1. Trauma in Pregnancy 1 Tanya L. Zakrison Clinical Fellow Ryder Trauma Center University of Miami Jan. 05 th, 2010

2. Case: ID: 27F, 8 months pregnant Call info: unbelted passenger involved in a high speed MVC On arrival: primary survey unremarkable obvious seat belt sign over pregnant abdomen What next? CT scan:

4. Case: She now becomes hypotensive How do you manage this? She now goes into cardiac arrest in the resuscitation bay after CT How do you manage this?

5. Outline of Trauma in Pregnancy Primary survey & resuscitation of mother Fetal assessment & detecting injury Secondary survey of mother with special considerations: Fetomaternal hemorrhage Imaging Medications Perimortem cesarian section Critical care concerns Mechanism & Prevention Early OB Consult

6. How Do You Know She is Pregnant? Ask her!  hCG on all women of childbearing age  hCG doubles q 1.6 days early on then q 3-4 days by 7 th week if > 1800 can see gestational sac Ultrasound / FAST 11% pregnancies diagnosed this way in the trauma room

7. Trauma in Pregnancy Hospitalization in 0.4% of pregnant women Leading cause of non-obstetrical mortality Causes of death: Mother: Mother: head injury Fetus: Fetus: maternal shock placental abruption direct injury (GSW to fetus or pelvic fractures of mother) What do I need to do to care for the unborn child? CARE FOR THE MOTHER CARE FOR THE MOTHER

8. Mother - Physiology A: A: Friable mucous membranes (E 2 ), decreased LES tone, increased abdominal pressure B: B: Higher diaphragm – 20% less FRC, 20% increased oxygen consumption Increased Vt and minute ventilation (50%) C: C: Elevated HR (10-15), SV (23%), CO (25-43%) – anemia with hypervolemia Lower SVR, BP (10-15 mmHg/lowest 2 nd trimester) Low venous return when supine (30% CO) BLOOD: >10 weeks increasing plasma (45% at term) > increased RBC (15-30%) oCan MASK up to 35% blood loss Hypercoagulable state Hypercoagulable state Ongoing c-spine precautions

9. Mother – Initial Management A: A: Endotracheal intubation, avoid nasal passages B: B: (Pre)oxygenate well (will desaturate < 1 min) Watch potential for aspiration, watch chest tube placement C: C: Fetal distress first sign of maternal hypotension (tilt to left > 20 wks) Supine Hypotensive Syndrome (SHS) (tilt to left > 20 wks) D: D: Eclampsia vs. brain injury E: E: Estimate age of fetus

10. Estimate Fetal Age 1 st trimester uterus is thick walled and intra-pelvic Out of pelvis > 12 weeks 2 nd trimester uterus contains large amount of amniotic fluid 3 rd trimester uterus is thin walled, large, fetal head engages pelvis At 36 weeks uterus reaches costal margin Ensure distended abdomen is 2 dary to fetus and not blood

11. Fetal Viability by Age Beyond umbilicus is likely viable (> 24 weeks)

12. Fetal Assessment Avoid fetal hypoxia at all costs Maternal blood oxygen content Uterine blood flow Fetal oxygen dissociation curve is shifted to left: small change in maternal PaO 2 = large change in fetal oxygen saturation Avoid maternal hyperventilation Maternal alkalosis poorly tolerated Leads to uterine vasoconstriction

13. How do I manage the fetus? Resuscitate the mother Oxygen & blood Monitor the fetus cardiotocographic monitoring (CTM) if >20 weeks, x 6 hrs (EAST Guidelines, 2005) Watch for warning signs of injury to the fetus Vaginal bleeding, fetomaternal hemorrhage, uterine contractions, uterine rupture, placental abruption, premature labour Fetal distress is often first sign of maternal hypotension Fetal distress is often first sign of maternal hypotension

14. Fetal Monitoring Uterine contractions: A) Uterine contractions: 90% stop spontaneously Fetal HR: B) Fetal HR: Normal HR (120-160) Beat to beat variability Baseline variability Decelerations (esp. late) EARLY LATE

15. Fetal Monitoring Monitor 6 – 24 hours if: Uterine contractions Vaginal bleeding Uterine tenderness Rupture of membranes Non-reassuring fetal HR pattern Significant maternal injury EARLY LATE

16. Fetal Injury? Treat maternal injuries first Uterine rupture Uterine rupture: rare, rapidly fatal Placental abruption Placental abruption: 3-50% of trauma >50% fatal for fetus Uterine contractions, pain, bleeding (78%) Can lead to DIC, hemorrhagic shock, renal failure Can bleed profusely with pelvic fracture due to dilated veins FETUS FETUS rarely directly injured until 3 rd trimester (skull, long bone) Kleihauer-Betke (KB) test to detect fetal blood mixed into maternal blood

17. Secondary Survey & Considerations Secondary Survey: Secondary Survey: Pelvic examination: ◦ Vaginal bleeding ◦ Ruptured membranes ◦ Bulging perineum ◦ Prolapsed cord Ongoing CTM: ◦ Presence of contractions ◦ Abnormal fetal heart rate and rhythm Special considerations: Special considerations: Fetomaternal hemorrhage Imaging Medications

18. Fetomaternal Hemorrhage Mixing of fetal blood into maternal circulation Complications: ◦ Maternal isoimmunization ◦ Mother Rh (-), fetus Rh (+) ◦ Fetal exsanguination KB test to detect fetal Hb in maternal circulation ◦ All pregnant women > 12 weeks gestation ◦ Watch false positives with sickle cell trait RhoGAM® RhoGAM® if KB test positive 300  g IM (72 hr. window), repeat in 12 weeks + 300  g for each 30ml of fetal-maternal transfusion

19. Imaging Concerns Do not defer imaging as pt. is pregnant (benefit outweighs risk) i.e. Fetal risk of harm less than risk of death/ harm from missed injuries or delays in treatment Risk related to ionizing radiation and IV contrast CXR: 0.001 radsCT abdo/pelvis: 0.6-5.0 rads Teratogenicity: Fetal exposure to 10 – 50 rads in first 6 weeks of gestation Oncogenicity: Increased risk of childhood leukemias (RR 1.5-2.0) Other: Mental retardation with 5 – 15 rads at 8-15 weeks No increase in fetal anomalies or pregnancy loss if < 5 rads exposure (American College of Obstetrics & Gynecology) Therefore exposure to < 5 rads is safe Therefore exposure to < 5 rads is safe

20. Medication Concerns SAFEAVOID Tetanus toxoid Fentanyl, morphine LMW Heparins Propofol Cephalosporins Penicillins Benzodiazepines Metronidazole Warfarin Pancuronium Furosemide Prednisone A) Direct risk of teratogenicity or death to fetus B) Direct risk of placental vasoconstriction & hypoxia Most vasoconstrictors www.motherisk.org

21. Perimortem Cesarean Section Consider in any moribund pregnant woman of ≥ 24 weeks gestation Can do crash C-section with up to 70% survival of baby if done within 4-5 minutes of arrest (must be viable age) Fetal neurologic outcome a time to c-section Premature Labour  <1% of minor trauma  Higher as severity increases  approx. 11% of traumas  commonest cause is abruption but may be due to other causes

22. Mechanisms & Prevention BLUNT (90%): BLUNT (90%): MVC (50%) > assault = falls (22%) > pedestrian injuries PENETRATING: PENETRATING: Stab wounds: Stab wounds: rarely penetrate thick uterus Gunshot wounds: Gunshot wounds: up to 70% abdominal wounds strike fetus with 40-65% mortality If mom shot in lower abdomen fetus injured only 20-30% of time will have injuries outside uterus If mom shot upper abdomen mother injured mother has 100% injuries and 38% fetal death

23. Mechanisms & Prevention MVC: MVC: leading cause of blunt injury Only 46% pregnant trauma patients are restrained Fears about seat-belt related harm to fetus Unbelted has 2x risk of premature birth and 4x risk of fetal death Only 17% women counselled on appropriate use Lap belt low at the pelvic brim Violence: Violence: significant cause of blunt and penetrating injury ALWAYS HAVE A HIGH INDEX OF SUSPICION Rule out domestic & sexual violence

24. Pregnancy in the Critical Care Unit Directly related to pregnancy Directly related to pregnancy Pre/eclampsia, HELLP, acute fatty liver of pregnancy, amniotic fluid embolism, obstetrical sepsis Exacerbated by pregnancy Exacerbated by pregnancy Aspiration, VTE disease, pyelonephritis, gestational diabetes, connective tissue disease Non-specific Non-specific Cardiorespiratory failure, sepsis, post-traumatic complications Early obstetrical consult +/- general surgery

25. Summary In pregnant trauma usual ABC management principles apply BUT need to be more vigilant In pregnant trauma usual ABC management principles apply BUT need to be more vigilant Oxygen and IV fluids for all If mom >20 weeks, tilt left side down Best chance for fetus is to treat mother well Best chance for fetus is to treat mother well If mom Rh (–) think of Rhogam Don’t defer important imaging Give appropriate medications Involve obstetricians early in the trauma Involve obstetricians early in the trauma Estimate fetal age Prevention is best medicine Prevention is best medicine

26. Thank You!