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Two for One: Caring for the Pregnant Trauma Patient

Nabil Alzadjali FRCP III McGill University

CASE 1
25 Yrs F, 35 wks Preg. PC : MVC PMH : nil, Rh +ve, HPI : Driver, belted, rear ended by another car, air bag deployed Complaining of occasional abdominal pain, ?cramping. Unsure about fetal movements. Very concerned regarding fetal well being. ABC stable. BP 120/70 HR 88 RR 15 No signs of injuries on exam. FHR 140, No uterine contractions palpable. No guarding. No lap belt sign. No PV bleeding. Os Closed

How do we manage this patient?

CASE 2
20 Yrs F, 30 weeks gestation Struck by truck across the street from hospital. Cardiac arrest at scene. U/G Technician have intubated and started CPR. Down time about 5 minutes. Arrival in ER, Pulseless Electrical Activity.

How do we manage this patient?

Incidence Physiological Alterations Anatomical Alterations Unique Problems in the Gravid Abdomen Prehospital Considerations Diagnostic Studies Management of trauma
Unstable Mother Stable Mother

Perimortem Cesarean Section

Incidence
The Leading cause of non-obst. mortality - 46% Trauma during pregnancy - 7% Causes of Trauma (1) MVA 54.6 % Domestic abuse & Assault 22.3 % Falls 21.8 % Penetrating inj. 1.3 % < 1% of trauma admissions are pregnant Preterm Labor in 11.4 % & P. Abruption in 1.58 %
(1) Connolly A, Katz VL, Bash KL, et al: Trauma and pregnancy. Am J Perinatol 14:331-336, 1997

Physiological Changes During Pregnancy

Hemodynamic Changes of Pregnancy (Mean Values)


HR Sys. BP Dias. BP C. Output CVP Bld V (ml) Hct with Fe (%) WBC (cell/mm3 )
Non P. 70 115 70 4.5 9.0 4000 40 7200 Trim. 1 78 110 60 4.5 7.5 4200 36 9100 Trim. 2 82 102 63 6 4.0 5000 34 9700 Trim. 3 85 114 70 6 3.8 5600 36 9800

Supine Hypotensive Syndrome(1)

(1) Milson I, Forssman L: Factors influencing aortocaval compressionin late pregnancy, Am J Obtst Gynecol 148: 764-771, 1984

Respiratory
Respiratory alkalosis Reduce oxygen reserve (reduced FRC 20% & increased O2 consumption by 15 %) Residual volume decreased by 40% Respiratory rate increased Impaired buffering capacity

GI
Intestine are concentrated in upper abdomen Decrease GI motility Decrease peritoneal irritation

GU
Bladder is displaced upward >10 wks Dilitation of renal pelvis and ureters

Alterations in Anatomy
1st trimester uterus is thick walled and intrapelvic Out of pelvis > 12 wks. Second trimester uterus contains large amount of amniotic fluid Third trimester uterus is thin walled, large Fetal head engaging pelvis At 36 weeks uterus reaches costal margin

Injuries unique to pregnancy


Premature Contractions
Rarely progress to preterm delivery Tocolysis is not proven in trauma.(1)

Abruptio Placentae
Different elastic properties in uterus & placenta shearing 3 % of minor trauma and upto 50 % in severe trauma
(1) GoodwinTM, Breen MT: Pregnancy outcome and fetomaternal hemorrhage after noncatastrophic trauma, Am J Obstet Gynecol162: 665-671, 1990.

Uterine Rupture Rare, 0.6 % of severe abdominal trauma (1) Direct trauma after 12 wks of gestation Prior Surgery (C/S or Myomec.) the risk

Maternal-Fetal Hemorrhage
Trimesters 1 3%, T2 12%, T3 45% 4-5 X more common in injured pregnant women Causes isoimmunization & fetal death Kleihauer-Betke test - volume of fetal blood .01- .03 cc sensitize, 5 cc +ve KB Test. To determine amount of Rhogam needed

1. Pearlman MD, Tintinalli JE, Lorenz RP: Blunt trauma during pregnancy, N Engl J Med 323:1609, 1990

Special Considerations
Blunt Abdominal Trauma Penetrating Abdominal Trauma
Stabbing injury Gunshot injury

Blunt Trauma
Injuries
Head injury most common Retroperitoneal hemorrhage Abruptio placenta DIC Uterine Rupture

Seatbelts 3 Points Restraints


1/3 improperly or dont use belts Unbelted is at 2.3X to give birth <48 hrs & 4.1X fetal death

Penetrating Injury
GSWs
Gravid uterus alter injury pattern to the mother. If missile enter upper abdomen; increased probability of harm (upto 100%). If enters below uterine fundus visceral injury less likely (0%) Awwad et al (1) Fetal death rate is 67% 38 % for injuries above the uterus.
(1) Awwad JT et al: High-velocity penetrating wounds of the gravid uterus: Review of 16 years of civil war, Obstet Gynecol 83:259, 1994.

Stabbing Injury
Rare rare, only 19 cases reported in literature Morbidity 93 % - Mortality 50 % Many advocate exploratory laprotomy since uterus laceration is devastating b/c of its enlarged circulation.

Meizner et al (1) An injury to uterus can rapidly change to a hypotensive emergency. It is difficult to know the size and depth of uterine rupture
(1) Meizner I, Potashnik G: Sharpnel penetration in pregnanc resulting in fetal death, Isr J Med Sci 24:431, 1988.

Pre-hospital Consideration
Oxygen Shock should be anticipated ED should be notified early, GA >24 wks Transport in L lateral position (GA > 20 wks) National Association of EM Physician, 1997 PASG class III intervention worsen the supine hypotension

Diagnostic Studies

Modalities for Evaluating Trauma


Plain Films X-rays Ultrasound CT & MRI Cardiotocographic Monitoring DPL Laparotomy

Plain Films
Risk of 1 rad to fetus is approx. 0.003 < 5-10 rads causes No risk on congenital malformation, abortions or intra-uterine growth ret. Smaller risk of increase in childhood cancer

Radiation doses > 10 rads 6 % chance of severe mental ret. < 3 % chance childhood cancer.

Radiographic examination

Dose to Ovary/Uterus-mrad <1 <1 <1 <1 <1

Low Dose Group: Head C-Spine Thoracic Spine Chest Extremities High Dose Group: Lumbar Spine Pelvic Hip Intravenous pyelogram Urethrocystogram KUB

204 1260 190 357 124 450 503 880 1500 200 503

Rosenstein M:Handbook of selected organ doses for projections common in diagnostic radiology. HEW publication(FDA) 89-8031. Rockville, MD. US Dept. Of Health And Human Services, Centre For Devices And Radiologic Health, 1988.

Ultrasound
Best modality to assess both fetus and mother

Not sensitive: Colonic lesions Biliary tree lesions Sub-placental hematoma


Safe procedure

CAT SCAN
Complementary to U/S & DPL Penetrating wounds of flank & back

Can miss diaphragmatic and bowel injuries


Portability Spiral CT reduces radiation exposure by 14-30 %

Radiographic examination Computed Tomography


Head (1 cm slice) Chest (1 cm slice) Upper Abdomen
(20 slices 2.5 cm above uterus)

Dose (mrad)
< 50 < 1000 < 3000 3000 9000

Lower Abdomen
(10 1 cm slices over the uterus/fetus)

Angiography
Cerebral Cardiac Catheterization Aortography < 100 < 500 < 100

Rosenstein M:Handbook of selected organ doses for projections common in diagnostic radiology. HEW publication(FDA) 898031. Rockville MD,. US Dept. Of Health And Human Services, Centre For Devices And Radiologic Health, 1988.

Cardiotocographic Monitoring
FHR

Rate (120-160) Beat-to-beat variability Baseline variability Decelerations, esp. late

Cardiotocographic Monitoring
Variability:

Cardiotocographic Monitoring
Decelerations: Early and Late

Cardiotocographic Monitoring
Decelerations: Variable

Diagnostic Peritoneal Lavage


CT & U/S are better in stable patient.
Hypotensive unstable pt and if bedside U/S is not available Can be performed in any trimester Gravid uterus does not reduce the accuracy of DPL for OR Limited in detecting bowel perforation and does not assess retroperitoneal hemorrhage or intrauterine pathology

Diagnostic Peritoneal Lavage


Rothenberger et al (1)
n=12 (4 Supra umbilical & 8 infra umbilical)

Sensitivity 100 % (8 internal bleeding confirmed by lapratomy), Specificity 100 % ( 4 no bleeding) No Complications from the procedure

Esposito et al (2)
n=40 , 13 had DPL PPV = 100 %
(1) Rothenberger DA, et al:Diagnostic peritoneal lavage for blunt trauma in pregnant women, Am J Obstet Gyneco 129:479-48,1977.

(2)

Eposito TJ, et al: Evaluation of blunt abdominal trauma occurring during pregnancy, J Trauma 29:1628-1632, 1989.

Management
Avoid distractions and avoid focus on the fetus

Be aggressive! But temper with common sense.


An apparently stable mother may be compensating at expense of the fetus If < 24 weeks, intermittent fetal doppler If > 24 weeks, then continuous cardiotocographic monitoring to assess FHR and uterine activity

I. Initial maternal Resuscitation


Airway
Assess & control Preoxygenate and sellicks maneuver is important before intubation

Breathing
Assess and manage Place CT in 4th intercostal space

Circulation
Assess maternal circulation IV access Telt to left if > 20 wks

Management
The hemodynamically unstable mother

The hemodynamically stable mother

II. The hemodynamically unstable mother

Fetal Viability
Weeks gestation 22 23 24 25

6-month survival (%) 0


15 56 79

Survival with no severe abnormalities (%) 0


2 21 69

Data from Morris JA Jr et al: Ann Surg 223:481, 1996.

III. The hemodynamically stable mother


Stable fetus
Minor trauma does not exclude significant fetal injury; 1-3 % of all minor trauma results in fetal loss from placenta abruption. (1) Asymptomatic mother or with no obvious abdominal injury needs monitoring for fetoplacental pathology

(1) Pearlman MD, Philip ME: Safety belt use during pregnancy, obstet Gynecol 88: 1026, 1996

Pearlman et al (1) Minimum 4 hrs CTG monitoring Extended to 24 hrs if : . >3 contractions per hour . Persistent uterine tenderness . Non reassuring fetal monitor strip . Vaginal bleeding . ROM . Serious maternal injury present All placental abruption were detected within 4 hrs 70 % of pt required admission. All discharged home subsequently had live birth.
1. Pearlman MD, Tintinalli JE, Lorenz RP: Blunt trauma during pregnancy, N Engl J Med 323:1609, 1990

III. The hemodynamically stable mother


Unstable fetus
Fetal death rates are 3-9 times higher than mat. No infant survive if there is no fetal heart tone before C/S Morris et al (1) Heart tone is best survival marker for f. to undergo C/S If fetal heart tone is present and the GA is > 26 wks the survival is 75% 60 % of fetal death occurs with under use of CTG and delay recognition of fetal distress.

Perimortem Cesarean Section


~200 successful cases reported in the literature Maternal CPR <5 minutes, fetal survival excellent

<23 weeks gestation survival chance is 0%


Maternal CPR >20 minutes, fetal survival unlikely

Fetal Viability Weeks gestation 22 23 24

6-month survival (%) 0


15 56

Survival with no severe abnormalities (%) 0


2 21

25

79

69

Data from Morris JA Jr et al: Ann Surg 223:481, 1996.

Perimortem Cesarean Section 4 Minute Rule: Maternal CPR for 4 minutes, Infant should be delivered by the 5th minute.

Perimortem Cesarean Section


Technique: Make sure it is indicated first and that resuscitative team is ready Vertical incision from xyphoid to pubis Continue straight down through abdominal wall and peritoneum Cut through uterus and placenta (if anterior) Bluntly open uterus and remove fetus Cut and clamp cord

Summary
Anatomic and physiologic changes Vigorous fluid and blood replacement Treat the mother first and treat her just like any other trauma patient High index of suspicion for blunt or penetrating uterine trauma & abruptio placenta. Consider perimortem C/S in unstable women or cardiac arrest with viable fetus after 24 wks.

When to Intervene and Consult

EARLY !

Remember

What is Best for the Mother is Best for the Fetus!

Questions ?