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This reduces the period between the final scan and needle insertion cheap hyzaar generic pulse pressure 85, thereby allowing the operator to maintain recent memory of the angle of approach during needle insertion trusted 12.5mg hyzaar heart attack remind for you. The transducer with sterile sleeve is part of the field setup purchase hyzaar 50 mg without a prescription ulterior motive quotes, thereby allowing scanning during the procedure discount 12.5 mg hyzaar with mastercard blood pressure medication ramipril, because the operator may choose to reconfirm site, depth, and angle for needle insertion following sterile site preparation. The angle of needle insertion for device insertion duplicates the angle of probe angle that identified the safe trajectory for needle insertion. Confirmation of wire or catheter insertion may be accomplished by direct visualization using 2D ultrasonography. If there is a question of proper position, several milliliters of agitated saline may be injected through the catheter to document catheter position. Similar to thoracentesis and paracentesis, pericardiocentesis does not require real-time guidance with ultrasonography. However, it is important to have the transducer with sterile cover in place for immediate use throughout the procedure, in case there is a need to rescan and document successful device insertion. Pitfalls: Common and Uncommon Skin compression artifact is a common problem, because it may cause an underestimation of the depth for needle insertion. This occurs in the obese or edematous patient when the operator pushes the probe into the skin while searching for a safe needle insertion site. Measurement of needle insertion distance is made while compressing the skin and underlying soft tissue. On removal of the probe pressure, the skin rebounds, such that the needle insertion is underestimated. During actual needle insertion, the operator is appropriately concerned, if there is no fluid obtained at the depth measured from the ultrasound machine screen. The solution to this problem is to rescan the patient, confirm the angle of insertion, and estimate the compression artifact more accurately. Another cause for difficulty is movement of the mark that designates the appropriate site for needle insertion. Skin is movable, so the injudicious application of force by the operator’s hand may shift the skin mark. The needle should be inserted at the mark without any tension applied to the area that might shift the mark position. Similarly, a “dry tap” might result from inaccurate duplication of the angle at which the transducer was held, or an inaccurate skin mark. Generally, it is easier to duplicate a perpendicular transducer angle than one that is acutely angled. This favors an anterior or lateral chest wall approach (if fluid is accessible), because the transducer is often perpendicular to the chest wall when scanning in these areas. Overly vigorous probing of the anterior costal cartilage (if using a parasternal approach) may also block the needle with cartilage, causing the operator to insert the needle too deeply, with potential complications to the patient. A large anterior pericardial fat pad may be mistaken for a pericardial effusion by the inexperienced ultrasonographer. However, it is very uncommon for a consequential pericardial effusion to occur anterior to the heart without a significant posterior pericardial effusion also being present. An uncommon pitfall of pericardiocentesis occurs when the anesthesia needle penetrates the pericardium after having traversed a pleural effusion. The pericardial effusion may then drain into the pleural space through the defect in the pericardium made by the anesthesia needle. The operator is unpleasantly surprised by the lack of pericardial effusion, and the presence of a new pleural effusion. To avoid this situation, device insertion should promptly follow infiltration of the local anesthesia. Ultrasonography allows the intensivist to select a safe site, angle, and depth for needle and device insertion. Careful attention to image acquisition and interpretation allows the operator to avoid the serious complication of myocardial or coronary artery laceration. The critical care ultrasonographer is strongly encouraged to develop proficiency in ultrasound guidance of pericardiocentesis, because it is superior to subcostal fluoroscopic guidance. Permayer-Miulda G, Sagrista-Sauleda J, Soler-Soler J: Primary acute pericardial disease: a prospective study of 231 consecutive patients. Sagrista-Sauleda J, Merce J, Permanyer-Miralda G, et al: Clinical clues to the causes of large pericardial effusions. Zayas R, Anguita M, Torres F, et al: Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis. The task force on the diagnosis and management of pericardial diseases of the European Society of Cardiology. Competence in the performance of transvenous pacing also requires the operator to have training in central venous access (Chapter 6) and hemodynamic monitoring (Chapter 28) [2]. Tachyarrhythmias Temporary cardiac pacing is used less often for the prevention and termination of supraventricular and ventricular tachyarrhythmias. Pacing termination of atrial flutter in cardiac surgery patients with epicardial leads may be preferable to synchronized cardioversion, which carries the risk associated with sedation. A critical pacing rate (usually 125% to 135% of the flutter rate) and pacing duration (usually about 10 seconds) are important in the successful conversion of atrial flutter to sinus rhythm [3]. Temporary cardiac pacing with a mild tachycardia is the treatment of choice to stabilize the patient while a type I antiarrhythmic agent exacerbating ventricular irritability is metabolized. However, in less urgent situations, conversion of ventricular tachycardia via rapid ventricular pacing may be useful. This technique is less effective when ventricular tachycardia complicates acute myocardial infarction or cardiomyopathy. Rapid ventricular pacing is most successful in terminating ventricular tachycardia when the ventricle can be “captured” (asynchronous pacing for 5 to 10 beats at a rate of 50 beats per minute greater than that of the underlying tachycardia). A cardiac defibrillator should be immediately available, because pacing may result in acceleration of ventricular tachycardia or degeneration to ventricular fibrillation. This technique may also assist in the diagnosis of wide-complex tachycardias in which the differential diagnosis includes supraventricular tachycardia with aberrant conduction; sinus tachycardia with bundle branch block; and ventricular tachycardia. This rhythm strip should reveal1 the conduction pattern between atria and ventricles as antegrade, simultaneous, retrograde, or dissociated. Bradyarrhythmias unresponsive to medical treatment that result in hemodynamic compromise or symptoms require urgent treatment. Action: There are four possible actions, or therapeutic options, listed and classified for each bradyarrhythmia or conduction problem: 1. In general, because the increase in sinus rate with atropine is unpredictable, this is to be avoided unless there is symptomatic bradycardia that will likely respond to a vagolytic agent, such as sinus bradycardia or Mobitz I, as denoted by the asterisk, above. It is assumed, but not specified in the table, that at the discretion of the clinician, transcutaneous pads will be applied and standby transcutaneous pacing will be in effect as the patient is transferred to the fluoroscopy unit for temporary transvenous pacing. Level of Evidence: This table was developed from published observational case reports and case series, published summaries, not meta-analyses, of these data; and expert opinion, largely from the prereperfusion era. The left anterior descending artery is the major blood supply to the His bundle and the bundle branches, and an anterior wall infarction with new bundle branch block represents extensive myocardial damage and confers an increased risk of heart failure and mortality. Thrombolytic therapy or percutaneous coronary intervention takes precedence over placement of prophylactic cardiac pacing, because prophylactic pacing has not been shown to improve mortality.

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Common clinical features include facial erythema (flushing) and inflammatory lesions that are similar to acne lesions 12.5mg hyzaar otc blood pressure jumps from low to high. It2 is available as a gel and its major adverse effects are burning buy hyzaar 12.5mg otc arrhythmia quiz, localized warm feeling generic hyzaar 50mg mastercard arrhythmia education inc, and flushing order hyzaar 50 mg on-line heart attack and vine cover. It is available as a capsule and tablet, and its major adverse effects include diarrhea, nausea, dyspepsia, and nasopharyngitis. It is believed to work in rosacea through anti-inflammatory or immunosuppressive effects, rather than through its antibacterial effects. It is available as a cream, gel, and lotion, and its major adverse effects are burning, erythema, skin irritation, xeroderma, and acne vulgaris. It is available as a cream, and its major adverse effects are application site dermatitis, worsening inflammatory lesions, site pruritus, site erythema, and a burning sensation. It is available as a cream, and its major adverse effects are burning, irritation, pruritus, and erythema. Agents for Pigmentation Disorders the color of skin is derived from melanin produced by melanocytes in the basal layer of the epidermis. When the melanocytes are damaged, the melanin levels are affected, which ultimately leads to pigmentation disorders. If the body does not make enough melanin, the skin gets lighter (hypopigmentation). Pigmentation disorders can be widespread and affect many areas of the skin or they can be localized. Agents used for pigmentation disorders are discussed below and summarized in ure 43. It is often used in combination with topical retinoids to treat the signs of photoaging. The mechanism of action of hydroquinone is through inhibition of the tyrosinase, an enzyme required for melanin synthesis. Hydroquinone lightens the skin temporarily and is commonly used as a 4% preparation. It should not be used in higher concentrations, or in excessive quantities for an extended duration, as it is associated with possible carcinogenicity. Methoxsalen inhibits cell proliferation and promotes cell differentiation of epithelial cells. Topical methoxsalen may be used for small patches of vitiligo, and oral therapy is used for more widespread disease. Because of the possibilities for aging of the skin and carcinogenicity, it is used with caution. Tazarotene Tazarotene is a topical retinoid, which decreases hyperpigmentation, and is sometimes used to treat the signs of photoaging. The most common adverse effects include itching, burning, erythema, rash, and dryness. Agents for Psoriasis Psoriasis is a chronic autoimmune skin disease that manifests as epidermal hyperplasia and dermal inflammation, which can range from mild to disabling. It is a condition that has significant genetic associations and it tends to wax and wane, with flare-ups that can be triggered by a number of environmental factors including stress and skin trauma. There are several forms of psoriasis, with the most common form being plaque psoriasis. Plaque psoriasis is characterized by the presence of sharply demarcated, thick, erythematous plaques that are usually covered by dry silvery-white scales (ure 43. In mild-to-moderate cases, these plaques cover less than 5% of the body surface area, but in more severe cases, they can cover more than 20% of the body. Therapies may target inflammation and the abnormal immune response, as well as epidermal hyperproliferation. It works by inhibiting phosphodiesterase-4, which ultimately leads to reduced production of several inflammatory mediators in psoriasis. Biologic agents Biologics are agents isolated from natural sources, including humans, animals, and microorganisms. They can be composed of sugars, proteins, or nucleic acids or complex combinations of these substances. They are used for moderate-to-severe psoriasis and their mechanism of action results from their interaction with specific cytokines that induce or mediate T-cell effector function, which is important in autoimmune diseases such as psoriasis. Though each agent has specific potential risks and adverse effects, among the adverse effects that they share include injection or infusion reactions and increased risk of infections due to their suppression of the immune system. In addition, because they are foreign proteins, there is a risk for the development of antidrug antibodies, which may affect efficacy over the course of therapy. Keratolytic agents Keratolytic agents such as coal tar and salicylic acid are effective in localized psoriasis, especially on the scalp. Coal tar inhibits excessive skin cell proliferation and may also have anti- inflammatory effects. Because it is cosmetically unappealing, coal tar may have a low acceptance rate among patients and, consequently, its use has been largely supplanted by the newer topical agents. Among the common potential adverse effects are nausea, diarrhea, mouth ulcers, hair loss, and skin rashes. The primary long-term risk is the potential for liver damage, and therefore, periodic liver function tests are required for patients using methotrexate. Retinoids Retinoids normalize keratinocyte differentiation and reduce hyperproliferation and inflammation. Similar to oral isotretinoin used in acne, acitretin is teratogenic and women must avoid pregnancy for at least 3 years after the use of this drug (due to its long duration of teratogenic potential). Topical corticosteroids Topical corticosteroids have been a mainstay of psoriasis therapy for over 50 years, and are used in many other skin conditions as well. The available agents differ in potencies and are formulated in a variety of dosage forms, including solutions, lotions, creams, ointments, gels, and shampoo (ure 43. Upon binding to intracellular corticosteroid receptors, these agents produce numerous effects that can be beneficial for psoriasis, including anti- inflammatory, antiproliferative, immunosuppressive, and vasoconstrictive effects. Potential adverse effects, especially with the long-term use of potent corticosteroids, include skin atrophy, striae, acneiform eruptions, dermatitis, local infections, and hypopigmentation. In children, excessive use of potent agents applied to a large surface area can cause systemic toxicity, including possible depression of the hypothalamic–pituitary–adrenal axis and growth retardation. They inhibit keratinocyte proliferation, enhance keratinocyte differentiation, and inhibit inflammation. Calcipotriene is available in cream, ointment, solution, and foam formulations, and calcitriol is available as an ointment. Potential adverse effects include itching, dryness, burning, irritation, and erythema. Agents for Alopecia Alopecia (baldness) is the partial or complete loss of hair from areas where hair normally grows.

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There is increasing awareness of the need Formal resuscitation plans are required for certain high‐ for palliation cheap hyzaar american express arteria inflamada del corazon, improving management and increasing risk deliveries order 50 mg hyzaar with mastercard blood pressure chart age 13, such as extreme prematurity at the mar- availability of resources for neonatal palliative care purchase hyzaar with amex blood pressure target. Neonatal Care for Obstetricians 447 Communication following neonatal death Neonatal transport In circumstances where neonatal death is the outcome 50 mg hyzaar otc prehypertension caffeine, Ensuring that babies receive the appropriate level of care family support by neonatal staff should include the ante- ideally requires delivery in the correct place if delivery natal team wherever possible. Continuing engagement is predictable and safe antenatal transfer of mother is by the obstetric staff in the postnatal care of the baby possible. Postnatal transfer of babies to the correct level and family is especially helpful when the outcome is of unit after delivery also needs to be available. This ongoing com- neonatal transfer services are evolving that have the munication between the antenatal and postnatal teams expertise and equipment and thus help to avoid deplet- improves quality of care for the individual family and for ing specialist staff from the either the referral unit or the all babies in general, as open dialogue fosters respect specialist centre. In order to facilitate family involve- ment, it is also expected that the infant should be cared Providing the appropriate level of care for the mother for within the network rather than being transferred and/or her baby requires careful planning and well‐ great distances. Managed neonatal clinical networks Birth and postnatal adaptation: neonatal resuscitation Managed health service networks aim to deliver appro- priate healthcare to a defined local population in the Only 1% of normal birthweight babies require active most effective and efficient manner. Although the need for resuscitation may be Department of Health Toolkit for High‐Quality Neonatal predictable based on risk factors, 30% of babies requiring Services [6] set the standards of care that should be pro- resuscitation are not predicted. Included in these rec- risk of not making a successful adaptation without assis- ommendations was the stipulation that neonatal care tance include those in the following groups: preterm should be delivered in managed clinical networks. The level of meconium‐stained liquor, malpresentation and breech, care provided by each hospital is based on resources, multiple pregnancies, caesarean section under general capacity, geography and the availability of appropri- anaesthesia or for fetal distress, risk of fetal infection and ately skilled and trained staff. The development of coterminous maternity net- that all professionals present at the time of birth are pro- works are also enhancing the organization of perinatal ficient in resuscitation of the newborn [7]. These units have 24‐hour cover from specialized nursing staff and neona- tal specialist doctors. Local neonatal (level 2) units pro- Antenatal and newborn screening vide respiratory support for babies of 28 weeks’ gestation or more and special care (level 1) units provide care Antenatal screening continues after birth with newborn for babies that do not require respiratory support for screening programmes. In England and Wales, there were 700 000 liveborn babies in 2013, 7% preterm and 1. England Wales Scotland Ireland the infant mortality rate (deaths at less than 1 year of age) in term infants was 3. Of those born at less than 32 Cystic fibrosis √ √ √ √ weeks of gestation, 15% resulted in an infant death and this Sickle cell disease √ √ √ √ accounted for over half of all infant deaths. Variation may Phenylketonuria √ √ √ √ be due to methodological differences such as case ascer- Medium‐chain acyl √ √ √ √ tainment, selection bias, and varying outcome definitions dehydrogenase deficiency and follow‐up duration. Reports from geographically Maple syrup urine disease √ √ – – defined population‐based studies show lower survival rates than single‐centre selective studies that are subject to bias. Isovaleric acidaemia √ √ – – Variation in preterm birth rates (all births) also appears Glutaric aciduria type 1 √ √ – – to have a major influence on reported neonatal mortal- Homocystinuria √ √ – – ity rates between populations. European regions, the delivery rate per 1000 births +6 between 22 and 31 weeks in two regions in England (Trent: 16. Live birth influence antenatal management of mother and fetus rates showed similar trends. When comparisons were and, in some cases, postnatal management of the made between regions after adjustment for prematurity newborn. The specific and whether neonatologists perform resuscitation and areas included are the detection of congenital cata- redirection of care during intensive care, all potentially racts (red reflex), congenital heart disease, develop- have effects on reported survival and outcome. There are limited data on longer‐term morbidity in this group but recent reports suggest this neglected area should be Neonatal outcome studied in greater detail. There are five times more late preterm babies born than babies born before 32 weeks’ Prematurity gestation and therefore as a group require considerable Prematurity is the major determinant of neonatal out- healthcare resources. Overall rates do not appear to be changing signifi- the following two decades, the use of antenatal corticos- cantly as survival increases, but there is concern that the teroids, use of surfactant and improvements in respira- absolute prevalence will increase with increased survival tory support have resulted in striking improvements in of the most immature babies. During the study regionalized neonatal care was percentage of those with developmental impairment poorly developed. During the school years this domain of during 2006 for babies born between 22 and 26 weeks’ impairment is even more significant. Less severe impairments are more common and include squints and refractive errors. Neonatal mortality and early morbidity Academic attainment Neonatal death in preterm births is largely due to Cognitive impairment appears to be the major determi- respiratory complications, periventricular haemorrhage nant of school performance. Antenatal steroids, the use of early sur- 20% of very low birthweight babies require special edu- factant and continuous positive airway pressure are all cation and for those in regular schools, 25% repeat a year associated with a reduction in death and morbidity. Statements of palsy, poor cognitive performance and sensory impair- Special Educational Needs were issued for 34% of the ments (visual and auditory deficits). The definitions used for neurodevelopmental impairments and disability between studies are not uni- Behavioural/psychiatric sequelae form but more rigorous definitions are evolving. A meta‐analysis functional impairments, including non‐ambulatory cere- of six follow‐up studies revealed a relative risk of 2. Neuromotor domain Although cerebral palsy is the most commonly quoted Outcome in teenage and adult survivors outcome after very preterm birth, developmental and Various functional limitations occur in 86% of early teen- cognitive impairments are more common. Growth dis- refers to static injury to the developing brain that affects orders (49%), mental or emotional problems (58%), motor function. Different patterns are described and restrictions on physical activity (32%) and visual impair- most commonly after preterm birth spastic diplegia is ment (31%) are found and 75% use aids such as spectacles found. Other morbidity Many preterm survivors experience less severe problems Important clinical conditions such as clumsiness, visual impairment (e. The most common reasons for babies to require neonatal Respiratory management or admission are management of prematu- More than 50% of extremely low birthweight babies rity, respiratory distress and possible infection. These admissions Common problems in neonatal care are usually due to respiratory illness precipitated by lower respiratory infections. The rate is higher as birthweight and gestation mia due to their reduced body fat and energy stores. Significant airflow limitation on lung function tests this reason, the temperature of the delivery room should is found in adolescent survivors. Also, delivering very pre- term infants into a plastic bag significantly increases Growth their temperature on admission to the neonatal unit and Growth failure is common during infancy and early improves early survival [16]. Despite this catch‐up, extremely low birth- Respiratory distress syndrome (surfactant deficiency) weight babies remain at a height disadvantage to normal the respiratory distress syndrome caused by inadequate birthweight controls. In the longer term, there are con- surfactant production is mainly a disease of the preterm cerns that accelerated weight gain may lead to increased infant. However, it can occur in term infants, particularly risk of hypertension and other cardiovascular diseases as those of diabetic mothers or after caesarean section well as type 2 diabetes. The classical clinical pres- Effect on family entation is an infant with tachypnoea, subcostal and the psychological distress that parents of high‐risk pre- intercostal recession and nasal flaring that becomes pro- term babies experience is greatest during the first month gressively worse over the first 60 hours after birth, and after birth and persists for the first 2 years. The greatest chest radiography shows a ground‐glass appearance with effect of stress is found in families of low income and air bronchograms.

The severity of disease is influenced not only by maternal and placental factors but also likely by paternal and environmental factors [47] cheap hyzaar blood pressure medication ok for pregnancy. Management Though all of the complications of preeclampsia can be treated discount hyzaar generic pulse pressure variation, the ultimate treatment for preeclampsia is delivery safe 12.5mg hyzaar arrhythmia management institute of south florida. Patients who are preterm without evidence of severe features can be managed expectantly with close monitoring until term gestation is reached (37 weeks) or severe features develop discount 50 mg hyzaar with visa blood pressure log sheet printable. For selected patients remote from term with severe features, expectant management can be undertaken at a tertiary care center [45]. It has been shown to be superior to other antiepileptics for the prevention of seizure activity [48,49]. In severe refractory cases, muscle paralysis with general anesthesia and ventilatory support may be needed [48]. Diuresis is indicated when there is fluid overload, although this is rare because most patients are volume depleted. Miscarriage is common (up to 25% of pregnancies), and significant bleeding requiring transfusion, while rare, does occur [51]. Another less prevalent (∼2% of pregnancies) cause of hemorrhage during the first trimester is ectopic pregnancy. Rupture of an ectopic pregnancy can be a life-threatening emergency and aggressive monitoring of hemodynamic status, fluid resuscitation, and administration of blood products may be required. Vaginal bleeding in the second and third trimester is less common but may be a medical emergency dependent on etiology; the possibilities are described below. This diagnosis is uncommon, occurring in ∼4/1,000 births [52], but the sequelae of this condition has the potential for severe bleeding. Classically, the patient with placenta previa will resent with painless vaginal bleeding; however, some women will present with pain or contractions in association with bleeding [53,54]. Any woman without an ultrasound documenting placental location who presents with bleeding should undergo ultrasound evaluation for placental location. Ultrasound should be performed prior to digital examination of the cervix to avoid palpation of the placenta and severe hemorrhage. Women with placenta previa are at increased risk of hemorrhage during the antepartum, intrapartum, and postpartum periods [55]. They are therefore more likely to undergo blood transfusion, peripartum hysterectomy, uterine artery embolization to have a placenta accreta [56]. Maternal mortality secondary to previa is low in resource-rich countries; however, in the third world, this remains a high risk of maternal mortality [56]. Because the risk of severe bleeding and emergent, unscheduled delivery outweigh the risks of late preterm birth, delivery of patients with known previa is recommended by cesarean section between 36 and 37 weeks of gestation [57,58]. Though an actively bleeding placenta previa is a potential emergency, most cases of acute bleeding are self-limited. If the bleeding is active, both the mother and fetus should be closely monitored and supportive care provided. Indications for emergent cesarean delivery include refractory, life-threatening hemorrhage, non-reassuring fetal status or a significant bleed after 34 weeks of gestation. A course of antenatal corticosteroids should be given for fetal benefit given the potential for preterm delivery. When delivery is undertaken, close coordination and planning with anesthesia should be undertaken as the presence of previa increases the risk of hemorrhage and placenta accreta and percreta. Abruption Placenta Placental abruption is the premature separation of the placenta from the uterus (prior to the delivery of the infant). The clinical presentation of abruption is vaginal bleeding with associated uterine pain or contractions. The bleeding may be vaginal or confined to the uterus, so the amount of vaginal bleeding is not a reliable indicator of severity. Ultrasound is not a reliable indicator of abruption (only 2% of abruption can be visualized on ultrasound). If coagulopathy occurs, resuscitation with blood- replacement products such as fresh-frozen plasma or cryoprecipitate should occur [59]. If the patient is preterm and the abruption is limited and fetal status is not affected, potential inpatient surveillance can be undertaken. Other causes include retained products of conception, lacerations of the cervix and vagina, and unrecognized coagulopathies [60]. Blood loss of more than 500 mL at vaginal delivery or 1,000 mL at cesarean section is classified as postpartum hemorrhage. Delayed hemorrhage, 3 to 7 days postpartum, most often is due to retained placental fragments or unrecognized congenital coagulopathies [60]. Manual exploration of the uterus is performed both to assess tone and to apply uterine massage if atony is noted. Methergine, misoprostol and Hemabate may all be used and the order in which they are used does not appear to be important. An intrauterine examination under anesthesia for retained products and dilatation and uterine curettage may be performed. If all measures have failed to resolve the bleeding, hysterectomy may be employed as a last resort [64–66]. Clinically, patients present with sudden onset of cardiovascular and respiratory collapse at or around the time of delivery [68]. When amniotic fluid enters the intervascular space, vasoactive and fibrinolytic components precipitate cardiovascular collapse and respiratory failure. Extra corporeal membrane oxygenation has been used to rescue patients with refractory cardiorespiratory collapse. Trauma Complicating Pregnancy Trauma is the most common cause of death during pregnancy not related to obstetric factors. Motor vehicle accidents and domestic violence make up the majority of cases; however, there are many other potential causes of trauma. Though trauma is a common occurrence during pregnancy, less than 1% will require hospitalization [72]. Because of these, particularly the increased blood volume, the pregnant trauma patient is less likely to immediately manifest signs of shock. The abdominal position of the uterus in the third trimester makes this organ more susceptible to both blunt and penetrating trauma. As the uterus grows, the bladder is pulled superior and rendered more susceptible to traumatic injury in pregnancy. Following blunt injury secondary to a motor vehicle accident, placental abruption is the most common complication associated with the pregnancy. Contraction monitoring with a tocometer has a high negative predictive value for abruption and most abruptions will occur during the first 4 to 8 hours postinjury. No consensus exists as to the length of the post-trauma monitoring interval, but at least 4 hours is recommended [77,78]. As small amounts of fetal blood may enter the maternal circulation, all patients require blood type and screen, and Rh-negative patients should receive Rhogam.