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Trauma in Pregnancy

Trauma in Pregnancy. James Huffman Resident Rounds – October 12, 2006 Thanks to Yael and Shawn. Epidemiology. Trauma occurs more often during the 3 rd trimester than at any other time in a woman’s life 7% of pregnancies are complicated by trauma

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Trauma in Pregnancy

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  1. Trauma in Pregnancy James Huffman Resident Rounds – October 12, 2006 Thanks to Yael and Shawn

  2. Epidemiology • Trauma occurs more often during the 3rd trimester than at any other time in a woman’s life • 7% of pregnancies are complicated by trauma • It is the leading cause of maternal death, accounting for 46% of fatalities in pregnant women • Most common causes are MVCs, falls, assults, and domestic violence plays a very significant role in this population

  3. Challenges • Smaller evidence base • Two patients • Determining fetal viability • Physiologic and anatomic changes • 1-3% of minor trauma results in fetal death!

  4. Approach • Four groups: • Early pregnancy – mothers not aware, vulnerable to radiation • Fetus not yet viable – well protected in bony pelvis, required maternal survival for development • Viable pregnancies (>24-26 weeks) – most challenging, two patients to consider • Perimortem – resuscitation +/- C-section • Being pregnant does not affect maternal survival • The most common causes of fetal death are maternal death and placental abruption*

  5. Anatomic Changes • Uterus – pelvic in T1, then pushes structures out of the way • Decreased sensitivity to peritoneal injury • Pelvic outlet widening • Symphysis pubis and SI joint spaces increase in the 7th month  pelvic x-rays • “Supine Hypotensive Syndrome” • At >20 weeks GA, the uterus can compress the IVC, decreasing preload

  6. Cardiovascular Changes Some changes present like shock: • Hypotension • declines in T1, stabilizes in T2, returns to normal in T3 • SBP (2-4 mmHg) < DBP 5-15mmHg • d/t progesterone and supine hypotensive syndrome • Increased baseline HR (usu. 10-15 bpm) • CVP decreases to 4 from 9mm Hg by term Do not attribute changes in BP or HR entirely to physiology – consider them harbingers of shock!

  7. Cardiovascular Changes - 2 Some changes mask shock: • Increased blood volume – as much as 48-58%, peaking at 32-34/52 • Cardiac output increased by 40% at term (6L/min) • With significant blood loss, maternal BP is preserved at the expense of the uteroplacental and splanchnic circulation  early fetal monitoring Blood loss will exceed 30% of total blood volume before hypotension is manifest

  8. Respiratory Changes • Pregnancy significantly reduces oxygen reserve: • 20% reduction in FRC 2° to diaphragm elevation • 15% increase in oxygen consumption related to the growing fetus, uterus and placenta • Progesterone stimulates the respiratory centre in the medulla, leading to hyperventilation and respiratory alkalosis with metabolic compensation (pCO2 usually ranges from 27-32) • Significance:Intubation and Chest-tube placement!

  9. Gastrointestinal Changes • ↓ GE sphincter tone and gastrointestinal motility • ↑ acid production in stomach Increased risk of aspiration!

  10. Hematologic Changes • Blood volume increased more than RBC mass  dilutional “anemia” (Hg as low as 100, and Hct of 32-34%) • ↑ WBC (up to 18 000) • ESR increased but CRP unchanged • Increased risk of thromboembolism: • ↑ stasis (venous compression, capacity, bed rest) • ↑ coagulation factors V, VII, VIII, IX, X, XII and fibrinogen (by T3) exceeds fibrinolytic activity.

  11. ECG changes • The elevated diaphragm causes a leftward axis shift averaging 15° • Q waves in leads III and aVF • Flattening of T-waves in III and aVF

  12. Mechanisms of Injury: Blunt Trauma • Most common cause is MVCs; half of pregnant women are not using seatbelts correctly or at all • Next are assaults (domestic violence) and falls • 20% incidence of domestic violence in the pregnant population • 80% of falls occur after 32 weeks GA • If the mother survives, placental abruption is the most common cause of fetal mortality • Incidence in minor trauma is 2-4%; 30-50% incidence in survivors of major trauma • Sensitivity of US is <50%, clinical signs and symptoms are often also unreliable • Incidence of fetal loss from minor trauma is 1.7%

  13. Penetrating Trauma • Maternal visceral injuries are less common during pregnancy • Fetus is at high risk • Fetal injury complicates 66% of gunshot wounds to the uterus • Fetal mortality ranges from 40-70% in cases of penetrating trauma (stab wounds carry a lower mortality for both mother and fetus)

  14. Burns • In severe burns there is a dramatic increase in fetal mortality, approaching 100% for burns >50% TBSA; only 6% survival for burns >30% TBSA • Risk to the fetus is maternal death, fetal death, and preterm labor (PGE2) • Maternal carbon monoxide levels are a poor predictor of fetal carboxyhemoglobin

  15. Other Mechanisms of Injury • Domestic Abuse • between 0.9% and 20.1% of pregnant women are victims of domestic violence • Self-harm • Suicide was the cause of death in 13% of maternal deaths in one study (New York)

  16. General Management • The most common cause of fetal death is maternal death*, so efforts to assess fetal well being are second to resuscitation of the mother • Fetal distress may be the earliest indication of maternal injury, so FHR should be used early as an adjunct to the secondary survey • Prehospital tachycardia (HR >110), chest pain, LOC, and 3rd trimester GA all independently correlate with the need for a trauma centre

  17. Primary Survey • Should be no different in the pregnant patient Airway • Fetal RBC have increased affinity for O2, so oxygen can provide significant improvement in fetal saturation Breathing • Consider hyperventilation due to chronic resp. alkalosis • ABG for acidosis, Base Deficit (hemorrhage) and hypoxia Circulation • IVC compression  need to displace uterus to the left • Early crystalloid fluid resuscitation (RL vs NS) • Avoid vasopressors  reduce uterine blood flow • Likely little roll for tocolytics • Caudal central venous access if possible

  18. Primary Survey - 2 *Abdominal exam/Fetal Primary Survey • Assess uterine size re:fetal viability (beware of uterine rupture) • Viable fetus (22-26 weeks) – 2-3 finger breadths above uterus • Uterine Rupture/Abrutio Placentae • Peritoneal finding will likely be masked • Initial fetal heart tones (FHT) >10 weeks • Continuous Cardiotocographic monitoring (CTM) if viable fetus

  19. Algorithm

  20. Secondary Survey • The secondary survey includes a more thorough fetal assessment, a pelvic exam and a history including pertinent prenatal information. • Re-assessment of fetal viability • CTM should be initiated in a viable fetus • The pelvic exam includes a sterile spec exam for amniotic fluid, cervical dilation & effacement, signs pelvic trauma, vaginal bleeding (+/- cultures) but… NO PELVIC IN T3 BLEEDS! • Diagnostic adjuncts (labs, imaging)

  21. Intellectual Breather… • Who needs a preg test?

  22. Intellectual Breather… • Oldest person to give birth? • Adriana Iliescu • Age 66 • Romania • 2005

  23. Intellectual Breather… • Youngest person to give birth? • Lina Medina • 5 years, 7 months • Peru • 1939

  24. Laboratory • “trauma labs” plus Rh status, coags, fibrinogen levels • βhCG: • +’ve in serum 9d post conception • +’ve in urine 28d after last menstrual period • A Kleihauer-Betke test may be considered in an Rh –’ve mother for evaluation of fetal-maternal hemmorhage • Complications include Rh sensitization, fetal anemia or fetal death from exsanguination • Lab only screens for FMH of >5mL, therefore all Rh –’ve mothers should receive prophylactic RhIG

  25. RhIG • 1st trimester patients should receive 50mcg dose (covers 5mL bleeding); patients >12 weeks should get 300mcg dose (protects against 30mL FMH) • KB test quantifies FMH – >12 weeks may have more than 30mL FMH and need a second dose of RhIG • RhIG effective if given in first 72 hours after FMH

  26. Diagnostic Imaging General rule: If imaging is indicated, it should be done • 1 rad of exposure – no increase risk to the fetus • 10 rad exposure – carries only a small increase in the number of childhood cancers • 15 rads exposure - carries a 6% chance of MR, 3% chance of cancer, 15% chance of microcephaly • >20 weeks, radiation is unlikely to cause fetal anomalies, particularly if the exposure is <10 rads • A CT abdo pelvis exposes the fetus to 5-10 rads

  27. Low dose plain film Head, c-spine, thoracic spine, chest, extremities (<1 mrad) High dose plain film L-spine (204-1260) Pelvis (190-357) Hip (124-450) IVP (503-880) KUB (200-503) CT Head (<50) Chest (<1000) Upper abdomen (<3000) Lower abdomen (3000-9000) Radiation Doses (mrad)

  28. Diagnostic Imaging Adjuncts • Ultrasound/FAST • Best modality for assessment of mother and fetus in setting of trauma, rapid and safe • Sensitivity of 88%, specificity of 99% for detecting abdominal injury in blunt trauma • Screens for free fluid and establishes fetal well being, GA and placental location • DPL • Supra-umbilical approach, open technique • Useful in the first trimester patient with an equivocal FAST, and later in pregnancy to help differentiate intraperitoneal bleeding from a uteroplacental source

  29. Algorithm

  30. Fetal Evaluation - FHT • Fetal heart tones can be heard by doppler beginning at 10-14 weeks • If FHR <120 or >160, fetal distress is likely and urgent obstetric consultation is indicated (they should hopefully be there already!) • If FHR is normal, proceed to continuous CTM for at least four hours

  31. Fetal Evaluation • CTM has an excellent sensitivity for detecting abruption; 100% NPV for adverse outcomes if reassuring clinical exam and normal observation period • If >3 uterine contractions/hr, persistent uterine tenderness, non-reassuring fetal monitoring strip, vag bleeding, ROM, or serious maternal injury = admit for long term monitoring • CTM recommended for a minimum of 4 hours for all patients >20 weeks GA with any multisystem or minor abdominal trauma • Increase to 24 hours if any abnormalities

  32. CTM – what are we looking for? • Baseline FHR (120-160) • Variability – indicator of oxygenation • Beat-to-beat (CNS) • Long term (fetal activity) • Periodicity • Accelerations • Decelerations

  33. CTM - Decelerations • Early Decelerations: • Gradual and uniform in shape • Early in contraction and quick return to baseline • Benign, vagal response to head compression • Variable Decelerations: • Variable in shape, onset and duration • Usually due to cord compression • Benign unless meets the rule of 60’s: • decel to <60bpm, >60 below baseline, >60s in duration

  34. CTM - Decelerations • Late Decelerations: • Uniform shape • Onset is late in contraction • Must see 3 in a row (same shape) • Due to fetal hypoxia, acidemia, maternal hypotension • Sign of uteroplacental insufficiency

  35. CTM - Decelerations

  36. Discharge and Disposition Mother stable/fetus stable: • Should be instructed to record fetal movements for 1 week • Should return to hospital if <4 FM over 1 hour or <10 FM in 12 hours • Should also return if any abdominal pain, leaking fluid, vag bleeding, or >6 uterine contractions/hr

  37. Algorithm

  38. Discharge and Disposition Mother stable/fetus unstable: • In trauma, fetal death rates are 3-9 times that of maternal death rates • If a viable fetus remains in distress despite maternal optimization, c-section should be performed • No survival if no fetal heart tone before emergency C-section begins • If FH tones present and >26 weeks, infant survival for emergency C/S is 75% in the trauma setting

  39. Algorithm

  40. Discharge and Disposition Mother unstable/fetus unstable • If mom’s conditions is critical, primary repair of her wounds is the best course even if fetus is in distress • However, extended and exclusive attention to the mother in cardiac arrest mother may prevent recovery of a potentially viable fetus • If no response to ACLS and there is a potentially viable fetus (fundal height above the umbilicus & FHT +’ve) a decision for perimortem c-section must be made

  41. Algorithm

  42. Perimortem Cesarean Section • If performed at appropriate time, can benefit both fetus and mother (due to improvement in maternal circulation) • If mother arrests and does not respond to resuscitative efforts within 4 minutes, preparation for open cardiac massage and C-section should begin • 70% of children who survived perimortem C-sections were delivered in less than 5 min of onset of arrest (4 min resuscitation and prep time, 1 min delivery time)

  43. Perimortem Cesarean Section • Vertical midline incision from epigastrum to symphysis pubis • Penetrate all abdominal layers into peritoneum • Vertical midline incision in anterior aspect of uterus from fundus to bladder (avoid paired uterine vessels laterally) • Extend caudally using blunt dissection (scissors), placing your hand between the uterine wall and the fetus • Deliver head and shoulders, body follows spontaneously • Suction, clamp and cut cord, resuscitate neonate prn

  44. Questions?

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