Penetrating injuries in most cases must be evaluated using radiography. Because clinical response to peritoneal irritation is blunted during pregnancy, an aggressive approach to exploratory laparotomy is pursued. Whereas exploration is mandatory for abdominal gunshot wounds, some clinicians advocate close observation for selected stab wounds. Diagnostic laparoscopy has also been used (Chap. 46, p. 901).
The necessity for cesarean delivery depends on several factors. Laparotomy itself is not an indication for hysterotomy.
FIGURE 47-1 1 Fast scan. Upper quadrant scan shows anechoic free fluid (asterisk) between the liver edge (arrow) and kidney (Morison pouch). The patient had 2500 mL of blood in the peritoneal cavity. (Reproduced with permission from Mendez-Figueroa H, Rouse OJ: Trauma in pregnancy. In Yeomans ER, Hoffman BL, Gilstrap, III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili, 2017.)
Some considerations include gestational age, fetal condition, extent of uterine injury, and whether the large uterus hinders adequate management of other intraabdominal injuries (Tsuei, 2006).
Because fetal well-being may relect the status of the mother, fetal monitoring is another "vital sign" that helps evaluate the extent of maternal injuries. Even if the mother is stable, electronic monitoring may suggest placental abruption. In a study by Pearlman and coworkers (1990), no woman had an abruption if uterine contractions were less often than every 10 minutes within the 4 hours after trauma was sustained. lmost 20 percent ofwomen who had contractions more frequently than every 10 minutes in the irst 4 hours had an associated placental abruption. In these cases, abnormal tracings were common and included fetal tachycardia and late decelerations. Conversely, no adverse outcomes were reported in women who had normal monitor tracings (Connolly, 1997). Importantly, if tocolytics are used for these contractions, they may obfuscate findings, and we do not recommend them.
Because placental abruption usually develops early following trauma, fetal monitoring is begun as soon as the mother is stable. The ideal duration ofposttrauma monitoring is not precisely known. From data cited above, observation for 4 hours is reasonable with a normal tracing and no other sentinel indings such as contractions, uterine tenderness, or bleeding. Certainly, monitoring should be continued as long as there are uterine contractions, nonreassuring fetal heart patterns, vaginal bleeding, uterine tenderness or irritability, serious maternal injury, or ruptured membranes (American College ofObstetricians and Gynecologists, 2017b). In rare cases, placental abruption has developed days after trauma (Higgins, 1984).
It is unclear whether routine use of the Kleihauer-Betke or an equivalent test in pregnant trauma victims might modiy adverse outcomes associated with fetal anemia, cardiac arrhythmias, and death (Pak, 1998). In a retrospective review of 125 pregnant women with blunt injuries, the Kleihauer-Betke test was judged to be of little value during acute trauma management (Towery, 1993). Others have reached similar conclusions, although a positive test with fetal cells of0.1 percent was predictive of uterine contractions or preterm labor (Connolly, 1997; Muench, 2003, 2004).