OBSTETRICAL TRAUMADr. Joe HaegertRCH and ERH
SPH Conference 2013
Main message Two patients Focus mainly on resuscitating mother
Overview Physiologic differences Anatomic differences Pregnancy Specific Issues: Abruptio Placenta PROMRuptured UterusSupine Hypotensive SyndromeRh negative mothers and KB testing Imaging in pregnancy Management algorithms
Mother stable, Fetus stable Mother stable, Fetus unstable Mother unstable, Fetus unstable
Perimortem C section
Case 1 22 yr old female shot in head and chest 32 weeks pregnant GCS 3, BP 70/P, P 100 Fetal heart rate of 50
Case 2 32 year old female 34 weeks pregnant MVA head on GCS 14, P 110, BP 80/P Severe chest trauma Bilateral femur # Fetal heart rate 170
Case 3 39 weeks pregnant T bone MVA 20 inches intrusion Airbags deployed Stable vitals, GCS 15, mild chest pain
and neck pain, no abdominal pain Cspine and CxR and FAST normal FHR 140
Intro Trauma is leading cause of nonobstetrical death
in pregnancy (mvas, falls, assault) 7% of pregnancies will have trauma 8% of female trauma admits of child bearing
age do not know that they are pregnant Severity of maternal injuries is a poor predictor
of fetal distress and outcome Trauma in pregnancy is associated with
increased risk of: - - preterm labor - abruptio placentae - fetomaternal hemorrhage
- fetal death
Incidence of trauma increases with gestational age
Most maternal deathes are due to HI or hemorrage
Cause of fetal death With severe maternal trauma the baby
dies because of maternal death or maternal hemorrhagic shock
With mild maternal trauma the baby dies because of abruption
Physiologic Differences Hypoxia decreases uterine flow Lower FRC and increased metabolic rate increased risk of hypoxiaO2 therapy on alllower threshold for intubation Acidosis decreases uterine flow Normal PC02 runs 30-35No role for permissive hypercapniaSet vent rate faster than normal Decreased lower esophageal sphincter pressure and increased
gastric acidityRegard all intubations as high risk for aspiration Increased airway edema and secretionsHave smaller ETT ready Increased thrombogenesis DVT prophylaxis for admitted trauma patients
Physiologic Differences Hypervolemia with dilutional anemia (40% increased BV)
Compensated (i.e. unrecognized) shock more common Shock (including compensated shock) causes uterine artery
constriction Volume resuscitate aggressively
BP lower in 2nd trimester, higher in 3rd trimester Diagnosis of shock a bit more tricky
Uterus has increased blood flow (entire blood volume in 10 minutes)
Abruptio placentae and Uterine rupture can bleed massively Pelvis has increased blood flow Increased risk of massive pelvic hemorrhage Increased venous pressure in legs
Increased bleeding from leg injuries Vasopressors constrict the uterine artery
Avoid vasopressors
Anatomical Differences Large uterus: 12 weeks at symphysis 20 weeks at
umbilicus 36 weeks at xiphoid processpelvis not protective after 12 weeksfemoral line not the best optionsupine hypotensive syndrome after 20 weeks Compression of upper abdominal viscerastab abdomen may hit many structures Widened symphysis pubisbe aware that this may be normal….not open book # Higher diaphragm Heart displaced up and to left place chest tube 2 interspaces higher There is a baby! initiate fetal monitoring early baby can be injured
Supine hypotensive syndrome
> 20 weeks gest. Can decrease venous return up to 45% Systolic BP can drop by as much as
30mm Place wedge under right hip displacing
uterus to the left (left lat tilt position)
Amniotic Fluid leakage (PROM) Vaginal exam on all major pregnant
trauma PH greater or equal to 7 suggests
amniotic fluid Ferning also suggestive of amniotic fluid Oligohydramnios on ultrasound Increasing risk with gestational age and
trauma severity
Imaging in pregnancy
Image as if patient nonpregnant Highest risk of radiation induced fetal
injury in first 2 weeks Concerns are death, congenital malformation,
teratogenesis, carcinogenesis, mental retardation
Over 200ms may cause fetal damage, still unclear the long term cancer risk
Ultrasound and MRI are safe in pregnancy
Radiation risk Background………………….. 3mSv/yr 10 hr flight………………… 0.03mSv CxR………………………….0.01mSv CT head………………………. 2 mSv CT neck………………………..4mSv CT chest……………………….4mSv CT abdomen/pelvis.……….. 7 mSv Pan CT………………………...17mSv
So none of these is close to the dangerous 200mSv
So what is my approach toblunt abd trauma in pregnancy?
Unstable and positive FAST or peritonitis………………………….OR
Stable and positive FAST………..CT Stable and negative FAST………..US +
Observ
Obstetrical complications of trauma
Fetomaternal hemorrhage Abruption Preterm labour Fetal Injury Uterine rupture Amniotic fluid embolism
Kleihauer Beikte test Calculates degree of feto maternal
transfusion Uses: 1) Rh negative mother 2) To access degree of fetomaternal transfusion
RHIG and Tetanus RHIG 300ug….will protect up to 30ml
fetomaternal hemorrhage Dose guided by KB test Have up to 72 hours to give it Give RHIG to all Rh neg mothers even if
negative KB test Dose is 50ug in first trimester (or 300ug )
Tetanus and TIG are NOT contraindicated in pregnancy
Placental Abruption
Can be occult Triad: pain, hardness of uterus, vag
bleeding 70% of fetal loss comes from placental
abruption Is a clinical diagnosis….ultrasound not
sensitive Coagulopathy rare
Risk of abruption Usually happens within 4-6 hours Risk: minor trauma 1.6% (but minor
trauma is common) major trauma 37.5%
Fetal Injury Abruption is commonest cause of death Maternal shock is next Direct fetal injury less common- pelvic # 9% maternal death rate, 40% fetal death rate - penetrating uterine trauma: fetal injury 60-90%(gsw worse than stab), fetal mortality 40-70%
Traumatic Uterine Rupture Usually presents with shock and
hemoperitoneum Consider in setting of free fluid and high
riding dead baby Commonest is a fundal tear Maternal mortality 10% Fetal mortality 100%
Preterm Labour Abruption Fetomaternal hemorrhage Rupture of membranes Fetal distress Maternal Shock Abnormal Fetal monitoring
Dating
At 20 weeks uterus at umbilicus. At 24 weeks = umbilicus + 4 cm At 36 weeks at xiphoid process Symphysis to fundus in cm = # weeks
So key # is SFH>24 or umbilicus to fundus of >4
Ultrasound: BPD, OFD, FL, HL, HC, AC
Fetal Monitoring Recommended that all trauma patients >
24 weeks be monitored for 4-6 hours If normal monitoring for 4 hours this is
>90% predictive of positive fetal outcome
If patient is critical (i.e. in ICU) then continuous monitoring is indicated
Start monitoring on arrival to ED if patient badly injured /major mechanism
Fetal Monitoring: abnormal Fetal heart rate outside normal range of 120-160 Greater than 3 contractions per hour Lack of beat to beat variablity Fetal decelerations with contractions
Indications for prolonged FM - abnormal 4 hour FM - uterine pain persists - vaginal bleeding or amniotic fluid leakage-mother unstable
Clinical scenarios > 24 weeks
Mother stable, Baby stable Mother stable, Baby unstable Mother unstable, Baby unstable Perimortem C section
Mother stable, Fetus stable
1-3% of minor trauma leads to fetal death
For patients less than 24 weeks….no FM For patients > 24 weeks…CFM for 4 hours
with OB consult Discharge criteria and advice
Mother stable, Fetus unstable
Less than 24 weeks….no C section Greater than 24 weeks….C
section….exact # weeks is site dependent
Obviously this is a OB decision and likely not and EP’s decision
Mother Unstable, Fetus Unstable
First priority is the mother If despite good resuscitation there is fetal
distress…AND… patient over 24 weeks…AND it is thought that the CS will not make the mother clinically deteriorate…consider CS
If fetus has no FHR there is no indication for emergency CS
Perimortem C section Indications
- over 24 weeks gestation - intact fetal heart rate on ultrasound - maternal pulselessness or - fetal distress in a mother with injuries that are likely to be fatal (i.e. severe head injury,)
Perimortem C section Procedure
Incision from xiphoid to pubis Longitudinal uterine incision Get baby out (5 min rule…from time of
maternal arrest) Clamp cord Give baby to infant resus. team
Prevention Seat belts: -
Air bags:
Screen for domestic violence
Educate re: increase risk of falls in 3rd trimester
Summary of treatment differences
Early oxygen Intubate early Early fetal monitoring Place on left lat tilt position over 20
weeks Call Ob early
Summary of treatment differences
Beware compensated shock can cause fetal distress
Avoid pressors Avoid acidosis Chest tubes higher Neck or subclavian lines best
Summary of treatment differences
Don’t forget about KB test and RHIG Do not withhold CT if it is indicated Perimortem C section…know when to
pull the trigger….and how to do it If baby viable and minor trauma.. do 4 h
fetal monitoring
Main take home message 2 patients Focus on resuscitating the mother Best chance of baby doing well is the
mother doing well
Case 1 22 year old female, 32 weeks pregnant,
shot in head and chest with fetal P 50
Perimortem C section
Case 2 32 yr old female, 34 weeks with chest
trauma, bilateral femur fractures and hypotension
Resuscitate the mother!!
Case 3 39 week pregnant female with moderate
vehicle damage, but clinically stable
Needs 4 hour FM and then discharge if OK
Top Related