoral arteries maintains pressure.
- Decreased maternal heart rate conserves circulatory volume.
- Maternal blood volume increases by 40-50% during pregnancy. (Correct answer)
- Physiological anemia of pregnancy lowers oxygen demand.
Correct answer: Maternal blood volume increases by 40-50% during pregnancy.
During pregnancy, the maternal blood volume increases by up to 50%. [8, 14] This state of hypervolemia allows the mother to lose a larger quantity of blood (up to 30%) before classic signs of shock like hypotension become apparent. [3, 25] Tachycardia is often an earlier and more sensitive sign of hypovolemia in this population. [13]
Question 4: When managing a critically injured pregnant patient, what is the single most important principle for ensuring the well-being of the fetus?
- Determining fetal heart tones with a doppler.
- Administering medications to prevent preterm labor.
- Preparing for a potential emergency field delivery.
- Aggressively resuscitating and stabilizing the mother. (Correct answer)
Correct answer: Aggressively resuscitating and stabilizing the mother.
The primary principle in managing trauma in pregnancy is that the best treatment for the fetus is the optimal resuscitation of the mother. [14, 22] Maternal stability, including maintaining adequate blood pressure and oxygenation, is essential for uterine perfusion and fetal survival. [28] Efforts to assess the fetus are secondary to life-saving interventions for the mother. [4]
Question 5: A 28-year-old female who is 26 weeks pregnant has signs of hemorrhagic shock after a fall. How should fluid resuscitation for this patient differ from that for a non-pregnant patient?
- Fluid resuscitation should be less aggressive to prevent pulmonary edema.
- Resuscitation should be more aggressive due to physiological hypervolemia. (Correct answer)
- Crystalloid fluids are contraindicated; only blood products should be used.
- The target systolic blood pressure should be lower (permissive hypotension).
Correct answer: Resuscitation should be more aggressive due to physiological hypervolemia.
Due to the 40-50% increase in maternal blood volume, a pregnant patient requires more aggressive fluid resuscitation to restore perfusion. [8] Uterine blood flow is not autoregulated and is dependent on maternal blood pressure; therefore, permissive hypotension is generally avoided as it can severely compromise fetal oxygenation. [27, 28] It is crucial to err on the side of hyper-hydration to support both mother and fetus. [27]
Question 6: In the context of maternal trauma, which finding is the most critical indicator that fetal perfusion is likely compromised?
- Maternal tachycardia
- Presence of uterine contractions
- Maternal hypotension (Correct answer)
- A fundal height smaller than expected for gestational age
Correct answer: Maternal hypotension
Uterine blood flow is directly dependent on the mother's blood pressure and cardiac output; it is not autoregulated. [27, 28] Therefore, maternal hypotension is a critical sign that blood is being shunted away from the uterus to preserve the mother's vital organs, severely compromising fetal perfusion and oxygenation. Fetal distress is often an early sign of maternal shock. [28]
ITLS - International Trauma Life Support Trauma in Pregnancy Questions and Answers
You are treating a 30-year-old female, 32 weeks pregnant, who was involved in a motor vehicle collision.
She is secured to a long backboard.
Her initial BP was 110/70 mmHg, but it has now dropped to 90/50 mmHg with an increased heart rate.
What is the most appropriate immediate intervention?