Management of minor trauma

1. The minor trauma patient with a fetus that is less than 20 weeks gestation (not yet viable), with no significant injury can be safely discharged after documentation of fetal heart rate. Patients with potentially viable fetuses (over 20 weeks of gestation) require fetal monitoring, laboratory tests and ultrasonographic evaluation.

2. A complete blood count, urinalysis (hematuria), blood type and screen (to check Rh status), and coagulation panel, including measurement of the INR, PTT, fibrinogen and fibrin split products, should be obtained. The coagulation panel is useful if any suspicion of abruption exists.

3. The Kleihauer-Betke (KB) test a. This test detects fetal red blood cells in the maternal circulation. A KB stain should be obtained routinely for any pregnant trauma patient whose fetus is over 12 weeks.

b. Regardless of the patient's blood type and Rh status, the KB test can help determine if fetomaternal hemorrhage has occurred.

c. The KB test can also be used to determine the amount of Rho(D) immunoglobulin (RhoGAM) required in patients who are Rh-negative.

d. A positive KB stain indicates uterine trauma, and any patient with a positive KB stain should receive at least 24 hours of continuous uterine and fetal monitoring and a coagulation panel.

4. Ultrasonography is less sensitive for diagnosing abruption than is the finding of uterine contractions on external tocodynamometry. Absence of sonographic evidence of abruption does not completely exclude an abruption.

5. Patients with abdominal pain, significant bruising, vaginal bleeding, rupture of membranes, or uterine contractions should be admitted to the hospital for overnight observation and continuous fetal monitor.

6. Uterine contractions and vaginal bleeding are suggestive of abruption. Even if vaginal bleeding is absent, the presence of contractions is still a concern, since the uterus can contain up to 2 L of blood from a concealed abruption.

7. Trauma patients with no uterine contraction activity, usually do not have abruption, while patients with greater than one contraction per 10 minutes (6 per hour) have a 20% incidence of abruption.

References: See page 184.

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