Two for One: Caring for the Pregnant Trauma Patient

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Two for One Caring for the Pregnant Trauma
Patient

• Nabil Alzadjali
• FRCP III
• McGill University

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• CASE 1
• 25 Yrs F, 35 wks Preg.
• PC MVC
• PMH nil, Rh ve,
• HPI Driver, belted, rear ended by another car,
  air bag
• deployed Complaining of occasional abdominal
  pain,
• ?cramping. Unsure about fetal movements. Very
• concerned regarding fetal well being.
• ABC stable. BP 120/70 HR 88 RR 15
• No signs of injuries on exam. FHR 140, No
  uterine contractions palpable. No guarding. No
  lap belt sign. No PV bleeding. Os Closed
• How do we manage this patient?

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• CASE 2
• 20 Yrs F, 30 weeks gestation Struck by
• truck across the street from hospital. Cardiac
• arrest at scene. U/G Technician have intubated
• and started CPR.
• Down time about 5 minutes. Arrival in ER,
• Pulseless Electrical Activity.
• How do we manage this patient?

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• Incidence
• Physiological Alterations
• Anatomical Alterations
• Unique Problems in the Gravid Abdomen
• Prehospital Considerations
• Diagnostic Studies
• Management of trauma
• Unstable Mother
• Stable Mother
• Perimortem Cesarean Section

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Incidence

• The Leading cause of non-obst. mortality - 46
• Trauma during pregnancy - 7
• Causes of Trauma (1)
• MVA 54.6
• Domestic abuse Assault 22.3
• Falls 21.8
• Penetrating inj. 1.3
• lt 1 of trauma admissions are pregnant
• Preterm Labor in 11.4 P. Abruption in 1.58
  

(1) Connolly A, Katz VL, Bash KL, et al Trauma
and pregnancy. Am J Perinatol 14331-336, 1997  
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Physiological Changes During Pregnancy
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Hemodynamic Changes of Pregnancy (Mean Values) Hemodynamic Changes of Pregnancy (Mean Values) Hemodynamic Changes of Pregnancy (Mean Values) Hemodynamic Changes of Pregnancy (Mean Values) Hemodynamic Changes of Pregnancy (Mean Values)
Non P. Trim. 1 Trim. 2 Trim. 3
HR 70 78 82 85
Sys. BP 115 110 102 114
Dias. BP 70 60 63 70
C. Output 4.5 4.5 6 6
CVP 9.0 7.5 4.0 3.8
Bld V (ml) 4000 4200 5000 5600
Hct with Fe () 40 36 34 36
WBC (cell/mm3 ) 7200 9100 9700 9800
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Supine Hypotensive Syndrome(1)
(1) Milson I, Forssman L Factors influencing
aortocaval compressionin late pregnancy, Am J
Obtst Gynecol 148 764-771, 1984
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• Respiratory
• Respiratory alkalosis
• Reduce oxygen reserve (reduced FRC 20
  increased O2 consumption by 15 )
• Residual volume decreased by 40
• Respiratory rate increased
• Impaired buffering capacity

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• GI
• Intestine are concentrated in upper abdomen
• Decrease GI motility
• Decrease peritoneal irritation
• GU
• Bladder is displaced upward gt10 wks
• Dilitation of renal pelvis and ureters

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Alterations in Anatomy

• 1st trimester uterus is thick walled and
  intra-pelvic
• Out of pelvis gt 12 wks.
• Second trimester uterus contains large amount of
  amniotic fluid
• Third trimester uterus is thin walled, large
  Fetal head engaging pelvis
• At 36 weeks uterus reaches costal margin

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Injuries unique to pregnancy

• Premature Contractions
• Rarely progress to preterm delivery
• Tocolysis is not proven in trauma.(1)
• Abruptio Placentae
• Different elastic properties in uterus placenta
  shearing
• 3 of minor trauma and upto 50 in severe
  trauma

(1) GoodwinTM, Breen MT Pregnancy outcome and
fetomaternal hemorrhage after noncatastrophic
trauma, Am J Obstet Gynecol162 665-671, 1990.
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• Uterine Rupture
• Rare, 0.6 of severe abdominal trauma (1)
• Direct trauma after 12 wks of gestation
• Prior Surgery (C/S or Myomec.) the risk
• Maternal-Fetal Hemorrhage
• Trimesters 1 3, T2 12, T3 45
• 4-5 X more common in injured pregnant women
• Causes isoimmunization fetal death
• Kleihauer-Betke test - volume of fetal blood
• .01- .03 cc sensitize, 5 cc ve KB
  Test.
• To determine amount of Rhogam needed

1. Pearlman MD, Tintinalli JE, Lorenz RP Blunt
trauma during pregnancy, N Engl J Med 3231609,
1990
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Special Considerations

• Blunt Abdominal Trauma
• Penetrating Abdominal Trauma
• Stabbing injury
• Gunshot injury

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Blunt Trauma

• Injuries
• Head injury most common
• Retroperitoneal hemorrhage
• Abruptio placenta
• DIC
• Uterine Rupture
• Seatbelts 3 Points Restraints
• 1/3 ½ improperly or dont use belts
• Unbelted is at 2.3X to give birth lt48 hrs 4.1X
  fetal death

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Penetrating Injury

• GSWs
• Gravid uterus alter injury pattern to the mother.
• If missile enter upper abdomen increased
  probability of harm (upto 100).
• If enters below uterine fundus visceral injury
  less likely (0)
• Awwad et al (1)
• Fetal death rate is 67
• 38 for injuries above the uterus.

(1) Awwad JT et al High-velocity penetrating
wounds of the gravid uterus Review of 16 years
of civil war, Obstet Gynecol 83259, 1994.
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• Stabbing Injury
• Rare rare, only 19 cases reported in literature
• Morbidity 93 - Mortality 50
• Many advocate exploratory laprotomy since uterus
  laceration is devastating b/c of its enlarged
  circulation.
• Meizner et al (1)
• An injury to uterus can rapidly change to a
  hypotensive emergency.
• It is difficult to know the size and depth of
  uterine rupture

(1) Meizner I, Potashnik G Sharpnel penetration
in pregnanc resulting in fetal death, Isr J Med
Sci 24431, 1988.
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Pre-hospital Consideration

• Oxygen
• Shock should be anticipated
• ED should be notified early, GA gt24 wks
• Transport in L lateral position (GA gt 20 wks)
• National Association of EM Physician, 1997
• PASG class III intervention worsen the
  supine hypotension

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Diagnostic Studies
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Modalities for Evaluating Trauma

• Plain Films X-rays
• Ultrasound
• CT MRI
• Cardiotocographic Monitoring
• DPL
• Laparotomy

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Plain Films

• Risk of 1 rad to fetus is approx. 0.003
• lt 5-10 rads causes
• No risk on congenital malformation, abortions or
  intra-uterine growth ret.
• Smaller risk of increase in childhood cancer
• Radiation doses gt 10 rads
• 6 chance of severe mental ret.
• lt 3 chance childhood cancer.

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Radiographic examination Dose to Ovary/Uterus-mrad
Low Dose Group Head C-Spine Thoracic Spine Chest Extremities lt1 lt1 lt1 lt1 lt1
High Dose Group Lumbar Spine Pelvic Hip Intravenous pyelogram Urethrocystogram KUB 204 1260 190 357 124 450 503 880 1500 200 503
Rosenstein MHandbook of selected organ doses for
projections common in diagnostic radiology. HEW
publication(FDA) 89-8031. Rockville, MD. US Dept.
Of Health And Human Services, Centre For Devices
And Radiologic Health, 1988.
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Ultrasound

• Best modality to assess both fetus and mother
• Not sensitive
• Colonic lesions
• Biliary tree lesions
• Sub-placental hematoma
• Safe procedure

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CAT SCAN

• Complementary to U/S DPL
• Penetrating wounds of flank back
• Can miss diaphragmatic and bowel injuries
• Portability
• Spiral CT reduces radiation exposure by 14-30

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Radiographic examination Dose (mrad)
Computed Tomography Head (1 cm slice) Chest (1 cm slice) Upper Abdomen (20 slices 2.5 cm above uterus) Lower Abdomen (10 1 cm slices over the uterus/fetus) lt 50 lt 1000 lt 3000 3000 9000
Angiography Cerebral Cardiac Catheterization Aortography lt 100 lt 500 lt 100
Rosenstein MHandbook of selected organ doses for
projections common in diagnostic radiology. HEW
publication(FDA) 89-8031. Rockville MD,. US Dept.
Of Health And Human Services, Centre For Devices
And Radiologic Health, 1988.
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Cardiotocographic Monitoring

• FHR
• Rate (120-160)
• Beat-to-beat variability
• Baseline variability
• Decelerations, esp. late

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Cardiotocographic Monitoring
Variability
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Cardiotocographic Monitoring
Decelerations Early and Late
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Cardiotocographic Monitoring
Decelerations Variable
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Diagnostic Peritoneal Lavage

• CT U/S are better in stable patient.
• Hypotensive unstable pt and if bedside U/S is
  not available
• Can be performed in any trimester
• Gravid uterus does not reduce the accuracy of
  DPL for OR
• Limited in detecting bowel perforation and does
  not assess retroperitoneal hemorrhage or
  intra-uterine pathology

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Diagnostic Peritoneal Lavage

• Rothenberger et al (1)
• n12 (4 Supra umbilical 8 infra umbilical)
• Sensitivity 100 (8 internal bleeding confirmed
  by lapratomy),
• Specificity 100 ( 4 no bleeding)
• No Complications from the procedure
• Esposito et al (2)
• n40 , 13 had DPL
• PPV 100

1. Rothenberger DA, et alDiagnostic peritoneal
   lavage for blunt trauma in pregnant women, Am J
   Obstet Gyneco 129479-48,1977.
2. Eposito TJ, et al Evaluation of blunt abdominal
   trauma occurring during pregnancy, J Trauma
   291628-1632, 1989.

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Management

• Avoid distractions and avoid focus on the fetus
• Be aggressive! But temper with common sense.
• An apparently stable mother may be compensating
  at expense of the fetus
• If lt 24 weeks, intermittent fetal doppler
• If gt 24 weeks, then continuous cardiotocographic
  monitoring to assess FHR and uterine activity

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I. Initial maternal Resuscitation

• Airway
• Assess control
• Preoxygenate and sellicks maneuver is important
  before intubation
• Breathing
• Assess and manage
• Place CT in 4th intercostal space
• Circulation
• Assess maternal circulation
• IV access
• Telt to left if gt 20 wks

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Management

• The hemodynamically unstable mother
• The hemodynamically stable mother

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II. The hemodynamically unstable mother
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Fetal Viability Fetal Viability Fetal Viability
Weeks gestation 6-monthsurvival () Survival withno severeabnormalities ()
22 0 0
23 15 2
24 56 21
25 79 69
Data from Morris JA Jr et al Ann Surg 223481, 1996. Data from Morris JA Jr et al Ann Surg 223481, 1996. Data from Morris JA Jr et al Ann Surg 223481, 1996.
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III. The hemodynamically stable mother

• Stable fetus
• Minor trauma does not exclude significant
  fetal injury 1-3 of all minor trauma results
  in fetal loss from placenta abruption. (1)
• Asymptomatic mother or with no obvious
  abdominal injury needs monitoring for
  feto-placental pathology

• (1) Pearlman MD, Philip ME Safety belt use
  during pregnancy, obstet Gynecol 88 1026, 1996

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1. Pearlman MD, Tintinalli JE, Lorenz RP Blunt
trauma during pregnancy, N Engl J Med 3231609,
1990

• Pearlman et al (1)
• Minimum 4 hrs CTG monitoring
• Extended to 24 hrs if . gt3 contractions per
  hour . Persistent uterine tenderness . Non
  reassuring fetal monitor strip . Vaginal
  bleeding . ROM . Serious maternal injury
  present
• All placental abruption were detected within 4
  hrs
• 70 of pt required admission.
• All discharged home subsequently had live birth.

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III. The hemodynamically stable mother

• Unstable fetus
• Fetal death rates are 3-9 times higher than mat.
  
• No infant survive if there is no fetal heart
  tone before C/S
• Morris et al (1)
• Heart tone is best survival marker for f. to
  undergo C/S
• If fetal heart tone is present and the GA is gt 26
  wks the survival is 75
• 60 of fetal death occurs with under use of CTG
  and delay recognition of fetal distress.

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Perimortem Cesarean Section

• 200 successful cases reported in the literature
• Maternal CPR lt5 minutes, fetal survival
  excellent
• lt23 weeks gestation survival chance is 0
• Maternal CPR gt20 minutes, fetal survival unlikely

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Fetal Viability Fetal Viability Fetal Viability
Weeks gestation 6-monthsurvival () Survival withno severeabnormalities ()
22 0 0
23 15 2
24 56 21
25 79 69
Data from Morris JA Jr et al Ann Surg 223481, 1996. Data from Morris JA Jr et al Ann Surg 223481, 1996. Data from Morris JA Jr et al Ann Surg 223481, 1996.
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Perimortem Cesarean Section

• 4 Minute Rule
• Maternal CPR for 4 minutes, Infant should be
  delivered by the 5th minute.

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Perimortem Cesarean Section

• Technique
• Make sure it is indicated first and that
  resuscitative team is ready
• Vertical incision from xyphoid to pubis
• Continue straight down through abdominal wall and
  peritoneum
• Cut through uterus and placenta (if anterior)
• Bluntly open uterus and remove fetus
• Cut and clamp cord

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Summary

• Anatomic and physiologic changes
• Vigorous fluid and blood replacement
• Treat the mother first and treat her just like
  any other trauma patient
• High index of suspicion for blunt or penetrating
  uterine trauma abruptio placenta.
• Consider perimortem C/S in unstable women or
  cardiac arrest with viable fetus after 24 wks.

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When to Intervene and Consult

• EARLY !

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Remember

• What is Best for the Mother is Best for the Fetus!

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Questions ?