SURGERY IN THE PREGNANT PATIENT - PowerPoint PPT Presentation

Loading...

PPT – SURGERY IN THE PREGNANT PATIENT PowerPoint presentation | free to download - id: 6bfd77-YzY2Y



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

SURGERY IN THE PREGNANT PATIENT

Description:

trauma and surgery in the preganant patient principles of surgery-2011 nicholas leyland,basc,md,mhcm,frcsc professor and chair, department of obstetrics and gynecology, – PowerPoint PPT presentation

Number of Views:5
Avg rating:3.0/5.0
Slides: 41
Provided by: DrLey9
Learn more at: http://surgery.utoronto.ca
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: SURGERY IN THE PREGNANT PATIENT


1
TRAUMA AND SURGERY IN THE PREGANANT PATIENT
PRINCIPLES OF SURGERY-2011 NICHOLAS
LEYLAND,BASc,MD,MHCM,FRCSC PROFESSOR AND
CHAIR, DEPARTMENT OF OBSTETRICS AND GYNECOLOGY,
FACULTY OF HEALTH SCIENCES, MICHAEL G. DEGROOTE
SCHOOL OF MEDICINE, McMASTER UNIVERSITY
2
SURGERY IN THE PREGNANT PATIENT
  • Learning objectives
  • 1)TRAUMA IN PREGNANCY
  • 2)THE ACUTE ABDOMEN IN PREGNANCY
  • 3)NEUROVASCULAR EMERGENCIES
  • 4)CASES
  • 5) UPDATE LEYLAND

3
THERAPEUTIC PARALYSIS
4
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

5
TRAUMA IN PREGNANCYMATERNAL 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
  • Consider Tocolysis as indicated
  • Vaginal exam to rule out PPROM

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
  • Risk 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
  • CTXs 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 CTXs 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, PPROM, 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
CARDIOPULMONARY RESUSCITATION
  • There are special considerations for
    cardiopulmonary resuscitation (CPR) conducted in
    the second half of pregnancy.
  • uterine displacement is paramount to accompany
    other resuscitative efforts

25
G.I. DISEASE IN PREGNANCYAPPENDICITIS
  • Abdominal pain, nausea,vomiting
  • Anorexia
  • Localization of the pain and tenderness
  • Ultrasound?
  • Laparoscopy?Negative Laparotomy Rate
  • Fetal Mortality and Maternal Morbidity rates are
    directly correlated to the delay in diagnosis and
    treatment

26
OB/GYNE CONDITIONS MIMICKING APPENDICITIS
  • PRETERM LABOUR
  • PLACENTAL ABRUPTION
  • DEGENERATION OF FIBROIDS
  • ADNEXAL EVENTS
  • ROUND LIGAMENT PAIN
  • ECTOPIC PREGNANCY
  • CHORIOAMNIONITIS

27
CHOLECYSTITIS IN PREGNANCY
  • SIGNS AND SYMPTOMS
  • DDx
  • MI
  • ACUTE FATTY LIVER OF PREGNANCY
  • APPENDICITIS
  • SEVERE PREECLAMPSIA/HELLP
  • PUD
  • PANCREATITIS

28
CHOLECYSTITIS IN PREGNANCY
  • DIAGNOSISU/S
  • TREATMENTMEDICAL.1ST AND 3D TM
  • SURGICAL.2ND TM
  • FAILURE OF MEDICAL OR RECURRENT ATTACKS
  • LAPAROSCOPY?

29
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?

30
PANCREATITIS IN PREGNACY
  • PRESENTATION
  • INVESTIGATIONS
  • MANAGEMENT
  • FETAL CONSIDERATIONS?

31
NEUROVASCULAR EMERGENCIES IN PREGNANCY
  • AVMs, ANEURYSMS
  • SURGICAL MANAGEMENT TREATMENT AT THE TIME OF
    PRESENTATION(ANEURYSM)
  • AVM LESS CLEAR
  • SUPERIOR SAGITAL SINUS THROMBOSIS

32
CASE 1
  • 29 YR OLD _at_ 34 WEEKS GESTATION
  • N/V X 8 HOURS, ANOREXIA (NEW ONSET)
  • PX AFEBRILE, TENDER MID- ABDOMEN RIGHT WITH
    REBOUND
  • UTERUS NON TENDER BUT CAUSES TENDERNESS ON RIGHT
    WITH PALPATION FROM THE LEFT

33
CASE 1
  • INVESTIGATIONS?
  • DDx?
  • FETAL CONSIDERATIONS?
  • MANAGEMENT

34
CASE 2
  • THE MOOSE STORY

35
CASE 2
  • THE MOOSE STORY
  • NOW IN THE NEUROSURGICAL ICU
  • CONSULTS OBS RE CT, ANGIOGRAPHY
  • CONSIDERATION OF TERMINATION?

36
CASE 2
  • THE MOOSE STORY
  • THE HAPPY ENDING.

37
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?

38
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

39
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

40
SURGERY IN THE PREGNANT PATIENT
  • Learning objectives
  • 1)TRAUMA IN PREGNANCY
  • 2)THE ACUTE ABDOMEN IN PREGNANCY
  • 3)NEUROVASCULAR EMERGENCIES
  • 4)CASES

THANKS!
41
References
  • Van Hook, JW. Trauma In Pregnancy. Clin Ob Gyn,
    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
    A Management Algorithm. J Trauma. 49450-456,
    2000
  • Whitten M. Postmortem and perimortem caesarean
    sections what are the indications?. J R Soc Med
    936-9, 2000.
  • Shah KH. Trauma in Pregnancy Maternal and Fetal
    Outcomes. JTrauma. 45(1)83-86, 1998.
  • Baerga Varela, Y. Trauma in Pregnancy. Mayo
    Clinic Proceedings. 75(12)1243-1248, 2000.
  • Pak LL. Is adverse pregnancy outcome predictable
    after blunt abdominal trauma. AJOG
    179(5)1140-1144, 1998.
  • Pearlman M. Automobile crash simulation with the
    first pregnant crash test dummy. AJOG.
    175(4)977-981,1996.
  • Moorcroft DM. Computational model of the pregnant
    occupant Predicting the risk of injury in
    automobile crashes. AJOG 1889(2)540-544, 2003.

42
TRAUMA IN PREGNANCYBLUNT ABDOMINAL TRAUMA
  • MVA, ASSAULT, FALLS
  • MANGEMENT PRINCIPLES..
  • OBS PRINCIPLES.

PLACENTAL CONSIDERATIONS FETAL MATERNAL
TRANSFUSION UTERINE RUPTURE PRETERM LABOUR FETAL
MONITORING!!!!!!!!!
43
TRAUMA IN PREGNANCY
  • RADIOLOGIC INVESTIGATIONS ADVERSE AFFECTS TO
    FETUS RARE lt 10cGy
  • cSPINE, CXR, Angiography, CT, MRI
  • Shielding of abdomen

44
CARDIOVASCULAR DISEASE
  • KEY POINTS
  •   ?    Hemodynamic changes in pregnancy may
    adversely affect maternal cardiac
    performance.  ?    Intercurrent events during
    pregnancy are usually the cause of
    decompensation.   ?    Labor, delivery, and
    postpartum are times of hemodynamic
    instability.  ?    Invasive hemodynamic
    monitoring should be used to address specific
    clinical questions.  ?    Many maternal heart
    conditions can be medically managed during
    pregnancy. A few are associated with a very high
    risk of maternal mortality.  ?    Many patients
    with congenital heart disease can successfully
    complete a pregnancy.  ?    Preconceptual
    counseling is based on achieving a balance
    between medical information and the patient's
    value system.

45
Penetrating Trauma in the Pregnant Patient
  • 1. There were visceral injuries when the entrance
    wound was in either the upper abdomen or
    back.2. When the entry wound site was anterior
    and below the uterine fundus, there were no
    visceral injuries.3. Half the women had
    perinatal deaths due to either maternal shock,
    uteroplacental injury, or direct fetal injury.

46
TRAUMA IN PREGNANCYPenetrating Abdominal Trauma
  • Gunshot Woundsentry/ exit
  • Xray localization
  • Laparotomyuterine status/ fetal viability
  • Knife Woundsfistulogam?
  • Uterus 500 ml/min at term
  • Postmortem Ceasarean

47
Fetal Mortality
  • Retrospective review of hospitalized trauma
    patients 1986-1996 for short and long term
    pregnancy outcomes
  • 61 patients, long term followup in 53
  • Successful pregnancy neonate surviving neonatal
    period

Baerga Varela
48
Fetal Mortality
49
MANAGEMENT OF TRAUMA
  • An important aspect of management is
    repositioning of the large uterus away from the
    great vessels to diminish its effect on decreased
    cardiac output.
  • Almost 20 percent of women who had contractions
    more frequently than every 10 minutes in the
    first 4 hours had an associated placental
    abruption.
  • For the woman who is D-negative, administration
    of anti-D immunoglobulin should be considered.
About PowerShow.com