Trauma in pregnancy — structured SAQ (15 marks)

(a) Primary survey modifications and resuscitation (4 marks)

One mark per element. [1][4][10]

• Position her immediately: 15-30 degree left lateral tilt on the spinal board, or manual left uterine displacement, to relieve aortocaval compression from 20 weeks. This is the first modification.
• Airway with cervical spine control: pre-oxygenate; anticipate a difficult pregnant airway (oedema, friability, anterior larynx); intubate early with a smaller cuffed tube and rapid-sequence induction.
• Circulation: two large-bore cannulae, bloods including group and antibody screen, crossmatch; early blood products — she has likely lost up to 1.5 L before hypotension; tranexamic acid within 3 hours of major bleeding.
• General: high-flow oxygen; keep her warm (avoid the lethal triad); treat the mother aggressively — maternal stabilisation is fetal resuscitation.[1][4][10]

(b) Secondary survey and fetal assessment (4 marks)

One mark per element. [2][9]

• Obstetric abdomen: symphysis-fundal height and gestation, tenderness, tone, contractions, fetal lie and presentation, vaginal bleeding; speculum only after placenta praevia excluded.
• Continuous CTG from arrival for at least 4 hours, extended to 24 hours if any uterine activity, bleeding or abnormal trace; frequent contractions are the earliest sign of abruption.
• Bedside ultrasound for fetal viability, placental location and free intraperitoneal fluid (FAST/eFAST); proceed to contrast-enhanced CT where clinically indicated — pregnancy is NOT a contraindication to indicated imaging.
• Trauma bloods: FBC, coagulation with fibrinogen, crossmatch, U&E, LFTs, lactate; group and antibody screen; β-hCG if gestation unknown.[2][9]

(c) Diagnosis and management of suspected abruption (4 marks)

One mark per element with reasoning. [2][9]

• Diagnosis: concealed/placental abruption — uterine tenderness, frequent contractions and fresh vaginal bleeding 6 hours after trauma is classic. Distinguish from preterm labour, uterine rupture (peritonism, loss of station, CTG changes) and vasa praevia.
• Resuscitate: two large-bore cannulae, FBC, coagulation with fibrinogen (falls first in obstetric DIC), crossmatch 4 units, U&E; correct coagulopathy with fibrinogen replacement; warm the patient.
• Continuous CTG and plan delivery if maternal or fetal compromise, established labour, or uncontrolled coagulopathy. Vaginal birth acceptable if mother and fetus are stable; caesarean for fetal or maternal compromise.
• Activate major haemorrhage protocol and involve senior obstetric, anaesthetic and neonatal teams; magnesium for fetal neuroprotection if preterm and delivery is anticipated.[2][9]

(d) Kleihauer, anti-D, IPV screening and discharge safety (3 marks)

One mark per element. [2][11][13]

• Kleihauer-Betke (or flow cytometry) to quantify fetomaternal haemorrhage; give standard prophylactic anti-D within 72 hours and additional anti-D if the fetomaternal bleed exceeds the volume covered by the standard dose.
• Screen for intimate partner violence in private with the partner absent, using a validated tool (HITS or HARK); a positive screen triggers a structured safety assessment, social-work involvement, and a documented safety plan — do not discharge to an unsafe environment.
• Discharge only when safe: normal CTG and maternal observations, no bleeding or contractions, anti-D given, Kleihauer reviewed, IPV safety plan in place, and a clear follow-up plan including serial growth scans for FGR risk.[2][11][13]