BabyonBoard!ThePregnantTraumaPatient

GillianSchmitz,MD,FACEP

OBJECTIVES

1. Maternal-fetal anatomy & physiology2. Approach to Resuscitation3. Uterine pathology4. Fetal Monitoring5. Perimortem cesarean delivery (PMCD)6. Evidence based approach for disposition

AnatomicChanges

AnatomicChanges

PhysiologicChanges

• HRincreases10-20bpm• BPdecreasesby10-15mmHG

• Canlose30-35%circulatingbloodvolumebeforemanifestingclinicalsignsofshock!

Increasedminute

ventilation

Respiratoryalkalosis

Fasterdesaturation

Respiratory

• Tidal volume• Respiratory rate• O2 consumption• PCO2

• Arterial pH

• é (by 25%)• é (40-50%)• é (15-20%)• ê (27-32)• é (7.40-7.45)

Relative hypocapnea & faster desaturation

Renal / GI

• Kidneys• Bicarbonate• Base excess• Creatinine• Gastric emptying

• hydronephrosis• ê (19-25)*• ê (3-4) • ê

• ê

SupineHypotensionSyndrome

Labs

ApproachtoResuscitation:PrimarySurvey

ADEQUATERESUSCITATIONOFMOTHER

Airway:earlyRSI

• é riskdifficultintubation• Failedintubation8xé– éWeightgain(aspirate)– éRespiratorytractmucosaledema• Smallertube

– é Airwayresistance– ê Respiratorysystemcompliance– é Oxygenrequirements

No. 325, June 2015 Guidelines for the Management of a Pregnant Trauma Patient

Vital Signs in Pregnancy

–Normal is NOT normal –Up to 30% (2 L) loss of blood volume

before vital signs change–Maternal shock = fetal survival 20%

ApproachtoResuscitation:SecondarySurvey

• Headtotoeexam• Abdominalexam/fetalviability• GUexam• Fetalmonitoring/earlyOBconsultation• EarlyNGtubeplacement/IVF/blood

• ADEQUATERESUSCITATIONOFMOTHER

ImaginginPregnancy

PlacentalAbruption

PlacentalAbruption

FetalMonitoring

UterineRupture

PenetratingTrauma

Intimate Partner Violence

• Focus is on the fetus–Abdomen (60%)

• éPreterm delivery• éFetal demise

DomesticViolence

• Thinkaboutit• Askwhenpatientisalone• Socialservicesevaluationorreferral

InjuryPrevention

Expectantmomwithseaton

© Mark Pearlman MD

ResuscitativeHysterotomy

SurvivingInfantswithTimeofMaternalArrestin

Perimortem CSection

KatzV,Balderston K,DeFreest M.Perimortem cesareandelivery:wereourassumptionscorrect?.AmJObstet Gynecol.2005Jun.192(6):1916-20;discussion1920-1.

MaternalImprovementafterCsection

KatzV,Balderston K,DeFreest M.Perimortem cesareandelivery:wereourassumptionscorrect?.AmJObstet Gynecol.2005Jun.192(6):1916-20;discussion1920-1.

Considerations

• EstimatedGestationalAge

• Adequacyofresuscitativeefforts

• ElapsedTime

WhatdoIneed?

TreatmentAlgorithm>20weeks

Unstable Stable

Resuscitate

TransfertoOR

PerimortemCsection

TreatmentAlgorithm>20weeksStable

FASTExam/Ultrasound

+ -

Serialexams

ConsiderCT

FetalMonitoringOBconsultation

SurgicalandOBconsultation

CTvs OR

FetalMonitoringADMIT

Unstable

TreatmentAlgorithm>20weeksStable

CTneg

TocodynamometerMonitoring

• Monitoringfor4hoursissufficienttoruleoutmajortrauma-relatedcomplicationsinlowriskpatients

FetalMonitoring

HospitalizationanduterineactivitymonitoringbyEFMfor24hoursforpatientswith:

• uterinetenderness,vaginalbleeding• contractionsduringamonitoringperiodof4hours

• ruptureofthemembranes• atypicalorabnormalfetalheartrate• highriskmechanismofinjury(motorcycle,pedestrian,

• highspeedcrash)

Fetomaternal Hemmorhage

• Apttest• Kleihauer-Betke (KB)test• Rhogam• Tetanus

TakeHomePoints

• Focusresuscitationonmom• Notallminortraumaisminor!• Vitalsignsnotreliableindicators• Imaginginpregnancy• PMCSnowResuscitativeHysterotomy

Questions?

GillianMD@gmail.com