Despite two individuals being at risk, the first and primary goal in treating a pregnant trauma victim is maternal stabilization. Achieving maternal wellbeing offers the best chance for preventing fetal morbidity and mortality. Simple measures like preventing hypotension through compression of the vena cava by placing pregnant patients greater than 20 weeks gestation in the left lateral decubitus position throughout resuscitation will help decrease potential fetal problems.

Early obstetric consultation should be obtained while initial resuscitation and assessment are occurring. A full obstetric history should be included along with the usual history and physical examination. An estimation of gestational age derived from the history and by accessing fundal height is an important factor in the decision regarding early delivery if needed. In addition to the trauma physical examination, a pelvic examination is required to rule out factors associated with fetal or placental injury, such as vaginal bleeding, ruptured membranes, or a bulging perineum.

Assault or interpersonal violence effects up to 20 % of all pregnant women sometime during gestation, though perhaps as few as 4–10 % of cases present for medical care. Such violence is commonly associated not with just a single event, but rather multiple episodes are the norm (Fig. 43.2). Violence occurs across all races and socioeconomic levels. Its been shown that abused mothers are twice as likely to begin their prenatal care in the third trimester. Women who report a history of abuse are at increased risk of poor fetal outcome. Interestingly, women who decline to be interviewed for interpersonal violence have even higher rates of fetal complications. Because a single trauma admission may be the only chance to pick up these types of events before a serious maternal or fetal injury may occur, screening using a validated three question questionnaire is currently recommended and included in advanced trauma life support (ATLS) recommendations (Table 43.1.) Interpersonal violence should be considered when:

As in other trauma scenarios, imaging plays a major role in the diagnostic assessment of the pregnant trauma patient. Choosing the proper imaging examination to evaluate the pregnant patient can pose a dilemma for the clinician who is trying to facilitate prompt diagnosis while balancing radiation dose. Although imaging modalities that do not use ionizing radiation, such as US and magnetic resonance imaging (MRI), are strongly preferred when possible, their limitations can be substantial. The availability, speed and reliability of computed tomography (CT) are advantageous, but CT is associated with significant radiation exposure. Plain radiography and angiography are additional potential sources of ionizing radiation used in this setting. Although there are theoretical risks of fetal carcinogenesis, congenital malformations and mental retardation, there is no documented risk at current exposure levels commonly associated with diagnostic imaging. The risk of abnormality is considered to be negligible at 50 mGy or less. Practice guidelines for imaging the pregnant patient are based on the guiding principle that the mother’s health is the most important factor for fetal survival and favorable outcome. Therefore, concerns regarding fetal radiation dose exposure should not delay or preclude radiologic evaluation in trauma patients requiring accurate and prompt diagnosis.