Trauma in pregnancy: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma.

Background: The care of the injured pregnant patient presents unique challenges. There is no consensus on how best to approach certain aspects of injury during pregnancy. In this review, we aim to clarify the current care of the injured pregnant patient by reviewing the existing literature guided by clinical experience.

Methods: Clinically relevant questions regarding the management of pregnant trauma patients with defined Population, Intervention, Comparison, and Outcomes (PICOs) were determined specific to resuscitative hysterotomy (RH), fetal monitoring, pregnancy-specific laboratory tests, imaging, and timing of fetal evaluation. A systematic literature review and meta-analysis were conducted using Grading of Recommendations Assessment, Development, and Evaluation methodology. Appropriate studies that met the inclusion criteria did not exist for PICO1 on RH and PICO5 on timing of fetal evaluation. We therefore relied on a literature review and expert consensus to address these PICOs.

Results: Sixteen studies were identified for systematic review, and a subset was deemed appropriate for meta-analysis. In trauma patients with pregnancies (estimated gestational age, ≥20 weeks) undergoing resuscitative thoracotomy for traumatic arrest, we conditionally recommend RH as soon as possible. In trauma patients with viable pregnancies, we conditionally recommend a formal observation period of at least 4 to 6 hours. In trauma patients with viable pregnancies, we cannot recommend for or against pregnancy-specific laboratory tests and nonionizing radiation imaging being performed. The workgroup suggests that possible effects of ionizing radiation exposure should not prevent medically indicated diagnostic imaging. Kleihauer-Betke testing should be performed in patients who are Rh negative to determine an appropriate dose of Rh D immunoglobulin. In trauma patients with viable pregnancies, we conditionally recommend that fetal assessment should be performed at the end of the primary survey after a rapid maternal evaluation.

Conclusion: This work summarizes the best available evidence pertaining to the management of trauma in pregnancy, as the best early treatment of the fetus is the optimal resuscitation of the mother.

Level Of Evidence: Systematic Review/Meta-analysis; Level III.