trauma in pregnancy praneel
DESCRIPTION
trauma in pregancy -Emergency managementTRANSCRIPT
TRAUMA IN PREGNANCY
Praneel Kumar Bundaberg Hospital Emergency
Department
Outline
Introduction Take home point A & P changes in pregnancy and clinical
significance Emergency management Traumatic Complications Of Pregnancy
Introduction
7% of all pregnancies 8% of women age 15-40 admitted to
trauma centre do not know they are pregnant
Order of frequencies – MVA – Interpersonal Violence and falls
Viable fetus – 24 to 26 weeks of gestation or extimated fetal weight of 500gram
Take Home Points
Maternal Life takes Priority The best chance of fetal survival is
maternal survival Initial management – ATLS protocol with
some caveats Imaging should not be withheld if it
provides significant diagnostic information
Anatomical Changes
Uterus – 12 weeks intrapelvic / 20 weeks umbilicus and costal margin by 34 to 36weeks
Diaphragm rises as pregnancy progress – significance
Abdominal viscera are pushed upward by enlarging uterus
Stretching abdominal wall modifies normal response to peritoneal irritation – guarding /rebound can be blunted despite significant bleeding and injury
Anatomical Changes
Bladder displaced into abdominal cavity after 12weeks
Baseline diastasis of the pubic symphysis may exist – can be mistaken for pelvic disruption on a radiograph
AND REMEMBER SUPINE HYPOTENSION SYNDROME
Physiological Changes CVS
BP – declines in the first trimester/ level out in 2nd trimester and return to no pregnant level in the 3rd Trimester ( Systolic decline of 2-4mg and diastolic decline of 5-15mg ) ?? Significance
HR – does not rise by more than 10-15 beats per minute
Blood volume – may increase to as much as 45% peaking at 32 -34weeks of gestation with 25% increase in RBC – physiological anemia
Physiological ChangesCVS
Marked venous congestion in the pelvic and lower extremities in the 3rd trimester – increasing potentional of hemorrage from both bony and soft tissue pelvic injuries
Physological changes Pulmonary
Reduced oxygen reserve – due to decrease FRC caused by Diaphragm and increase in O2 consumption
Minute ventilation increases leading to hypocapnea
Physiological Changes GI
Gastro esophageal sphincter response is reduced and GI motility is deceased
Increased risk of aspiration
EMERGENCY MANAGEMENT
Primary SurveyABCDEF
GET YOUR TEAM READY Airway - Intervene as early as possible- Prolong bag mask ventilation increase risk of
aspiration ( already increased abdominal pressure and decreased lower esophageal tone
- Difficult airway – proportion of Mallampati class 4 increase by 34% from 12 to 38weeks
- NG decompression – to be performed to minimize the risk of ongoing Aspiration
Breathing -Supplemental oxygen in all patient –Fetus
vulnerable to hypoxia -Apnoeic oxygenation during RSI - Remember the diaphragm during
thoracostomy – use ultrasound to confirm where diaphragm is
Circulation - Significant blood loss before hypotension - Displace uterus to the Lt after 20weeks of
gestation – either manually or tilting the backboard with wedge or pillow
- RH Neagtive blood should be used - AVOID VASSOPRESSORS – decrease
uterine blood flow
Disability/Dextrose- Same as non pregnant – GCS /Pupil and
gross motor function and sensation Exposure and Environment- Examine all areas of the body - Log roll
F- FAST /FINGER / FOLEYS / FAMILY + FETUS
- EFAST - Finger – check every orifice for bleeding - Foleys – IDC if indicated - Family
FETUS - Use bedside ultrasound –HR and
movement - CTG ideal –minimum observation is
4hours- HR 120 -160 - Be-aware Very Angry Doctor Coming - Fetal distress can be sign of occult
maternal distress
Secondary Survey
Similar in general to non pregnant patient Specific emphasis on abdominal and
Vaginal examination - Abdomen : fundal height – age / decrease
may suggest traumatic PPROM - Vaginal: preferably by obstetric
specialist / evaluate vaginal lac or bony fragment and fluid
IMAGING
Use it if needed Radiation risk – teratogencity,birth defect and
increase life time risk of malignancy Loss of viability – risk greatest in the first 2
weeks post conception /risk with failure to implant at 50rad
Radiation induced malformation at 2-15weeks - Small head size / mental retardation/ organ
malformation - Afer 25 weeks – lifetime increase in malignancy Risk negligible < 5 rads exposure Risk increases > 15 rads exposure
Approximate Fetal Radiation Dose
Study Dose (rads)
Chest X-ray <0.001
Pelvis 0.04
CT Head <0.05
CT Chest 0.01-0.2
CT Abdomen 0.8-3.0
CT Pelvis 2.5-7.9
Spine series 0.37
9 month background dose
0.1
Complications
Placental Abruption- Most common cause of fetal death - Vaginal bleeding / abdominal cramps /
uterine tenderness/ fetal distress- Ultrasound – 50% sensitive - 3.9 fold increase in Preterm labour - More likey to have DIC
Uterine Injury-Rare, but always consider in significant
trauma-Associate with near 100% fetal death rae-Cause:Pelvic fractures striking uterus:Penetrating trauma:Inappropriate seatbelt placement, too high-can lead to uterine contractions
Fetomaternal Hemorrage - Rh –ve mum /Rh positive baby- All RH –ve women sustaining abdo
trauma should receive RH immune globulin
Mother stable/Fetus stable Mother stable / Fetus Unstable Mother Unstable /Fetus Unstable
Take Home Points
Maternal Life takes Priority The best chance of fetal survival is
maternal survival Initial management – ATLS protocol with
some caveats Imaging should not be withheld if it
provides significant diagnostic information