Trauma in pregnancy, older people and anticoagulated patients

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Special populations require the same decisive trauma care with more cautious interpretation. Standard airway, breathing, circulation, disability and exposure priorities remain. Pregnancy changes anatomy and physiological reserve; frailty makes mechanisms and vital signs less reliable; anticoagulants make bleeding disproportionate and laboratory interpretation agent-specific. The safest approach is to name the modifier during the initial brief, call appropriate specialists early and document how it changes positioning, imaging, drugs and destination.

In pregnancy, maternal oxygenation and perfusion are the immediate fetal treatments. After roughly twenty weeks, the uterus can compress the inferior vena cava and aorta when supine, reducing preload. Use manual left uterine displacement or a left tilt compatible with spinal protection and procedures. Secure a threatened airway early because oedema and reduced oxygen reserve accelerate desaturation. Obtain gestation, rhesus status and obstetric symptoms, but never delay control of maternal haemorrhage for fetal assessment.

Imaging in pregnancy should be justified and optimised, not reflexively withheld. Ultrasound is useful for fetal assessment and some maternal questions but cannot exclude all major injury. CT head, spine or contrast-enhanced torso imaging proceeds when it is the best test for a serious maternal threat. Involve radiology promptly to limit unnecessary phases and repeats. Fetal monitoring and ultrasound follow maternal stabilisation and gestation, with obstetric decisions based on viability, contractions, bleeding and suspected abruption.

Older adults can have severe injury after a standing-height fall. Osteoporosis predisposes to cervical, thoracic, pelvic and hip fracture; anticoagulation raises intracranial risk; stiff chest walls and lung disease worsen rib injury. Baseline hypertension can make a conventionally normal pressure relatively low, beta-blockers blunt tachycardia and cognitive impairment obscures pain. Ask witnesses and carers about baseline cognition, mobility and medicines, but perform complete exposure and imaging before attributing confusion or immobility to frailty.

Frailty care starts during resuscitation. Use careful weight-based medicines, avoid unnecessary sedative and anticholinergic burden, correct vision and hearing barriers, treat pain, maintain warmth and hydration, and remove catheters or lines when no longer needed. Early orthogeriatric, pharmacy, therapy and nutrition involvement reduces delirium and deconditioning. Seek the cause of a fall—ECG, glucose, lying and standing pressure when safe, infection and medication review—after urgent injuries are addressed.

Anticoagulant assessment must identify the actual agent. Warfarin effect is measured by INR; dabigatran is affected strongly by renal clearance; apixaban, rivaroxaban and edoxaban may not prolong routine tests reliably. Establish last dose, renal function and thrombotic indication. Obtain urgent CT head under NICE criteria and image other suspected bleeding sites. Life-threatening bleeding requires immediate drug cessation, local major-haemorrhage activation and an agent-specific reversal decision with haematology or transfusion support.

Reversal is not the end of treatment. Prothrombin-complex concentrate dosing for warfarin is product- and INR-based and is given with intravenous vitamin K; the emergency protocol provides the exact dose. Idarucizumab is a specific dabigatran antidote, while factor-Xa inhibitor strategies depend on bleed site, licence, national recommendations and availability. After control, document the original indication and set a daily plan for mechanical prophylaxis, pharmacological prophylaxis and anticoagulant restart, balancing rebleeding against stroke or venous thrombosis.

Key points

Use the standard trauma sequence for all three groups; differences modify thresholds, positioning, doses and follow-up rather than replacing CABCDE priorities.
Resuscitate the pregnant patient first and avoid supine aortocaval compression in later pregnancy with manual uterine displacement or left tilt that does not compromise spinal care.
Do not withhold necessary CT or contrast because of pregnancy; discuss optimisation promptly, but maternal diagnosis and survival take priority over theoretical radiation risk.
Involve obstetrics early, determine gestation and rhesus status, and arrange fetal assessment appropriate to viability after maternal stabilisation; give anti-D according to the maternity protocol when indicated.
Treat low-energy falls in frail older people as potentially major: fully expose, examine spine, chest, pelvis and head, reconcile baseline cognition and mobility and use a lower imaging threshold.
Identify anticoagulant name, indication, last dose, adherence, renal function and interacting drugs immediately; send coagulation tests but recognise routine PT or APTT may not exclude direct-oral-anticoagulant effect.
For warfarin-associated traumatic intracranial haemorrhage, NICE supports immediate prothrombin-complex concentrate with intravenous vitamin K through the emergency reversal protocol.
After haemostasis, reassess reversal, thromboprophylaxis and anticoagulant restart daily with the relevant specialist because both recurrent bleeding and thrombosis are time-dependent.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Pregnancy-related exposure

Road collisions, falls and assault remain common mechanisms, while the gravid uterus and altered centre of gravity change injury distribution and fetal risk.

Frailty and low-energy falls

Sarcopenia, osteoporosis, sensory impairment, polypharmacy and environmental hazards produce head, rib, spine, pelvis and hip injury from modest force.

Antithrombotic-associated bleeding

Warfarin, direct oral anticoagulants, heparins and antiplatelet drugs amplify traumatic bleeding, with renal impairment and interacting medicines prolonging effect.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Pregnancy compensation
Increased circulating volume may delay obvious maternal hypotension despite important loss, while aortocaval compression after mid-pregnancy reduces venous return when supine.
2
Placental vulnerability
Shearing can cause placental abruption without major external injury; maternal hypoxia and hypotension rapidly impair uteroplacental perfusion.
3
Reduced physiological reserve
Frailty, cardiac disease, impaired thermoregulation and limited renal reserve increase decompensation, delirium and complications after injury or treatment.
4
Impaired coagulation
Anticoagulants inhibit vitamin-K factors, thrombin or factor Xa; trauma, renal dysfunction, hypothermia and tissue injury can compound the resulting haemostatic defect.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Aortocaval compression

Later pregnancy with supine hypotension, pallor or nausea that improves with uterine displacement suggests reduced venous return, while haemorrhage must still be excluded.

Placental abruption

Abdominal or back pain, uterine tenderness, contractions, vaginal bleeding or fetal abnormality may occur after trauma, and visible blood can underestimate concealed loss.

Occult frailty injury

New immobility, focal tenderness, guarding, delirium or functional decline after a fall may be the only evidence of vertebral, pelvic, hip or rib fracture.

Relative shock in older age

A normal-range pressure can represent marked decline from baseline, while beta-blockade, pacing or autonomic disease can remove compensatory tachycardia.

Clinically relevant anticoagulation

Recent dose, renal impairment, interacting medicines or raised INR increases bleeding concern even when routine examination and early haemoglobin are reassuring.

Recurrent neurological decline

New headache, vomiting, confusion, focal deficit, seizure or GCS fall after head impact requires immediate reassessment and CT regardless of earlier appearance.

Red flags requiring action

Pregnancy with shock, abdominal pain, vaginal bleeding, uterine tenderness, contractions or reduced fetal movement requires maternal resuscitation plus immediate obstetric assessment for abruption, uterine injury and fetal compromise.
An older person with new confusion, inability to mobilise, focal spine or groin pain, chest-wall tenderness or anticoagulant exposure may have major occult injury after a seemingly minor fall.
Head impact, neurological change, persistent vomiting, unexplained haemoglobin fall, expanding bruising or hypotension in an anticoagulated patient requires urgent imaging, drug identification and reversal planning.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
First-line maternal trauma assessmentFirst stepFirst line
Why
Identify life threats and pregnancy modifiers without delaying resuscitation.
Interpretation and limitations
Use continuous observations, blood gas, FBC, group and crossmatch, coagulation and abdominal examination; determine gestation and rhesus status alongside, not ahead of, maternal care.
02
Obstetric and fetal assessment
Why
Detect abruption, labour and fetal compromise after maternal stabilisation.
Interpretation and limitations
Use cardiotocography when gestation and local criteria support it, ultrasound for fetal and placental information and senior obstetric review; normal ultrasound does not exclude abruption.
03
Preferred CT when serious injury is suspectedPreferred
Why
Diagnose maternal head, spine, thoracic, abdominal or pelvic injury accurately.
Interpretation and limitations
Do not delay necessary imaging because of pregnancy; radiology should optimise coverage and avoid repeats while the result drives maternal treatment.
04
Older-person targeted imaging
Why
Find injuries concealed by frailty, osteoporosis or unreliable examination.
Interpretation and limitations
Use a lower threshold for CT head, cervical spine, chest or pelvis based on focal signs and NICE criteria; plain radiographs may miss sacral and vertebral fractures.
05
Anticoagulant identification panel
Why
Estimate residual drug effect and choose reversal.
Interpretation and limitations
Check INR for warfarin, renal function, FBC, group and crossmatch and agent-specific assays when rapidly available; normal PT or APTT cannot reliably exclude all DOAC activity.
06
Medication and fall assessment
Why
Identify reversible contributors after immediate injuries are addressed.
Interpretation and limitations
Reconcile prescriptions and recent changes, obtain ECG and glucose, assess infection and perform orthostatic testing only when safe; distinguish cause from consequence of the fall.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Medical cause of the fall

Arrhythmia, orthostatic hypotension, infection, stroke, seizure, hypoglycaemia and medication adverse effects may have precipitated trauma and need concurrent investigation.

Obstetric emergency

Placental abruption, uterine rupture, labour, pre-eclampsia or pulmonary embolism may coexist with or mimic trauma-related pain, shock and breathlessness.

Delirium without head injury

Pain, urinary retention, hypoxia, infection and drugs cause acute confusion, but intracranial bleeding and cervical injury require active exclusion first.

Spontaneous anticoagulant bleed

Retroperitoneal, gastrointestinal or intracranial haemorrhage may cause collapse and secondary fall, changing the search from impact site to primary bleeding source.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01PregnancyResuscitate mother and assess fetusFirst stepA pregnant patient has sustained potentially significant trauma.

1Run CABCDE, provide spinal protection as indicated and use manual uterine displacement or compatible left tilt in later pregnancy while treating maternal threats.
2Activate trauma, anaesthetic and obstetric teams, establish gestation and rhesus status and control haemorrhage with standard maternal priorities.
3Proceed with the best indicated maternal imaging after rapid radiology optimisation; do not substitute limited ultrasound for necessary CT.
4After stabilisation, monitor fetus and uterine activity according to gestation and symptoms and follow the maternity anti-D and fetomaternal-haemorrhage pathway.

02Older personFind occult injury and preserve functionLow-energy mechanism, frailty, abnormal function or unreliable examination raises concern.

1Establish baseline cognition, mobility, residence and medicines from the patient and collateral source while completing full trauma exposure and examination.
2Use age- and finding-appropriate CT or targeted imaging with a low threshold for head, cervical, chest and pelvic injury.
3Treat pain, hypoxia, hypothermia, dehydration and sensory barriers while avoiding unnecessary sedatives, restraints and invasive devices that precipitate delirium.
4Involve orthogeriatrics, pharmacy, therapy and falls services early and define mobility, nutrition and discharge goals from baseline function.

03AnticoagulationStop bleeding and reverse preciselyPotentially life-threatening bleeding or traumatic intracranial haemorrhage occurs during antithrombotic treatment.

1Stop the anticoagulant, determine agent, last dose, indication and renal function, activate major-haemorrhage support and obtain urgent source-directed imaging.
2Use the current local and national agent-specific reversal pathway with haematology or transfusion input; give PCC plus intravenous vitamin K promptly for warfarin-associated intracranial bleeding.
3Achieve surgical, endovascular or other source control and repeat neurological, haemoglobin, coagulation and renal assessment after reversal.
4Document thrombosis risk and review mechanical prophylaxis, pharmacological prophylaxis and anticoagulant restart every day after haemostasis.

Key medicines and prescribing safety2 treatments · regimens, roles and cautions

Rapidly replaces vitamin-K-dependent factors in major warfarin-associated bleeding, including traumatic intracranial haemorrhage, while definitive haemostasis proceeds.

Four-factor prothrombin-complex concentrate for warfarin reversal

For emergency warfarin reversal, use the selected four-factor PCC product's INR- and weight-based intravenous regimen; for Beriplex, factor IX doses are 25, 35 or 50 IU/kg at INR 2–3.9, 4–6 or above 6, capped at 2,500, 3,500 or 5,000 IU respectively.

Give with intravenous vitamin K under the emergency protocol, recheck INR and watch for thrombosis; confirm product-specific dosing because units and maximums must not be transferred between PCC brands.

Provides sustained restoration of vitamin-K-dependent factor synthesis after the short-lived infused factors from PCC decline.

Phytomenadione for emergency warfarin reversal

Give vitamin K1 5–10 mg by slow intravenous injection with PCC for severe bleeding, following the current local reversal protocol and selected product instructions.

Intravenous administration can rarely cause serious hypersensitivity, so give slowly with monitoring; vitamin K alone acts too slowly for life-threatening haemorrhage and can complicate later anticoagulation restart.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Fetal loss or preterm birth

Maternal shock, abruption, uterine injury and fetomaternal haemorrhage can cause fetal compromise even when maternal external injuries seem limited.

Delayed intracranial deterioration

Anticoagulant exposure and cerebral atrophy increase intracranial bleeding risk and space for initially occult haematoma before neurological decline.

Delirium and deconditioning

Pain, immobility, sleep disruption, catheters and medication burden rapidly reduce function and independence in a frail older person.

Reversal-related thrombosis

Stopping and reversing anticoagulation protects haemostasis but re-exposes the original thrombotic indication, requiring daily restart assessment after control.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

In pregnancy, trend maternal physiology continuously and document uterine displacement, gestation, fetal plan, rhesus status and obstetric symptoms.
In older adults, repeat cognition, pain, respiratory function, skin, hydration and mobility assessment and compare with a collateral baseline.
For anticoagulant bleeding, trend neurological status, haemoglobin, renal function and agent-relevant coagulation or drug levels after reversal and source control.
Monitor for thrombosis after reversal and record daily decisions on mechanical prophylaxis, pharmacological prophylaxis and treatment anticoagulation restart.
Ensure incidental imaging findings, falls causes, safeguarding concerns and medication changes have named follow-up owners at transfer and discharge.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Maternal care is fetal care

Airway oxygenation, left uterine displacement, perfusion and haemorrhage control improve fetal status more reliably than delaying for fetal tests.

Frailty changes thresholds

A minor mechanism label should not overrule new inability to mobilise, focal pain or altered cognition in an older person.

Normal routine coagulation can mislead

PT and APTT have variable sensitivity to direct oral anticoagulants and cannot universally clear clinically relevant exposure.

Reversal has a second risk

Restoring coagulation controls bleeding but removes stroke or venous-thrombosis protection, making restart planning part of initial care.

Baseline function is a vital sign

Cognition, mobility and independence before injury provide the reference needed to detect deterioration and plan meaningful recovery.

11Common pitfallsFrequent interpretation and management errors.

01
Allowing fetal assessment to delay maternal airway, oxygenation, circulation or haemorrhage control.
02
Withholding necessary maternal CT solely because ionising radiation is involved.
03
Calling a standing-height fall minor despite new immobility, delirium or focal tenderness.
04
Using absence of tachycardia to exclude shock in beta-blocked or paced older patients.
05
Assuming a normal PT or APTT proves no direct-oral-anticoagulant effect.
06
Reversing anticoagulation without documenting the indication and a daily restart plan.