The levels of recommendation (1-3) and classes of evidence (I-III) are defined at the end of the "Major Recommendations" field.
Level 1
- There are no Level 1 standards.
Level 2
- All pregnant women >20 weeks' gestation who suffer trauma should have cardiotocographic monitoring for a minimum of 6 hours. Monitoring should be continued and further evaluation should be carried out if uterine contractions, a nonreassuring fetal heart rate pattern, vaginal bleeding, significant uterine tenderness or irritability, serious maternal injury or rupture of the amniotic membranes is present.
- Kleihauer-Betke analysis should be performed in all pregnant patients >12 weeks' gestation.
Level 3
- The best initial treatment for the fetus is the provision of optimum resuscitation of the mother and the early assessment of the fetus.
- All female patients of childbearing age with significant trauma should have a beta-human chorionic gonadotropin (beta-HCG) performed and be shielded for x-rays whenever possible.
- Concern about possible effects of high-dose ionizing radiation exposure should not prevent medically indicated maternal diagnostic x-ray procedures from being performed. During pregnancy, other imaging procedures not associated with ionizing radiation should be considered instead of x-rays when possible.
- Exposure to less than 5 rad has not been associated with an increase in fetal anomalies or pregnancy loss and is herein deemed to be safe at any point during the entirety of gestation.
- Ultrasonography and magnetic resonance imaging (MRI) are not associated with known adverse fetal effects. However, until more information is available, magnetic resonance imaging is not recommended for use in the first trimester.
- Consultation with a radiologist should be considered for purposes of calculating estimated fetal dose when multiple diagnostic x-rays are performed.
- Perimortem Cesarean section should be considered in any moribund pregnant woman of >24 weeks gestation.
- Delivery in perimortem cesarean sections must occur within 20 minutes of maternal death but should ideally start within 4 minutes of the maternal arrest. Fetal neurological outcome is related to delivery time after maternal death.
- Consider keeping the pregnant patient tilted left side down 15 degrees to keep the pregnant uterus off the vena cava and prevent supine hypotension syndrome.
- Obstetric consult should be considered in all cases of injury in pregnant patients.
Definitions:
Rating Scheme for Strength of Recommendations
Level 1
The recommendation is convincingly justifiable based on the available scientific information alone. This recommendation is usually based on Class I data, however, strong Class II evidence may form the basis for a Level I recommendation, especially if the issue does not lend itself to testing in a randomized format. Conversely, low quality or contradictory Class I data may not be able to support a Level I recommendation.
Level 2
The recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion. This recommendation is usually supported by Class II data or a preponderance of Class III evidence.
Level 3
The recommendation is supported by available data but adequate scientific evidence is lacking. This recommendation is generally supported by Class III data. This type of recommendation is useful for educational purposes and in guiding future clinical research.
Rating Scheme for Strength of Evidence
Class I
Prospective randomized controlled trials
Class II
Clinical studies in which data was collected prospectively and retrospective analyses that were based on clearly reliable data. Types of studies so classified include observational studies, cohort studies, prevalence studies and case control studies.
Class III
Studies based on retrospectively collected data (i.e. clinical series, database or registry review, larger series of case reviews and expert opinion)
