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Three Part Question

In [pregnant patients who have sufferered an abdominal trauma] is [ uterine tenderness a reliable indicator ] of [foetomaternal haemmorrhage] ?

Clinical Scenario

A pregnant patient in her 3rd trimester is admitted to the Emergency Department following a motor vehicle accident where she had the seat belt placed over the abdomen. There are no obvious signs of injury and no vaginal bleed but on palpation she does feel tender in the right upper quadrant.

Search Strategy

Medline 1950 to 11/2007 using Ovid Interface
EMBASE 1980-2008 Week 1
The Cochrane Library

[{exp pregnancy/ OR pregnancy.mp. OR exp pregnancy complications OR pregnancy complications} AND {uterine tenderness.mp.} AND {fetomaternal haemorrhage.mp. OR foetomaternal haemorrhage.mp.}] LIMIT to human and English language

Search Outcome

1 paper was found and was relevant. However, 2 other papers were identified from other BET searches that address the main subject area of trauma in pregnancy

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Tweedle CJ, 2005, USA	Pregnant trauma patients	Review for an article for continuing education	In patients with placental abruption there may or may not be vaginal bleeding, but persistent abdominal pain is usually evident.	Abdominal pain is usually evident in placental abruption	No search strategy
Weinberg et al, 2005, Australia	Pregnant trauma patients	Review	Uterine tenderness, contractions and tone should be included in the secondary survey	Uterine tenderness can be a sign of placental abruption	No search strategy
Goodwin TM, Breen MT, 1990, USA	205 gravid women following noncatastrophic trauma over an 18 month period from Jan 87 – Sep 88	Consecutive case study	Patients with obstetric findings (vaginal bleeding, uterine tenderness or contractions) had an incident rate of FMH of 12%, patients who had obstetric findings with significant evidence of trauma had an incident rate of FMH of 40%. It was also found that none of the 20 patients who had vaginal bleeding or spotting had demonstrable FMH.	Uterine tenderness is a likely indicator of FMH	Study was only based on non-catastrophic trauma

Comment(s)

Part of the secondary survey in a pregnant patient suffering from an abdominal trauma should include and obstetric examination and this should include assessing for uterine tenderness. Foetomaternal haemorrhage can occur even without signs and it may be as a result of a threatened abortion, placental abruption or placental praevia. In a pregnant patient who has undergone abdominal trauma there is a high likelihood of abruption and therefore uterine tenderness could be a very useful sign as an abruption may in fact be covert and therefore present with little or no vaginal bleeding. Foetal maternal haemorrhages occur more frequently after motor vehicle accidents than from any other type of trauma and this due to the shearing force that occurs between the myometrium and the placenta in a rapid deceleration.

Clinical Bottom Line

Uterine tenderness could be a sign of a covert FMH and should not be ignored

References

1. Tweddale CJ. Trauma during pregnancy. Crit Care Nurs Q. 2005:29(1);53-67
2. Weinberg L et al. The pregnant trauma patient. Anaesthesia and Intensive Care. 2005:33(2);167-80.
3. Goodwin TM, Breen MT. Pregnancy outcome and foetomaternal hemorrhage after noncatastrophic trauma. Am J Obstet Gynecol 1990;162:665-71.