Leybie Ang
Oct 9 2008

• Incidence
• General consideration
• Initial Management
– Primary survey
– Secondary survey
• Injury prevention
• Summary

• Trauma in 6-7% of all pregnancies
• Significant cause of maternal death
• Rate increases in younger women
• Most common causes of injury during pregnancy
– MVC 55%
– Assaults 22%
– Falls 22%

• Typical prehospital and ATLS protocols must be modified because of alterations in anatomy and physiology
• Uterus first becomes an intra-abdo organ at 12 weeks
• As uterus enlarges, displaces adbo contents upwards reaching costal margin between 34 and 38 weeks

Uterine size at different weeks of gestation. (From Kravis TC,
Warner CG [eds]: Emergency Medicine: A Comprehensive
Review. Rockville, Md, Aspen Publishers, 1979

• Bp declines in T1, levels out in T2 and returns to normal in T3
• HR increases (not more than 10-
15bpm)
• Blood volume gradual increase as much as 48% to 58% above normal, peaking at 32-34 wk GA
• Increased circulatory reserve

• CO increased by early T2 and the remaining of the pregnancy
• Blood flow to uterus increases from
60mL/min nonpregnant to
600mL/min at term
– Major source of blood loss when injured

• After 20 weeks GA, uterus at level of IVC
• Enlarged uterus compressing on IVC
• Decreasing venous return
• Decrease cardiac preload
• Decrease CO by 28%
• Reduce sbp by 30mmHg
• In late pregnancy, common for IVC to have complete occlusion

• Significant reduced oxygen reserve
• Reduction in FRC by 20% at term
– Diaphragm elevation
– Increase in oxygen consumption
• Increase minute ventilation by 40%
• Moderate hypocapnia
– Nml PaCO2 – 30mmHg

• Increase RBC volume by 30%
– Physiologic anemia
– Hct 30-35% in T3
• Greater risk of thromboembolism
– Stasis – IVC compression , increase venous capacity
– Increased in coagulation factors V, VII,
VIII, IX, X and XII and fibrinogen

• Reduced in GE sphincter response
• Decreased in GI motility
• INCREASE RISK OF ASPIRATION

• 24 year old female
• Restrained passenger in MVC
• Car was moving at 50km/hr and hit against lamp post
• Air bag deployed
• Reported no LOC
• C/o RUQ pain

• Oh forget to mention, she is pregnant 30 weeks GA

• Clinical condition of patient
• Status of pregnancy
• Obstetric capabilities
• If spine precautions - left lateral tilt position or manual displacement of uterus
• Late T3 – spine might be intolerable (resp distress)
• Try 30 degree reverse Trendelenberg positioning

• GCS 15/15
• c/o RUQ pain
• Afebrile HR 130 bp 110/68
• RR 20 O2 sat 92% on RA
• Alert, speaking in full sentences
• Good a/e to bases of lung bilateral
• Tachycardic, Nml S1, S2, cap refill <
3sec

• Primary survey
• A
• B
• C

• Oxygen therapy should be instituted early
– reduced oxygen reserve and increased oxygen consumption
• RSI
– Safe
– preferred method for intubation
– 6 P’s
– Pregnant patients are prone to aspiration and desaturation
– LMA

• Mechanical ventilators need to be adjusted for increased tidal volumes and resp alkalosis
• Chest tube placed one or two interspaces higher than the usual fifth interspace site

• IV access!!!
• The ~50% increase in blood volume and increase in CO may mask significant blood loss
• Uterus is not a critical organ, blood flow reduced when maternal circulation is compromised
• Fetal distress may be earliest indicator of impending hemodynamic instability

• Fluid resuscitation – LR preferred (more physiology and shown to be more effective in restoring fetal oxygenation)
• Type-specific blood or O-negative blood
• Avoid use of vasopressors
• 15 to 30 degree tilt to the left or right hip elevation
• If severe injury, CVP to monitor cardiac preload

• O2 sat 100% on 2L NC
• HR 120’s
• 18 G IV obtained
• Receiving 1L LR

• Performed with several modifications
• Fetal monitoring
• Vaginal exam
• FAS

• Should be initiated for all viable gestation
– > 23 weeks
– Continued for at least 4-6 hr
• Monitoring benefit mother
– Fetal hemodynamics are more sensitive to decreases in maternal blood flow and oxygenation
• Nml FHR ranges between 120 bpm to 160bpm
• Beat-to-beat variability measures autonomic nervous function
• Long term variability indicates fetal activity
• HR variability increases with GA

Data from Morris JA Jr et al: Infant survival after cesarean section for trauma. Ann Surg 223:481,
1996

• Monitor for 24hr to 48hr (potential delayed manifestation)
– presence of uterine contractions (3 contractions/hr)
– a nonreassuring FHR pattern
– vaginal bleeding
– significant uterine tenderness or irritability
– severe maternal injury

• Assess for presence of blood or amniotic fluid, cervical effacement and dilation
• Vaginal fluid examined for ferning and elevated pH~7
– Traumatic ROM

• Physiologic anemia
• Slight elevation of WBC and ESR
• Mild decrease in serum bicarbonate
• Increased fibrinogen
• ABG – elevated pH, mild hyperventilation, pCO2 ~30mmHg
• EKG – left axis shift averaging 15 degrees, causing diaphragm elevation +/- Q waves in leads II and aVF

• Provides valuable info for both fetus and mother
• No associated radiation exposure
• For detection of intraabdominal injuries
– Sensitivity 88%
– Specificity 99%
• Not sensitive for identifying bowel and biliary tree lesions

• Diagnostic peritoneal lavage
• Accurate in pregnant patients
• Can be performed safely with no increase in fetal loss
• Supraumbilical approach using open technique
• Limited in detection bowel perforations, not for assessment for retroperitoneal or intrauterine pathology

• Clinically necessary imaging studies should not be deferred because of concern about radiation
– Uterus should be shielded as much as feasible
• Risk to fetus of a 1 rad exposure is
0.003%
• Cumulative radiation does associated with an increased risk of fetal malformation –
>15 rads
• Exposure to 10 rads – small increase in number of childhood cancers

Data from Bureau of Radiological Health: Gonad Doses and Genetically Significant
Dose from Diagnostic Radiology. US 1964 and 1970. Rockville, Md, U.S.
Department of Health, Education, and Welfare, 1976; Eliot G: Pregnancy and radiographic examination. In Haycock CE (ed): Trauma and Pregnancy. Littleton,
Mass. PSG Publishing, 1985; and United Nations Scientific Committee on the effects of atomic radiation: Sources and Effects of Ionizing Radiation. New York,
United Nations 1977.

Data from Wagner LK, Lester RG, Saldana LR: Exposure of the Pregnant
Patient to Diagnostic Radiations: A Guide to Medical Management.
Philadelphia, JB Lippincott, 1985; and Esposito TJ et al: Evaluation of blunt abdominal trauma occurring during pregnancy. J Trauma 29:1628, 1989.

• Doc, she is having vaginal bleeding

• Kleihauer-Betke test identifies fetal blood cells within maternal blood sample
• Rh positive fetus possesses antigen after 6 week GA
• As little as 0.0001mL of fetal blood transplacentally can cause maternal sensitization

• ACEP recommends administration after even minor trauma to all Rh negative trauma patient
• ACOG recommends administration to all
Rh negative trauma patient with positive
KB test
• T1 – 50 microgram dose (protects 5mL of
FMH)
• T2 and T3 – 300 microgram dose
(protects against 30mL FMH)

• Second most common cause of mortality
• Incidence range from between 1 to
60%
• Can occur even after minor abdominal trauma

• 50% to 70% of all fetal losses
– Nonseverely injured pregnant women have a
3.7 fold increased risk of placental abruption
– Severely injured have 17 fold risk of PA
• Placenta shearing away from uterus with bleeding into the space and clot formation
• Elasticity of uterus matched against the relative stiffness of placenta create vulnerable interface

• Abdominal cramps, vaginal bleeding, uterine tenderness, maternal hypovolemia or change in FHR
• US – sensitivity ~50%
– If abruption bleeds externally, not enough blood collects to be seen on US
– Posteriorly placed placenta
– Counfounding uterine or placental structural condition
• Most sensitive indicator – FETAL
DISTRESS

• Rare consequence of maternal trauma
• < 1% of blunt trauma
• Commonly in patient who have had previous C/S
• 10% maternal mortality rate
• Uterine tenderness, variable shape, hemodynamic instability and ability to palpate fetal parts

• Leggon and colleagues in 2002
• 101 pelvic and acetabular fractures
• Maternal mortality 9%
• Fetal mortality 35% (direct injury to uterus, placenta or fetus and maternal hemorrhage)
• ?independent predictor of adverse fetal outcome

• Stabilisation of unstable pelvic
• Percutaneous and open fixation maybe performed with good fetal and maternal outcomes
• If hemodynamically unstable tpelvic fractures, use of angiography to coil or embolise bleeding pelvis or retroperitoneal vessels

• Asystole
• Intubated
• CPR
• Epi
• Still asystole
• What next?

• Performed in traumatic arrest if fetal is potentially viable
• Originally proposed by Katx and collegues in 1986
– Data shown inefficacy of CPR resuscitation in T3
• Emptying uterus relieves uterocaval compression and improves venous return and consequently CO

• Ideally within 4 mins of maternal arrest to minimise potential of maternal neurologic outcome
• Studies reported maternal survival rates of 72% and fetal survival rates of 45%
• 2005, Katz and collegues f/u review
– does not improve maternal outcome
– fetal outcome – less effective than nontraumatic CPR

Figure 35-1 Decision-making algorithm in emergency obstetric care. C-section, cesarean section; FHTs, fetal heart tones; U/S, ultrasonography.

• MVC
• ~ one third of pregnant patients do not use safety restriants peoperly
• Less than half of all pregnant women reporting routine proper use of restraints
• Low to moderate severity crashes, proper restraint use +/- air bag deployment generally leads to acceptable fetal outcome
• For high severity crashes, proper restraint does not improve fetal outcome

• Lap belt underneath the pregnant abdomen against the pelvis
• Shoulder belt to the side of the pregnant abdomen
• Shoulder belt passes between the breasts and over the mid portion of clavicle

• Experimental data showed airbags may impart dangerous force to the uterus with improper use
• In 1997, National Highway Traffic Safety
Administration issed guidelines that describe the benefits of airbags as outweighing potential risks and recommended that positioning the sternum and/or uterien fundus at least 10 inches away from airway civer

• Most assaults are attributable to boyfriends or spouses 70% to 85%
• Most common area involved during pregnancy – abdomen
• Frequency and/or nature of abuse may escalate during pregnancy, associated with late entry into prenatal car, prematurity, and LBW
• Increased rates of maternal mortality and uterine rupture
• Only 2/3 receive medical treatment but only 3% disclosure to physician

• More prevalent after 20 wk GA
• Protuberance of abdomen, loosening of pelvic ligament, strain on lower back and fatiganility

• Management of life- and limb-threatening injury in the mother comes first
• Major trauma carries the highest risk of fetal demise
• Minor trauma can cause fetal demise
• Fetus is viable at 24-25 wk GS. A fetus is estimated to be viable if fundus is at or above the umbilicus
• Fetus can be distressed even though the mother looks well. Therefore, continual fetal monitoring is vital to recognise ealry fetal distress

• Stable pregnancies after trauma should be monitored for 4 hours
• Keeping the mother tilted 30 degrees to the left, or in the left lateral decubitus position may alleviate hypotension and improve perfusion for the mother and fetus
• Perimorten C/S should be performed only for a viable fetus with positive life signs
• Plained radiography is not CI in pregnancy and should be performed as necessary in the pregnant trauma patient
• US is the diagnostic abdo test of choice in the stable pregnant patient