Trauma in Pregnancy
The "Two Patients" Paradigm
Trauma affects ~8% of pregnancies. While 90% is classified as "minor trauma," it can still result in catastrophic complications such as uterine rupture, foeto-maternal haemorrhage, placental abruption, pre-term labour, and foetal loss.
"One of these patients must be resuscitated aggressively to save the other and, very occasionally, the baby has to be delivered to save the mother." (Sugrue & Kolkman)
Common Mechanisms & Specific Injuries
Motor Vehicle Accidents (MVAs) account for 54% of all injuries and 70% of major, life-threatening injuries. Other causes include domestic violence, assaults, and accidental falls.
- Uterine Rupture: Risk increased due to large circulating blood volume.
- Placental Abruption: Anatomical changes make the placenta prone to shearing forces during sudden deceleration.
Paramedic Management Priorities
- Maintain a high degree of suspicion: Do not underestimate "minor" mechanisms.
- Aggressive Maternal Resuscitation: Oxygenate the mother routinely (titrate SpO2 95-98%). Fetal hypoxia occurs rapidly if the mother is compromised.
- Positioning: If >20 weeks gestation, position in a left lateral tilt to prevent aortocaval compression (supine hypotensive syndrome).
- Interventions: Obtain early IV access. Do not withhold treatments or investigations if they are in the best interest of the mother.
- Expedite Transport: Minimise scene time.
Maternal Sepsis
A Leading Cause of Maternal Death
Infection and sepsis remain leading causes of maternal mortality in Australia. Pregnancy naturally induces an impaired immune state to prevent rejection of the fetus, making patients highly susceptible to rapid deterioration.
Key Risk Factors:
- Prolonged rupture of membranes
- Pelvic infections / Invasive procedures
- Prolonged labour / Multiple vaginal exams
- Caesarean delivery
- Obesity and Anaemia
- Impaired glucose tolerance
- Postpartum Haemorrhage (PPH)
- Delivery in unhygienic conditions
Paramedic Management
The pregnant or post-natal woman with sepsis requires a hyper-vigilant approach as physiological adaptations of pregnancy (like baseline tachycardia and vasodilation) can mask early signs of septic shock.
- Early Identification: Have a high index of suspicion based on history (e.g., recent birth, prolonged rupture of membranes).
- Early Oxygenation: Support increased metabolic demand.
- Early Haemodynamic Resuscitation: Aggressive fluid management per protocol.
- Immediate Transport: Initiate treatment en route. Pre-notify the receiving hospital.
Thromboembolism and Pulmonary Embolism (PE)
The Hypercoagulable State
Pregnancy induces a physiological hypercoagulable state to protect the mother from fatal haemorrhage during childbirth. However, this dramatically increases the risk of clot formation. Pregnant women are at high risk for thromboembolism for the entire duration of the pregnancy and the post-partum period.
PE is the most common type of thromboembolism in pregnancy and a leading cause of maternal death.
Risk Factors & Identification
Always consider PE in a pregnant/post-partum patient presenting with sudden onset dyspnoea, pleuritic chest pain, unexplained tachycardia, or hypoxia.
Cumulative Risk Factors:
- Age (particularly >35 years)
- Obesity
- Smoking
- Parity of 4 or more
- Previous PE or DVT
- Prolonged immobility (>4 days bed rest)
- Prolonged labour (>12 hours)
- Extensive pelvic surgery (Caesarean)
- Gross varicose veins
Drug and Substance Use in Pregnancy
Substance use during pregnancy introduces significant risks to both maternal and fetal physiology, often resulting in complex presentations.
| Substance | Maternal / Fetal Risks |
|---|---|
| Smoking | Malnourishment, low birth weight, premature birth, preterm ROM, placental abruption, increased risk of SIDS, miscarriage, stillbirth. |
| Alcohol | Foetal Alcohol Syndrome (FAS), birth defects, brain damage, cognitive impairment, behavioural problems, developmental delay. |
| Illicit Drugs | Low birth weight, miscarriage, birth defects, withdrawal syndrome, increased risk of SIDS. |
CRITICAL ALERT: Heroin/Opioid Use & Neonatal Resuscitation
While heroin use is no more common than other illicit drugs, it carries a highly specific risk regarding paramedic interventions during neonatal resuscitation.
Narcan (Naloxone) is CONTRAINDICATED in neonates born to opioid-addicted mothers.
- It induces immediate, severe, and potentially life-threatening withdrawal in the neonate.
- Hypoventilating neonates will be hypercapneic. Administering Narcan in this state can precipitate dysrhythmias, seizures, and pulmonary oedema.
- Management: Focus entirely on airway management and positive pressure ventilation (BVM) to treat neonatal respiratory depression.
Post Natal Depression (PND)
Definition
Onset of depression typically occurring from one month up to one year post-birth. It affects up to 20% of postnatal women in Australia. This is a severe clinical condition and is not the transient "baby blues." It is driven by a combination of physical, emotional, and social factors.
Symptom Recognition
- Depressed, sad mood, tearfulness
- Low self-esteem, feelings of inadequacy/guilt
- Feeling that life is meaningless / unable to cope
- Loss of interest in usual activities / low sex drive
- Anxiety, panic attacks, heart palpitations
- Insomnia or extreme changes in sleeping patterns
- Difficulty concentrating / memory loss
- Red Flag: Thoughts about harming themselves or the baby to escape.
Paramedic Management & Assessment
Management focuses on de-escalation, empathy, and thorough risk assessment.
- Communication: Gain rapport and trust. Show empathy, understanding, and provide reassurance.
- Competency Check: Does the patient show competency and capacity to make their own health care decisions?
- Mental Health Risk Assessment: Evaluate the following key domains:
- Signs & Symptoms: Note abnormal state of mind or agitated behaviour.
- Thoughts: Assess for delusions, hallucinations, or illogical thinking.
- Appearance: Visually assess grooming, posture, and expressions.
- Threats: Ask directly about acts harmful to self or others (including the baby).
- Emotions: Gauge levels of sadness, hopelessness, anger, or extreme distress.