MANAGEMENT OF THE TRAUMATIZED PREGNANT PATIENT

U. Kaswiyan

Department of Anesthesiology & Reanimation Medical Faculty University of Padjadjaran Hasan Sadikin General HospitalBANDUNG

IntroductionThe Committee on Trauma of The American College of Surgeons: trauma during pregnancy 6-7% and leading non-obstetric cause of maternal death fetal mortality 40-70%

Anatomic and physiologic changes of pregnancy: trauma assessment more difficult alter the patients response to trauma injury need modified in assessment, treatment, and transportation

A multidisciplinary approach to pregnant trauma victim is required two victims (mother and fetus)

The main principle: resuscitating the mother will resuscitate the fetus

save the mother save the fetus

Causes and Types of TraumaThe primary causes include:- 42% MVCs- 34% falls- 18% assaults- < 1% burns

Trauma is often classified as blunt vs penetrating

Blunt TraumaMechanism- MVAs- Falls

Injuries- Head injury- Hemorrhage- Obtetric complications (preterm labour or abortion, premature rupture of membrane, placental abruption, uterine rupture)

Penetrating TraumaIt usually the result of gunshot or knife woundFetal mortality > 70%Maternal mortality < 5%

Probably relates to the enlarge uterus, amniotic sac, and fetus taking the brunt of the injury while the displaced maternal organs are preserved

Effect of trauma on the fetusDirect fetal injury:Fetal mortality Blunt trauma (in 3rd trimester) Penetrating trauma (stabbing / gunshots)

Skull fracture and ICH

Indirect fetal injury: when maternal injury, inadequate uteroplacental perfusion & fetal oxygenation

Unique Problems in the Gravid AbdomenPlacenta: is devoid of elastic tissue, Myometrium: very elastic predisposing to shearing

Blunt injury Abruptio placenta Fetal skull fractures

Supine hypotensive syndrome 10%

Alterations in Anatomy1st trimester: uterus is thick walled and intrapelvic uterus rises out of pelvis after 12 weeks

2nd trimester: uterus contains large amount of amniotic fluid

3rd trimester: uterus is thin walled, large fetal head engaging pelvis at 36 weeks uterus reaches costal margin

Maternal Physiology and Anatomy vs TraumaI. Cardiovascular and hematological:

- HR , CO , blood plasma - SVR , CVP , BP - supine hypotensive syndrome may complicate:- the evaluation of intravascular volume- the assessment of blood loss- the diagnosis of hypovolemic shock

Hyperdynamic&Hypervolemic

Maternal Physiology and Anatomy vs TraumaII. Respiratory:

- diaphragma rises 4 cm, chest diameter 2 cm - FRC , MV , TV , oxygen consumption 20% - supine hypotensive syndrome - predispose rapid falls in PaO2- buffering capacity in the presence of acidosis- chest tubes (thoracostomy) being misplaced

III. Tractus gastrointestinalis:

- intragastric pressure - intragastric pH - LES tone Risk of pulmonary aspiration

General Approach to The Pregnant Trauma PatientStabilize the mothers condition

Priorities assessing and managing are the same to non pregnant woman the ABCs, adequate airway, ventilatory and circulatory support with spinal precautions, haemorrhage control and rapid assessment, stabilization and transport

Resuscitating the mother is the key to survival of both mother and fetus

Traumatic Event in Pregnancy 6Emergency Medicine Physician:1. Prehospital care2. Primary and secondary surveys (fetal evaluation)3. Resuscitative care4. Initiate diagnostic studies5. Perimortem C-section6. Assess for domestic violenceThird-trimester viable infantMinor traumaCatastrophic trauma

Minor traumaCatastrophic traumaTrauma Surgeon1. Primary and secondary surveys (fetal evaluation)2. Diagnostic studies3. Definitive care4. Perimortem C-section5. Subspecialty consultsObstetrician1. Evaluation for pregnancy related complications2. Fetal monitoring3. C-section as indicated4. OB follow-up needsAnticipated trauma related deliveryNeonatologist (or Emergency Physician if unavailable)1. Primary and secondary surveys 2. Resuscitative care3. NICU-nursery requirements4. Subspecialty consults

Classification of Pregnancy and Trauma(Henderson & Mallon)Group 1 : - Pregnancy unknown - Need pregnancy testGroup 2 : - Pregnant < 23 weeks - Maternal priorityGroup 3 : - Pregnant > 23 weeks - two patients, mother and foetusGroup 4 : - Maternal perimortem - Rescucitation SC perimortem (?)

Initial Management

Avoid distractions and avoid the urge to focus on the fetus Be aggressive! But temper with common sense. An apparently stabile mother may be compensating at expense of the fetus

Prehospital Trauma CareAirway

Oxygen

Position :- left lateral recumbent position- leftlateral supine position with back board

Primary SurveyBLS, ATLS, ACLS Begin as you would with any other trauma patient2. Oxygenation, Airway managementRapid sequence induction3. Utero-plasental blood flow position4. Neurological deficit GCS, ICP control, cardiotocographic monitoring to assess FHR and uterine activity5. Fluid rescucitation with RL diuresis monitoring6. Vasopressor (?) ephedrine

Secondary Survey Laparatomy, CT, DPL, USG, LaparascopyAssess and reassess uterine size, tenderness, tone

Vaginal / Pelvic examination- Blood- pH (vaginal - 5 amniotic fluid - 7) nitrazine paper- Station- Dilation of cervix

1. Anamnesis & Physical Examination :2. Modalities for Evaluating Abdominal Trauma :

Secondary SurveyObtain what the patient needs, dont hold back Avoid repeated and unnecessary studies 0.05 to 0.1 rad safe to fetus- Single Pelvis X-ray is < 0.01 rad- Abd CT is 0.05 - 0.1 rad3. Laboratory screening : Hb, Ht, Blood group, Urine analysis, Lactate, BGA, Bicarbonate serum Fetomaternal Blood Mixing - Kleihaure-Betke test to check for fetal cells - Important in Rh negative women who need Rhogam (300 micrograms)4. Radiographic Studies :

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

Uterine Activity- If < 1 contraction / 10 min. for 4 hours, risk of complications drops to baseline.- If greater, then 20% risk of placental abruption5. Cardiotocographic Monitoring :

Perimortem Cesarean Section

200 successful cases reported in the literature 20 minutes, fetal survival unlikely Maternal CPR

Example (during 2003):1. Pregnancy + Orthopaedi: 3 cases2. Pregnancy + Minor trauma: 3 cases3. Pregnancy + Head Injury : 2 casesPregnancy + Fetal distress + Gemelli + Mild head injury with subdural haematoma frontotemporoparietal dextra (GCS=14) Caesarean section Craniotomy evacuation(Neuroanesthesia technique)

Remember ... you will lose both mother and infant if you cannot restore blood flow to the mothers heart

Summary

Anatomic and physiologic changes.Vigorous fluid and blood replacement.Oxygen.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, amniotic fluid embolism, isoimmunization, premature rupture of membranes.

When to Intervene and Consult

EARLY !!!What is Best for The Mother is Best for The Fetus !!!