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Chapter 79 THIRD-TRIMESTER COMPLICATIONS AND DELIVERY558
diastolic BP greater than 110 mm Hg. If symptoms do not resolve, pregnancy termination at
less than 24 weeks gestation may need to be considered for maternal safety. For patients
between 24 and 34 weeks’ gestation, corticosteroids are administered to enhance fetal lung
maturity. Expectant management can be considered in these patients. However, if the
condition persists or worsens within 48 hours, delivery may be the safest option for the
mother. Patients with severe preeclampsia at greater than 34 weeks’ gestation should
undergo delivery.
8. What antihypertensive medications can be used?
n
Hydralazine: 5 to 10 mg intravenously every 20 minutes until desired effect to a maximum
dose of 30 mg.
n
Labetalol: 20 mg intravenously, may repeat 40 mg within 10 minutes if no effect, then
80 mg every 10 minutes for a maximum of 300 mg.
n
Nifedipine: 10 mg orally every 15 to 30 minutes with a maximum of three doses.
n
Sodium nitroprusside: This medication can be used in severe hypertensive emergency if the
previous medications have been ineffective. However, cyanide poisoning of the fetus may
occur and thus its long term use should be limited.
Contraindicated antihypertensives: angiotensin-converting enzyme inhibitors, diuretics
9. What are the complications of preeclampsia?
There are several complications of preeclampsia, the most serious being eclampsia,
intracerebral hemorrhage, hemolysis with elevated liver enzymes and low platelets
(HELLP) syndrome, renal failure, and posterior reversible encephalopathy syndrome
(PRES).
10. Is there a way to prevent preeclampsia?
No proven definitive method of prevention has been identified. However, some studies have
described the use of calcium, low-dose aspirin, or vitamins C plus E in the prevention or
reduction in severity of preeclampsia.
11. Is any pregnant woman with hypertension considered to have preeclampsia?
No. There are four categories of hypertensive disorders in pregnancy:
n
Chronic hypertension
n
Gestational hypertension
n
Preeclampsia
n
Preeclampsia superimposed on chronic hypertension
12. What is gestational hypertension?
Gestational hypertension is defined as a systolic BP greater than 140 mm Hg or a diastolic BP
greater than 90 mm Hg after 20 weeks’ gestation in a previously normotensive woman. Blood
pressure returns to normal less than 12 weeks’ postpartum.
13. What is HELLP syndrome?
Hemolysis, elevated liver enzymes, and low platelet count. Patients typically present with
epigastric or right upper abdominal pain, nausea, and vomiting. Some patients may also
complain of malaise, headache, or visual disturbances. Others may present atypically with
nonspecific viral syndrome-like symptoms.
14. What are the complications and mortality rate of HELLP syndrome?
Complications include abruptio placentae, disseminated intravascular coagulation (DIC) with
resultant severe postpartum hemorrhage, rupture of a subcapsular liver hematoma,
intracranial hemorrhage or infarction, and acute renal failure.
n
Maternal mortality is considered to be approximately 1.1%, although some studies have
reported the mortality rate to be as high as 25%. The leading causes of maternal death are
intracerebral hemorrhage, cerebral infarction, and hepatic rupture.
Chapter 79 THIRD-TRIMESTER COMPLICATIONS AND DELIVERY 559
n
Fetal mortality rates range from 7.4% to 34%, with improved survival after 32 weeks’
gestation. The most common causes of neonatal death with HELLP syndrome are abruptio
placentae, placental insufficiency, and prematurity.
15. How is HELLP treated?
In the patient . 34 weeks’ gestation, immediate delivery is the treatment of choice. Between
27 and 34 weeks gestation, corticosteroids are administered for fetal lung development and
delivery is recommended within 48 hours of evaluation and stabilization. For gestations
, 27 weeks, conservative management can be considered for 48 to 72 hours of evaluation,
along with corticosteroid administration.
16. What is eclampsia?
Eclampsia is defined as new onset of grand mal seizure or unexplained coma in a patient with
signs and symptoms of preeclampsia.
17. What is the treatment for eclampsia?
Immediate stabilization of airway, breathing, and circulation (ABCs) is necessary, with
administration of oxygen, placement of intravenous lines, and monitoring of mother and fetus.
Magnesium sulfate 4 to 6 g intravenously, followed by a maintenance dose of 2 g/hr.
Administration of a benzodiazepine may be considered if the patient seizes a second time.
After magnesium, blood pressure should be controlled with hydralazine or Labetalol. The
definitive treatment of eclampsia is delivery.
18. What are the findings of magnesium toxicity, and how should the patient be
monitored?
Magnesium toxicity usually presents when levels reach 8 to 12 mg/dL, with loss of patellar
reflexes, somnolence, slurred speech, and flushing. At levels of 15 to 17 mg/dL, muscle
paralysis and respiratory arrest may occur. Cardiac arrest is seen at levels of 30 to 35 mg/dL.
For patients receiving magnesium, patellar tendon reflexes and respiratory rate should be
checked every hour and magnesium levels should be drawn every 4 to 6 hours.
19. What is the most common cause of death in a patient with preeclampsia-
eclampsia?
Central nervous system complications, including cerebral edema, hemorrhages, and infarctions.
20. Does a woman have to be pregnant to have preeclampsia or eclampsia?
No. It can occur in the postpartum period. Usually symptoms develop within 48 hours of
delivery, but it can present as late as 1 month post-partum.
21. Are there atypical presentations of preeclampsia or eclampsia?
Yes. Preeclampsia or eclampsia can occur at , 20 weeks’ gestation, primarily in the setting of
a molar or partial molar pregnancy. However, hypertension and proteinuria at , 20 weeks’
gestation, among other laboratory abnormalities, may indicate another disease process in the
woman, such as hemolytic uremic syndrome, antiphospholipid antibody syndrome, lupus
nephritis, or thrombotic thrombocytopenic purpura.
1. Preeclampsia or eclampsia can present any time from 20 weeks’ gestation to 4 weeks’
postpartum.
2. Hydralazine and Labetalol are used to treat hypertension in preeclampsia or eclampsia.
3. Magnesium sulfate is the first-line treatment in eclampsia.
KEY POINTS: PREECLAMPSIA AND ECLAMPSIA
Chapter 79 THIRD-TRIMESTER COMPLICATIONS AND DELIVERY560
22. What do I need to do to stabilize a pregnant patient brought into the ED?
The unplanned delivery of babies in the ED will occur. After vital signs and chief complaint are
obtained, establish intravenous access. Most mistakes in the care of the mother and baby are
made as the result of lack of preparation and planning. Help should be sought from Obstetrics
and Pediatrics as soon as it is evident that a delivery is going to occur in the ED. Labor and
delivery is a natural process, which usually proceeds to its conclusion with limited
intervention and without difficulty.
23. What information do I need to care properly for the pregnant patient?
Obtain the patient’s age, her due date, and number of past pregnancies. Ask her if she feels the
baby moving and if she is having contractions, vaginal bleeding, or leakage of fluid from the
vagina. Inquire about any problems with the current pregnancy and clarify that she is only
carrying one baby presently. In addition to identifying her current medications, ask about illicit
drug use. Find out where she is getting her prenatal care and the name of her doctor or midwife.
24. How are the baby and pregnancy evaluated?
Indirect evaluation of the baby can provide some information. Fetal heart tones should be
obtained as soon as the mother is stabilized. A normal fetal heart rate is between 120 and 160
beats per minute. The fundal height (the distance in centimeters from the symphysis pubis to
the top of the pregnant uterus) should be measured to give a rough estimate of gestational
age. For example, a fundal height of 32 cm would indicate a gestational age of roughly 30 to
34 weeks.
25. How do you check cervical dilation?
Under sterile conditions, a digital pelvic examination is performed. The diameter of the cervical
opening in front of the baby’s head is estimated in centimeters. The measurements vary from
closed up to 10 cm. Practice is required for accuracy. To avoid exacerbating a placenta previa, a
digital pelvic examination is contraindicated in the ED for any patient bleeding in the late second
and third trimesters; immediate obstetrical consultation should be initiated.
26. What should be in an emergency delivery pack?
The contents of an emergency delivery pack may vary. At a minimum, each pack should
contain:
n
A bulb syringe to clear the baby’s nose and mouth
n
Sterile gloves in various sizes for the delivering health care provider
n
Sterile towels to dry off baby and a baby blanket to keep the baby warm
n
Four Kelly clamps for the umbilical cord or vaginal or perineal bleeders
n
Mayo scissors to cut the umbilical cord
n
Two ring forceps
n
Three packs of 4-3-4 sponges
n
Container for placenta
27. How can I determine if a delivery is imminent?
This can be difficult. Some patients will not appear to be in any distress one minute, and there is a
baby in the bed the next minute. If delivery is imminent, most patients will feel the urge to push or
bear down in response to the pressure of the baby as it moves down the birth canal. The patient
may say, “The baby is coming” or “I have to have a bowel movement.” She may be visibly
bearing down or pushing with contractions. If examination of the patient reveals the cervix is
6 cm or more dilated, delivery may occur before or during transport to labor and delivery.
28. I have a laboring pregnant patient in the ED and the baby can be seen
distending the mother’s perineum. The obstetrician is on the way but will not
make it in time. What do I do now?
Wearing sterile gloves, apply gentle pressure against the presenting part to prevent sudden
expulsion and to allow gradual stretching of the perineum.
Chapter 79 THIRD-TRIMESTER COMPLICATIONS AND DELIVERY 561
29. Okay, the baby is part way out. Should I pull on the baby to help the delivery?
In most cases, the mother will push the baby out without help. Pulling on the baby may
interrupt the normal delivery process unless you are experienced with deliveries. The best way
to help with the delivery is to use your hands to help control and guide the delivery of the rest
of the baby’s body. The baby may deliver very quickly, so keep a good grip.
30. If the umbilical cord is wrapped around the neck during a delivery, what
should I do?
If the cord is wrapped around the neck, it should be pulled gently over the head, if possible,
so that it does not tighten as the baby is being born. If the cord is too tight to lift over the
head, carefully apply two clamps to the cord and cut the cord between the clamps. Then the
cord can be unwound from around the neck and the baby delivered. See Chapter 67 for the
approach to neonatal resuscitation.
31. The placenta is still inside. What should I do now?
There is no hurry to deliver the placenta until the obstetrician arrives, unless there is heavy
bleeding.
If there is heavy bleeding, have the mother try to push out the placenta. Provide very
gentle traction using ring forceps on the distal end of the cord, winding it around the forceps
as the placenta is delivered; never forcibly pull on the cord. If the placenta delivers by itself,
massage the uterus gently but firmly to keep it contracted into a firm ball. As long as the
uterus stays firmly contracted, bleeding should be minimal (up to 500 mL is considered within
the normal range).
1. Labor and delivery is a natural process, which usually proceeds to its conclusion without
difficulty. In most cases, little intervention is required on the part of the health care provider.
2. It is essential to have intravenous access during the delivery process.
3. During delivery, the health care provider should not attempt to speed up the process by
pulling or pushing on the baby. In most cases it is unnecessary to do more than attempt to
guide and control the process.
KEY POINTS: CHILDBIRTH IN THE ED
BIBLIOGRAPHY
1. Barton JR, Sibai BM: Prediction and prevention of recurrent preeclampsia. Obstet Gynecol, 112:359–372, 2008.
2. Haddad B, Sibai BM: Expectant management in pregnancies with severe preeclampsia. Semin Perinatol
33(3):143-51, 2009.
3. Haram K, Svendsen E, Abildgaard U: The HELLP syndrome: clinical issues and management. A review. BMC
Pregnancy Childbirth 9:8, 2009.
4. Henry CS, Biedermann SA, Campbell MF, et al: Spectrum of hypertensive emergencies in pregnancy. Crit Care
Clin 20(4):697–712, 2004.
ACKNOWLEDGMENT
The editors gratefully acknowledge the contributions of Dane M. Chapman, MD, and Richard O.
Jones, MD, authors of this chapter in the previous edition.
Chapter 79 THIRD-TRIMESTER COMPLICATIONS AND DELIVERY562
5. Maynard S, Epstein FH, Karumanchi SA: Preeclampsia and angiogenic imbalance. Annu Rev Med 59:61–78, 2008.
6. Rumbold AA, Duley L, Crowther CA, et al: Antioxidants for preventing preeclampsia. Cochrane Database Syst
Rev (1):CD004227, 2008.
7. Sibai BM: Diagnosis and management of atypical preeclampsia-eclampsia. Am J Obstet Gynecol 200(5):481e1–e7,
2009.
8. Stallard TC, Burns B: Emergency delivery and per-mortem C-section. Emerg Med Clin North Am 21(3):679–693,
2003.
563
MULTIPLE TRAUMA
CHAPTER 80
Peter Rosen, MD
XVI. TRAUMA
1. What is multiple trauma?
Significant injury to more than one major body system or organ.
2. What is new in the management of trauma?
n
Diagnostic peritoneal lavage (DPL), which for many decades was the principle
diagnostic study for an objective evaluation of a traumatized abdomen, has largely
been displaced by the ultrasound-focused abdominal sonography for trauma (FAST)
examination. Both are overly sensitive, and can tell you that there is blood or fluid in
the abdomen, but not whether there is an injury serious enough to warrant laparotomy.
A DPL may still be performed on an unstable patient with blunt abdominal trauma, but
it is no longer useful to obtain cell counts because one would only operate if the return
were grossly positive.
n
It has become apparent from the use of computed tomography (CT) scan of the chest, that
many patients harbor a small pneumothorax after blunt chest trauma that formerly went
unrecognized on plain film imaging of the chest. It is further apparent that most of these
cases of small pneumothorax can be watched without a tube thoracostomy. The exception
would still be a patient who needs mechanical ventilation, either because of a need for
immediate surgery or because of ventilatory failure from another cause.
n
Not only is plain film study insensitive to the presence of a pneumothorax, it is dependent
upon the position of the patient (more accuracy is obtained when the patient is upright,
which of course is impossible for most multitrauma patients.) Ultrasound imaging has
shown new utility in the identification of pneumothorax and is part of the utility provided by
use of bedside ultrasound for the trauma patient along with the FAST examination. Repeat
examinations should be performed in the patient who is not responding to resuscitation,
even if the initial examination appeared accurate and negative.
n
For many years Ketamine was thought to be a harmful drug to use for airway management
in a trauma patient, but recent experience shows that it may be extremely helpful for the
combative trauma patient who needs emergent airway management. It does not raise
intracranial pressure as was once thought, does raise blood pressure, unlike most sedating
agents, provides quick control of a combative patient, and is not only helpful for the
emergency intubation, but also for any other acute invasive procedure that needs to be
performed. It is also safer than Haldol or Droperidol, which both have concerns for seizure
induction and serious dysrhythmia production, especially in the presence of alcohol
consumption, perhaps accompanied by other drugs such as cocaine.
n
Surgical airway management has become less and less necessary with improvements in
intubation equipment, and with more experience in the management of difficult airways.
There are still patients in whom it will be necessary, although it is more and more
difficult to find the means of providing the technical training to residents in emergency
medicine.
3. Define mechanism of injury.
Mechanism of injury refers to the events and conditions that lead to visible and occult
traumatic injuries. Significant mechanism of injury is associated with a higher likelihood of
multiple trauma. Less obvious mechanism is of greater concern with increasing age or
Chapter 80 MULTIPLE TRAUMA564
preexisting disease. A 70-year-old patient with ankylosing spondylitis is much less able to
tolerate blunt trauma to the spinal column and pelvis than is a healthy younger person. Even
trivial mechanism of injury can produce significant damage in patients with prior disease or
in patients of advanced age. Many times the mechanism of injury is obscure or not known
when the patient arrives at the ED or trauma unit; it is helpful to know if anyone on the
scene was killed, severely injured, or perhaps taken to a different location than the patient
being treated as sometimes happens with remote trauma or when there are multiple
casualties.
4. Give examples of significant mechanisms of injury.
Blunt trauma
n
Automobile crashes: fatality at the scene or in the same vehicle, passenger ejection, vehicle
rollover, significant interior damage
n
Automobile-pedestrian accidents: high speed, damage to exterior of vehicle
n
Falls: Greater than one story (12–15 feet)
Penetrating trauma
n
Gunshot wounds to head, neck, or torso
n
Stab wounds to neck or torso
5. List the first steps in managing multiple trauma in the ED.
n
Activate the trauma resuscitation team.
n
Designate a trauma captain and call for O-negative blood if indicated by prehospital course
and vital signs.
n
Transfer the patient from the ambulance stretcher or other conveyance to the ED
resuscitation bed using spinal injury precautions if indicated.
n
Quickly obtain a history, including the mechanism of injury, field treatment, and response
to this field treatment.
n
Obtain vital signs while the patient is being undressed.
n
Assess the airway, breathing, and circulation (ABCs) and intervene as needed.
n
Draw blood for type, cross-matching, and baseline laboratory testing.
6. How should the patient be undressed?
Because immobilization is necessary until the spine can be cleared, all movement should be
avoided. To obtain complete visualization rapidly while protecting the spine, simply cut the
clothes away. Keep in mind that one of the purposes of clothing removal is to rid the patient
of objects that can cause further damage to the patient or injury to the health care providers,
such as shards of broken glass, bits of metal, or weapons.
7. What are the ABCs (and D) of trauma?
n
A 5 Airway
n
B 5 Breathing
n
C 5 Circulation
n
D 5 Disability
8. Discuss assessment of the airway.
Airway patency is evaluated by listening for vocalizations, asking for the patient’s name, and
looking in the patient’s mouth for signs of obstruction (e.g., blood, emesis, or foreign debris).
The trauma captain must determine if the patient needs active airway management and verify
that supplemental oxygen is being administered continuously to all patients who do not
require immediate intubation.
Mandatory indications for airway management in trauma include the following:
n
Massive facial injuries
n
Head injury with Glasgow Coma Scale (GCS) less than 8
n
Penetrating injury to the cranial vault
n
Missile penetrating injury to the neck
Chapter 80 MULTIPLE TRAUMA 565
n
Blunt injury to the neck with expanding hematoma or alteration of the voice
n
Multisystem trauma with persistent shock
n
Any patient with an injury that has the potential to distort the patient’s anatomy (e.g.
penetrating wound of the neck). It is much more prudent to intubate these patients while it
is still possible to do so than to have to try when the anatomy is distorted, the patient is
obstructing the airway, and the emergent airway management becomes a difficult flail.
Relative indications for airway management in trauma include the following:
n
Upper airway obstruction from any cause
n
Any patient with injuries impairing ventilation
n
Flail chest with increasing respiratory rate or deteriorating oxygenation
n
Any patient with one or more rib fractures who is going to need a ventilator or a general
anesthetic
n
Patients with bilateral pneumothorax
n
Bilateral missile penetrating injuries of the thorax
n
Patients with severe hypovolemic shock
n
Patients with recurrent hemothorax, or who do not respond to tube thoracostomy
9. How is breathing assessed?
Ventilation is assessed by observing for symmetric rise and fall of the chest and by listening
for bilateral breath sounds over the anterior chest and axillae. The chest should be palpated
gently for subcutaneous air and bony crepitus. Oxygen saturation should be monitored
continuously. The trauma captain determines whether or not tube thoracostomies or
ventilatory support is needed immediately.
10. How is circulation assessed?
Circulatory function is assessed by noting the patient’s mental status; skin color and
character (cool and clammy versus warm and dry); vital signs; and presence or absence of
radial, femoral, and carotid pulses. Continuous cardiac monitoring should be started.
Prehospital vascular access and type and amount of volume infused are assessed. The
trauma captain determines whether additional vascular access or volume of crystalloid is
needed and whether blood should be administered. A FAST examination should be
performed on any patient with torso trauma to detect free fluid (blood) in the abdomen or
perineum. See Chapter 5.
11. How is disability assessed?
The patient’s neurologic status should be assessed (level of consciousness and gross motor
function). An initial ED GCS rating should be ascertained, and this should be compared with
the prehospital GCS. With any alteration of consciousness, it is useful to perform a rectal
examination to determine anal sphincter tone.
12. What type of intravenous access should be established in a patient with major
trauma?
At least two large-bore (16-gauge) intravenous catheters should be placed. Forearm or
antecubital veins are the preferred sites for initial access. Although subclavian and internal
jugular catheters allow central venous pressure monitoring, they rarely provide access for
high-volume intravenous infusions unless a Cordis introducer is left in place. These routes
should be used only if no other access exists, and catheters should be placed on the ipsilateral
side of the chest trauma unless a subclavian vascular injury is suspected. Femoral lines and
saphenous cutdowns are indicated in patients with a dropping blood pressure because large-
volume infusions will be needed quickly. Central line placement is aided by use of an
ultrasound probe. This will also make femoral line insertion safer.
13. Where should cutdowns be performed?
The ankle. The distal saphenous vein can be found between the anterior tibialis tendon and the
medial malleolus.
Chapter 80 MULTIPLE TRAUMA566
14. What parameters should be monitored in multiple trauma victims?
Vital signs, neurologic status, cardiac rhythm, oxygen saturation, and, if possible, central
venous pressure and urinary output. Hypothermia adversely affects outcome, and core
temperature can drop rapidly when the patient is disrobed and receives large quantities of cold
intravenous fluid. Tachypnea is a sensitive sign of hypoxia and acidosis and should be
measured accurately rather than estimated. Neurologic status, skin color and character, and
urinary output over time should be monitored.
15. When should blood be administered?
O-negative (universal donor) blood should be reserved for patients who are in arrest from
hypovolemic shock. If 50 mL/kg of crystalloid is infused rapidly and there is no significant
improvement in the patient’s circulatory status, type-specific noncross-matched blood should
be administered if available. Otherwise, use type 0 initially. (For more details, see Chapter 4.)
16. Are laboratory tests useful?
No, although all major trauma victims should have a clot blood tube sent for type and cross-
match. Baseline values of hematocrit and serum amylase (or preferably lipase) may be useful
in detecting occult injuries and preexisting anemia. Urinalysis should be done to detect
hematuria. Many trauma centers obtain an extensive trauma panel, which may be useful if the
patient requires surgery or has underlying disease. No laboratory test defines injury, however,
and the trauma panel is of little use in determining initial management, disposition, or need for
surgery. Common initial lab tests in multiple trauma include the following:
n
Complete blood cell count
n
Type and cross-match
n
Electrolytes
n
Urinalysis
n
Blood urea nitrogen, creatinine
n
Blood alcohol as indicated
n
Glucose
n
Toxicology as indicated
n
Prothrombin and partial thromboplastin times
n
Amylase, lipase
17. What is the secondary survey?
The complete physical examination performed after the ABCs have been assessed and
stabilized. This survey includes assessment of the chest, abdomen, pelvis, back, and
extremities. A repeat neurologic examination and rectal examination also should be done. The
purpose of the rectal examination is to determine if there is gross blood in the rectum, if there
is adequate sphincter tone and sensation, and if the prostate gland is in a normal position.
1. Trauma care is a team sport involving prehospital providers and emergency physicians and
surgical staff.
2. All trauma patients should be completely undressed and examined.
3. All trauma victims must be assessed for occult bleeding in the cranial vault, chest, and
abdomen.
4. When indicated by mechanism of injury, symptoms, or signs, spinal precautions must be
maintained until the spine is cleared.
KEY POINTS: MULTIPLE TRAUMA
Chapter 80 MULTIPLE TRAUMA 567
18. Which radiologic studies need to be obtained immediately?
n
When the patient is stabilized, portable radiographs of the lateral cervical spine, chest, and
pelvis should be obtained.
n
In gunshot wounds, portable films in two planes may be needed to determine the location
of the bullet.
n
If the mechanism of injury is an ejection or a fall, a cross-table lumbar spine film should be
added to the initial series.
19. How do I prioritize diagnostic tests?
Prioritization is based on potential life threats. After external hemorrhage is controlled,
diagnosing intraperitoneal hemorrhage takes precedence. Unless an indication for immediate
laparotomy is present, the patient should undergo diagnostic peritoneal lavage, abdominal CT
scan, or abdominal ultrasound to assess the intraperitoneal cavity. After these procedures,
attention should be focused on ruling out correctable intracranial hemorrhage, such as a
subdural or an epidural hematoma. Based on the mechanism of injury and the initial course,
other specialized studies to evaluate the aorta and the retroperitoneum should be done. If the
patient has a bleeding diathesis (e.g., hemophilia) or is on an anticoagulant, even minor head
injury mandates a CT scan.
20. How are fluids managed in pediatric trauma?
Start with a bolus of 20 mL/kg of normal saline (NS) or lactated Ringer’s (LR). This can be
repeated until up to 50 mL/kg has been reached. At this point, start packed red blood cells at
10 mL/kg. See Chapter 90.
21. What is the significance of blunt abdominal trauma in the pregnant woman?
n
During the first trimester, the fetus is well protected, and the best treatment for the fetus is
to protect the mother from hypovolemic shock.
n
In the second trimester, the fetus is more vulnerable and must be monitored for signs of
placental abruption
n
In the third trimester, the fetus is the most vulnerable, and even minor trauma necessitates
fetal monitoring for several hours. If the signs of abruption occur, emergency caesarian
section must be performed. See Chapter 89.
BIBLIOGRAPHY
1. Feliciano DV, Moore EE, Mattox KL, editors: Trauma, ed 3, Stamford, CT, 1996, Appleton & Lange.
2. Gin-Shaw S, Jorden RC: Approach to the multiple trauma patient. In Marx JA, Hockberger RS, Walls RM,
editors: Rosen’s emergency medicine: concepts clinical practice, ed 5, St. Louis, 2002, Mosby, 2002,
pp 242–256.
3. Greenfield LJ, Mulholland MW, Oldham KT, et al, editors: Surgery: scientific principles and practice, ed 2,
Philadelphia, 1997, Lippincott-Raven.
4. Rosen P, Legome E: General principles of trauma. In Wolfson AB, Hendey GW, Hendry PL, et al, editors:
Harwood-Nuss’ clinical practice of emergency medicine, ed 4, Philadelphia, 2005, Lippincott Williams &
Wilkins, pp 890–899.