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No. 325 Management of a Pregnant Trauma Patient
SOGC Guideline June 2015
Terms in this set (48)
What is the leading cause of non-obstetric maternal mortality?
What percent of maternal death is related to trauma? What is the incidence of non lethal associated injuries?
1 in 12
What changes to the respiratory system make airway maintenance in a pregnant women more challenging?
Edema of the resp tract
Decreased resp system compliance
Increased airway resistance
Increased 02 requirements
*intubate earlier that you usually would
**failed intubation is 8 times more likely in a pregnant woman
What other factors make intubation more challenging?
Delayed gastric emptying
Higher risk of aspiration
Pregnant women are considered to have a full stomach 24 hours after eating
Consider NG tube
What 02 sat do you need to maintain in a pregnant patient?
Why is a left lateral tilt needed?
- Compression of the IVC by the gravid uterus as of mid-pregnancy
- Can lead to 30% decrease in cardiac output.
What is the leading cause of maternal death? Fetal Death?
- In the pregnant population, MVC is the leading cause of maternal death, and after placental abruption, maternal death is the leading cause of fetal death.
What amount of fetal blood can cause Rh antigen sensitization? After what gestational age does this occur?
-Rh antigen is well developed by 6 weeks and 0.001 mL can cause maternal sensitization
Is the tetanus vaccine safe in pregnancy?
What changes do you see in maternal HR during pregnancy?
- 15% increase in heart rate in pregnancy
When to use vasopressors in a pregnant woman?
Avoid using pressors unless unresponsive to fluid resuscitation
This is due to their adverse effect on the uteroplacental unit.
When do you initiate Continuous FEM in a trauma patient?
- CEFM if above 23 weeks should be started ASAP
Where do you place a thoracostomy tube in a pregnant woman?
- If needing a thoracostomy tube, place it 1-2 intercostals higher than usual.
When is teratogenic risk from radiation exposure highest?
What are the risks from radiation exposure later in pregnancy?
- 5-10 weeks GA (organogenesis)
- growth restriction, CNS effects
Fibrinogen Levels in Pregnancy
Fibrinogen levels are higher in pregnancy ( > 4 g/L)
Therefore a decrease to normal value range of 2.5-3 g/L may represent a mild hypofibrinogenemia.
Levels below 2 g/L may represent DIC
Creatinine in Pregnancy
Serum creatinine levels are decreased during pregnancy to 50-60 mcmol/L and even a value as low as 90 mcmol/L may be abnormal
What radiation dose is associated with fetal malformation or CNS effects?
cumulative dose >5-10 rad (50-100 mGy) is assoc. with increased risk of fetal malformation or CNS effects limited usually to a GA < 18 weeks
Abdominal CT = 3-3.5 rads
Concern for fetal exposure should not preclude or delay any indicated radiological evaluation
What is the carcinogenic risk related to fetal radiation exposure?
- likely similar to exposure in childhood
- one group estimated less than 2% increased risk (0.6% in childhood) in exposure <5 Rad, on a 40% background risk.
Is FAST u/s useful in assessing pregnant trauma patients?
yes, comparable to non pregnant patients
Objectives of fetal assessment (> 23 wks) in trauma patient (5)
1. ID impending hypoxemic fetal injury/ddeath as a result of uteroplacental compromise
2. Detection of trauma related complications in pregnancy (abruption, PTD, SROM)
3. Eval. degree of maternal-fetal hemorrhage and resultant fetal anemia
4. fetal injuries
5. ID compensated maternal hypovolemia manifested by decreased placental perfusion
What is the first sign of maternal hemodynamic compromise?
Fetal Heart Rate Abnormalities
Fetal Loss rate with maternal trauma
Major maternal injuries - 61%
Minor maternal injuries - 27%
Insignificant maternal injuries - 0%
Most common finding with maternal trauma?
Occasional uterine contractions
- 40 % of cases
- Resolves in 90% of cases with no adverse fetal outcome
- Intensity and frequency of ctx are predictive of complications such as traumatic placental abruption/PTL
In Utero Resuscitation
- Supplemental oxygen
- IV fluids
- Left lateral decubitus
What percent of trauma patients will need a c/s shortly after trauma?
need for c/s is also a risk for maternal mortality
What length of monitoring is required for the pregnant trauma patient?
4 hours CEFM
24 hours CEFM/admitted in:
- patients at high risk for fetal demise, preterm labor or placental abruption
- motorcycle or high velocity MVC
- pedestrian or MVC with ejection
- patients with persistent maternal tachycardia or abn FHR's
- uterine tenderness/abdo pain
- vaginal bleeding
- Fibrinogen <200 mg/dL
- contraction frequency > q 10 min
How frequently does maternal fetal hemorrhage complicate maternal trauma ?
- vast majority of these are smaller and subclinical
- Massive MFH are rare and clinically evident
In which cases should Rhogam be administered?
- Pregnant trauma patients thats are Rh neg
- Rh antigen is well developed by 6 weeks and 0.001 mL can cause maternal sensitization
- A single dose of 300 mg, administered within 72 hours of injury, provides protection against sensitization for up to 30 mL of fetal blood in the maternal circulation
- The feto-placental blood volume is estimated to be 120 mL/kg of fetal weight
- The estimated volume of fetal blood in the maternal circulation is less than 15 mL
- In > 90% of cases it is less than 30 mL
Use of U/S in Pregnant Trauma Patients (9)
- Fetal cardiac rate/rhythm
- placental location/ exclusion of previa
- amniotic fluid volume
- cervical length
- fetal well being (BPP)
- detection of fetal anemia by peak systolic flow velocity in the MCA
- delineation of possible fetal injury
- confirmation of fetal demise
EFM more sensitive at preddicting obstetrical complications, use as adjunct to this
recommend follow-up U/S two weeks after trauma to assess normalcy or document fetal intracranial anatomy & interval growth
What is the most common cause of fetal death in blunt maternal trauma?
- 5-50% of maternal trauma cases
- most abruptions occur between 2-6 hours after injury, almost all by 24 hours
- 20% of abruptions will go into preterm labour
Findings of placental abruption (6)
- Abdo pain
- Uterine tenderness
- Uterine contractions/hypertonicity
- Vaginal bleeding
- Atypical or Abnormal FHR tracing
Mode of Delivery for Placental Abruption
< 23 weeks SVD
> 23 weeks w/ hemodynamically stable mother and normal FHR IOL & SVD
> 23 weeks w/ unstable mother or abn FHR, C/S
Deterioration in fetal condition or maternal hemodynamic instability indicates need for immediate delivery, even at the expense of prematurity
Mechanism of PTL post placental abruption
Extravasation of blood at the placental margin may lead to decidual necrosis, which in turn, could initiate production of prostaglandins, thereby leading to preterm labour.
Traumatic injury to the uterus may also result in destabilization of the lysosomal enzymes which initiate prostaglandin production.
Trauma 2x higher risk PTD
How common is uterine rupture post trauma? How much does it contribute to perinatal mortality?
- rare, 0.6% of all maternal injuries, most (75%) involve the fundus
- 17.5% of MVC related perinatal mortality
What are some signs and symptoms or uterine rupture secondary to trauma?
- maternal shock
- abdominal distension
- irregular uterine contour
- palpable fetal parts
- sudden abnormal fetal heart rate pattern
- ascent of fetal presenting part and peritoneal irritation (abdominal rigidity, guarding and tenderness)
How frequently is direct fetal trauma seen?
- < 1% of blunt maternal trauma
- Usually fetal skull and brain
Indications for surgical exploration in pregnant trauma patient
- positive findings on lavage
- progressive abdominal distension w/ declining hematocrit
- abdominal wall disruption/perforation
Factors that influence decision to proceed with C/S in setting of trauma
- Severity of fetal injury
- degree of uteroplacental compromise
- parameters of fetal well being
- need for hysterectomy w/ extensive uterine injury
What is the incidence of visceral injury in maternal penetrating injuries? How does penetrating injury affect the fetus?
- 15-40% compared to 80-90% in non pregnant women (due to presence of large uterus)
- Depending on the gestational age and the size of the uterus, the fetus is much more likely than the mother to sustain significant injury (and to die) after a penetrating abdominal trauma.
- The fetus sustains injury in 60% to 70% of cases, while visceral maternal injuries are seen only in approx. 20% of penetrating abdominal trauma.
How does gunshot wound affect the fetus?
- 70% of abdominal gunshot wounds result in fetal injury, and 40% to 65% of these fetuses die.
- Fetal mortality generally results from premature delivery, maternal shock, uteroplacental injury, or direct fetal injury
When is the highest risk for domestic violence?
The abdomen is the most commonly affected body part (64%)
What reduction in maternal death is associated with the use of seatbelts?
- reduction of maternal death rate from 33% to 5%!
- The lap belt should be positioned below the abdomen and not over the uterus.
- The shoulder belt should be placed between the breasts.
What percentage of maternal trauma is attributable to falls?
- than 10% are associated with significant maternal or fetal injury
- most common after 32 weeks GA due to changed centre of gravity
Management of electrical trauma in pregnancy
- Rare in pregnancy
- 5th leading cause of fatal occupational related injuries in the US
Risk Factors for maternal/fetal injury:
- current pathway
- entrance and exit points
- magnitude of the current
- current that traverses through the amniotic fluid (an excellent conductor) may lead to spontaneous abortion, fetal demise, or fetal burns.
- urine test for maternal muscle injury
- xray and CT PRN
- 24 hrs of CEFM in cases of maternal loss of consciousness, abnormal EKG, or known maternal CVS illness
-Should be done within 4 minutes of maternal cardiac arrest (to get more effective CPR)
- Neurologic injury in the mother begins 6 minutes after cessation of cerebral blood flow; to obtain cardiac return by 5 minutes and avoid neurological damage
- Caesarean section should be started 4 minutes after the maternal pulse ceases
What type of blood should pregnant women be transfused with?
To avoid rhesus D (Rh) alloimmunization in Rh-negative mothers, O-negative blood should be transfused when needed until cross matched blood becomes available
Buchsbaum Criteria for Major/Minor Trauma
- suspected internal bleeding
- loss of consciousness
Describe risk factors in trauma associated with maternal death (4)
- bruising injuries to abdomen, pelvic, low back
- pelvic fractures
- intrabdominal injuries
- penetrating trauma
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