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Trauma in Pregnancy

Trauma in Pregnancy. Stephen Lu, MD, FACS UNM Department of Surgery. Introduction. Potential for pregnancy in any woman between the ages of 10 and 50 years Pregnancy causes changes involving nearly every organ system in the body There are two patients, the mother and fetus

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Trauma in Pregnancy

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  1. Trauma in Pregnancy Stephen Lu, MD, FACS UNM Department of Surgery

  2. Introduction • Potential for pregnancy in any woman between the ages of 10 and 50 years • Pregnancy causes changes involving nearly every organ system in the body • There are two patients, the mother and fetus • Initial treatment priorities for an injured pregnant patient are the same as for a nonpregnant patient • Consider early surgical and obstetric consultation

  3. Epidemiology • Trauma is the leading cause of maternal mortality in pregnancy • 7% of pregnancies complicated by injury • Injuries requiring ICU care affect 3-4 per 1000 deliveries • Approximately 60% motor vehicle collisions • 10-30% falls and physical abuse

  4. Epidemiology • Incidence of domestic violence complicating pregnancies 5-20% • Associated with 3% maternal and 16% fetal mortality • Sexual abuse has been reported to be as high as 17%

  5. Alterations of Pregnancy: Anatomic

  6. Physiologic Changes • First Trimester • Uterus is intrapelvic and thick-walled • Fetus is protected from direct injury • Risks • Abortion • Isoimmunization

  7. Physiologic Changes • Second Trimester • Uterus is extrapelvic • Large volume of amniotic fluid • Risks • Abruptio placenta • Amniotic fluid embolism • Isoimmunization

  8. Physiologic Changes • Third Trimester • Uterus is thin-walled • Maternal abdominal viscera displaced • Inferior vena cava compression

  9. Physiologic Changes • Third Trimester • Risks • Pelvic fractures with maternal hemorrhage and direct fetal injury • Abruptio placenta • Amniotic fluid embolism • Isoimmunization

  10. Physiologic Changes • Increased • Minute ventilation • Blood volume • Heart rate/cardiac output • Glomerular filtration rate • Gastric emptying time • Leukocytosis • Decreased • pCO2 • Hematocrit

  11. Initial Assessment • Airway • Aspiration risk • Breathing • Difficult ventilation • Circulation • Failure to recognize blood loss early • Disability • Eclampsia • With maternal blood loss, fetal distress precedes change in maternal vital signs

  12. Prehospital Care • Supplemental oxygen • Liberal use of IV fluids • Tilt backboard to left in late pregnancy • Inform receiving institution/obstetric team • If delivery appears imminent, remove clothing to allow fetal delivery

  13. Management • Two patients – mother and fetus • Primary survey/resuscitation of mother • Fetal assessment • Secondary survey of mother • Definitive care of mother and fetus • Rh-negative mothers receive immunoglobulin therapy (unless injury remote from uterus) • Early OB consult

  14. Initial Evaluation and Resuscitation of the Mother • Initial treatment priorities the same • Continue with provision of oxygen, vigorous fluid resuscitation, avoidance of supine hypotension • Thoracostomy tubes should be placed one to two innerspaces higher than usual • Blood products should be Rh negative • Consider eclampsiavs brain injury

  15. Initial Evaluation and Resuscitation of the Mother • Goals of secondary survey- identify maternal injuries, establish viability of pregnancy • All radiographs necessary to fully evaluate the mother should be obtained • DPL, abdominal CT, abdominal ultrasonography can all be used to objectively evaluate the abdomen

  16. Use of Diagnostic Imaging • Attempt to minimize ionizing radiation if alternate modalities may provide similar information • However, in major mechanisms or hemodynamic instability benefits of CT imaging far outweigh fetal risks of radiation

  17. Use of Diagnostic Imaging • Shield fetus if possible • Typical effective doses • CXR (0.002 rad) • Pelvic XR (0.06 rad) • CT abdomen/pelvis (1.5 rad)

  18. Use of Diagnostic Imaging • Risks • Loss of viability greatest within 2 wks of conception, exposure >50 rads • Radiation induced malformation during organogenesis (2-7wk) • Risk increases above 5 rads • Growth retardation above 50 rads • Little data for cancer risk • CDC states risk increases to 1-6% when cumulative exposure >50 rad

  19. Maternal-Fetal Circulation Considerations • The American College of Obstetrics and Gynecology has recommended consideration of D-immunoglobulin (RhoGAM) for all unsensitized Rh negative pregnant patients who are evaluated for abdominal trauma. • Kleihauer-Betke testing should only be used to quantitate the necessary dose of immunoglobulin

  20. Initial Evaluation of the Fetus • Resuscitation of the fetus requires resuscitation of the mother • Examine uterus for size, tenderness, contractions • Pelvic examination • Evaluate fetal heart tones

  21. Initial Evaluation of the Fetus • Consider fetal injury with • Vaginal bleeding • Abruption placenta • Uterine tenderness • Uterine rupture • Labor

  22. Ultrasonography

  23. Ultrasonography • Goodwin et al 2001 • Abdominal ultrasound examination in pregnant blunt trauma • FAST exams in 177 pregnant women • 85% second or third trimester • Sensitivity 83% • Specificity 98%

  24. Cardiotocographic Monitoring (CTM)

  25. Predicting Fetal Outcome after Trauma • Curet MJ; Schermer CR; Demarest GB; J Trauma, 2000 • Retrospective chart review 1/90-12/98 • 15,268 admitted trauma patients • 271 pregnant patients with blunt trauma

  26. Risk Factors for Contractions/Preterm Labor • Gestational age >35 wk • Assaults • Pedestrian collisions

  27. Risk Factors for Fetal Death • Ejections, motorcycle and pedestrian collisions • Maternal tachycardia, ISS>9, maternal death • Placental abruption • Abnormal fetal heart rate

  28. Recommendations • Pregnant patients who present after blunt trauma with risk factors for contractions, preterm labor, or fetal loss should be monitored for at least 24 hours. • Patients without these risk factors can be monitored for 6 hours before discharge.

  29. Treatment of Injuries During Pregnancy • In general, injuries are treated in a similar fashion to those occurring in nonpregnant individuals • Indications for cesarean section: • Uterine injury • Maternal shock in near-term pregnancy • Severe DIC • Mechanical limitation to repairing maternal injuries secondary to presence of uterus • Fetal distress during operative therapy

  30. Fetal Outcome after Cesarean Section for Trauma • Morris, JA et al; Annals of Surgery, 1996 • Multicenter retrospective study of 441 pregnant patients, 32 emergency cesarean sections • Fetal viability defined by EGA >=26wk, presence of FHT • No FHT, survival = 0% • Present FHT, EGA >= 26wk; survival = 75%

  31. Conclusions • The anatomic and physiologic changes of pregnancy may influence the evaluation and treatment of the injured pregnant patient • Aggressively prevent and correct maternal and fetal hypoxemia and shock • Obtain surgical and obstetric consultation early in the evaluation of the pregnant trauma patient

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