trauma in pregnancy and the ed delivery
DESCRIPTION
Trauma in pregnancy and the ED delivery. Rebecca Burton-MacLeod Oct 30, 2003. Background . Trauma in 6-7% of pregnancies accounts for nearly half deaths in pregnancy (46.3%) most commonly due to MVC (>50%), assault, fall. 10 physiological changes….[that exam question!]. - PowerPoint PPT PresentationTRANSCRIPT
Trauma in pregnancy and the ED delivery
Rebecca Burton-MacLeodOct 30, 2003
Background Trauma in 6-7% of pregnancies accounts for nearly half deaths in
pregnancy (46.3%) most commonly due to MVC (>50%),
assault, fall
10 physiological changes….[that exam question!]
Dec BP first trimester (dec sys 2-4mmHg, dec dias 5-15mmHg)
inc HR (by 10-15bpm) CVP 4cm (instead of 7.5cm) blood volume inc 48-58% CO inc 40% inc clotting factors FRC dec by 20% oxygen consumption inc by 15% dec gastric motility inc gastric acid production
10 anatomical changes….[that other question!]
•diaphragm rises 4cm with rib flaring resulting•inc size uterus•bladder displaced upwards•bowel displaced and modified peritoneal irritation signs•sympheseal distraction (7.7-7.9cm)•ureteral dilation•dec gastroesophageal sphincter response•supine hypotensive syndrome•blood flow to uterus inc 10x•inc peripheral venous pressure
Case 28 y.o. female G1P0 30wks GA. MVC.
Unconscious when arrives in ED. Sats 88%. Decreased A/E right side
Airway/breathing management…what considerations in pregnant patient?
Airway/Breathing Oxygen promptly (dec oxygen reserve,
inc consumption) RSI (high risk of aspiration) adjust mechanical respirators (inc TV) Chest tube insertion 1-2 IC spaces
above normal (raised diaphragm)
Case cont’d Circulation issues in pregnancy? High index of suspicion for shock (inc blood
volume, but uterine blood flow compromised first)
avoid vasopressors, if possible (dec uterine blood flow even more)
use RL (more physiologic and less acidotic) tilt pt 15-30 degrees, or elevate right hip
Secondary survey Complete hx obstetrical hx physical exam evaluating/monitoring fetus
Obstetrical hx LMP EDC problems/complications of current
pregnancy problems/complications past pregnancies determination of fetal GA (uterine size)
– GA >24wks, wt >500gm (survival 20-30%)
Estimation of GA Rough estimate--
any fundus palpable above umbilicus is viable!
Physical exam Rectal exam pelvic exam:
– speculum for signs of vaginal trauma, cervical dilation, source of vaginal fluid…do swabs for GBS, chlamydia/gonorrhea if leakage of amniotic fluid, slide for ferning of amniotic fluid
– bimanual exam for bony pelvic trauma, advanced labour
Fetal evaluation FHR and Fetal movement!!! If <24wks then intermittent FHR
monitoring if >24wks then continuous external FHR
monitoring
FHR strips A--accelerations B--baseline (120-160bpm), beat to beat
variability (loss indicates fetal distress) C--contractions D--decelerations (late decels indicates
fetal hypoxia)
FHR strips Variability
Decelerations
Labs Routine trauma bloodwork blood type and Rh status coagulation studies if abruption
suspected ABG for maternal hypoxia and acidosis
Imaging questions What options exist for diagnostic
imaging modalities?
Imaging options Plain films CT/MRI U/S
Imaging questions Any concerns with radiation exposure?
Radiography Major effects of exposure to radiation for fetus:
– congenital malformations (small risk b/w 2-15wks GA if rads>100 mrad)
– growth retardation (15% risk of small head size)
– postnatal neoplasia (0.2-0.8% for CT pelvis)– death(<1% during first 2wks after conception)
Radiography exposure1000 mrad = 1 rad
Low exposure group (<1 mrad):– head– c-spine– s-spine– extremities– chest
High exposure group:– l-spine (204-1260
mrad)– pelvis (190-357
mrad)– hip (124-450 mrad)– IVP (503-880 mrad)– UCG (1500 mrad)– KUB (200-503 mrad)
Radiography exposure of <5-10 rad causes no
significant increases in fetal complications
take precautions--shield abdomen, focus beams
naturally occurring rad during 9mos is 50-100 mrad
CT scans Head/chest CT-- <1 rad abdo above uterus -- <3 rad pelvic -- 3-9 rad spiral CT reduce radiation exposure by 14-
30% fetal assessment--CT will NOT show fetal
injury, but will show uterine rupture, placental separation, placental ischemia
U/S Best modality for assessment of mother and
fetus (GA, placental location, fetal demise) sensitivity 83-88%, specificity 98-99% similar ability to detect intraperitoneal fluid in
pregnant pts as compared to non-pregnant less sensitivity for evaluating kidneys /
pancreas / bowel / biliary tree than CT safe for fetus, therefore firstline imaging
Imaging questions Will this affect what studies are
ordered?
Imaging Bottom line: radiation deemed
necessary for maternal evaluation should not be withheld on basis of potential problems for fetus
Other procedures Kleihauer-Betke test FMH (8-30% after trauma) complications--Rh sensitization, fetal
anemia, fetal distress, or fetal death from exsanguination
acid elution on maternal blood--adult cells colourless, fetal cells purple; ratio calculated
Kleihauer-Betke test only sensitive for over 5ml, but as little as 1ml can
sensitize 70% of Rh neg mothers thus, all Rh neg mothers should receive one 300 mcg
Rhogam within 72h KB test only done on pts at risk for massive FMH
which would require more than one dose of Rhogam (>30ml FMH)– less than 1% trauma, and 3.1% major trauma
pts KB not necessary <16wk GA as circulating blood
volume <30ml
Types of trauma Blunt penetrating fetal injury placental injury uterine injury
Blunt trauma MVC, abuse, falls Seatbelt use--no belts inc fetal death 4.1x, 3-
point belt best as long as positioned correctly physical abuse--4-17% (perpetrator usually
known to pt); only 3% of pts tell MD what happened
falls--2% of pts fall more than once during pregnancy
Penetrating trauma Organs most likely involved if upper
abdomen affected (dec order): sm bowel, liver, colon, stomach
uterus almost exclusively during third trimester (fetal injury 60-90%)
GSW--maternal mortality 7-9%, fetal mortality 70%
Penetrating trauma GSW: above uterus
injuries require exploration
laparotomy for uterine wounds
Stab: if above uterus then
operative intervention based on clinical findings/imaging results
laparotomy for uterine wounds
Fetal injury Leading causes fetal death: maternal
death, maternal shock/hypoxia, placental abruption, direct fetal injury (intracranial hemorrhage, skull #)
Predictors of fetal death/preterm birth
Predictors fetal death:– Higher Injury Severity
Scores (ISS>25, 50% incidence fetal death)
– lower GCS– lower admitting
maternal pH– low serum bicarbonate– FHR <110 bpm
Predictors preterm birth:– ROM– placental abruption– not associated with
abdo tenderness or uterine contractions
Placental injury Abruption occurs 2-4% minor trauma, 38% major
trauma can occur with no signs of inj to abdominal wall s/s--vaginal bleeding, abdominal cramps, uterine
tenderness, amniotic fluid leakage, maternal hypovolemia, or a change in FHR
also associated uterine contractions--if less than 1/10min then unlikely abruption
U/S only accurate in <50% of cases best indicator--fetal distress (60% of cases), thus
FHR monitoring immediately
Abruption If mother/fetus stable--expectant mgmt
if <32wk GA, otherwise, C/S delivery recommended
54x more likely to have coagulopathies if abruption
DIC directly proportional to amount of abruption
Uterine injury 27y.o. 33wk GA had fall. Presents with
contractions. Cx long, hard, posterior. Use of tocolytics indicated? Not routinely as 90% stop
spontaneously and those that do not are often pathological in origin and tocolytics contraindicated
Uterine rupture Caused by severe MVC, penetrating
injuries s/s--maternal shock, abdominal pain,
easily palpable fetal anatomy, fetal demise
mgmt--either suture tear or hysterectomy
Disposition
Mother/fetus stable Minimum 4h continuous FHR monitoring if >3 uterine contractions/hour, persistent
uterine tenderness, abnormal FHR strip, vaginal bleeding, ROM, any serious maternal injury (ejections, motorcycle/ped collisions, no seatbelts) = 24h minimum monitoring
all pts settled and d/c within 24h had live births!
Monitoring One survey showed FHR monitoring
often does not take place during first hour of maternal work-up (68%)
in survey only 15% of departments had adequate FHR monitoring equipment
often inadequate FHR monitoring despite fact fetal distress without overt clinical signs!
Mother stable/ fetus unstable
If GA >24wks and FHR unstable = C/S stat
If FHR present and GA >26wks then 75% survive
other indications for C/S--uterine rupture, fetal malpresentation during premature labor, and uterus mechanically limits maternal repair
Mother unstable/ fetus unstable
32y.o. 30wk GA by dates. MVC. P110, BP 80/45. FHR 72. Splenic rupture. Which first--operative splenic mgmt or C/S?
Mother before fetus! Repair of injuries that are life/limb
saving for mother first then if fetus still viable, consider C/S
Maternal arrest/ fetus unstable
Within 4min of maternal arrest, if no response to advanced cardiac life support consider perimortem C/S– Potential for fetal and maternal survival– No MD in US ever found liable for performing
perimortem C/S GA >24wks by best estimate 70% of fetus that survive are delivered within
5min of ED arrival 4min for maternal resuscitation, 1min for C/S!!
Perimortem C/S Call for help (obs, peds) continue CPR during procedure, consider thoracotomy
with OCM midline vertical incision from epigastrium to symphysis
pubis through all layers to peritoneal cavity, using large scalpel
vertical incision through anterior uterus from fundus to bladder reflection, using large scalpel/scissors; if bladder encountered, rupture
if placenta encountered on opening uterus, it should be incised to reach fetus
clamp and cut cord after delivery of fetus
ED deliveries ED suboptimal location Consider transfer if in periphery and pt not in
active labour Call for obstetrical help if available Perinatal mortality 8-10% for ED deliveries
– ED selected by pts with complications (hemorrhage, PROM, eclampsia, PTL, abruptions, precipitous delivery, psychosocial complicating factors)
Stages of labour
First stage Latent phase—slow cx dilation up to
4cm Active phase—rapid dilation Lasts 8h in primip, 5h in multip Examine cx for effacement, dilation,
position, station, presentation
Second stage Full dilation of cx and urge to push with
contractions 50min primip, 20min multip FHR monitoring and U/S useful—
viability, lie, presentation
Delivery Equipment:Sterile gloves,
Towels, Cord clamps (2), Hemostats, Placenta basin, Surgical scissors, Rubber bulb syringe, Neonatal airways, Syringes, needles (small gauge), Gauze sponges
Lithotomy position Once crowning, finger sweep
to ensure cord not wrapped around neck
Modified Ritgen manoeuver used for delivery of head
Delivery cont’d Suction nares/mouth Downward traction on
head for delivery of anterior shoulder
Upward pull subsequently will allow posterior shoulder to pass
Clamp cord and cut
Third stage Delivery of placenta Uterus firm and globular, gush of blood,
umbilical cord protrudes from vagina 5-20min in duration
Fourth stage First hour post-delivery of placenta PPH most likely to occur during this time
– Uterine exploration to ensure expulsion of entire placenta
– Pack uterus with 4-inch gauze using ring forceps
– Uterine artery embolization or hysterectomy Repair of lacerations Oxytocin 20-40 u/l at 200ml/h
Risks/benefits of adjunctsprocedure Risk Benefit Useful in ED?
NPO and IV’s Fluid overload, A-B disturb
Venous access, dec risk of aspiration
Yes
Enemas Time consuming Less pain by constipation
No
Pubic shaving Infection / irritation
None No
Nitrous oxide analgesia
Incomplete pain control
Self-admin, few fetus SE
Yes
Narcotics Fetal depression Good paincontrol PRN
Regional anesthesia
Technically difficult, incomplete pain control
Good pain control when technically correct
PRN
Risk/benefits of adjuncts cont’d
Procedure Risks Benefits Useful in ED?
FHR monitoring Inc surgical intervention
Early dx fetal distress
Variable
U/S None Adds to database Yes
Amniotomy Augmented labour, prolapsed cord
None No
Episiotomy Poor maternal outcomes
None if uncomplicated
No
Ritgen maneuver None Decreased trauma yes
Complications of delivery Dystocia—shoulder dystocia (1/300 live
births) Malpresentation—breech delivery (1/25
live births)
Breech presentations A—frank breech B—complete breech C—incomplete
breech
Breech delivery Identification—Leopolds maneuvers (not
useful in ED), U/S, vaginal exam Complications—head entrapment, umbilical
cord prolapse Mgmt—generous episiotomy, knee flex and
sweep out legs, pull out 10-15cm of cord after umbilicus clears perineum, use pelvis to hold infant, mauriceau maneuver
Shoulder dystocia Identification—”turtle sign”, shoulders vertically aligned Mgmt—
– H—help (obs, neonat, anaesth)– E—generous episiotomy– L—legs flexed (McRoberts maneuver)– P—pressure (suprapubic and shoulder pressure)– E—enter vagina (Rubin’s or Wood’s maneuver)– R—remove posterior arm (splint, sweep, grasp, and
pull to extension)
McRoberts maneuver
Rubins maneuver
Summary Most importantly, get obstetrical help
ASAP!
References Marx: Rosen’s Emergency Medicine: Concepts and clinical practice. 5 th ed. 2002. Mosby Inc. Kolb et al. Blunt trauma in the obstetric patient: monitoring practices in the ED. Am J Emerg
Med 2002. Oct;20(6):524-7. Curet et al. Predictors of outcome in trauma during pregnancy: identification of patients who
can be monitored for less than 6 hours. J Trauma 2000. Jul;49(1):18-24 Stallard et al. Emergency delivery and perimortem C-section. Emerg Med Clin North Am.
2003. Aug;21(3):679-93. Shah et al. trauma in pregnancy. Emerg Med Clin North Am. 2003. Aug;21(3):615-29. Rogers et al. A multi-institutional study of factors associated with fetal death in injured
pregnant patients. Arch Surg 1999. Nov;134(11):1274-7. Pak et al. Is adverse pregancy outcome predictable after blunt abdominal trauma? Am J
Obstet Gynecol 1998. Nov;179(5):1140-4. Desjardins. Management of the injured pregnant patient. Trauma.org: trauma in pregnancy.
http://www.trauma.org/resus/pregnancytrauma.html Goldman et al. Radiologic ABCs of maternal and fetal survival after trauma: when minutes
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