Trauma x Two: The Pregnant Victim

1. Trauma x Two: The Pregnant Victim Douglas S. Ander, MD Emory University School of Medicine Professor of Emergency Medicine Assistant Dean for Medical Education

2. Disclosures • “I, Douglas Ander, have no real or perceived vested interests that relate to this presentation nor do I have any relationships with pharmaceutical companies, biomedical device manufacturers, and/or other corporations whose products or services are related to pertinent therapeutic areas.”

3. Frequently Asked Questions • What are the statistics? • What is the role of domestic violence? • How do the physiologic changes of pregnancy affect management? • How to I recognize the possibility of fetomaternal injuries? • How do I recognize abruptio placenta? • What do I need to know about fetal monitoring? • Should pregnant women wear seatbelts? • What do I do when my patient codes? • What is the significance of fetomaternal hemorrhage? • What xrays should I do?

4. What are the statistics?

5. Introduction • Accidental injury occurs in 6-7% of all pregnancies • Trauma is the leading cause of maternal death, 46.3% • Overall 6-7% maternal mortality • Fetal mortality 61% in major trauma, 80% if cases of maternal shock • < 1% of trauma admissions are pregnant Peckham CH et al. Am J Ob Gyn 1963;87:609 Fildes J et al. J Trauma 1992;32:643 Connolly A et al. Am J Perinatol 14:331-336, 1997

6. Causes of Trauma Drost et al. J Trauma 1990;30:574.

7. What is the role of intimate partner violence?

8. Domestic Violence • 154 acts of violence per 1000 pregnant women during first 4 months, increases to 170 per thousand during the 5-9th months. • Only 8 of 24 sought medical care • May lead to increased complications • 41.8% vs. 11.8%, P<.01 • 17.1% (assault) vs. 7.1% (MVC) 1985 National Family Violence Study, Helton AS et al. Am J Public Health 1987;77:1337 Pak LL et al. Am J Ob Gyn 1998;179:1140 Goodwin and Breen. Am J Ob Gyn 1990;162:665

9. How do the physiologic changes of pregnancy effect management?

10. Cardiovascular • Plasma volume increases by 50% • Heart rate increases by 10-15 bpm • Cardiac output increases by 40-50% • Total peripheral resistance decreases • Oxygen consumption increases by 20% • Decrease in venous return

11. Cardiovascular • 30-35% decrease in maternal blood flow can cause a 10-20% decrease in uterine blood flow prior to detectable hemodynamic changes in the mother • Warm and pink shock patient

12. Respiratory • Decrease in functional residual capacity • Decreased oxygen reserve • Increased risk of maternal hypoxemia during RSI

13. Gastrointestinal • Decreased motility and tone • Increased risk of aspiration • Stretching of abdominal wall • Decreased response to peritoneal irritation

14. Diaphragm rises 4cm • Perform thoracotomy 1-2 interspaces higher • Compartmentalization of the small intestine into the upper abdomen • Increased risk injury • Uterus may shield the intestines • Increased cardiac output to uterus • Increased risk for significant hemorrhage Anatomic

15. Supine Hypotensive Syndrome Milson I, Forssman L: Am J Obtst Gynecol 148: 764-771, 1984

16. How to I recognize the possibility of fetomaternal injuries?

17. Major Trauma • 24% of the women died • All fetuses expired • Average gestational age 22.4 weeks • Of the 31 who survived • 6 fetal deaths • 4/6 of abruptio placenta • 8/10 women in shock had fetal demise Rothenberger et al. J Trauma 1978;18:173

18. Minor Trauma • Pearlman • 75/75 no fetal death, 3 abruptio placentae • Goodwin • 5 abruptio placentae • Schiff • Relative risk for abruption in non-severe trauma, 3.7 (1.3-7.9) • Morris • 3/5 infants considered salvageable died from mothers with mild to moderate injury, ISS < 16 • Cahill • 317 patients, ISS 0, only 1 abruptio placentae which was unrelated to the trauma

19. How do I recognize abruptio placenta?

20. Recognition of abruptioplacentae - >20 wks • Pearlman et al • No women had an abruption if no uterine contractions were detected or if their frequency was less than every 10 minutes during 4 hours of monitoring after trauma was sustained Pearlman et al. Am J ObstetGynecol 1990;162:1502-1510.

21. Monitoring Recommendations • All women >20-week gestation: • Minimum 6 hours monitoring • Extended to 24 hours if : . >3 contractions per hour . Persistent uterine tenderness . Non reassuring fetal monitor strip . Vaginal bleeding . Rupture of membranes . Serious maternal injury • Controversy based on the minor trauma literature

22. What do I need to know about fetal monitoring?

23. Fetal Monitoring • Heart rate • Bradycardia <110 bpm • Tachycardia >160 bpm • Variability • Presence of decelerations

24. Variability

25. Fetal Monitoring: Late Decelerations • Onset is 30 seconds or more after onset of the contraction, nadir well after the peak contraction and returns to baseline after the contraction is over • Fall of 10-20 bpm • Always believed to indicate fetal distress

26. Seatbelts in pregnancy?

27. Seatbelt Statistics • Most wore restraints before pregnancy, but increased restraint use during pregnancy (79% vs. 86%, chi squared, p = 0.02) • Only 52% - 72.5% used restraints properly • 55.3% reported that restraints would protect their baby, 10.7% harm and 34.0% unsure • If they felt restraints were beneficial they were more likely to always wear restraints ( 84.4% vs. 64.6%, p<0.0001) • Only 21% - 36.9% of women were educated on proper restraint use during pregnancy. Tyroch et al. J Trauma 1999;46:241 Mcgwin et al. J Trauma 2004;56:670

28. Seatbelt Evidence Curet MJ et al. J Trauma 2000;49:18

29. Proper seatbelt use is key Air bag had no effect on force transmission.

30. What do I do when my pregnant trauma patient codes?

31. Resuscitation • Mom first • Most common cause of fetal demise is maternal demise • B-HCG on all child bearing age patients

33. Perimortem Cesarean Section Survival • Maternal CPR <5 minutes, fetal survival excellent • <23 weeks gestation survival chance is 0% • Maternal CPR >20 minutes, fetal survival unlikely

35. Technique

36. Technique • Ideally started within 4 minutes

37. What is the significance of fetomaternal hemorrhage?

38. Fetomaternal Hemorrhage • As little as 5 cc can sensitize Rh-negative women • Increased risk of abruptio placentae and predictor of preterm labor – some controversy • KB analysis all patients >12 week-gestation • Rhogam for all Rh-negative pregnant patients • As a rule can give 300mcg of Rhogam for every 30cc of fetal blood detected in maternal circulation Dahmus MA et al. AM J Ob Gyn1993;169:1054. Goodwin TG et al. Am J Ob Gyn1990;162:665 Rose PG et al. Am J Ob Gyn 1985;153:844 Dhanraj d et al. Amer J Ob Gyn2004;190:1461 Pearlman et al. Am J ObstetGynecol1990;162:1502-1510 Meunch et al. J Trauma 2004;57:1094-1098

39. What xrays should I do?

40. Radiology • Perform clinically indicated studies • Below 5 rads(50 mGy) exposure no significant risk • Shielding of the abdomen provides additional protection by as much as 75%

41. Radiology • Most common fetal malformation caused by high-dose radiation are CNS changes • 2-15 weeks gestation • At least 20 – 40 rad • Slight increase in leukemia • Background rate of leukemia in children is about 3.6 per 10,000 • Exposure to 1-2 rad increases this rate to 5 per 10,000

43. US for Trauma in Pregnancy Negative FAST is valuable Richards et al. Radiology 2004; 233:463–470

44. US for Abruptio Placentae Specific not sensitive Glantz et al. J Ultrasound Med 21:837–840, 2002

45. Xrays to perform? • Those that are clinically relevant Radiation Safety Poster From 1947

46. Trauma in PregnancyKey Points • Remember domestic violence • Consider physiologic changes • Early monitoring and a minimum of 4 hours • Seat belt education • Resuscitate the mother • Rhogam and KB testing • Failed resuscitation consider c-section • Use radiologic procedures appropriately • Ultrasound has value in trauma evaluation

47. Questions? Douglas Ander, MD dander@emory.edu