6/8/2018 Trauma in Pregnancy Disclosures UCSF AIM Conference • Consultant, Bloomlife Technology Deirdre Lyell, MD Professor, Maternal-Fetal Medicine Stanford • Investor, ZenFlow Medical Director, Labor and Delivery Associate Division Director Objectives Trauma in pregnancy • Understand epidemiology of trauma in pregnancy • Leading cause of non-obstetric death among reproductive-age women in US • Describe pregnancy-specific challenges • Leading cause of non-obstetric maternal and fetal death • Describe approach to management major of and minor trauma • 1 in 12 pregnancies affected • Can lead to SAB, PTL, PPROM, abruption, uterine rupture, non-reassuring • Educate ED and others about care of pregnant women with fetal status, IUFD trauma • Mortality is 2-fold higher in pregnant vs. non-pregnant trauma (i.e. pregnancy increases risk for death in trauma) • Educate patients on trauma prevention • Risk for violent trauma increases in pregnancy • Mortality is 3-fold higher in violent trauma 1
6/8/2018 Causes Pregnancy-specific challenges • Pregnancy: • Airway: aspiration risk, increased soft-tissue edema more MVC and assault • Hemodynamics: vitals more difficult to interpret • Younger population; hemorrhagic shock may show late • Less falls • Distorted anatomy altering surgical possibilities • Two patients • Limited experience in EDs • Limited professional guidelines Outcomes of trauma in pregnancy Physiologic changes in pregnancy • Blood volume increases by 20% (8 weeks) to 50% by 32 weeks • Fractures, dislocations, sprains and strains are the most common • Heart rate increases 15-20 beats/min • Depends on mechanism and severity of trauma, gestational age • Underestimation or failure to recognize severity or extent of injury or blood loss • Uterus is protected in pelvis until about 12 weeks • Cardiac output increases • Bladder is displaced upward and vulnerable • Placental abruption, uterine rupture, direct fetal injury • Physiologic anemia • Placental abruption: cause of 50-70% of losses • Supine position decreases cardiac output by 25-30% • Fibrinogen elevation; normal or decreased levels are abnormal 2
6/8/2018 Placental abruption Placental abruption • Accounts for 50-70% of trauma-related losses • Elastic myometrium vs. inelastic placenta • Shearing or blunt injury • Major trauma: up to 50% (most common >16 weeks) • Amniotic fluid is not compressible • Minor trauma: 2-4% • Coup-contrecoup injury • Most common mechanisms that result in abruption: • Immediate or delayed for several hours • MVCs (50%), assaults (5%), falls (3%) Penetrating uterine trauma Placental abruption diagnosis • 9% of maternal abdominal injuries • Clinical: bleeding, • 73% gunshot wounds, 23% stabbings, 4% shotgun contractions, pain, uterine • Bowel is displaced peripherally rigidity, non-reassuring FHR, late decelerations, or • Uterus is anterior to the great vessels asymptomatic • Maternal mortality 3-4% (decreased from non-pregnant) • Abnormal labs: fibrinogen, • Fetal injury and mortality 73% platelets • Fetal loss: 71% of gunshot wounds, 43% of stabbings to the • Ultrasound? Most not seen. uterus Subchorionic hematoma is suggestive Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014” p. 42 WikiJournal of Medicine 3
6/8/2018 Major trauma Primary survey • Same approach as if were not pregnant • ABCDE • A irway and C-spine protection. O2 sats > 95% • Primary survey: • B reathing and ventilation • identify and treat life-threatening injuries • C irculation and hemorrhage control. • few minutes • Uterine displacement. Volume. Fibrinogen >200 mg/dL • stabilize mother first • D isability. Assign injury severity score. • Secondary survey • E xposure. Remove all clothing. Assess for wounds, ecchymoses • fetal assessment • vaginal and rectal exam Secondary survey Radiology • After initial stabilization, evaluate for specific maternal injuries, • Radiology: FAST survey for intra-abdominal fluid assess fetal well-being • Pericardial, perihepatic, perisplenic, peripelvic space • Vaginal exam (if no previa): dilation, bleeding, ROM? • Can eliminate need for unnecessary CT scan • Fetal assessment • Other imaging as needed • Other radiologic exams • No single radiologic study threatens fetal well-being • None > 5 rads (x-ray, CT scan, MRI) • Hall EJ. Scientific view of low-level radiation risks. Radiographics 1991;11:509–18 • Pearl • Reactive NST suggests good maternal perfusion 4
6/8/2018 Radiology Question Royal Women’s Hospital, Melbourne: state’s major obstetric When the ED calls and asks which radiologic imaging studies they trauma center, should order for a woman who underwent a major MVC at 20 weeks, your best answer is: Among women who experienced high-risk (severe) trauma, 95% only 19% received recommended radiologic assessment A. X-rays only • Plain x-rays are often used to avoid CT • No single radiologic study exceeds the maximal recommended B. What would you order if she weren’t fetal exposure to radiation pregnant? C. Why are you calling me? 5% 0% y ? n l e . o . . m h s y s g n a f r i l i - r l X e a c d r u o o y u o e y r a d y u l h o W w t a h W How can we help in major trauma? Perimortem Cesarean • “What would you do if she weren’t pregnant? Do that.” • If the uterus is at or above the umbilicus • Estimate gestational age. Umbilicus: ~20 weeks • Cardiopulmonary resuscitation • Left uterine displacement • Uterine displacement (>20 weeks?) • If delivery is thought to benefit mother • Manual or wedge, 15 degree lateral tilt • “Five minute rule”: • Advise on radiologic studies • Initiate delivery within 4 minutes • Deliver by 5 minutes • Advise on maternal evaluation • Simulation • Normal vital signs, fibrinogen • Advise on fetal evaluation after primary survey 5
6/8/2018 Fetal monitoring Minor trauma • Contractions <q10 minutes: up to 20% risk of abruption • 90% of trauma in pregnancy • EFM is more sensitive for detecting abruption than ultrasound, KB, or physical exam • 60-70% of fetal losses • No validated minimum • Most abruptions diagnosed 2-6 hours after injury • Delayed placental abruption rare • unlikely if no contractions, normal FHR pattern over 4-6 hours • Deliver if deteriorating fetal status Fetal monitoring Fetal monitoring: how long? • Generally 2-6 hours if minor injury, normal FHR tracing • Contractions >q10 minutes: up to 20% risk of abruption • Good negative predictive value • EFM is more sensitive for detecting abruption than ultrasound, • Consider continuous EFM 24-48 hours if: KB, or physical exam • uterine tenderness, vaginal bleeding, abdominal bruising, category II • No validated minimum FHR pattern, contractions q10 minutes/hour, cervical dilation • Most abruptions diagnosed 2-6 hours after injury • multiple or severe maternal injuries • Delayed placental abruption rare • hemodynamically unstable mother • unlikely if no contractions, normal FHR pattern over 4-6 hours • abnormal laboratory studies (KB, fibrinogen) • abnormal imaging studies • Deliver if deteriorating fetal status 6
6/8/2018 Immunizations Ultrasound • Individualize use • Anti-D Immune globulin: Rh negative, bleeding or abdominal trauma • Placental location • Quantification by Kleihauer-Betke • Gestational age • KB for non-Rh negative women? • Abruption: likely if subchorionic hematoma is seen • 75% are not identified by ultrasound • Tetanus vaccine. Administer if: • Dirty wound: • If <3 doses or unknown (add tetanus immune globulin) • If >3 doses but >5 years since last dose • Clean wound: • >3 doses but >10 years since last dose • <3 doses or unknown vaccination Motor vehicle injuries Correct seat belt use • 170,000 MVCs/year • Approximately half of fetal losses could be prevented • The leading cause of by correct seat belt use • non-obstetric maternal death • Klinich KD, AJOG 2008 • traumatic fetal death • 1-3% of live born infants are • ACOG: women should be exposed counseled during prenatal care • Seat belt use reduces adverse about proper seat belt use maternal and fetal outcomes • CDC: 53% of women counseled during prenatal care https://www.cdc.gov/prams/pdf/snapshot- https://www.cdc.gov/prams/pdf/snapshot- report/motorvehicleinjuries.pdf report/motorvehicleinjuries.pdf 7
6/8/2018 Finally Trauma in Pregnancy UCSF AIM Conference • Evaluate for domestic violence Deirdre Lyell, MD Professor, Maternal-Fetal Medicine Stanford Medical Director, Labor and Delivery Associate Division Director 8
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