TRAUMA IN PREGNANCY

Praneel Kumar Bundaberg Hospital Emergency

Department

Outline

Introduction Take home point A & P changes in pregnancy and clinical

significance Emergency management Traumatic Complications Of Pregnancy

Introduction

7% of all pregnancies 8% of women age 15-40 admitted to

trauma centre do not know they are pregnant

Order of frequencies – MVA – Interpersonal Violence and falls

Viable fetus – 24 to 26 weeks of gestation or extimated fetal weight of 500gram

Take Home Points

Maternal Life takes Priority The best chance of fetal survival is

maternal survival Initial management – ATLS protocol with

some caveats Imaging should not be withheld if it

provides significant diagnostic information

Anatomical Changes

Uterus – 12 weeks intrapelvic / 20 weeks umbilicus and costal margin by 34 to 36weeks

Diaphragm rises as pregnancy progress – significance

Abdominal viscera are pushed upward by enlarging uterus

Stretching abdominal wall modifies normal response to peritoneal irritation – guarding /rebound can be blunted despite significant bleeding and injury

Anatomical Changes

Bladder displaced into abdominal cavity after 12weeks

Baseline diastasis of the pubic symphysis may exist – can be mistaken for pelvic disruption on a radiograph

AND REMEMBER SUPINE HYPOTENSION SYNDROME

Physiological Changes CVS

BP – declines in the first trimester/ level out in 2nd trimester and return to no pregnant level in the 3rd Trimester ( Systolic decline of 2-4mg and diastolic decline of 5-15mg ) ?? Significance

HR – does not rise by more than 10-15 beats per minute

Blood volume – may increase to as much as 45% peaking at 32 -34weeks of gestation with 25% increase in RBC – physiological anemia

Physiological ChangesCVS

Marked venous congestion in the pelvic and lower extremities in the 3rd trimester – increasing potentional of hemorrage from both bony and soft tissue pelvic injuries

Physological changes Pulmonary

Reduced oxygen reserve – due to decrease FRC caused by Diaphragm and increase in O2 consumption

Minute ventilation increases leading to hypocapnea

Physiological Changes GI

Gastro esophageal sphincter response is reduced and GI motility is deceased

Increased risk of aspiration

EMERGENCY MANAGEMENT

Primary SurveyABCDEF

GET YOUR TEAM READY Airway - Intervene as early as possible- Prolong bag mask ventilation increase risk of

aspiration ( already increased abdominal pressure and decreased lower esophageal tone

- Difficult airway – proportion of Mallampati class 4 increase by 34% from 12 to 38weeks

- NG decompression – to be performed to minimize the risk of ongoing Aspiration

Breathing -Supplemental oxygen in all patient –Fetus

vulnerable to hypoxia -Apnoeic oxygenation during RSI - Remember the diaphragm during

thoracostomy – use ultrasound to confirm where diaphragm is

Circulation - Significant blood loss before hypotension - Displace uterus to the Lt after 20weeks of

gestation – either manually or tilting the backboard with wedge or pillow

- RH Neagtive blood should be used - AVOID VASSOPRESSORS – decrease

uterine blood flow

Disability/Dextrose- Same as non pregnant – GCS /Pupil and

gross motor function and sensation Exposure and Environment- Examine all areas of the body - Log roll

F- FAST /FINGER / FOLEYS / FAMILY + FETUS

- EFAST - Finger – check every orifice for bleeding - Foleys – IDC if indicated - Family

FETUS - Use bedside ultrasound –HR and

movement - CTG ideal –minimum observation is

4hours- HR 120 -160 - Be-aware Very Angry Doctor Coming - Fetal distress can be sign of occult

maternal distress

Secondary Survey

Similar in general to non pregnant patient Specific emphasis on abdominal and

Vaginal examination - Abdomen : fundal height – age / decrease

may suggest traumatic PPROM - Vaginal: preferably by obstetric

specialist / evaluate vaginal lac or bony fragment and fluid

IMAGING

Use it if needed Radiation risk – teratogencity,birth defect and

increase life time risk of malignancy Loss of viability – risk greatest in the first 2

weeks post conception /risk with failure to implant at 50rad

Radiation induced malformation at 2-15weeks - Small head size / mental retardation/ organ

malformation - Afer 25 weeks – lifetime increase in malignancy Risk negligible < 5 rads exposure Risk increases > 15 rads exposure

Approximate Fetal Radiation Dose

Study Dose (rads)

Chest X-ray <0.001

Pelvis 0.04

CT Head <0.05

CT Chest 0.01-0.2

CT Abdomen 0.8-3.0

CT Pelvis 2.5-7.9

Spine series 0.37

9 month background dose

0.1

Complications

Placental Abruption- Most common cause of fetal death - Vaginal bleeding / abdominal cramps /

uterine tenderness/ fetal distress- Ultrasound – 50% sensitive - 3.9 fold increase in Preterm labour - More likey to have DIC

Uterine Injury-Rare, but always consider in significant

trauma-Associate with near 100% fetal death rae-Cause:Pelvic fractures striking uterus:Penetrating trauma:Inappropriate seatbelt placement, too high-can lead to uterine contractions

Fetomaternal Hemorrage - Rh –ve mum /Rh positive baby- All RH –ve women sustaining abdo

trauma should receive RH immune globulin

Mother stable/Fetus stable Mother stable / Fetus Unstable Mother Unstable /Fetus Unstable

Take Home Points

Maternal Life takes Priority The best chance of fetal survival is

maternal survival Initial management – ATLS protocol with

some caveats Imaging should not be withheld if it

provides significant diagnostic information