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TRAUMA AND SURGERY IN THE PREGANANT PATIENT IN THE PREGANANT PATIENT PRINCIPLES OF SURGERY-2011 NICHOLAS LEYLAND,BASc,MD,MHCM,FRCSC PROFESSOR AND CHAIR,

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Presentation on theme: "TRAUMA AND SURGERY IN THE PREGANANT PATIENT IN THE PREGANANT PATIENT PRINCIPLES OF SURGERY-2011 NICHOLAS LEYLAND,BASc,MD,MHCM,FRCSC PROFESSOR AND CHAIR,"— Presentation transcript:

1 TRAUMA AND SURGERY IN THE PREGANANT PATIENT IN THE PREGANANT PATIENT PRINCIPLES OF SURGERY-2011 NICHOLAS LEYLAND,BASc,MD,MHCM,FRCSC PROFESSOR AND CHAIR, DEPARTMENT OF OBSTETRICS AND GYNECOLOGY, FACULTY OF HEALTH SCIENCES, MICHAEL G. DEGROOTE SCHOOL OF MEDICINE, McMASTER UNIVERSITY McMASTER UNIVERSITY

2 SURGERY IN THE PREGNANT PATIENT Learning objectives: 1)TRAUMA IN PREGNANCY 2)THE ACUTE ABDOMEN IN PREGNANCY 3)NEUROVASCULAR EMERGENCIES 4)CASES 5) UPDATE LEYLAND

3 “THERAPEUTIC PARALYSIS”

4 TRAUMA IN PREGNANCY Incidence: Maternal mortality rate 3.5% – Mortality rate is similar for non-pregnant women Fetal mortality rate 1% in minor trauma 15% in major trauma Overall fetal death rate from trauma = 1/30000 pregnancies Trauma occurs in 6-7% of pregnancies % of Traumas are complicated by pregnancy

5 TRAUMA IN PREGNANCY: MATERNAL PHYSIOLOGY Surgical Implications: Cardiovascular Changes; CO ^ 50%,Blood Vol^ 50% Maternal rbc ^ 30% ‘Dilutional Anaemia’ WBC ^ 12000, Labour 20,000 GI: Appendix (localization), Progesterone Decreased motility,^ alk phosphatase, no change in Transaminases Respiratory Changes: e.g. Decreased pCO2

6 General Management Principles Maternal Assessment Primary Survey – ABCs…Fetus Lateral Tilt – Supine position can  cardiac output by 30% – 15° tilt is appropriate – Can decrease effect of CPR

7 General Management Principles Fetal Assessment Ultrasound – GA – Placentation/Abruption – Fetal viability – Extent of fetal trauma/demise – BPP? Celestone as indicated Initiate FHM after patient is stabilized Consider Tocolysis as indicated Vaginal exam to rule out PPROM

8 General Management Principles Maternal Assessment Rhogam: – Administer within 72 hrs – 10-30% of trauma have evidence of admixture – Betke-Kleihaurer test to determine quantity of hemorrhages – 90% of hemorrhages are < 30 cc Anterior placed placentas have higher risk

9 General Management Principles Maternal Assessment Exploratory Laparotomy – usually necessary in penetrating trauma – C/S may be required to attain adequate surgical exposure Tetanus – As usual

10 Imaging & Radiation Harmful effects: 1.Cell death and teratogenesis – High doses of radiation before implantation is likely lethal – In humans, high dose  growth restriction, microcephaly, mental retardation – Effects are greatest at 8-15 wks gestation – No proven effects before 8 wks or after 25 wks – Risk are not increased until radiation exposure = 5 rad

11 Fetal Exposure CXR (2 views) mrad Abdo XR (3 views)100mrad CT Head/Chest<1rad CT Abdo3.5rad Total4.8rad Fetal Radiation Exposure in typical trauma ACOG guidelines suggest that imaging is safe when exposure is ≤ 5 rad Imaging & Radiation

12 Blunt Trauma MVAs and abuse most common Fetal death can follow direct blunt trauma or maternal death – Specifically head trauma and ejection from vehicle Abdominal contents shifted in pregnancy – Retroperitoneal & splenic injury more frequent – GI injuries less frequent

13 Blunt Trauma - Consequences Placental Abruption – In up to 40% of severe blunt trauma – In up to 3% of minor blunt trauma – CTXs q10min = 20% risk of abruption – Abruption confers 50% fetal mortality Uterine rupture – Increases with force and gestation – Fetal death frequent here, but maternal death 10% Pelvic Fracture – Consider fetal skull fracture – MAST trousers contraindicated – If stable vaginal delivery still feasible Pre-Term Labour …

14 Blunt Trauma – Pre Term Labour Can PTL be predicted after blunt abdominal trauma? 85 patients over 3 yrs with non-catastrophic trauma Findings Preterm Labour in 13 (15%) Presence of Abdo pain or CTXs do not predict PTL Domestic abuse victims were more likely to have repeated trauma (Pak 1998)

15 MVAs Frequency In USA, 2% of all live births have been exposed to a reported MVA Seatbelts Up to 25% of pregnant drivers are unrestrained. Seatbelts positioned improperly cause a 3-4 fold increase in energy transmission through the uterus

16 MVAs Pregnant occupant in a 35 km/hr crash at peak uterine strain. a) An unbelted pregnant occupant contacting the steering wheel results in large deformation of the uterus. b) A matched belted occupant simulation steering wheel contact is minimal considerable neck flexion, which could lead to maternal injury. c) Airbag deployment combined with a three-point belt and airbag

17 MVAs Airbags No large scale data of airbags in pregnancy Pregnancy is not an indication for deactivation of airbags Pregnant Crash Test Dummy:

18 Penetrating Trauma Uterus may serve to protect maternal organs – Visceral injury from penetrating trauma in pregnancy = 38% vs 90% – Of GSWs to abdomen, death in pregnancy is 1/3 rate of non-pregnant – Fetal death rate: 71% of GSWs, 42% stabs Penetrating trauma is generally an indication for exploratory laparotomy Half the women had perinatal deaths due to either maternal shock, uteroplacental injury, or direct fetal injury.

19 A Unified Approach Is there a need for a standardized protocol for obstetrical patients who experience trauma? The low incidence of trauma during pregnancy leaves trauma teams at risk of ignoring steps that may prevent adverse outcomes. An organized approach of stabilizing the injured gravida and then initiating ultrasound and EFM in pregnancies beyond 24 wks will ensure the best outcome for the mother and her unborn child. It is now a requirement in Australia for a level 1 trauma centre to have a protocol detailing the management of pregnant patients after trauma.

20 A Unified Approach Issues to consider Delayed monitoring during primary survey and imaging – Average time to clear c-spine estimated at 36 minutes Access to FHR monitor in ER may not be available – Estimated that 15% of ERs in USA have this Other activities in resuscitation room may preclude continuous access to FH, or hinder ability to hear it Patients transferred to labour floor for ongoing monitoring may not receive optimal management of non-obstetrical issues – Eg. Soft tissue injury, Physiotherapy, occupational therapy, etc.

21 TRAUMA IN PREGNANCY- Key Points: Trauma occurs in 6-7% of pregnancies Physiologic changes of pregnancy may confuse the picture ABCs should not be abandoned in managing a pregnant trauma patient Consider Rhogam, Celestone, PPROM, and initial FH monitoring Education regarding proper use of seatbelts in pregnancy is paramount Consideration of a standardized trauma protocol or record for obstetrical use may be warranted.

22 TRAUMA IN PREGNANCY- Key Points: Investigations ….LEYLAND’S AXIOM… “IF AN INVESTIGATION IS INDICATED DO IT” Fetal viability….24 weeks Fetal monitoring….OBS/PERINATOLOGY Transfer to regional center ONLY after maternal stabilization

23 TRAUMA IN PREGNANCY: Head Trauma Dead Mother = Dead Fetus

24 CARDIOPULMONARY RESUSCITATION There are special considerations for cardiopulmonary resuscitation (CPR) conducted in the second half of pregnancy. uterine displacement is paramount to accompany other resuscitative efforts

25 G.I. DISEASE IN PREGNANCY: APPENDICITIS Abdominal pain, nausea,vomiting Anorexia* Localization of the pain and tenderness Ultrasound? Laparoscopy?…Negative Laparotomy Rate Fetal Mortality and Maternal Morbidity rates are directly correlated to the delay in diagnosis and treatment******

26 OB/GYNE CONDITIONS MIMICKING APPENDICITIS: PRETERM LABOUR PLACENTAL ABRUPTION DEGENERATION OF FIBROIDS ADNEXAL EVENTS ROUND LIGAMENT PAIN ECTOPIC PREGNANCY CHORIOAMNIONITIS

27 CHOLECYSTITIS IN PREGNANCY: SIGNS AND SYMPTOMS = DDx: MI ACUTE FATTY LIVER OF PREGNANCY APPENDICITIS SEVERE PREECLAMPSIA/HELLP PUD PANCREATITIS

28 CHOLECYSTITIS IN PREGNANCY: DIAGNOSIS…U/S TREATMENT…MEDICAL.1ST AND 3D TM …SURGICAL.2ND TM …FAILURE OF MEDICAL OR RECURRENT ATTACKS LAPAROSCOPY?

29 G.I. DISEASE IN PREGNANCY: BOWEL OBSTRUCTION Morbidity and Mortality related to the delay in diagnosis* Previous Surgery and Adhesions--3d TM Volvulus, Hernia, Intussusception Signs and Symptoms = Diagnosis Serial Assessments and Serial AXRs Management?

30 PANCREATITIS IN PREGNACY PRESENTATION INVESTIGATIONS MANAGEMENT FETAL CONSIDERATIONS?

31 NEUROVASCULAR EMERGENCIES IN PREGNANCY: AVMs, ANEURYSMS SURGICAL MANAGEMENT: TREATMENT AT THE TIME OF PRESENTATION(ANEURYSM) AVM LESS CLEAR SUPERIOR SAGITAL SINUS THROMBOSIS

32 CASE 1 29 YR 34 WEEKS GESTATION N/V X 8 HOURS, ANOREXIA (NEW ONSET) PX… AFEBRILE, TENDER MID- ABDOMEN RIGHT WITH REBOUND UTERUS NON TENDER BUT CAUSES TENDERNESS ON RIGHT WITH PALPATION FROM THE LEFT

33 CASE 1 INVESTIGATIONS? DDx? FETAL CONSIDERATIONS? MANAGEMENT

34 CASE 2 “THE MOOSE STORY”

35 CASE 2 “THE MOOSE STORY” NOW IN THE NEUROSURGICAL ICU CONSULTS OBS RE CT, ANGIOGRAPHY CONSIDERATION OF TERMINATION?

36 CASE 2 “THE MOOSE STORY” THE HAPPY ENDING……….

37 CASE 3 30 YR OLD WOMAN AT 24 WEEKS GESTATION MVA HIT FROM BEHIND HAD SEAT BELT ON, NO HEAD INJURY O/E VSS, BRUISED AND TENDER ABDOMEN FETAL HEART TONES HEARD WHAT ARE THE ISSUES HERE?

38 CASE 3 MATERNAL CONSIDERATIONS FIRST! FETUS SECONDARY MONITORING IF FETUS VIABLE FETAL MATERNAL TRANSFUSION BETKE-KLEIHAUER SURGICAL DELIVERY IF FETAL DISTRESS AND MOTHER IS STABLE

39 SURGERY IN THE PREGNANT PATIENT AVOID “THERAPEUTIC PARALYSIS” IF AN INVESTIGATION IS INDICATED FOR DIAGNOSIS ---DO IT! NEVER COMPROMIZE THE MATERNAL CARE FOR THE SAKE OF THE FETUS! THERE ARE VERY FEW DRUGS OR INVESTIGATIVE TESTS WHICH CAUSE SERIOUS FETAL DAMAGE

40 SURGERY IN THE PREGNANT PATIENT Learning objectives: 1)TRAUMA IN PREGNANCY 2)THE ACUTE ABDOMEN IN PREGNANCY 3)NEUROVASCULAR EMERGENCIES 4)CASES THANKS!

41 References Van Hook, JW. Trauma In Pregnancy. Clin Ob Gyn, 45(2): , Mattox KL. Trauma in Pregnancy. Crit Care Med 33(10):S385-S389, Tweddale CJ. Trauma During Pregnancy. Crit Care Nurs Q. 29(1):53-67, 2006 ACOG Educational Bulletin. Obstetric Aspects of Trauma Management. Number 251, Sep Stone IK. Trauma in the obstetric patient. Obs Gyn Clin NA. 26(3):459, ACOG Committee on Obstetric Practice. ACOG Committee Opinion. Number 299, September Guidelines for diagnostic imaging during pregnancy. Obstetrics & Gynecology. 104(3):647-51, Fildes J. Trauma: the leading cause of maternal death. JTrauma. 32(5):643-5, (Abstract Only) Kang AH. Traumatic Spinal Cord Injury. Clin OG. 48(1)67-72, Dahmus MA. Blunt Abdominal Trauma: Are there any predictive factors for abruptio placentae or maternal-fetal distress. AJOG. 169(4): , 1993 Towery R. Evaluation of pregnant women after blunt injury. JTrauma. 35(5):731-5, (Abstract only) Gilson, GJ. Acute spinal cord injury and neurogenic shock in pregnancy. Obstet Gynecol Surv. 50(7): , 1995 Banit DM. Evaluation of the Acute Cervical Spine: A Management Algorithm. J Trauma. 49: , 2000 Whitten M. Postmortem and perimortem caesarean sections: what are the indications?. J R Soc Med 93:6-9, Shah KH. Trauma in Pregnancy: Maternal and Fetal Outcomes. JTrauma. 45(1):83-86, Baerga Varela, Y. Trauma in Pregnancy. Mayo Clinic Proceedings. 75(12): , Pak LL. Is adverse pregnancy outcome predictable after blunt abdominal trauma. AJOG 179(5): , Pearlman M. Automobile crash simulation with the first pregnant crash test dummy. AJOG. 175(4): ,1996. Moorcroft DM. Computational model of the pregnant occupant: Predicting the risk of injury in automobile crashes. AJOG 1889(2): , Pearlman MD. Aprospective controlled study of outcome after trauma during pregnancy. AJOG. 162(6):1502-7, (Abstract only) Mabrouk AR. Burns during pregnancy: a gloomy outcome. Burns. 23(7/8) , Hyde LK. Effect of motor vehicle crashes on adverse fetal outcomes. Obstet Gynecol. 102: , Warner MW. Management of trauma during pregnancy. ANZ J Surg. 74: , Kolb JC. Blunt trauma in the obstetric patient: monitoring practices in the ED. AJEM. 20(6):524527,2002. Handbook Of Trauma Care.The Liverpool Hospital Trauma Manual6th Edition: El Kady D. Maternal and Neonatal Outcomes of Assaults During Pregnancy. Obstet Gynecol 105:357-63, 2005.

42 TRAUMA IN PREGNANCY: BLUNT ABDOMINAL TRAUMA MVA, ASSAULT, FALLS MANGEMENT PRINCIPLES….. OBS PRINCIPLES…. PLACENTAL CONSIDERATIONS FETAL MATERNAL TRANSFUSION UTERINE RUPTURE PRETERM LABOUR FETAL MONITORING!!!!!!!!!

43 TRAUMA IN PREGNANCY: RADIOLOGIC INVESTIGATIONS…… ADVERSE AFFECTS TO FETUS RARE < 10cGy cSPINE, CXR, Angiography, CT, MRI Shielding of abdomen

44 CARDIOVASCULAR DISEASE KEY POINTS ▴ Hemodynamic changes in pregnancy may adversely affect maternal cardiac performance. ▴ Intercurrent events during pregnancy are usually the cause of decompensation. ▴ Labor, delivery, and postpartum are times of hemodynamic instability. ▴ Invasive hemodynamic monitoring should be used to address specific clinical questions. ▴ Many maternal heart conditions can be medically managed during pregnancy. A few are associated with a very high risk of maternal mortality. ▴ Many patients with congenital heart disease can successfully complete a pregnancy. ▴ Preconceptual counseling is based on achieving a balance between medical information and the patient's value system.

45 Penetrating Trauma in the Pregnant Patient 1. There were visceral injuries when the entrance wound was in either the upper abdomen or back. 2. When the entry wound site was anterior and below the uterine fundus, there were no visceral injuries. 3. Half the women had perinatal deaths due to either maternal shock, uteroplacental injury, or direct fetal injury.

46 TRAUMA IN PREGNANCY: Penetrating Abdominal Trauma Gunshot Wounds…entry/ exit Xray localization Laparotomy…uterine status/ fetal viability Knife Wounds…fistulogam? Uterus 500 ml/min at term Postmortem Ceasarean

47 Fetal Mortality Retrospective review of hospitalized trauma patients for short and long term pregnancy outcomes 61 patients, long term followup in 53 Successful pregnancy = neonate surviving neonatal period Baerga Varela

48 Fetal Mortality

49 MANAGEMENT OF TRAUMA An important aspect of management is repositioning of the large uterus away from the great vessels to diminish its effect on decreased cardiac output. Almost 20 percent of women who had contractions more frequently than every 10 minutes in the first 4 hours had an associated placental abruption. For the woman who is D-negative, administration of anti-D immunoglobulin should be considered.


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