Trauma in Pregnancy

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Trauma in Pregnancy

• Dr N du Plessis
• Dept of Obstetrics and Gynaecology
• March 2013

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Introduction

• Unique challenge evaluation of pregnant trauma
  patient
• Two patients potentially at risk
• Influence of pregnancy-related anatomic and
  physiological changes

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Four groups

• Injured unaware of pregnancy
• All pregnant till proven otherwise
• Teratogenic effects
• Gestation lt 26 weeks
• Maternal resus primary
• Gestation gt 26 weeks
• 2 patients
• Perimortem state
• Early C/S maternal resus, fetal survival

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Incidence and etiology of trauma in pregnancy

• Major contributor to maternal mortality worldwide
• USA leading cause of pregnancy-associated
  maternal deaths
• Two-thirds MVA. Other domestic violence,
  assaults, suicide.
• Pregnancy risk factor for being assaulted
• SA - ? incidence of trauma and violence

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Anatomy

• Uterine enlargement
• 12w, 20w, 36w
• Uterine wall
• Amniotic fluid
• Placenta
• Descent of fetal head
• Upward displacement
• GIT
• Diaphragm
• On XR

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Pregnancy-related changes

• Cardiovascular system
• - ? CO, from 1st trimester, ?? 20 weeks
• - HR ? 15 beats/min
• - BP ? 10mmHG, nadir _at_ 26 weeks, ? to
  pre-pregnancy values _at_ term - ?systemic vascular
  pressure
• - maternal hemorrhage compensated for by fetal
  distress (rather than tachy and hypotension)
• - supine hypotension syndrome (30 degree tilt
  after 20 w)
• - loss of 30 blood volume before symptomatic

NB
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• Pulmonary system
• - By 20 weeks? FRC and ? in tidal volume
• - No changes FEV1 and respiratory rate
• - Respiratory alkalosis due to physiological
  hyperventilation?? PaCO2, ?PaO2 and ? bicarbonate
  concentration

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• Haematological system
• - Plasma volume ? 45 (6-8w), physiological
  anaemia dilution effect
• - Hb 10,5 g/dL
• - WCC 6 000 16 000 (1st and 2nd trimester), 20
  000 30000 (peripartum)
• - Fibrinogen concentration gt 200mg/dL

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• Gastrointestinal system
• - gastric aspiration ? intra-abdominal
  pressure, relaxation of lower esophageal
  sphincter
• ? early gastric decompression
• Neurological/ CNS
• Enlarged pituitary susceptible to shock
• Pre-eclampsia mimic head injury
• Changes in need for anesthetic drugs
• Renal system
• - glomerular hyperfiltration reduction in
  normal plasma creatinine (35 40 mmol/L)

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Cardiopulmonary resuscitation

• External chest compression more difficult -
  ?chest compliance
• Hand position on sternum
• Above center accommodate upward displacement of
  the diaphragm by gravid uterus
• Not effective (2nd and 3rd trimester) aortacaval
  compression, ?cardiac output
• C/Section required to perform effective CPR
  within 4-5 minutes

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Assessment and resuscitation

• Penetrating trauma
• Similar management
• Better prognosis than gun shot wound
• Fetus at greater risk with enlarged uterus
• Indication for laparotomy unchanged, well
  tolerated

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• Blunt trauma
• 1 evaluate and resus mother
• Assess and monitor fetus
• Secondary survey of mother
• Definite care standard trauma protocols
• Remember
• NG tube
• O2
• Positioning (spinal injury excluded)
• Signs of maternal hemorrhage (fetal distress)
• Avoid vasopressors
• Rhesus typing
• Radiographic studies

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• Burns
• Fetus fluid loss, hypoxemia and sepsis
• Hospitalize
• smoke inhalation, electrical burns, burns of both
  hands and feet, gt 10 surface area involved and
  full-thickness burns
• Add 5 if anterior abdomen is involved
• O2, wound care, tetanus toxoid

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Resuscitation during pregnancy

• Call for help multi-disciplinary team
• Involvement of Obstetrician
• Displace uterus laterally and left if above
  umbilicus
• Initiate ABCs (CAB)
• Differentiate between obstetric and non-obstetric
  causes
• Estimate gestational age
• Uterine fundus 4 finger breadths above
  umbilicus, at 4 min, perimortem C/Section
• Defibrillation for adult defib, remove fetal
  monitoring equipment

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Fetus

• Document gestational age and heart auscultation
• Factors predicting mortality and morbidity
  hypoxia, infection, drug effects and preterm
  delivery
• First trimester
• 13 24 weeks
• gt 24w supine hypotension, neurodevelopmental
  delay and preterm birth
• 3rd trimester neurodevelopment
• Primary disease process
• Surgical complications
• Anesthetic agents
• Anesthetic management (respiratory support)

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Increased vascularity and blood flow

• Dilated pelvic vasculature ? ? risk
  retroperitoneal haemorrhage from abdominal and
  pelvic trauma
• Blood flow to uterus 600ml/min
• Fetal oxygenation dependent on uterine blood
  flow, no autoregulation
• Also reduced from vasoconstriction (drugs),
  maternal hypercarbia an hypocarbia

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Changes in abdomen

• Pregnant women sustain abdominal trauma more
  easily
• Enlarged uterus protects against visceral injury
  from lower abdominal penetrating injuries and
  shields retroperitoneal structures
• Penetrating injuries above uterus likely to
  injure bowel
• Rebound tenderness and guarding less prominent

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Respiratory support

• Liberal oxygen supplementation
• Anoxia develops sooner
• Oxygen saturation gt 95, if lt do blood gas (PaO2,
  PaCO2).
• Favourable placental oxygenation when PaO2 gt
  70mmHg
• Early intubation
• Airway edema
• Difficult to secure airway, risk of aspiration
• Cricoid pressure
• Chest tube remember diaphragm elevate

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Volume replacement

• Two large bore IV lines
• Prefer volume replacement, vasopressors can
  reduce uterine blood flow

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Caesarean delivery
NB

• Urgent delivery if imminent maternal death
• CPR not successful within 4 minutes
• Stable mother, non-reassuring CTG
• During laparotomy, gravid uterus prevents
  adequate surgery for injuries
• Perimortem C/Section optimum survival of fetus
  and mother if within 4 min
• Irreversible brain damage after 4-6min
• Pregnant pt anoxic sooner
• Effective resuscitation with empty uterus
• Improved fetal survival with shorter time to
  delivery

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Uterine rupture

• Sharp or blunt trauma
• Late second and third trimester
• Signs and symptoms shock, non-reassuring CTG,
  fetal death, uterine tenderness, peritoneal
  irritation, vaginal bleeding, palpable fetal
  parts
• Fortunately rare
• Early recognition and appropriate resus

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Placental abruption

• Incidence varies with different degrees of
  abdominal trauma
• Direct abdominal trauma, uterine and abdominal
  tenderness, vaginal bleeding (clots),
  non-reassuring CTG, premature labour
• Position of placenta can influence symptoms
• NB clinical diagnosis
• Monitoring for 48 hours delayed abruptio,
  preterm labour

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Fetomaternal haemorrhage

• More common in anterior placenta
• Complications fetal anemia, chronic asphyxia,
  fetal death, maternal iso-immunization
• Administration of anti-D immune globulin in all
  Rh-negative mothers after abdominal trauma
• Kleihauer-Betke test

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Preterm labour and premature rupture of membranes

• Consider and manage appropriately
• Potential consequence of trauma during pregnancy
• Maternal injury or death
• Fetal injury or death
• Pregnancy complications
• Any complications of trauma as in non-pregnant
  women

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Influence of gestational age

• First trimester uterus protected in pelvis
• Risk if maternal hypotension, serious pelvic
  injury (direct injury of fetus, uterus, placenta,
  uterine vessels)

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Influence of trauma severity

• Poor predictors of fetal outcome maternal
  hypotension, non-reassuring fetal heart pattern,
  direct injury to the uterus/fetus, maternal
  death, maternal coma, high injury severity score
• Highest risk mother with life-threatening
  trauma hypovolemic shock, coma, emergency
  laparotomy
• Minor trauma lt 5 pregnancy loss
• Delivery remote from trauma still significant
  risk of preterm birth, low birth weight, abruptio

NB
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Prevention

• Prenatal care include education about correct
  seat belt use, evaluation for presence of
  domestic violence (begins/increase during
  pregnancy/peripartum)
• Lap belt - under uterus, over middle portion of
  clavicle
• Decreased force transmission through uterus
• Airbags safe. Sternum 10cm away from dashboard
  or steering wheel containing airbag
• Multiple tools to detect presence of domestic
  violence, substance abuse
• Additional risk factors young age, drug or
  alcohol use

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Summary and Recommendations

• Anatomic and physiological changes related to
  pregnancy impact the evaluation and management of
  the pregnant trauma patient
• Initial evaluation stabilize mother
• Treatment and diagnostic imaging as needed
• Displace uterus to the left
• Empty uterus to save mothers life

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Summary and Recommendations

• After excluding catastrophic trauma, determine
  whether obstetric complications. Important
  symptoms contractions, vaginal bleeding,
  abdominal pain
• Abruptio irrespective of severity of trauma
• Fetal viability monitoring and uterine
  monitoring for signs of preterm labour and
  abruption (continuous for 4 hrs, then up to
  48hrs)
• Anti-D immune globulin administration to
  unsensitized Rh-negative women after abdominal
  trauma
• Screen for domestic violence

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Thank you