IMAGING OF TRAUMA IN PREGNANT PATIENT

Trauma: is the leading cause of non-obstetrical maternal mortality incidence: 5% to 7% of all pregnancies causes of trauma:motor vehicle collision other causes:FallsAssaultsBurns

Introduction

Major Trauma (life threatening trauma) fetal loss 40% to 50% Minor Trauma fetal loss 1% to 5% However Minor trauma is much more common Net Result: fetal losses occur more in minor trauma

Trauma

∗ Emergency: follow ATLS guide lines∗ Standard resuscitation techniques∗ To avoid Hypotension: Ensure left lateral 30 degree

decubitus position (>20 weeks pregnant)∗ After patient stabilization carry out USG to assess: . fetal well being and . gestational age

INITIAL Management

Following imaging modalities are used for evaluation:∗USG∗Conventional radiography ∗CT scan∗MRI scan

Imaging Evaluation

Most frequently used modality For initial evaluation of fetus: Abdomen US . Fetal wellbeing . gestational age For maternal evaluation: FAST SCANS . Free fluid in pericardial cavity . Free fluid in peritoneal cavity

USG EXAMINATION

∗ Sensitivity and specificity:- . Sensitivity: 61% to 83% . Specificity: 94% to 100%∗ Benefits:- .affordable . Easily available . No hazards of radiations

∗ Drawbacks:- . Free intra peritoneal fluid (< 400ml) is much more

difficult to detect . Cannot accurately detect solid and hollow organ

injuries . Requires excellent sonographer skills

CT is exceptionally best in hollow and solid organ injuries

How ever:deals with ionizing radiation

Conventional radiography and Computerized tomography(CT)

∗Radiation-induced Teratogenesis∗Radiation-induced Carcinogenesis

What’s the Big Deal?

Fetal radiation dose

Threshold value 50 mGy Natural background radiation 0.5 to 1.0mGy Abdominal CT with fetus in full view 25 mGy Other CT examinations in which fetus is not

in full view the radiation dose is very well below the threshold value

Estimated Fetal Dose

GESTATIONAL PERIOD EFFECTS THRESHOLD DOSE

< 2 WEEKS Failure of blastocyst implantation

50-100mGy

2-20 weeks teratogenesis 50 and 150mGy

Any time during pregnancy

carcinogenesis

Radiation-induced EFFECTS

Keeping in view the above hazards: decrease the dose of CT to the lowest possible multi phase study should be avoided until and unless necessary

FDA category B drug IV iodine contrast should be preferred if necessaryCan give better view of maternal and fetal injuries by

providing vascular contrast in organs and opacification of vascular structures

CT contrast: Iodine

∗ Typically not used as initial evaluation∗ however after initial evaluation it is an excellent choice

in: . Spinal injuries . Complex neurological and soft tissue injuries∗ can be used in follow up imaging

MRI

∗ No harmful effects on fetus are reported but some concerns are

. Potential effect of energy deposition . Resultant tissue heating in fetus . And potential effect of acoustic noise ∗ Gadolinium contrast is FDA category c drug and it

should be avoided until and unless absolutely necessary

Non pregnancy related injuries

Head injuries: Major cause of Maternal deaths

Spinal injuries

Thoracic injuries

a) Splenic injury b) liver injury

Abdominal injuries

Bladder injury

Pelvic injuries

Pregnancy specific injuries

∗ most common cause of fetal death in trauma cases where mother survives

∗ fetal mortality ranges from 67% to 75%Complications: . preterm delivery . Low birth weight Types: marginal and central

Placental Abruption

Not a sensitive tool for diagnosis∗ false negative values reported upto 50% to 80%∗ signs at USG . Marginal . Retro placental hemorrhage: >depends . Fresh hemorrhage :- hyperechoic to isoechoic . Old hemorrhage:- if > 2 weeks it will become sonolucent . Retro placental clot

Diagnosis: Ultrasonography

∗ first trimester: indistinguishable∗ second trimester: hyperattenuated relative to

adjacent myometrium∗ third trimester: increase heterogeneity and venous

lakes begins to appear on maternal side

Normal Placenta: CT SCAN

Normal Placenta: CT SCAN

CT findings of normal placenta at 40 weeks of gestation

∗ retro placental full thickness area of decrease enhancement

∗ retro placental hematoma∗ high attenuation blood products

Diagnostic findings of placental abruption on CT

CT findings: Placental abruption

CT findings of placental abruption in different patients

Findings of MR imaging in placental abruption

MR imaging for placental abruption

∗ incidence: 1%∗ fetal mortality: 100%∗ maternal mortality: 10%∗ diagnosis: CT scan is used as main diagnostic tools

Uterine rupture and penetrating injury

∗ full thickness defect in uterine wall∗ fetal parts present outside uterine cavity∗ haemoperitonium

Diagnostic findings on CT scan

Uterine rupture in 28 week pregnant women

Uterine laceration from penetrating trauma

Pre mature Rupture Of Membranes

Incomplete Spontaneous Abortion

Ectopic Pregnancy And Trauma

Fig: ruptured ectopic pregnancy

A negative examination can play vital role in directing appropriate non-surgical management of a pregnant trauma patient. Particularly true for women with penetrating injuries where CT may demonstrate only superficial injuries and an absence of deeper injury that would require surgery.

Value of negative imaging examination

Value of negative imaging examination

From an imaging standpoint, the workup of pregnant trauma patient should, proceed as for any patient, using conventional radiography, CT and MRI as needed. while using modalities with ionizing radiation, the dose should be kept as low as possible bearing in mind that all diagnostic imaging is less than 50 mGy.

The images should be interpreted accurately and a precise description should be given which will best guide the clinical management.

Conclusion