ICU and trauma10 / 13
Major trauma at 34 weeks for laparotomy28-year-old woman, 76 kg, 34 weeks pregnant
From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.
Know this first
- Resuscitating the mother is the best treatment for the fetus.
- Blood volume is up about 40% in pregnancy.
- Third trimester: left lateral uterine displacement; tilt the spinal board.
- Kleihauer–Betke positive in an RhD-negative mother: anti-D.
- In arrest, a uterus reaching the umbilicus or higher means resuscitative hysterotomy, delivered within 5 min.
The patient
28-year-old woman, 76 kg, 34 weeks pregnant, front-seat passenger in a car crash 40 minutes ago; abdominal pain and regular tightenings.
CT: liver laceration with free fluid. Blood group O RhD negative.
No regular drugs. Emergency laparotomy; obstetrician present.
Vitals: BP 104/62, HR 118, SpO2 96% on oxygen, RR 24; fetal heart 150/min.
The examiner asks
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Consider
What are your considerations?
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- A 28-year-old at 34 weeks with a liver laceration, for emergency laparotomy and possible delivery. Patient
- Pregnant trauma: I resuscitate the mother; that's the best care for the fetus.
- Her blood volume is up about 40%, so she can lose a lot before her pressure falls. Disease
- HR 118 with a near-normal pressure: I treat her as shocked.
- Pain and tightenings: abruption or preterm labour.
- Flat on her back, the uterus compresses her vena cava. Surgery
Prepare
What is your primary survey and preparation?
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- x: no external bleeding; she stays tilted left, the whole board if needed. Crisis
- A: talking now; when I intubate, her airway is swollen, so a smaller tube. Airway
- B: oxygen on; her small FRC and high oxygen use make her desaturate fast. Disease
- C: HR 118 means shock despite her pressure; RhD-negative blood only. Crisis
- Within 3 hours of injury: tranexamic acid 1 g over 10 minutes, then 1 g over 8 hours.
- Obstetric and neonatal teams here; fetal monitoring shows me her uterine perfusion. Disease
- D: GCS and pupils; E: fully exposed, then kept warm.
Plan
What is your anaesthetic plan?
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- Rapid sequence once the surgeons are scrubbed, videolaryngoscope ready. Airway
- Ketamine 1 mg/kg and rocuronium 1.0 mg/kg, given her shock.
- Massive transfusion ready; fibrinogen kept at 150–200 mg/dL in obstetric bleeding. Crisis
- Caesarean if she's in extremis, the uterus bleeds, or it blocks the surgeon. Surgery
- Kleihauer–Betke to measure any fetal blood in her circulation. After surgery
- Anti-D for her if positive and the baby is RhD positive.
Crisis
Her uterus becomes hard and tender; blood oozes from wounds and lines; fibrinogen 110 mg/dL, BP 82/46. What do you do?
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- Massive haemorrhage algorithm: concealed abruption with consumptive coagulopathy. (Crisis)
- Abruption bleeding threatens her life: emergency caesarean now.
- Fibrinogen 110: cryoprecipitate to bring it to 150–200.
- Plasma and platelets matched to red cells 1:1:1, with calcium for the citrate.
- After delivery: oxytocin 1–3 IU slowly, then an infusion.
Crisis
During the laparotomy, the fetal heart drops to 70/min; maternal BP 68/40, HR 140. What do you do?
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- Fetal bradycardia tells me the uterus is underperfused: fix the mother. Crisis
- Check the left tilt hasn't been lost during surgery.
- Blood fast, a vasopressor bridge, 100% oxygen.
- Obstetrician delivers now: the uterus is in the way and the baby is compromised.
- If she arrests: CPR with displacement, resuscitative hysterotomy, aiming to deliver by 5 minutes.
- Neonatal team ready for a 34-week baby. After surgery
Fatal mistakes
- Lying her flat without uterine displacement.
- Reading her normal-looking vital signs as stable.
- No anti-D for an RhD-negative mother.
Checked against: Miller 10e · Barash 9e · AHA guidelines: special circumstances of resuscitation (2025) · Updated initial trauma management: key changes in ATLS (2026)
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