When the creative miracle of pregnancy is threatened by the destructive force of trauma, an emotional situation exists. Trauma care providers at all levels respond to the vulnerability of a pregnant woman. The traumatized pregnant woman is often terrified that her child has been injured and may express her protective instincts during the resuscitation. The tragedy of either fetal or maternal death are real possibilities whenever trauma involves a pregnant woman.

In pregnancy, management to optimize both fetal and maternal outcome complicates trauma care. Even minor trauma may pose a real threat to fetal well-being. Once fetal viability is reached, two patients exist and both require assessment and treatment. The anatomic and physiologic changes of pregnancy make the trauma assessment more difficult and must be kept in mind throughout care. The impact of ionizing radiation, medications, and surgical procedures on the fetus are important considerations. With pregnancy, there is an increased risk of internal hemorrhage, and identification of bleeding is more difficult. Peritoneal signs are muted and delayed, making the abdominal examination less reliable. The diagnosis of trauma-related problems and their complications is therefore more difficult.

A multidisciplinary approach to the pregnant trauma victim is frequently required (Figure 1). The prehospital care and resuscitative phase of care is most often directed by an emergency physician. The first physician involved must be well versed in the selection of diagnostic studies and the consultation needs of the pregnant patient. Inpatient care is best managed by a trauma surgeon, but early involvement of other specialties can be critical to maximizing both fetal and maternal outcome. An obstetrician may be needed for invasive or noninvasive fetal monitoring. Tocodynamometry or bedside ultrasonography may indicate a need for cesarean section in patients who have no other surgical requirements. The management of preterm labor, a common complication of blunt abdominal trauma, is beyond the scope of a trauma surgeon's practice and thus necessitates involvement of an obstetrician at an early stage of care. In cases in which a critically ill or premature infant is anticipated, a neonatologist and high-level nursery care are needed.

It is clear that having a “two-in-one” patient present as a victim of trauma more than doubles the complexity of the medical decision-making process. All of these factors make trauma care in pregnancy particularly challenging.