Trauma in Pregnancy

Berita
Dua Polwan Bantu Ibu Hamil Yang Alami
Kecelakaan (18/07/17)
 Wanita Tengah Hamil 39 Minggu Tewas saat
Kecelakaan, Bayi yang Dikandungnya Berhasil
Selamat (30/07/18)
Alasan kenapa wanita hamil tidak
boleh menyetir
 Overview

• Dual goals in managing pregnant trauma

• Physiological changes of pregnancy
– Response to hypovolemia
• Types of injuries most commonly
associated
• Initial assessment and management
• Trauma prevention in pregnancy
 Trauma in Pregnancy

• Unique challenges
– Vulnerability of pregnant trauma patient
– Potential injuries to unborn child
• Dual roles
– Provide care to mother
– Provide care to fetus
 Trauma in Pregnancy

• Leading cause of morbidity and mortality

– 6–7% of pregnancies experience some
trauma
 1 in 12 injured experience significant trauma
– Major causes
 Motor-vehicle collisions
 Falls
 Abuse and domestic violence
 Penetrating injuries
 Burns
 Pregnant Patient

• Increased risk for trauma

– Fainting spells, hyperventilation, excess
fatigue commonly associated with early
pregnancy
– Balance and coordination affected by
changes throughout pregnancy
Fetal Development
Viability Assessment
Physiologic Changes
 Physiologic Changes

• Respiratory system
– Diaphragm elevated due to uterine size
– Decreased thoracic volume
– Relative alkalosis
– Predisposed to hyperventilation
 Vital Signs in Pregnancy

• Do not mistake normal vital signs

for signs of shock.
– Normal pulse: 10–15 beats faster
– Blood pressure: 10–15 mmHg lower
– 30–35% blood loss
before significant blood pressure change
• Be alert to all signs of shock
– Frequent ITLS Ongoing Exams
 Response to Hypovolemia

• Vasoconstriction and tachycardia

– Reduction of uterine blood flow by 20–30%
– Fetal heart rate and blood flow decrease
– Fetus becomes hypoxemic
• High-flow oxygen is essential
– Maternal shock has 80% fetal mortality rate
 Trauma in Pregnancy

• ITLS Primary and Secondary Surveys

• Optimize maternal and fetal outcome
– High-flow oxygen rapidly administered
 Fetal hypoxia occurs before maternal hypoxia
– Fluid administration must be prompt
 Fluid volume needed is greater
– Frequent Ongoing Exams
 Mortality of fetus related to maternal treatment
 Pregnant Trauma Arrest

• Treated same as for other victims

– Defibrillation settings are same
– Drug dosages are same
– Fluid volume needed increases
 4 liters normal saline rapid infusion during transport
• If mother unsalvageable:
– Continue CPR
– Notify hospital of possible cesarean section
 Supine Hypotension

• Venous return decreases 30% in supine

position with 20-week or larger uterus
– Acute hypotension
– Syncope
– Fetal bradycardia
 Supine Hypotension

• Transport position
– Tilt or rotate backboard 15–30° to patient's left
– Elevate right hip 4–6 inches (10–15 cm)
with towel
 Manually displace uterus to left

Courtesy of Louis B. Mallory, MBA, REMT-P

 Supine Hypotension

• Transport position
– Better stabilized
with vacuum backboard
– More comfortable
than standard backboard

© Pearson
Evaluation of Uterine Size
 Fetal Death

Relatively minor abdominal trauma

can cause fetal death.

Maternal death is most common cause

of fetal death.

International Trauma Life Support for Prehospital Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
 Types of Trauma

• Motor-vehicle collisions
• Penetrating injuries
• Domestic violence
• Falls
• Burns
 Motor-Vehicle Collisions

• 65–75% of pregnancy-related trauma

– <1% injured when minor vehicle damage
– Seatbelts significantly decrease mortality
 Have not shown any increase in uterine injury

Courtesy of Louis B. Mallory, MBA, REMT-P

 Motor-Vehicle Collisions
• Maternal death • Fetal injury
– Head injury – Fetal distress
 Most common – Fetal death
– Uncontrolled – Placental abruption
hemorrhage – Uterine rupture
 Second most common
– Preterm labor
 Assess pelvis
 Abdominal Trauma

• Physiologic changes
– Decreased sensitivity
 Gradual stretching
 Hormonal changes
 Uterus very vascular
• Clinical presentation
– Guarding, rigidity, rebound response absent
 Abdominal trauma requires ED evaluation
 Penetrating Injuries

• Gunshot wounds and stabbings

– Entry below fundus
 Uterus absorbs force, protects maternal organs
 High fetal mortality rate: 40–70%
 Lower maternal mortality rate: 4–10%
– Entry above fundus
 Bowel injury due to displacement
 Domestic Violence

• 10% experience abuse during pregnancy

– Proximal and midline injuries
 Face and neck most common
– Low birth weight
– Abused by spouse or boyfriend: 70–85%
(U.S.)
 Falls

• Injury from falls

– Increase with progression of pregnancy
 Center of gravity altered
– Proportionate to force and body part impacted
– Pelvic injuries
 Placental separation
 Fetal fractures
 Burns

• Fluid volume needed increases

– Mortality and morbidity
 Maternal mortality same as non-pregnant
 Fetal mortality increases with >20% BSA (Bovine
Serum Albumin)
 Trauma Prevention

• Proper seat-belt use

• Report domestic violence
• Counseling for domestic violence
• Patient education
– Multiple changes associated with pregnancy
 Physiological, anatomical, emotional
 Summary

• Trauma in pregnancy
– Knowledge of physiological changes
 Hypotension and hemorrhage easily overlooked
– Rapid evaluation and interventions to stabilize
 Aggressive oxygen administration
 Aggressive fluid resuscitation
– Prevent supine hypotension
• Fetal care depends on maternal care