Two for One: Caring for the Pregnant Trauma PatientNabil Alzadjali FRCP III McGill University

CASE 1 25 Yrs F, 35 wks Preg. PC : MVC PMH : nil, Rh +ve,HPI : Driver, belted, rear ended by another car, air bag deployed Complaining of occasional abdominal pain,?cramping. Unsure about fetal movements. Veryconcerned regarding fetal well being.

ABC stable. BP 120/70 HR 88 RR 15 No signs of injuries on exam. FHR 140, No uterine contractions palpable. No guarding. No lap belt sign. No PV bleeding. Os ClosedHow do we manage this patient?

CASE 2 20 Yrs F, 30 weeks gestation Struck by truck across the street from hospital. Cardiac arrest at scene. U/G Technician have intubated and started CPR. Down time about 5 minutes. Arrival in ER, Pulseless Electrical Activity.How do we manage this patient?

Incidence Physiological Alterations Anatomical Alterations Unique Problems in the Gravid Abdomen Prehospital Considerations Diagnostic Studies Management of traumaUnstable MotherStable Mother Perimortem Cesarean Section

Incidence The Leading cause of non-obst. mortality - 46% Trauma during pregnancy - 7% Causes of Trauma (1)MVA 54.6 %Domestic abuse & Assault 22.3 %Falls21.8 %Penetrating inj.1.3 % < 1% of trauma admissions are pregnant Preterm Labor in 11.4 % & P. Abruption in 1.58 %(1) Connolly A, Katz VL, Bash KL, et al: Trauma and pregnancy. Am J Perinatol 14:331-336, 1997

Physiological Changes During Pregnancy

Supine Hypotensive Syndrome(1)(1) Milson I, Forssman L: Factors influencing aortocaval compressionin late pregnancy, Am J Obtst Gynecol 148: 764-771, 1984

RespiratoryRespiratory alkalosisReduce oxygen reserve (reduced FRC 20% & increased O2 consumption by 15 %)Residual volume decreased by 40%Respiratory rate increasedImpaired buffering capacity

GI Intestine are concentrated in upper abdomenDecrease GI motilityDecrease peritoneal irritation

GUBladder is displaced upward >10 wksDilitation of renal pelvis and ureters

Alterations in Anatomy 1st trimester uterus is thick walled and intra-pelvic Out of pelvis > 12 wks. Second trimester uterus contains large amount of amniotic fluid Third trimester uterus is thin walled, large Fetal head engaging pelvis At 36 weeks uterus reaches costal margin

Injuries unique to pregnancy Premature ContractionsRarely progress to preterm deliveryTocolysis is not proven in trauma.(1)

Abruptio PlacentaeDifferent elastic properties in uterus & placenta shearing3 % of minor trauma and upto 50 % in severe trauma (1) GoodwinTM, Breen MT: Pregnancy outcome and fetomaternal hemorrhage after noncatastrophic trauma, Am J Obstet Gynecol162: 665-671, 1990.

Uterine RuptureRare, 0.6 % of severe abdominal trauma (1)Direct trauma after 12 wks of gestationPrior Surgery (C/S or Myomec.) the risk

Maternal-Fetal HemorrhageTrimesters 1 3%, T2 12%, T3 45% 4-5 X more common in injured pregnant womenCauses isoimmunization & fetal deathKleihauer-Betke test - volume of fetal blood.01- .03 cc sensitize, 5 cc +ve KB Test. To determine amount of Rhogam needed1. Pearlman MD, Tintinalli JE, Lorenz RP: Blunt trauma during pregnancy, N Engl J Med 323:1609, 1990

Special Considerations Blunt Abdominal Trauma Penetrating Abdominal TraumaStabbing injuryGunshot injury

Blunt Trauma InjuriesHead injury most commonRetroperitoneal hemorrhageAbruptio placentaDICUterine Rupture Seatbelts 3 Points Restraints1/3 improperly or dont use beltsUnbelted is at 2.3X to give birth

Penetrating Injury

GSWsGravid uterus alter injury pattern to the mother.If missile enter upper abdomen; increased probability of harm (upto 100%).If enters below uterine fundus visceral injury less likely (0%)

Awwad et al (1) Fetal death rate is 67% 38 % for injuries above the uterus.(1) Awwad JT et al: High-velocity penetrating wounds of the gravid uterus: Review of 16 years of civil war, Obstet Gynecol 83:259, 1994.

Stabbing InjuryRare rare, only 19 cases reported in literatureMorbidity 93 % - Mortality 50 %Many advocate exploratory laprotomy since uterus laceration is devastating b/c of its enlarged circulation.

Meizner et al (1)An injury to uterus can rapidly change to a hypotensive emergency. It is difficult to know the size and depth of uterine rupture(1) Meizner I, Potashnik G: Sharpnel penetration in pregnanc resulting in fetal death, Isr J Med Sci 24:431, 1988.

Pre-hospital Consideration Oxygen Shock should be anticipated ED should be notified early, GA >24 wks Transport in L lateral position (GA > 20 wks)

National Association of EM Physician, 1997 PASG class III intervention worsen the supine hypotension

Diagnostic Studies

Modalities for Evaluating Trauma Plain Films X-rays Ultrasound CT & MRI Cardiotocographic Monitoring DPL Laparotomy

Plain Films Risk of 1 rad to fetus is approx. 0.003

< 5-10 rads causesNo risk on congenital malformation, abortions or intra-uterine growth ret.Smaller risk of increase in childhood cancer

Radiation doses > 10 rads6 % chance of severe mental ret.< 3 % chance childhood cancer.

Rosenstein M:Handbook of selected organ doses for projections common in diagnostic radiology. HEW publication(FDA) 89-8031. Rockville, MD. US Dept. Of Health And Human Services, Centre For Devices And Radiologic Health, 1988.

Ultrasound

Best modality to assess both fetus and mother

Not sensitive:Colonic lesionsBiliary tree lesionsSub-placental hematoma

Safe procedure

CAT SCAN Complementary to U/S & DPL

Penetrating wounds of flank & back

Can miss diaphragmatic and bowel injuries

Portability

Spiral CT reduces radiation exposure by 14-30 %

Rosenstein M:Handbook of selected organ doses for projections common in diagnostic radiology. HEW publication(FDA) 89-8031. Rockville MD,. US Dept. Of Health And Human Services, Centre For Devices And Radiologic Health, 1988.

Cardiotocographic Monitoring FHRRate (120-160)Beat-to-beat variabilityBaseline variabilityDecelerations, esp. late

Cardiotocographic MonitoringVariability:

Cardiotocographic MonitoringDecelerations: Early and Late

Cardiotocographic MonitoringDecelerations: Variable

Diagnostic Peritoneal Lavage CT & U/S are better in stable patient. Hypotensive unstable pt and if bedside U/S is not available Can be performed in any trimester Gravid uterus does not reduce the accuracy of DPL for OR Limited in detecting bowel perforation and does not assess retroperitoneal hemorrhage or intra-uterine pathology

Diagnostic Peritoneal Lavage

Rothenberger et al (1) n=12 (4 Supra umbilical & 8 infra umbilical) Sensitivity 100 % (8 internal bleeding confirmed by lapratomy), Specificity 100 % ( 4 no bleeding)No Complications from the procedure

Esposito et al (2)n=40 , 13 had DPLPPV = 100 %Rothenberger DA, et al:Diagnostic peritoneal lavage for blunt trauma in pregnant women, Am J Obstet Gyneco 129:479-48,1977.Eposito TJ, et al: Evaluation of blunt abdominal trauma occurring during pregnancy, J Trauma 29:1628-1632, 1989.

ManagementAvoid distractions and avoid focus on the fetus

Be aggressive! But temper with common sense.

An apparently stable mother may be compensating at expense of the fetus

If < 24 weeks, intermittent fetal doppler

If > 24 weeks, then continuous cardiotocographic monitoring to assess FHR and uterine activity

I. Initial maternal Resuscitation

AirwayAssess & controlPreoxygenate and sellicks maneuver is important before intubation

BreathingAssess and managePlace CT in 4th intercostal space

CirculationAssess maternal circulationIV accessTelt to left if > 20 wks

Management

The hemodynamically unstable mother

The hemodynamically stable mother

II. The hemodynamically unstable mother

III. The hemodynamically stable mother

Stable fetus

Minor trauma does not exclude significant fetal injury; 1-3 % of all minor trauma results in fetal loss from placenta abruption. (1)

Asymptomatic mother or with no obvious abdominal injury needs monitoring for feto-placental pathology (1) Pearlman MD, Philip ME: Safety belt use during pregnancy, obstet Gynecol 88: 1026, 1996

1. Pearlman MD, Tintinalli JE, Lorenz RP: Blunt trauma during pregnancy, N Engl J Med 323:1609, 1990Pearlman et al (1) Minimum 4 hrs CTG monitoring Extended to 24 hrs if : . >3 contractions per hour . Persistent uterine tenderness . Non reassuring fetal monitor strip . Vaginal bleeding . ROM . Serious maternal injury present All placental abruption were detected within 4 hrs 70 % of pt required admission. All discharged home subsequently had live birth.

III. The hemodynamically stable mother

Unstable fetus Fetal death rates are 3-9 times higher than mat. No infant survive if there is no fetal heart tone before C/SMorris et al (1)Heart tone is best survival marker for f. to undergo C/SIf fetal heart tone is present and the GA is > 26 wks the survival is 75%60 % of fetal death occurs with under use of CTG and delay recognition of fetal distress.

Perimortem Cesarean Section ~200 successful cases reported in the literature

Maternal CPR

Perimortem Cesarean Section 4 Minute Rule:

Maternal CPR for 4 minutes, Infant should be delivered by the 5th minute.

Perimortem Cesarean SectionTechnique:Make sure it is indicated first and that resuscitative team is readyVertical incision from xyphoid to pubisContinue straight down through abdominal wall and peritoneumCut through uterus and placenta (if anterior)Bluntly open uterus and remove fetusCut and clamp cord

Summary Anatomic and physiologic changes Vigorous fluid and blood replacementTreat the mother first and treat her just like any other trauma patient High index of suspicion for blunt or penetrating uterine trauma & abruptio placenta.Consider perimortem C/S in unstable women or cardiac arrest with viable fetus after 24 wks.

When to Intervene and Consult EARLY !

What is Best for the Mother is Best for the Fetus!Remember

Questions ?

Pregnancy is one of the special challenges in traumatology and it produces changes that alter the usual course of trauma management, obviously, due to the existence of the 2nd life that is both helpless and hidden from view.

The unique situation in pregnancy, that there are two patients intimately interrelated and who must be cared for simultaneously, warrants a separate discussion of this problem.Here is an outline of this discussion.T in P remains the leading cause of non O. morbidity & Mort. accounting for 46 % of fatalities in pregnant women.

Since women remains active during preg it is reported that 6-7 % of them will have trauma.

The major cause of maternal death are the same as those in non pregnant; head injuries and hypovolemia.

Injury in pregnant women may be intentional or unintentional.

MVC & falls are most common cause of injury.

However, homicide and suicide accounts for 1/3 of cases.

In one study domestic violence occurred in at least 8-17 % of cases during pregnancy. Single kick to abdomen in late preg. is associated with abruption placentae and fetal loss.

In one series, 57% of the maternal deaths were due to homicides and 7% due to suicides.Causes of traumatic injury roughly parallel those seen in the general population, blunt being more common.10% of maternal deaths from trauma are due to head injury, like the general population.Maternal death rate is not statistically different from the general matched population. Trauma, however, does seem to raise the rate of fetal loss and placental abruption over baseline rates in pregnant population.

Each system of the mother undergoes changes to compensate for the growing metabolic demand and loadof the new fetus.

The cardiovascular and hematopoetic changes include those noted above.

Additionally, there are increased amounts of thrombolytic factors present in the placenta, although systemic measurements of coagulation are normal.

The placental vascular system is exquisitely sensitive to circulating catacholamines which may result in intense vasoconstriction.Maternal shock may result in 85% fetal mortality.Each system of the mother undergoes changes to compensate for the growing metabolic demand and load, and for the progressively space intruding fetus.The cardiovascular and hematopoetic changes include those noted above.Additionally, there are increased amounts of thrombolytic factors present in the placenta, although systemic measurements of coagulation are normal.The placental vascular system is exquisitely sensitive to circulating catacholamines which may result in intense vasoconstriction.Maternal shock may result in 85% fetal mortality.

Cardiovascular Total blood volume increases by 50%Shock-like changesUp to 20% acute and 30-35% gradual blood loss may show no sign of instabilityNormal baseline heart rate is increased up by 10-15 bpmDiastolic BP is decreased by 5-15 mmHgElevating the mother's right hip 10-15cm completely relieves aortocaval compression in 58% of term parturients The respiratory system with its changes brings about a state of physiologic respiratory alkalosis of pregnancy.

Dilation of the renal pelvises and ureters occurs after the 10th week.

The bladder is displaced up and forward after the 10th week.Very common after maternal trauma. It indicates uterine contusions or blood irritating the uterine muscle. They rarely progress to preterm delivery.Placenta is devoid of elastic tissue while myometrium is very elastic predisposing to shearing Abruptio placenta is most common blunt injury

Blunt trauma will deform the elastic and flexible myometrium which gets sheared from the relatively inflexible placenta.

Results b/c of ..resulting in shearing effect and subsequently leading to seperatiion between placenta and the uterus.

It is common following blunt abdo. T., occurs in Vag. Blding and abd. Tenderness are comon but abruption may be clinically occult.CTG is most sensitive and indicates fetal distress.U/S is specific but is not sensitive, it detects only 50 % of the casesIt is not used to determine the need for the rhogam but ..

Quantitation of feto-maternal haemorrhage (FMH) by flow cytometry (FC) has been shown to be more accurate than the Kleihauer-Bekte test.

As with the nonpregnant patients, head injury is the major cause of mortality and morbidity.Pelvic organs are increased in size as are the vessels which supply them. This predisposes to retroperitoneal hemorrhage.Placental separation >50% results in fetal death.Uterus may hold up to 2 liters of blood before showing vaginal bleeding. Up to 20% of abruptions have no vaginal bleeding. Abruption be not yet be visible on an early ultrasound; hence, observation is necessary.Release of placental stored thrombolytic factors may precipitate DIC; this may occur with placental abruption or amniotic fluid embolus.Uterine rupture carries a near 100% fetal mortality rate. Signs and symptoms are similar to placental abruption. Occurs at site of previous C-Section.Seat belts decrease injury and improve survival by preventing ejection.Used alone, a lap belt may cause injury to the uterus.Properly worn (if at all) with a shoulder harness, the lap belt should cross the pelvis, not the abdomen. This remains a controversial issue.Surgical exploration does not worsen fetal survival rate. Only rarely does the pregnancy need to be removed to repair maternal injuries.Fetal demise is not an indication to perform C-Section while undergoing exploratory laparotomy. Fetus will be expulsed spontaneously within one week.Stabbings may be explored locally and observed, imaged, or undergo formal laparotomy to ascertain extent of injury. This will be institution and surgeon variable.Essentially each of these modalities has the same advantages and disadvantages in the pregnant as in the nonpregnant patient.Laparotomy is safe for both the mother and the fetus and there is no increased risk compared to the nonpregnant cohort. It is obviously invasive but the most complete and accurate study to evaluate for injury.CT is safe. It may be somewhat difficult to interpret due to crowding of viscera in the upper abdomen. It is good for diagnosing retroperitoneal injuries.DPL has historically been a relative contraindication in pregnancy. But it is safe if performed using an open technique and above the level of the uterus by someone experienced in the technique. It gives no information about the retroperitoneum or intrauterine injury.Ultrasound may be very operator dependent.Laparoscopy is still under scrutiny and not yet recommended for routine use.Rosenstein M:Handbook of selected organ doses for projections common in diagnostic radiology. HEW publication(FDA) 89-8031. Rockville, MD. US Dept. Of Health And Human Services, Centre For Devices And Radiologic Health, 1988.Fetal assessmentFHT can be heard with conventional stethoscope at about 20 weeks gestation. With doppler they can be detected between 12-14 weeks gestation.A rate 160 is indicative of fetal distress.It is not sufficient to simply apply the cardiotocographic monitor. Staff must be knowledgeable in what to look for and recognize an abnormal from a normal tracing.Beat-to-beat variability is in response to autonomic function.Baseline variability results from fetal extremity movement, breathing, and responses to uterine pressure.Absence of variability suggests lack of fetal movement and depression of CNS.The late deceleration (which may be as small as a decease by 5 bpm) occurs after peak uterine contraction and when present repeatedly indicates depletion of fetal oxygen reserves and fetal hypoxia.Early decelerations are normal (10-30bpm decreases) secondary to vagal responses from fetal head and neck squeezing during uterine contractions.

Some states DPL is contraindicated in advanced pregnancy but review of literature reveals mostly case series

Esposito studied 40 pt with blunt abdo trauma. 13 had DPL. Found DPL had 100 % PPV and 92 % accuracy in this small series.

Despite the high accuracy of DPL NextPerimortem Cesarean SectionIndications:*Fetus >26 weeks gestation (>1000 grams birth weight)*Reasonable certainty of maternal demise*Knowledge of the operative technique*Available resources to appropriately resuscitate and support the infant.*Presence of any fetal heart activity during the mothers course.

If the mother has brain death, but adequate vital signs to maintain the pregnancy, then there is no need for emergent delivery.There are reported cases of maternal improvement after perimortem C-Section.One author has recommended if unsuccessful CPR has been performed for 4 minutes, then C-Section should be performed in the 5th minute. Perimortem C-Section has been recommended at up to 25 minutes.

Recommended Reading:

1) Trauma in Pregnancy, ATLS Manual, Chapter 11, 1994Concise, nuts and bolts text.

2) T. Esposito, Trauma During Pregnancy, Emergency Medicine Clinics of North America, vol. 12, No. 1, Feb. 94, p. 167.Excellent review and discussion, well written.

3) S. Higgins, Emergency Delivery: Prehospital Care, Emergency Department Delivery, Perimortem Salvage, Emergency Medicine Clinics of North America, vol. 5, No. 3, Aug. 87, p. 529.Quick review of post (peri) mortem C-Section included.

4) The Challenge of Trauma in Pregnancy, Emergency Medicine Reports, vol. 16, num. 18, Sept 4, 1995.