Managing Trauma in Pregnancy: Critical Care Approach

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