Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

For patients with trauma (obstetric and non-obstetric) sustained during pregnancy, what is the comparative effectiveness of diagnostic interventions for rapid

assessment of trauma to improve maternal and fetal outcomes?

For patients with trauma sustained during pregnancy what is the indication for and the comparative effectiveness of medical interventions (including hemodynamic stabilization, critical care medications, surgery and multidisciplinary team approaches) and harms and benefits to prevent further harms (medical and obstetrical complications) to mother and baby as a result of the trauma?

What is the effectiveness and comparative effectiveness of training methods (including programs, modules) for obstetric and emergency providers in the management of trauma during pregnancy?

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

hemodynamic agents

fluid resuscitation

medications including vasopressors

antithrombotic therapy, antiplatelet anesthetic agents imaging studies for diagnostic assessment, fetal doptones, ultrasound simulation models for training different laboratory, radiologic and physical diagnostic methods (as applicable, ie leopold manuever) to survey trauma in victim in different hospital settings and geographic locations (rural vs. urban, private vs. academic hospital)

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

obstetrical patients (women > 18 years to AMA, all racial-ethnic groups) low risk and high risk pregnancies

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

per above pregnancy, all trimesters geographic settings (rural vs. urban, community vs. academic settings) Low socioeconomic status African- Americans American-Indians Latino Asian

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

including but not limited to reduction in - maternal morbidity

maternal mortality fetal morbidity fetal mortality term delivery normal birth and neonatal course reduced length of stay in emergency room and hospital reduced risk for hospital acquired infections reduction in unnecessary interventions during pregnancy

Describe any health-related risks, side effects, or harms that you are concerned about.

including but not limited to - shoulder dystocia, orthopedic neonatal injuries forceps delivery placental abruption developmental disabilities bleeding/exsanguination/thrombosis maternal morbidity maternal mortality fetal morbidity fetal mortality preterm labor

preterm birth premature rupture of membranes uterine rupture sepsis still birth burns feto-maternal hemorrhage thoracoabdominal trauma perimortum emergent cesearean transfusion

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Developmental delays, attention-deficit hyperactivity disorder, and autism
• Functional limitations and disability
• Pregnancy, including preterm birth

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women
• Children
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• State Children's Health Insurance Program (SCHIP)

Importance

Describe why this topic is important.

In the United States, trauma is the leading nonobstetric cause of maternal death. The principal causes of trauma in pregnancy include motor vehicle accidents, falls, assaults, homicides, domestic violence, and penetrating wounds. The managing team evaluating and coordinating the care of the pregnant trauma patient should be multidisciplinary so that it is able to understand the physiologic changes in pregnancy and the impact of trauma. Blunt trauma to the abdomen increases the risk of placental abruption. Evaluation of the pregnant trauma patient requires a primary and secondary survey with emphasis on airway, breathing, circulation, and disability. Treatment approaches may be individualized and guided by a coordinating team effort to improve both maternal and fetal conditions. Understanding the role of fetal and maternal physiologic factors in conjunction to determining which assessment and intervention strategies to most effectively treat the obstetric trauma victim with minimal harms and adverse outcomes is important to guide health care providers and policy makers on best clinical practices in hospital, urgent and emergency care settings.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

Direct common clinical encounters I've observed in emergency and urgent care settings and various consultations with emergency care providers managing women's health conditions in acute care settings led to my nomination.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Understanding the variations in clinical care and having an transparent foundation of what constitutes the best evidence for the standard of clinical care management in the context of emergencies which occur during the course of pregnancy will be helpful to guide health systems, providers, trainees in emergency medicine and family practice and will also inform patients of what types of emergencies can occur during pregnancy and what are the diagnostic and treatment approaches available.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

Meets AHRQ priority conditions and per above will help inform diagnostic decisions, also aims to evaluate and analyze ALSO guidance, do a rigourous systematic review of models for emergency training and provide the evidence on modalities health systems, patients and providers can consider to enhance safety, prevent trauma and reduce adverse maternal, fetal and neonatal short and long-term outcomes in the event trauma occurs.

Describe the timeframe in which an answer to your question is needed.

10-13 months

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

this review should explore any health disparities in subpopulations in the evaluation and treatment of emergencies during pregnancy.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

Meets AHRQ priority conditions and per above will help inform diagnostic decisions, also aims to evaluate and analyze ALSO guidance, do a rigourous systematic review of models for emergency training and provide the evidence on modalities health systems, patients and providers can consider to enhance safety, prevent trauma and reduce adverse maternal, fetal and neonatal short and long-term outcomes in the event trauma occurs.

Are you making a suggestion as an individual or on behalf of an organization?

Individual

Please tell us how you heard about the Effective Health Care Program

Medical Officer & Physician