Disclosures Celmatix Advisor or Reviewer (spouse) Mindchild Advisor - PowerPoint PPT Presentation

6/11/2016 Disclosures Celmatix Advisor or Reviewer (spouse) Mindchild Advisor or Reviewer (spouse) Bob’s Red Mill Grant/Research Support (spouse) Management of Maternal Trauma During Pregnancy Susan Tran, MD Assistant Professor Maternal-Fetal Medicine June 11, 2016 2 Case Poll The next course of action is: OB team called emergently to ED for 32 yo visibly pregnant unrestrained passenger in MVC A. Move immediately to CT scanner • Vitals: Temp 98F, BP 70/42, P 136, RR 36, O2 B. Monitor the fetus 62% sat 95% on 100% facemask C. Intubate • No major deformities visible; abdomen gravid, D. Perimortem cesarean bruised; Pupils equal, round, reactive; Doesn’t 24% open eyes or respond to painful stimuli 10% 4% • Currently being transfused blood products 3 4 1

6/11/2016 Outline • Epidemiology • Maternal physiology • Motor vehicle crashes (MVCs) • Blunt and penetrating abdominal trauma – Falls EPIDEMIOLOGY • Evaluation and management – CPR and perimortem cesarean delivery 5 6 Epidemiology Trauma • Trauma is the leading cause of • Affects 6 - 8% of pregnancies nonobstetric maternal death – ~2/3 motor vehicle crashes (MVCs) – Falls and abdominal trauma – Domestic violence • Most incidents are considered minor • 0.4% pregnancies require hospitalization for trauma – 5 – 38% delivered during trauma hospitalization 7 8 2

6/11/2016 Fetal death from trauma Complications of OB trauma • ~3.7 fetal deaths per 100,000 • Preterm labor Petrone P et all, 2015 live births • Placental abruption • Can occur with apparently minor trauma • Emergency cesarean • Placental abruption occurs • Fetal loss • Premature rupture of membranes – Severe trauma: 40 - 50% • Spontaneous abortion – Minor trauma: 1 - 5% – Responsible for ~70% of fetal deaths after trauma • Uterine rupture 10 9 Physiologic adaptations • Heme – Plasma volume increases ~40% – Fibrinogen < 200 is abnormal in pregnancy – WBC normal 6k-16k in pregnancy • Cardiovascular – Increased cardiac output • Pulmonary – Decrease in functional residual capacity – Increase in tidal volume – Decrease in pCO2 MATERNAL PHYSIOLOGY • GI – Lower esophageal sphincter relaxes • Renal – GFR increases 50% 11 12 3

6/11/2016 Special considerations • Gravid uterus more likely to sustain injury • Aortocaval compression – Can result in a 25-30% reduction in cardiac output – Maternal positioning • Left lateral tilt MOTOR VEHICLE CRASHES – Can limit CPR efforts (MVCS) • At best, CPR generates ~10% cardiac output in term patients 13 14 MVCs Seat belts • 207 cases per 100,000 pregnancies • 3 point restraint seat belts save lives! • Mortality rates related to MVCs • ~1/3 pregnant women DON’T wear them – Maternal 1.4 per 100,000 pregnancies – Discomfort – Fetal 3.7 per 100,000 pregnancies – Inconvenience • Substance use a risk factor – Fears of hurting fetus / misinformation • ~50% no prenatal seat belt counseling – 40 - 45% tested positive for intoxicant(s) 15 16 4

6/11/2016 MVC mechanism of injury • Blunt abdominal trauma • Shearing forces – Coup-contrecoup BLUNT ABDOMINAL TRAUMA abruption 17 18 Blunt abdominal trauma Abruption • Bowel less likely to be injured • Up to 2/3 severe abdominal traumas • Traumatic uterine rupture • Doesn’t always – Fundal or posterior uterus correlate injury severity – Fetal mortality approaches 100% • Pelvic fractures • Ultrasound sensitivity ~25% – Risk factor for fetal head injury www.mayoclinic.com – Not a contraindication to vaginal delivery – A normal ultrasound does not Petrone P et al, 2015 • Fetomaternal hemorrhage rule out abruption! • Abruption 19 20 5

6/11/2016 Fetomaternal hemorrhage: Kleihauer Betke (KB) Testing • To determine Rhogam amount in Rh neg • Protocols vary – Give Rhogam to all Rh neg women with trauma – KB test in ALL pregnant trauma patients? PENETRATING ABDOMINAL • 46 of 71 pregnant trauma patients had positive KB tests * – 44 of those 46 had PTL compared to 0 patients with negative KB TRAUMA – EAST ‡ recommendation: routine KB testing in ALL trauma >12w GA * Muench et al. J Trauma. 2004 Nov;57(5):1094-8. ‡ Eastern Association for the Surgery of Trauma 21 22 Penetrating abdominal trauma Penetrating abdominal trauma: Injury • Gun shot wounds (GSWs) • Enlarged uterus • Stab wounds • Fetus: Usually less favorable prognosis • Associated with assault or suicide attempts – 40 – 70% mortality rates (injury below fundus) • Maternal: Usually more favorable prognosis – Visceral injury ~19% (vs 82% nonpregnant) – Mortality 3.9% (vs 12.5% nonpregnant) 23 24 6

6/11/2016 ATLS™ Assessment Advanced Trauma Life Support™ – American College of Surgeons (ACS) • Primary survey • Resuscitation EVALUATION OF THE • Secondary survey OBSTETRIC TRAUMA PATIENT • Re-evaluation • Definitive care 25 26 Assessment of the Primary evaluation – Rapid! pregnant trauma patient • Similar to nonpregnant patients SECONDARY PRIMARY – Do not withhold needed interventions because of fetus EVALUATION EVALUATION • Simultaneous stabilization and assessment • Maternal injuries • Evaluate mother and • > 20w GA, displace uterus off IVC & aorta stabilize • Abruption – ABCDE • Preterm labor – 15 degree left lateral tilt – IV’s • Fetal distress – O2 • Fetomaternal – Displace uterus hemorrhage • Fetal injuries 27 28 7

6/11/2016 Primary evaluation – ABCs Secondary evaluation • Systematic evaluation for traumatic injury • Airway • FETAL ASSESSMENT • Breathing – Gestational age • Circulation – Assess for vaginal bleeding, membrane rupture, labor • Disability – Fetal monitoring generally > 20w GA • Exposure • Remember pregnancy physiology – Aortocaval compression – Expanded circulating blood volume – Normal lab values 29 30 Diagnostic studies Estimated fetal radiation exposure Pregnancy should not preclude the use Radiologic examination Fetal radiation exposure (mrad) † of indicated diagnostic studies Chest radiograph (PA, lateral) <1 Abdomen plain film 200 - 300 C-spine radiograph <1 • Radiation exposure of <5 rads Hip / femur radiograph 100 - 400 CT chest 30 – No associated fetal abnormalities or pregnancy loss CT abdomen 250 • MRI does NOT produce ionizing radiation † Bentur Y. Ionizing and nonionizing radiation in pregnancy. In: Maternal-fetal toxicology, 2nd ed, Koren G (Ed), Marcel Dekker, New York, 1994 31 32 8

6/11/2016 Case • 29 yo G2 P1001 @ 33w4d who was the belted driver in an MVC in which she was rear ended by a car going ~ 20 mph – C/o mild contractions – Reports normal FM and denies LOF/VB A COMMON SCENARIO… – Exam: NAD; minimal TTP over seatbelt region; UCs q3”; category 1 FHRT 33 34 Poll L&D eval after maternal trauma How long do you monitor the fetus? Monitoring A. 1 hour 37% B. 2 hours • If no contractions or bleeding, monitor 4 hr 32% C. 4 hours 22% D. 6 hours • Concern for abruption? E. 24 hours – Monitor / observe for 24 hours and reassess 5% 3% 35 36 9

6/11/2016 Other evaluations • At least 4 hours of monitoring • Physical exam – Abdomen, pelvis, SSE • Ultrasound for fetal assessment CARDIOPULMONARY • Labs – CBC RESUSCITATION (CPR) AND – Blood type / Rh PERIMORTEM CESAREAN – Coags including fibrinogen – +/- KB – Consider toxicology / blood alcohol screen 37 38 CPR in the pregnant patient AHA: ACLS modifications for pregnant women • <24 weeks: similar to nonpregnant • Tilt the patient • >24 weeks: consider 4 minute rule • Early intubation – Unwitnessed arrest deliver after 1 minute if no response • Cricoid pressure • 20 – 30% blood volume to uterus • Do not use femoral access site • Cardiac output from chest compressions • No modifications to medications – Nonpregnant ~33% • Remove fetal monitors prior to defibrillation – Third trimester ~10% 39 40 10