Prehospital Trauma Compendium: Management of Injured Pregnant Patients– A Position Statement and Resource Document of NAEMSP

The assessment and management of critically injured pregnant trauma patients represents a high-risk, low-frequency event. One in every 12 pregnant patients experience physical trauma during their pregnancy, but only 0.1% experience major trauma with an injury severity score (ISS) greater than fifteen. It is crucial that emergency medical services (EMS) clinicians understand the anatomic and pathophysiologic changes that impact morbidity and mortality for pregnant trauma patients so they can effectively provide life-saving interventions and resuscitation for this patient population. For injured pregnant patients who are at least 20 weeks’ gestation (or fundal height at the level of the umbilicus), manual left lateral uterine displacement should be performed whenever possible.EMS clinicians should be aware that signs of hemorrhagic shock may be subtle or delayed in injured pregnant patients.EMS clinicians should be aware of clinical characteristics unique to the pregnant patient population that require modification of typical lifesaving interventions including hemorrhage control and resuscitation, airway and ventilation management, tension pneumothorax decompression, management of burn and inhalational injuries, and pain management.For Traumatic Out of Hospital Circulatory Arrest (TOHCA) in injured pregnant patients of at least 20 weeks’ gestation, after correctable causes of TOHCA have been addressed and spontaneous circulation has not returned, if an EMS physician is present, a resuscitative hysterotomy should be initiated ideally within four minutes of maternal arrest. EMS clinicians should understand when an in-hospital resuscitative hysterotomy is indicated, provide a clear and early pre-arrival notification, and expedite transport to the closest appropriate hospital.When a pregnant patient is considering refusal of medical aid, EMS clinicians should carefully consider and discuss the potential that life-threatening risks for maternal and fetal morbidity and mortality can occur after even seemingly minor trauma.EMS clinicians should promote conversations regarding injury prevention strategies unique to pregnancy, such as correct seatbelt use.EMS clinicians should consider the possibility of intimate partner violence when caring for injured pregnant patients. For injured pregnant patients who are at least 20 weeks’ gestation (or fundal height at the level of the umbilicus), manual left lateral uterine displacement should be performed whenever possible. EMS clinicians should be aware that signs of hemorrhagic shock may be subtle or delayed in injured pregnant patients. EMS clinicians should be aware of clinical characteristics unique to the pregnant patient population that require modification of typical lifesaving interventions including hemorrhage control and resuscitation, airway and ventilation management, tension pneumothorax decompression, management of burn and inhalational injuries, and pain management. For Traumatic Out of Hospital Circulatory Arrest (TOHCA) in injured pregnant patients of at least 20 weeks’ gestation, after correctable causes of TOHCA have been addressed and spontaneous circulation has not returned, if an EMS physician is present, a resuscitative hysterotomy should be initiated ideally within four minutes of maternal arrest. EMS clinicians should understand when an in-hospital resuscitative hysterotomy is indicated, provide a clear and early pre-arrival notification, and expedite transport to the closest appropriate hospital. When a pregnant patient is considering refusal of medical aid, EMS clinicians should carefully consider and discuss the potential that life-threatening risks for maternal and fetal morbidity and mortality can occur after even seemingly minor trauma. EMS clinicians should promote conversations regarding injury prevention strategies unique to pregnancy, such as correct seatbelt use. EMS clinicians should consider the possibility of intimate partner violence when caring for injured pregnant patients.