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Trauma in Pregnancy

Trauma in Pregnancy. Max Brinsmead MB BS PhD May 2015. Trauma in Pregnancy – Incidence. 6 - 7% of pregnant women - mostly trivial Life threatening trauma 3 - 4 per 1000 Maternal death 2 per 100,000 (A common cause of non obstetric maternal death) Significant Trauma

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Trauma in Pregnancy

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  1. Trauma in Pregnancy Max Brinsmead MB BS PhD May 2015

  2. Trauma in Pregnancy – Incidence • 6 - 7% of pregnant women - mostly trivial • Life threatening trauma 3 - 4 per 1000 • Maternal death 2 per 100,000 • (A common cause of non obstetric maternal death) • Significant Trauma • Motor vehicle accidents 65% • Falls 20% • Blunt trauma 10% • Penetrating wounds 4% • Burns 1%

  3. Possible Obstetric Outcomes • Maternal death • Fetal death in utero • Premature labour • Fetal injury • Abruptio placenta

  4. Predictors of Fetal Risk • Severe maternal injuries • Admission hypotension • Need for transfusion • Abdominal or Pelvic Injuries • Maternal DIC • INR > 1.2 APTT>38 sec • Platelets < 150 D Dimers • Abnormal CTG or fetal bradycardia

  5. About Premature Labour • Risk increases with increasing severity injuries • Risk increases with increasing gestation • Tocolytics are relatively contraindicated • Betamimetics • Ca channel blockers • A role for fetal fibronectin

  6. Fetal Death or Injury • Direct fetal damage is rare • Skull fracture • Intracranial haemorrhage • Most fetal deaths are associated with placental abruption • This can occur after relatively trivial event • With few maternal signs of trauma • May occur hours or days after the event • Possibly due to deceleration/shearing forces • ?role of the seat belt

  7. Management Guidelines • First resuscitate mother as per usual triage protocols • Treat life threatening maternal injuries • The best chance of fetal survival is maternal survival • HOWEVER • Before investigating and treating major maternal injuries... • Assess fetal welfare

  8. Assessment • Involvement of an obstetric team is desirable to... • Advise about resuscitation of a pregnant woman • Interpret viability tests eg CTG • Accurately assess gestation • Exclude abruption placenta • Exclude fetal injury • Advise about ongoing fetal monitoring • Emergency delivery may be necessary

  9. Obstetric Service Required for: • Emergency delivery - usually by CS • Maternal counselling • Steroids for possible premature delivery • Betamethasone chronodose 11.4 mg x2 12 hours apart • Anti D for Rh negative mother • Check dose required with maternal Kleihauer • Role of Kleihauer otherwise controversial

  10. Emergency Delivery Required: • ASAP if maternal arrest has not been reversed within 4 minutes • Non reassuring CTG • Maternal DIC • Clinical or other evidence of abruptio placenta • Uterus is impairing maternal resuscitation • Maternal death (but see below)

  11. Postmortem CS only when: • Fetus is viable • Must be at least 24 weeks • AND • Fetus is still alive • AND • Maternal condition critical or dead less than 10 minutes

  12. Fetal Monitoring • Aims to prevent “late” fetal death • Controversial with no clear guidelines • Should continue for 6 - 48 hours • Role of ultrasound and CTG controversial • Useful only if fetus is viable ie >24 weeks • Best done in an obstetric unit if maternal condition permits

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