Objectives

On successfully completing this topic, you will be able to:

• assess the patient who has sustained abdominal trauma, and recognise the possibility of injury

• appreciate the changes in anatomy and physiology that occur in pregnancy, and of how such changes may alter the response to trauma

• appreciate the diagnostic procedures available for the investigation of abdominal trauma, and the indications for their use

• understand the need for timely resuscitation and treatment, including surgical intervention.

Introduction

Abdominal injuries are a recurring cause of preventable deaths associated with major trauma in the pregnant and nonpregnant woman alike. Abdominal injuries in pregnancy are on the increase, from both accidental and nonaccidental causes. The prompt and accurate assessment of the presence of intra-abdominal injury, and its likely site, can be challenging and the existence of a gravid uterus makes the task more complex.

Obstetricians should become involved early in the management of victims of trauma when pregnancy is obvious or suspected. They need to be familiar with the patterns of abdominal injury in the pregnant and nonpregnant patient, and their degree of priority. They need to be aware, also, of the effects of pregnancy on the response to blood loss, affecting both mother and fetus. The mother, especially in later pregnancy, tolerates blood loss well; the fetus tolerates maternal blood loss very badly and reflects maternal hypovolaemia by demonstrating fetal distress on monitoring.

Specific challenges posed by pregnancy in assessment of the abdomen:

1. • the peritoneum is less sensitive

2. • the omentum is less able to contain local inflammation

3. • organ displacement occurs as the uterus enlarges; for example, the bowels are pushed upwards, which can pose diagnostic uncertainties.