Trauma In PregnancyTwo for One: Caring for the Pregnant Trauma Patient Presented by DR. Jameel T Miro
Does trauma management differ for the pregnant ? Yes No • Physiologic and Anatomic changes of pregnancy • Two patients requiring treatment!!! • ATLS Protocol the same • Priorities same as in non-pregnant patient
What is the Incidence and why its an important topic ? • The Leading cause of non-obst. mortality -46% • Trauma during pregnancy – 10% • So many morbidities Preterm Labor in 11.4 % P. Abruption in 1.58 % • Dead Mother = Dead Fetus • Most common cause of fetal death from trauma is maternal death
What is the types of trauma ? • Causes of Trauma • MVA 54.6 % • Domestic abuse & Assault 22.3% • Falls 21.8 % • Penetrating inj. 1.3 %
Anatomic changes • Intestinal tract is displaced upward and posterior • As gestation continues the uterus becomes more vulnerable as the walls thin and there is less protection by amniotic fluid
Why we should know the physiological changes in pregnancy • Normal pregnant vital signs mimic hypo perfusion • Assessment more difficult • Fetus can be in distress while mother appears stable • Retroperitoneal bleeding more common to non pregnant.
What is the approach ? AIRWAY + SPINE • recall the increased risk of aspiration • consider early endotracheal intubation. • assume full stomach • sellick’s maneuver
Breathing • auscultate for breath sounds and pulse oximetry • A chest tube thoracostomy : placed 1 or 2 intercostal spaces higher than usual to avoid diaphragmatic injury. • By 3rd trimester increase the need of oxygen 10-20% • Fetal oxygenation may be comprmized • Exlude the lethal causes : tension pnemothorax , flail chest etc.
Circulation • Assess maternal circulation + IV access • If greater than 20 weeks’ gestation should be placed in the left-lateral decubitus position • Early crystalloid fluid replacement • fetal distress maybe the first sign of maternal hemodynamic compromise ( so it’s a vital sign )
secondary survey • HEAD TO TOE include the back • Remember the Baby (fetal assessment) CTG at least 4 hr • Pregnancy history • Fundal height • The uterus for tenderness and contractions • sterile speculum examination • The cervix
What is the radiographic diagnostic modalities ? • Plain Films – X-rays • Ultrasound • CT & MRI • Cardiotocographic Monitoring • DPL • Laparotomy
Radiographic risks • 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.
Ultrasound • Best modality to assess both fetus and mother • Not sensitive: • Colonic lesions • Biliary tree lesions • Sub-placental hematoma • Safe procedure
FAST ?? How much fluid can FAST detect? • 250 cc total • 100 cc in Morison’s pouch Does FAST replace CT? Only at the extremes. • Unstable patient, (+) FAST OR • Stable patient, low force injury, (-) FAST consider observing patient.
CT SCAN • Complementary to U/S & DPL • Penetrating wounds of flank & back • Can miss diaphragmatic and bowel injuries • Spiral CT reduces radiation exposure by 14-30 %
Diagnostic peritoneal lavage • CT & U/S are better in stable patient. • Hypotensive unstable pt. • Can be performed in any trimester • Gravid uterus does not reduce the accuracy of DPL for OR • does not assess retroperitoneal hemorrhage or intra-uterine pathology
Special consedration • Fetomaternal Hemorrhage • Abruptio Placenta • Ruptured Uterus • Penetrating Injury If below uterine fundus visceral injury less likely (0%) Fetal death rate is 67% • Stabbing Injury Rare, only 19 cases reported in literature ( Laprotomy)
Injury Severity Score • head, face, thorax, abdomen, extremities (incl. pelvis). • 1 Minor, 2 Moderate, 3 Serious, 4 Severe, 5 Critical, 6 Maximal (currently untreatable). • ISS = A^2 + B^2 + C^2 • A Polytrauma is defined as ISS >= 16 • Indication of severity , prognosis and hospital stay
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
summery • ABC • secondary survey ….. Fetous !! • Limit radiation to 5 rads • High index of suspicion for abruptio placenta. • If mother unstable or arrested , with viable fetousconiderprimortem c/s !!!
Remember What is Best for the Mother is Best for the Fetus!