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SURGERY IN THE PREGNANT PATIENT

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... September 2004. Guidelines for diagnostic imaging during pregnancy ... Trauma occurs in 6-7% of pregnancies Physiologic changes of pregnancy may confuse ... – PowerPoint PPT presentation

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Title: SURGERY IN THE PREGNANT PATIENT


1
TRAUMA AND SURGERY IN THE PREGANANT PATIENT
PRINCIPLES OF SURGERY-2009 NICHOLAS
LEYLAND,BASc,MD,MHCM,FRCSC CHIEF OF OBSTETRICS
AND GYNAECOLOGY, MEDICAL DIRECTOR OF THE
WOMENS, CHILDRENS AND FAMILY HEALTH
PROGRAM ST.JOSEPHS HEALTH CENTRE, ASSOCIATE
PROFESSOR OF OB/GYN, UNIVERSITY OF TORONTO
2
Surgery and Trauma in the Pregnant Patient
  • Learning objectives
  • 1)TRAUMA IN PREGNANCY
  • 2)THE ACUTE ABDOMEN IN PREGNANCY
  • 3)CASES
  • 5) UPDATE LEYLAND

3
Trauma in Pregnancy-Incidence
  • Trauma occurs in 6-7 of pregnancies
  • 4.6-8.3 of Traumas are complicated by pregnancy
  • Maternal mortality rate
  • 3.5
  • Mortality rate is similar for non-pregnant women
  • Fetal mortality rate
  • 1 in minor trauma
  • 15 in major trauma
  • Overall fetal death rate from trauma 1/30000
    pregnancies

4
THERAPEUTIC PARALYSIS
5
Maternal PhysiologySurgical Implications
  • Cardiovascular Changes CO 50,Blood Vol 50
  • Maternal rbc 30 Dilutional Anaemia
  • WBC 12000, Labour 20,000
  • GI Appendix (localization), Progesterone
    Decreased motility, alk phosphatase, no change
    in Transaminases
  • Respiratory Changes e.g. Decreased pCO2

6
General Management PrinciplesMaternal Assessment
  • Primary Survey
  • ABCsFetus
  • Lateral Tilt
  • Supine position can ? cardiac output by 30
  • 15 tilt is appropriate
  • Can decrease effect of CPR

7
General Management PrinciplesFetal Assessment
  • Ultrasound
  • GA
  • Placentation/Abruption
  • Fetal viability
  • Extent of fetal trauma/demise
  • BPP?
  • Celestone as indicated
  • Initiate FHM after patient is stabilized
  • Vaginal exam to rule out PROM

8
General Management PrinciplesMaternal Assessment
  • Rhogam
  • Administer within 72 hrs
  • 10-30 of trauma have evidence of admixture
  • Betke-Kleihaurer test to determine quantity of
    hemorrhages
  • 90 of hemorrhages are lt 30 cc
  • Anterior placed placentas have higher risk

9
General Management PrinciplesMaternal Assessment
  • Exploratory Laparotomy
  • usually necessary in penetrating trauma
  • C/S may be required to attain adequate surgical
    exposure
  • Tetanus
  • As usual

10
Imaging Radiation
  • Harmful effects
  • Cell death and teratogenesis
  • High doses of radiation before implantation is
    likely lethal
  • In humans, high dose ? growth restriction,
    microcephaly, mental retardation
  • Effects are greatest at 8-15 wks gestation
  • No proven effects before 8 wks or after 25 wks
  • Risks are not increased until radiation exposure
    5 rad

11
Imaging Radiation
  • Fetal Radiation Exposure in typical trauma

Fetal Exposure
CXR (2 views) 0.02-0.07 mrad
Abdo XR (3 views) 100 mrad
CT Head/Chest lt1 rad
CT Abdo 3.5 rad
Total 4.8 rad
ACOG guidelines suggest that imaging is safe when
exposure is 5 rad
12
Blunt Trauma
  • MVAs and abuse most common
  • Fetal death can follow direct blunt trauma or
    maternal death
  • Specifically head trauma and ejection from
    vehicle
  • Abdominal contents shifted in pregnancy
  • Retroperitoneal splenic injury more frequent
  • GI injuries less frequent

13
Blunt Trauma - Consequences
  • Placental Abruption
  • In up to 40 of severe blunt trauma
  • In up to 3 of minor blunt trauma
  • Contractions q10min 20 risk of abruption
  • Abruption confers 50 fetal mortality
  • Uterine rupture
  • Increases with force and gestation
  • Fetal death frequent here, but maternal death 10
  • Pelvic Fracture
  • Consider fetal skull fracture
  • MAST trousers contraindicated
  • If stable vaginal delivery still feasible
  • Pre-Term Labour

14
Blunt Trauma Pre Term Labour
  • Can PTL be predicted after blunt abdominal
    trauma?
  • 85 patients over 3 yrs with non-catastrophic
    trauma
  • Findings
  • Preterm Labour in 13 (15)
  • Presence of Abdo pain or Contractions do not
    predict PTL
  • Domestic abuse victims were more likely to have
    repeated trauma

(Pak 1998)
15
MVAs
  • Frequency
  • In USA, 2 of all live births have been exposed
    to a reported MVA
  • Seatbelts
  • Up to 25 of pregnant drivers are unrestrained.
  • Seatbelts positioned improperly cause a 3-4 fold
    increase in energy transmission through the uterus

16
MVAs
  • Pregnant occupant in a 35 km/hr crash at peak
    uterine strain.
  • a) An unbelted pregnant occupant contacting the
    steering wheel
  • results in large deformation of the uterus.
  • b) A matched belted occupant simulation
  • steering wheel contact is minimal
  • considerable neck flexion, which could lead to
    maternal injury.
  • c) Airbag deployment combined with a three-point
    belt and airbag

17
MVAs
  • Airbags
  • No large scale data of airbags in pregnancy
  • Pregnancy is not an indication for deactivation
    of airbags
  • Pregnant Crash Test Dummy

18
Penetrating Trauma
  • Uterus may serve to protect maternal organs
  • Visceral injury from penetrating trauma in
    pregnancy 38 vs 90
  • Of GSWs to abdomen, death in pregnancy is 1/3
    rate of non-pregnant
  • Fetal death rate 71 of GSWs, 42 stabs
  • Penetrating trauma is generally an indication for
    exploratory laparotomy
  • Half the women had perinatal deaths due to either
    maternal shock, uteroplacental injury, or direct
    fetal injury.

19
A Unified Approach
  • Is there a need for a standardized protocol for
    obstetrical patients who experience trauma?

The low incidence of trauma during pregnancy
leaves trauma teams at risk of ignoring steps
that may prevent adverse outcomes. An organized
approach of stabilizing the injured gravida and
then initiating ultrasound and EFM in pregnancies
beyond 24 wks will ensure the best outcome for
the mother and her unborn child. It is now a
requirement in Australia for a level 1 trauma
centre to have a protocol detailing the
management of pregnant patients after trauma.
20
A Unified Approach
  • Issues to consider
  • Delayed monitoring during primary survey and
    imaging
  • Average time to clear c-spine estimated at 36
    minutes
  • Access to FHR monitor in ER may not be available
  • Estimated that 15 of ERs in USA have this
  • Other activities in resuscitation room may
    preclude continuous access to FH, or hinder
    ability to hear it
  • Patients transferred to labour floor for ongoing
    monitoring may not receive optimal management of
    non-obstetrical issues
  • Eg. Soft tissue injury, Physiotherapy,
    occupational therapy, etc.

21
TRAUMA IN PREGNANCY- Key Points
  • Trauma occurs in 6-7 of pregnancies
  • Physiologic changes of pregnancy may confuse the
    picture
  • ABCs should not be abandoned in managing a
    pregnant trauma patient
  • Consider Rhogam, Celestone, PROM, and initial FH
    monitoring
  • Education regarding proper use of seatbelts in
    pregnancy is paramount
  • Consideration of a standardized trauma protocol
    or record for obstetrical use may be warranted.

22
TRAUMA IN PREGNANCY- Key Points
  • Investigations .LEYLANDS AXIOM IF AN
    INVESTIGATION IS INDICATED DO IT
  • Fetal viability.24 weeks
  • Fetal monitoring.OBS/PERINATOLOGY
  • Transfer to regional center ONLY after maternal
    stabilization

23
TRAUMA IN PREGNANCYHead Trauma
  • Dead Mother Dead Fetus

24
Case
  • ID 21 y/o G1 P0 _at_ 18/40
  • HPI
  • Sudden onset of colicky right sided pain
  • Anorexia
  • No BM x 3 days, emesis x 1
  • Warmth x 2 days
  • No dysuria, no gross hematuria, no PV bleeding

25
Case
  • O/E
  • BP 110/55 HR 110 regular RR 18 Temp 37.9
  • Abdo uterine height of 20 cm, tender over right
    side of abdomen w/ rebound
  • V/E N

26
Case
  • DDx
  • Appendicitis
  • UTI
  • Renal calculi
  • Cholecystitis
  • Ovarian cyst / torsion
  • Ligamentous pain
  • Cecal diverticulitis
  • Acute iliitis

27
Case
  • Investigations?
  • Labs
  • Hb 130, WBC 14, Plt 350
  • Lytes, Cr, liver tests all normal
  • Urine RM trace protein, no leuks, no bacteria,
    trace blood
  • Imaging
  • Fetal U/S BPP 8/8
  • RLQ U/S - compressible blind-ended tubular
    structure w/ a maximal diameter of 9 mm, wall
    thickened to 5 mm

28
Appendicitis - Background
  • Of the most common causes of the acute abdo
  • Peaks in 2nd and 3rd decades of life, MgtF
  • Anatomy
  • Lies in the RLQ of the abdomen
  • Exceptions
  • Malrotation (LUQ)
  • Pregnancy (RLQ-RUQ)

29
Epidemiology
  • Incidence 0.05-0.07
  • Perforation 20-55 (versus 4-19 in general
    population)
  • Fetal mortality 1.5-9 w/o perf (up to 36 w/
    perf)
  • Overall correct diagnosis 50-86

30
Clinical
  • Symptoms non-specific initially
  • Initially dull, poorly localized periumbilical
    pain
  • Localizes to McBurneys point
  • Nausea/vomiting
  • Low grade fever 38 (if rupture, fever higher)
  • Eventually /- peritoneal signs

31
Labs/Imaging
  • Labs elevated WBC, no abnormalities that
    indicated an alternate dx (liver functions,
    B-HCG, etc)
  • CT 95 spec and sens
  • U/S 81 spec, 86 sens

32
Management
  • Surgical
  • Preop
  • Hydration
  • Abx prophylaxis
  • Non-perfed cefazolin 1 g IV, metronidazole 500
    mg IV
  • Perfed ceftriaxone 1 g IV, metronidazole 500 mg
    IV
  • Delaying intervention for gt24 hrs, risks perfs
  • Risk of preg comps (SA or prematurity) w/
    laparotomy decrease with gestational age
  • May do laparotomy or laparoscopy

33
G.I. DISEASE IN PREGNANCYAPPENDICITIS
  • Fetal Mortality and Maternal Morbidity rates are
    directly correlated to the delay in diagnosis and
    treatment

34
Acute cholecystitis - Background
  • A syndrome with
  • RUQ pain
  • Fever
  • Leukocytosis
  • Assoc w/ GB inflammation usually due to gallstone
    (in preg 90)

35
Epidemiology
  • Incidence of lt0.1 in pregnancy
  • Maternal mortality 0-1
  • 15 with pancreatitis
  • Fetal mortality 10-20
  • 60 with pancreatitis

36
Clinical
  • RUQ/epigastric pain, steady and severe gt4-6 hours
  • Nausea/vomiting, anorexia
  • Fatty food ingestion exacerbates pain 1 hour
    after intake
  • Ill looking, tachycardic, febrile, lie still,
    peritoneal signs, ve Murphys sign (inspiratory
    arrest) /- jaundice

37
Pathophysiology
  • Pregnancy predisposes to accumulation of GB
    stones by
  • Increasing viscosity of bile
  • Increasing the number of micelles on which
    cholesterol crystals precipitate
  • Relaxing the GB leading to stasis
  • Increased risk of cholelithiasis stays for up to
    5 years postpartum

38
Labs/Imaging
  • Labs
  • Elevated WBC w/ left shift
  • Elevated bili and ALP, /- high AST/ALT/amylase
  • U/S
  • Cholelithiasis
  • Wall thickening gt4.5 mm
  • Sonographic Murphys sign
  • Dilation of GB
  • Sens 88, spec 80
  • HIDA scan
  • Sens 97, spec 90

39
Management
  • IV hydration
  • Analgesia
  • Demerol preferred over morphine (morphine may
    produce spasm of sphincter of Oddi)
  • NPO
  • Abx
  • Metronidazole 500 mg IV q8h
  • Ceftriaxone 1 g IV q24h

40
Management
  • Surgery is safest to perform during TM2
  • Laparoscopic cholecystectomy has been performed
    during pregnancy but safety is uncertain
  • Patients w/ choledocholithiasis or pancreatitis
    can be mx w/ ERCP w/ sphincterotomy
  • If preg and have gallstones but asymptomatic no
    surgery
  • Pre-preg if have symptoms consistent w/
    gallstones consider cholecystectomy

41
G.I. DISEASE IN PREGNANCYBOWEL OBSTRUCTION
  • Morbidity and Mortality related to the delay in
    diagnosis
  • Previous Surgery and Adhesions--3d TM
  • Volvulus, Hernia, Intussusception
  • Signs and Symptoms
  • Diagnosis Serial Assessments and Serial AXRs
  • Management?

42
CASE 2
  • THE MOOSE STORY

43
CASE 2
  • THE MOOSE STORY
  • NOW IN THE NEUROSURGICAL ICU
  • CONSULTS OBS RE CT, ANGIOGRAPHY
  • CONSIDERATION OF TERMINATION?

44
CASE 2
  • THE MOOSE STORY
  • THE HAPPY ENDING.

45
CASE 3
  • 30 YR OLD WOMAN AT 24 WEEKS GESTATION MVA HIT
    FROM BEHIND
  • HAD SEAT BELT ON, NO HEAD INJURY
  • O/E VSS, BRUISED AND TENDER ABDOMEN
  • FETAL HEART TONES HEARD
  • WHAT ARE THE ISSUES HERE?

46
CASE 3
  • MATERNAL CONSIDERATIONS FIRST!
  • FETUS SECONDARY
  • MONITORING IF FETUS VIABLE
  • FETAL MATERNAL TRANSFUSION
  • BETKE-KLEIHAUER
  • SURGICAL DELIVERY IF FETAL DISTRESS AND MOTHER IS
    STABLE

47
SURGERY IN THE PREGNANT PATIENT
  • Learning objectives
  • 1)TRAUMA IN PREGNANCY
  • 2)THE ACUTE ABDOMEN IN PREGNANCY
  • 3)CASES

THANKS!
48
SURGERY IN THE PREGNANT PATIENT
  • AVOID THERAPEUTIC PARALYSIS
  • IF AN INVESTIGATION IS INDICATED FOR DIAGNOSIS
    ---DO IT!
  • NEVER COMPROMIZE THE MATERNAL CARE FOR THE SAKE
    OF THE FETUS!
  • THERE ARE VERY FEW DRUGS OR INVESTIGATIVE TESTS
    WHICH CAUSE SERIOUS FETAL DAMAGE

49
References
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    45(2)414-424, 2002.
  • Mattox KL. Trauma in Pregnancy. Crit Care Med
    33(10)S385-S389, 2005.
  • Tweddale CJ. Trauma During Pregnancy. Crit Care
    Nurs Q. 29(1)53-67, 2006
  • ACOG Educational Bulletin. Obstetric Aspects of
    Trauma Management. Number 251, Sep 1998.
  • Stone IK. Trauma in the obstetric patient. Obs
    Gyn Clin NA. 26(3)459, 1999.
  • ACOG Committee on Obstetric Practice. ACOG
    Committee Opinion. Number 299, September 2004.
    Guidelines for diagnostic imaging during
    pregnancy. Obstetrics Gynecology.
    104(3)647-51, 2004.
  • Fildes J. Trauma the leading cause of maternal
    death. JTrauma. 32(5)643-5, 1992. (Abstract
    Only)
  • Kang AH. Traumatic Spinal Cord Injury. Clin OG.
    48(1)67-72, 2005.
  • Dahmus MA. Blunt Abdominal Trauma Are there any
    predictive factors for abruptio placentae or
    maternal-fetal distress. AJOG. 169(4)1054-1059,
    1993
  • Towery R. Evaluation of pregnant women after
    blunt injury. JTrauma. 35(5)731-5, 1993.
    (Abstract only)
  • Gilson, GJ. Acute spinal cord injury and
    neurogenic shock in pregnancy. Obstet Gynecol
    Surv. 50(7)556-560, 1995
  • Banit DM. Evaluation of the Acute Cervical Spine
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  • Whitten M. Postmortem and perimortem caesarean
    sections what are the indications?. J R Soc Med
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    Outcomes. JTrauma. 45(1)83-86, 1998.
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