The pregnant trauma

patient

TOM ARCHER MD, MBA

UCSD ANESTHESIA
Outline

Epidemiology
General approach to the patient
Anesthesia and diagnostic studies.
Obstetric complications of trauma
(What the obstetrician will be thinking
about)
Relevant maternal / fetal physiology
FHR monitoring
Perimortem cesarean section
 Trauma in pregnancy

Trauma is most common non-obstetric cause of

maternal death.

Common major traumas: MVAs, falls and assaults.

5-10% of pregnancies are marred by some sort of

trauma (usually very minor and not seen in hospital).

In one study, 0.2% of all pregnant women were seen

in hospital for trauma during a given pregnancy.

Chestnut chap 53, El Kady D et al

Trauma in pregnancy

Incidence of trauma increases as pregnancy

progresses:

8% in first trimester
40% in second trimester
52% in third trimester
Causes of maternal
death

Most maternal deaths are due to head trauma

or hemorrhagic shock.
Commonest causes of
fetal death

In severe maternal injury, it is maternal death.

In minor injury, it is placental abruption

Pregnant women
need to wear seat
belts properly:

One strap under

uterus, the other
between breasts.

Many women dont

wear them for fear
of hurting the baby.

Improper placement
can injure fetus.

http://www.maternity-
seatbelt.jp/Seat_belt_photo.gif
Domestic violence

Domestic violence knows no boundaries of

race or economic status.

Pregnancy often represents dependency

and loss of autonomy and control.

Abusers will take advantage of this. They

may feel threatened by pregnancy and
attack abdomen as a way of retaliating
against fetus.
Domestic violence

Think of it as a possibility!

Look for emotional withdrawal,

depression, self-blame.

Look for other (older) signs of injury.

Face-to-face, one-on-one interviews.

Calm, matter-of-fact tone helps elicit
Hx.
What will happen to my baby?

Trauma appears to affect the fetus only in the

short-term

if there is no early placental abruption, fetal

death, premature rupture of membranes, or
urgent delivery, there is no significant
difference in pregnancy outcome

Shah KH 1998
 Trauma management in
pregnancy
Best
way to take care of baby is to take care of
mother. All ACLS guidelines apply.

Know how physiological / anatomical changes of

pregnancy affect vulnerability of patient to
stresses.

Planfor specific obstetric concerns (without

getting obsessed).

Common worries (patient, nurse, MD) : radiation,

drugs, abruption, anesthesia.
 Anesthesia in OB trauma
Maintaingood anesthesia, oxygenation,
normotension, normothermia, normocarbia
(PaCO2 = 30) and LUD. Avoid ketamine > 2
mg /kg (uterine hypertonus).

MonitorFHTs if practical. Loss of variability is

normal, but fetal tachy- or bradycardia may
mean hypoxia.

Defensive medicine: probably avoid

benzodiazepines and N2O early in gestation
(little to no solid evidence for this).
X-ray studies in pregnant
patients

Use x-ray studies judiciously but USE THEM

when needed!

Shield uterus when possible.

Consult with radiologist on minimizing

exposure.
 X-ray doses from studies

1 Rad = 10 mGy (milliGrey)

Mann FA et al 2000
 Risk from X-ray exposure
1 Rad = 10 mGy (milliGrey)

Benefit of judiciously chosen x-rays far outweighs risks in

pregnant trauma patients.
Intermediate exposure (50-100 mGy) roughly equivalent
to 3 years of natural background radiation exposure and
is associated with no increase in anomalies or growth
restriction.
Mann FA et al
2000
 X-ray studies in pregnant
patients
CT is gold standard for Dx of blunt abdominal trauma.

Transport from ER to CT scanner and radiation risks / fears remain

as obstacles to CT.

Miller MT 2003
 MVA, pregnant patient at 27 weeks EGA, lap belt worn across the
bulge.

CT scan: ruptured uterus with extruded products of conception.

Astarita DC et al
 MVA, pregnant patient at 27 weeks EGA, lap belt worn across the
bulge.
CT scan: ruptured uterus with extruded products of conception.

Astarita DC et al 1997
 Ultrasound in trauma
evaluation
Can ultrasound substitute for CT? Modality is
called FAST (Focused Abdominal Sonography
for Trauma).

Focusof FAST is detecting free fluid, presumed

to be blood.

FAST is part of screening process, but can miss

injuries (e.g. solid organ).

Miller MT 2003
 Lateral pelvic ultrasound: free fluid in cul-de-sac (+ Foley in bladder).

Richards JR 2004
 Obstetric complications of
trauma
Abruption
Pre-term labor
Ruptured membranes
Uterine rupture
Direct fetal injury (usually penetrating trauma)

Rare: amniotic fluid embolus, chorionic villus

embolus

Kingston NJ
2003
Predisposing factors to DIC / ARDS
after trauma in pregnancy:

Abruption.
Dead fetus.
Shock
Sepsis
Traumatic amniotic fluid embolus
(rare).
Factors in common are release of
abnormal substances into circulation.

Hypothermia and acidosis

exacerbate coagulopathy.
Ferrara A 1990
 Normal placental function: fetal and maternal circulations separated
by thin membrane (syncytiotrophoblast).
)Diffusion of O2 and CO2 is +/- complete.
Fetal O2 uptake limited by uterine blood flow.

Umbilical vein Umbilical artery (UA)

(UV)
Fetus

Fetal Lakes of
capillaries in maternal
chorionic villi blood

Mom
Uterine veins Uterine arterie

Archer TL 2006 unpublished

www.siumed.edu/~dking2/erg/images/placent
a.jpg
Placental
) abruption: fetal asphyxiation
(O2 supply is cut off).

Umbilical vein Umbilical artery (UA)

(UV)

Abruptio
n

Uterine veins Uterine arterie

Archer TL 2006 unpublished

Placental abruption

Placenta
shears off
Liquid placenta

Elastic myometrium
Abruption separates
here

www.simba.rdg.ac.uk
From Google images
 Placental abruption from minor
trauma

Usually happens within 4-6 hours (if its going to happen).

Incidence of abruption from minor trauma is low (1.6%), but

Minor trauma is common, so minor trauma causes many abruptions.

Major trauma is uncommon, but incidence of abruption is high (37.5%).

Pearlman MD
Millers Anesthesia chap.
 Placental abruption
Accompanies 1-5% of minor injuries, 20-50% of major injuries.

Abdominal tenderness
Uterine tenderness
Uterine contractions
Vaginal bleeding but hemorrhage may be hidden.
 Placental trauma (+/-
abruption):
More common with anterior placenta? (Pearlman
Feto-maternal hemorrhage
1990)

Chorionicvilli break, releasing fetal RBCs into

lakes of maternal blood.

Dangers:
Iso-immunization of Rh- mother by Rh+ fetal cells.
Fetal exsanguination / anemia / hydrops / brain
damage.
Premature labor (due to release of thrombin, lysozymes
or prostaglandins into maternal circulation?).
Placental
) disruption: feto-maternal
hemorrhage

Umbilical vein Umbilical artery (UA)

(UV)

Chorionic
villus
Uterine veins
disruption Uterine arterie

Archer TL 2006
www.siumed.edu/~dking2/erg/images/placent
a.jpg
 Chorionic villus
disruption causing
feto-maternal
hemorrhage

www.simba.rdg.ac.u
k
Kleihauer- Betke
preparation
Maternal blood smear eluted with acid wash.

Adult hemoglobin washed away

Fetal hemoglobin stays behind a few brightly

stained fetal cells amongst a sea of ghostly
maternal cells.
Kleihauer-Betke preparation: Massive fetal-maternal
hemorrhage

www.cbbsweb.org from Google images

KB prep to diagnose
Feto-maternal hemorrhage
One dose of RhoGam (anti-D antibody to
destroy fetal Rh+ RBCs) is routine with
trauma to Rh- mother (regardless of KB
results).

Kleihauer Betke prep sometimes used to

assess:
Need for repeated RhoGam doses (large FMH)
Probability of pre-term labor (?)
Does feto-maternal
hemorrhage promote pre-
term labor?
Theory: Kleihauer -Betke test predicts uterine contractions and
preterm labor

Muench MV et al
 Fetal heart rate monitoring

(for hypoxia)
Worryis abruption.after trauma
Usually combined with contraction
monitoring.
4 hours is routine.
>4 hours if:
Abruption suspected
Frequent uterine activity
Rupture of membranes
FHR abnormalities present
Mother is in critical condition

Chestnut chap 53
Ruptured uterus

Life-threatening emergency, 10% maternal

mortality

Fetus almost always dies.

Ruptured amniotic
membranes

Vaginal fluid leak avenue for infection.

By itself, not an emergency.

Maternal / fetal physiology and
anatomy relevant to trauma
 Mom
4 ml O2 / kg / min

Feto-placental unit
12 ml O2 / kg / min

Mother is consuming and delivering

oxygen for two!

www.studentlife.villanova.ed
Physiological changes of pregnancy at
term:
Maternal-fetal
O2 consumption increases 40-
50% over non-pregnant state.

Cardiac output increases by 50%.

Functionalresidual capacity (apneic reserve of

O2) decreases by 20%

Pregnant patient has diminished capacity

to tolerate apnea!
Chestnut chap. 53
Functional residual capacity (FRC) is our air tank for
apnea.

www.picture-newsletter.com/scuba-diving/scuba... from Google

Pregnant Mom has a smaller air tank.

Non-
pregnant
woman

www.pyramydair.c
om/blog/images/sc
uba-web.jpg
At term, mother has respiratory alkalosis
with metabolic compensation (less HCO3-
buffer).
ABGs Non- At term
pregnant
PaCO2 40 30

PaO2 100 103

pH 7.40 7.44

HCO3- 24 20

Chestnut
At term, mother also has lower
hemoglobin concentration to
buffer acid load:

Non-pregnant At term

Hemoglobin 12-14 gm / dL 11-12 gm / dL

Compared to non-pregnant state,
pregnant woman has less tolerance
for:

Apnea

Acidosis
Hematologic changes
at term:

Blood volume increased by

45%
Pregnant woman may
tolerate hemorrhage better
than non-pregnant woman,
before showing fall in BP.

Fibrinogen increased.
PT, PTT shortened 20%.
Increased platelet turnover.

Increase in coagulation
factors,
immobilization and aorto-
caval compression all
increase risk of DVT.
Vascular congestion

Swelling of respiratory mucosa (nose, rest of

airway).

Dont put anything through the nose if you can

avoid it prevent bad nose bleed.
GI tract

Decreased gastric emptying

Increase GERD

Full stomach precautions

Avoid aorto-caval compression: use
left uterine displacement (LUD)
LUD helps venous return. C/S as part of resuscitation?
LUD decreases chance of DVT
LUD increases O2 delivery to fetus:
Increases uterine artery pressure and decreases uterine venous
pressure.

Why we dont do it: It doesnt look right!

Normal placental function: fetal and maternal circulations separated by thin
membrane.
)
Diffusion of O2 and CO2 is +/- complete. Umbilical vessels have no tone.
Fetal O2 uptake limited by uterine blood flow.

Umbilical artery (UA)

Umbilical vein pH = 7.33
pH = 7.37 300 ml / min
(UV)
pO2 = 15
pO2 = 28 Fetus
pCO2 = 44
pCO2 = 35

Uterine artery
Uterine vein 700 ml / min

pH = 7.35 pH = 7.45
pO2 = 33 pO2 = 96
Mom
pCO2 = 37 pCO2 = 28

Data from Chestnut chap.4

Ohms Law of the placenta: O2 delivery = Placental blood flow = (P1
P2) / R
Aorto-caval compression decreases P1 (aorto) and increases P2
(caval)

Therefore, aorto-caval compression decreases O2 delivery

to fetus.

R = placental
resistance (fixed in
short term)
P1 = uterine
Placenta blood artery pressure
flow (O2 delivery)
=
(P1 P2) / R
P2 = uterine vein Archer TL
pressure
Colman-Brochu S
http://www.manbit.com/OA/f28-
 http://www.manbit.com/OA/f28-
Manbit images
Chestnut chap. 2
What happens if fetus doesnt get enough
oxygen? (What is the mammalian diving
response?)

www.doc.govt.nz/.../images/diving-whale-
 FIGURE 6. Nonreassuring pattern of late decelerations with
preserved beat-to-beat variability. Note the onset at the peak of
the uterine contractions and the return to baseline after the
contraction has ended. The second uterine contraction is
associated with a shallow and subtle late deceleration.
http://www.aafp.org/afp/990501ap/248
Humans have diving responses too!

Univ of Lund Thesis

Johan Andersson
http://www.biol.lu.se/z
oofysiol/Johan/Avhand
ling.html#Sv
 The human diving response. The changes in mean arterial blood
pressure (MAP), heart rate (HR) and skin capillary blood flow
(SkBF) during apnea with face immersions are shown. The heart
rate and skin capillary blood flow are reduced while the MAP
increases during apnea.
Univ of Lund Thesis Johan Andersson
http://www.biol.lu.se/zoofysiol/Johan/Avhandling.html#Sv
 The mammalian diving reflex shuts down blood
flow to all organs except the heart and brain, in
order to conserve oxygen.

The fetus response to hypoxia is related to this

reflex.

See Univ of lund thesis Johan Andersson

http://www.biol.lu.se/zoofysiol/Johan/Avhandling.htm
l#Sv
Perimortem cesarean section 5 minute rule

Chestnut chap.
Summary

MVAs, falls and assaults are the commonest

traumatic mechanisms in pregnancy.

Think of the possibility of domestic violence /

partner abuse.

Pregnant women need to wear seat belts

properly.
Summary

Dont over-react to the fact that patient is

pregnant.

ACLS and all usual diagnostic studies should be

performed. Ultrasound may be useful, but
perform needed x-ray studies!

Management of pregnancy is part of secondary

survey.
Summary
Abruption is commonest cause of fetal death in non-life-
threatening trauma to mother.

Abruption most likely with abdominal trauma.

Abdominal trauma can also cause feto-maternal

hemorrhage, uterine rupture, rupture of membranes and
pre-term labor.
Summary

Feto-maternal hemorrhage may be a cause of

pre-term labor.

KB prep may have value in screening for severe

feto-maternal hemorrhage and risk of pre-term
labor.

One dose of RhoGam is routine in trauma to Rh-

mother, regardless of KB results.
 Summary
Pregnant women are vulnerable to apnea and have swollen
airways.

They may be tolerant of blood loss, with delayed fall in BP.

LUD is important for 3 reasons:

Maternal hemodynamics
Fetal oxygenation
DVT prophylaxis
 Summary
Fetal oxygen uptake is proportional to placental blood flow.

The fetus will drop heart rate in response to hypoxia. This is the
basis for FHR monitoring after maternal trauma.

This response is related to the mammalian diving reflex.

Summary

To deliver an intact newborn, perimortem

cesarean section should deliver baby within 5
minutes of cessation of maternal circulation and
oxygenation.
My Website

You can download this

talk from:

www.archeranesthesia.i
nfo
Thank you!

The End
References

Astarita: J Trauma, Volume 42(4).April 1997.738-740

Chestnut DH, Obstetric Anesthesia, Principles and Practice, third edition.

Colman-Brochu S American Journal of Maternal Child Nursing. 29(3):186-92, 2004

May-Jun.

El Kady D et al American Journal of Obstetrics and Gynecology (2004) 190,

1661e8

Elovitz MA American Journal of Obstetrics & Gynecology. 185(5):1059-63, 2001

Nov.

Ferrara A American Journal of Surgery. 160(5):515-8, 1990 Nov.

Judich A Injury, Vol. 29, No. 6, 475-477, 1998.

Kingston NJ Am J Forensic Med Pathol 2003;24: 193197

References

Mann FA et al The Journal of Trauma (2000) Vol. 48, No. 2, pp.354-357

Miller MT Journal of Trauma Volume 54(1),January 2003,pp 52-60

Muench MV J Trauma. 2004;57:10941098.

Pearlman MD et al American Journal of Obstetrics & Gynecology. 162(6):1502-7;
discussion 1507-10, 1990 Jun.

Pearlman MD International Journal of Gynecology & Obstetrics 57 (1997) 127-132

Richards JR Radiology 2004; 233:463470

Shah KH J Trauma Volume 45(1),July 1998,pp 83-86

Warner MW ANZ J. Surg.2004;74: 125128