Presentation on theme: "Trauma x Two: The Pregnant Victim Douglas S. Ander, MD Emory University School of Medicine Professor of Emergency Medicine Assistant Dean for Medical Education."— Presentation transcript:
Trauma x Two: The Pregnant Victim Douglas S. Ander, MD Emory University School of Medicine Professor of Emergency Medicine Assistant Dean for Medical Education
Disclosures “I, Douglas Ander, have no real or perceived vested interests that relate to this presentation nor do I have any relationships with pharmaceutical companies, biomedical device manufacturers, and/or other corporations whose products or services are related to pertinent therapeutic areas.”
Frequently Asked Questions What are the statistics? What is the role of domestic violence? How do the physiologic changes of pregnancy affect management? How to I recognize the possibility of fetomaternal injuries? How do I recognize abruptio placenta? What do I need to know about fetal monitoring? Should pregnant women wear seatbelts? What do I do when my patient codes? What is the significance of fetomaternal hemorrhage? What xrays should I do?
Introduction Accidental injury occurs in 6-7% of all pregnancies Trauma is the leading cause of maternal death, 46.3% Overall 6-7% maternal mortality Fetal mortality 61% in major trauma, 80% if cases of maternal shock < 1% of trauma admissions are pregnant Peckham CH et al. Am J Ob Gyn 1963;87:609 Fildes J et al. J Trauma 1992;32:643 Connolly A et al. Am J Perinatol 14:331-336, 1997
Causes of Trauma Drost et al. J Trauma 1990;30:574.
Domestic Violence 154 acts of violence per 1000 pregnant women during first 4 months, increases to 170 per thousand during the 5-9th months. Only 8 of 24 sought medical care May lead to increased complications 41.8% vs. 11.8%, P<.01 17.1% (assault) vs. 7.1% (MVC) 1985 National Family Violence Study, Helton AS et al. Am J Public Health 1987;77:1337 Pak LL et al. Am J Ob Gyn 1998;179:1140 Goodwin and Breen. Am J Ob Gyn 1990;162:665
How do the physiologic changes of pregnancy effect management?
Cardiovascular Plasma volume increases by 50% Heart rate increases by 10-15 bpm Cardiac output increases by 40-50% Total peripheral resistance decreases Oxygen consumption increases by 20% Decrease in venous return
Cardiovascular 30-35% decrease in maternal blood flow can cause a 10-20% decrease in uterine blood flow prior to detectable hemodynamic changes in the mother Warm and pink shock patient
Respiratory Decrease in functional residual capacity Decreased oxygen reserve Increased risk of maternal hypoxemia during RSI
Gastrointestinal Decreased motility and tone Increased risk of aspiration Stretching of abdominal wall Decreased response to peritoneal irritation
Anatomic Diaphragm rises 4cm Perform thoracotomy 1-2 interspaces higher Compartmentalization of the small intestine into the upper abdomen Increased risk injury Uterus may shield the intestines Increased cardiac output to uterus Increased risk for significant hemorrhage
Supine Hypotensive Syndrome Milson I, Forssman L: Am J Obtst Gynecol 148: 764-771, 1984
How to I recognize the possibility of fetomaternal injuries?
Major Trauma 24% of the women died All fetuses expired Average gestational age 22.4 weeks Of the 31 who survived 6 fetal deaths 4/6 of abruptio placenta 8/10 women in shock had fetal demise Rothenberger et al. J Trauma 1978;18:173
Minor Trauma Pearlman 75/75 no fetal death, 3 abruptio placentae Goodwin 5 abruptio placentae Schiff Relative risk for abruption in non-severe trauma, 3.7 (1.3-7.9) Morris 3/5 infants considered salvageable died from mothers with mild to moderate injury, ISS < 16 Cahill 317 patients, ISS 0, only 1 abruptio placentae which was unrelated to the trauma
Recognition of abruptio placentae - >20 wks Pearlman et al No women had an abruption if no uterine contractions were detected or if their frequency was less than every 10 minutes during 4 hours of monitoring after trauma was sustained Pearlman et al. Am J Obstet Gynecol 1990;162:1502-1510.
Monitoring Recommendations All women >20-week gestation: Minimum 6 hours monitoring Extended to 24 hours if :. >3 contractions per hour. Persistent uterine tenderness. Non reassuring fetal monitor strip. Vaginal bleeding. Rupture of membranes. Serious maternal injury Controversy based on the minor trauma literature
Fetal Monitoring: Late Decelerations Onset is 30 seconds or more after onset of the contraction, nadir well after the peak contraction and returns to baseline after the contraction is over Fall of 10-20 bpm Always believed to indicate fetal distress
Seatbelt Statistics Most wore restraints before pregnancy, but increased restraint use during pregnancy (79% vs. 86%, chi squared, p = 0.02) Only 52% - 72.5% used restraints properly 55.3% reported that restraints would protect their baby, 10.7% harm and 34.0% unsure If they felt restraints were beneficial they were more likely to always wear restraints ( 84.4% vs. 64.6%, p<0.0001) Only 21% - 36.9% of women were educated on proper restraint use during pregnancy. Tyroch et al. J Trauma 1999;46:241 Mcgwin et al. J Trauma 2004;56:670
Seatbelt Evidence RisksFetal DeathPlacental Abruption Odds Ratio 95% CIOdds Ratio 95% CI Ejection32.87.5-18.104.22.168-33.5 Restrained0.2300.071-0.742NS Curet MJ et al. J Trauma 2000;49:18
Proper seatbelt use is key Air bag had no effect on force transmission.
What do I do when my pregnant trauma patient codes?
Resuscitation Mom first Most common cause of fetal demise is maternal demise B-HCG on all child bearing age patients
What is the significance of fetomaternal hemorrhage?
Fetomaternal Hemorrhage As little as 5 cc can sensitize Rh-negative women Increased risk of abruptio placentae and predictor of preterm labor – some controversy KB analysis all patients >12 week-gestation Rhogam for all Rh-negative pregnant patients As a rule can give 300mcg of Rhogam for every 30cc of fetal blood detected in maternal circulation Dahmus MA et al. AM J Ob Gyn 1993;169:1054. Goodwin TG et al. Am J Ob Gyn 1990;162:665 Rose PG et al. Am J Ob Gyn 1985;153:844 Dhanraj d et al. Amer J Ob Gyn 2004;190:1461 Pearlman et al. Am J Obstet Gynecol 1990;162:1502-1510 Meunch et al. J Trauma 2004;57:1094-1098
Radiology Perform clinically indicated studies Below 5 rads (50 mGy) exposure no significant risk Shielding of the abdomen provides additional protection by as much as 75%
Radiology Most common fetal malformation caused by high-dose radiation are CNS changes 2-15 weeks gestation At least 20 – 40 rad Slight increase in leukemia Background rate of leukemia in children is about 3.6 per 10,000 Exposure to 1-2 rad increases this rate to 5 per 10,000
US for Trauma in Pregnancy Richards et al. Radiology 2004; 233:463–470 Negative FAST is valuable
US for Abruptio Placentae Glantz et al. J Ultrasound Med 21:837–840, 2002 Specific not sensitive
Xrays to perform? Those that are clinically relevant Radiation Safety Poster From 1947
Trauma in Pregnancy Key Points Remember domestic violence Consider physiologic changes Early monitoring and a minimum of 4 hours Seat belt education Resuscitate the mother Rhogam and KB testing Failed resuscitation consider c-section Use radiologic procedures appropriately Ultrasound has value in trauma evaluation