1. Dr. Joe Haegert RCH and ERH SPH Conference 2013
Obstetrical Trauma
Dr. Joe Haegert
RCH and ERH
SPH Conference 2013

2. Main message
Two patients
Focus mainly on resuscitating mother

3. Overview Physiologic differences Anatomic differences
Pregnancy Specific Issues:
Abruptio Placenta
PROM
Ruptured Uterus
Supine Hypotensive Syndrome
Rh negative mothers and KB testing
Imaging in pregnancy
Management algorithms
Mother stable, Fetus stable
Mother stable, Fetus unstable
Mother unstable, Fetus unstable
Perimortem C section

4. Case 1 22 yr old female shot in head and chest 32 weeks pregnant
GCS 3, BP 70/P, P 100
Fetal heart rate of 50

5. Case 2 32 year old female 34 weeks pregnant MVA head on
GCS 14, P 110, BP 80/P
Severe chest trauma
Bilateral femur #
Fetal heart rate 170

6. Case 3 39 weeks pregnant T bone MVA 20 inches intrusion
Airbags deployed
Stable vitals, GCS 15, mild chest pain and neck pain, no abdominal pain
Cspine and CxR and FAST normal
FHR 140

7. Intro
Trauma is leading cause of nonobstetrical death in pregnancy (mvas, falls, assault)
7% of pregnancies will have trauma
8% of female trauma admits of child bearing age do not know that they are pregnant
Severity of maternal injuries is a poor predictor of fetal distress and outcome
Trauma in pregnancy is associated with increased risk of: preterm labor abruptio placentae fetomaternal hemorrhage
- fetal death

8. Incidence of trauma increases with gestational age
Most maternal deathes are due to HI or hemorrage

10. Cause of fetal death
With severe maternal trauma the baby dies because of maternal death or maternal hemorrhagic shock
With mild maternal trauma the baby dies because of abruption

11. Physiologic Differences
Hypoxia decreases uterine flow
Lower FRC and increased metabolic rate increased risk of hypoxia
O2 therapy on all
lower threshold for intubation
Acidosis decreases uterine flow
Normal PC02 runs 30-35
No role for permissive hypercapnia
Set vent rate faster than normal
Decreased lower esophageal sphincter pressure and increased gastric acidity
Regard all intubations as high risk for aspiration
Increased airway edema and secretions
Have smaller ETT ready
Increased thrombogenesis
DVT prophylaxis for admitted trauma patients

12. Physiologic Differences
Hypervolemia with dilutional anemia (40% increased BV)
Compensated (i.e. unrecognized) shock more common
Shock (including compensated shock) causes uterine artery constriction
Volume resuscitate aggressively
BP lower in 2nd trimester, higher in 3rd trimester
Diagnosis of shock a bit more tricky
Uterus has increased blood flow (entire blood volume in 10 minutes)
Abruptio placentae and Uterine rupture can bleed massively
Pelvis has increased blood flow
Increased risk of massive pelvic hemorrhage
Increased venous pressure in legs
Increased bleeding from leg injuries
Vasopressors constrict the uterine artery
Avoid vasopressors

13. Anatomical Differences
Large uterus: 12 weeks at symphysis weeks at umbilicus weeks at xiphoid process
pelvis not protective after 12 weeks
femoral line not the best option
supine hypotensive syndrome after 20 weeks
Compression of upper abdominal viscera
stab abdomen may hit many structures
Widened symphysis pubis
be aware that this may be normal….not open book #
Higher diaphragm
Heart displaced up and to left
place chest tube 2 interspaces higher
There is a baby!
initiate fetal monitoring early
baby can be injured

14. Supine hypotensive syndrome
> 20 weeks gest.
Can decrease venous return up to 45%
Systolic BP can drop by as much as 30mm
Place wedge under right hip displacing uterus to the left (left lat tilt position)

16. Amniotic Fluid leakage (PROM)
Vaginal exam on all major pregnant trauma
PH greater or equal to 7 suggests amniotic fluid
Ferning also suggestive of amniotic fluid
Oligohydramnios on ultrasound
Increasing risk with gestational age and trauma severity

17. Imaging in pregnancy Image as if patient nonpregnant
Highest risk of radiation induced fetal injury in first 2 weeks
Concerns are death, congenital malformation, teratogenesis, carcinogenesis, mental retardation
Over 200ms may cause fetal damage, still unclear the long term cancer risk
Ultrasound and MRI are safe in pregnancy

18. Radiation risk Background………………….. 3mSv/yr 10 hr flight………………… 0.03mSv
CxR………………………….0.01mSv
CT head………………………. 2 mSv
CT neck………………………..4mSv
CT chest……………………….4mSv
CT abdomen/pelvis.……….. 7 mSv
Pan CT………………………...17mSv
So none of these is close to the dangerous 200mSv

19. So what is my approach to blunt abd trauma in pregnancy?
Unstable and positive FAST or peritonitis………………………….OR
Stable and positive FAST………..CT
Stable and negative FAST………..US + Observ

20. Obstetrical complications of trauma
Fetomaternal hemorrhage
Abruption
Preterm labour
Fetal Injury
Uterine rupture
Amniotic fluid embolism

21. Kleihauer Beikte test Calculates degree of feto maternal transfusion
Uses: 1) Rh negative mother
2) To access degree of fetomaternal
transfusion

23. RHIG and Tetanus
RHIG 300ug….will protect up to 30ml fetomaternal hemorrhage
Dose guided by KB test
Have up to 72 hours to give it
Give RHIG to all Rh neg mothers even if negative KB test
Dose is 50ug in first trimester (or 300ug )
Tetanus and TIG are NOT contraindicated in pregnancy

24. Placental Abruption Can be occult
Triad: pain, hardness of uterus, vag bleeding
70% of fetal loss comes from placental abruption
Is a clinical diagnosis….ultrasound not sensitive
Coagulopathy rare

26. Risk of abruption Usually happens within 4-6 hours
Risk: minor trauma 1.6% (but minor trauma is common) major trauma 37.5%

27. Fetal Injury Abruption is commonest cause of death
Maternal shock is next
Direct fetal injury less common
- pelvic # 9% maternal death rate, 40% fetal
death rate
- penetrating uterine trauma: fetal injury
60-90%(gsw worse than stab), fetal mortality 40-70%

28. Traumatic Uterine Rupture
Usually presents with shock and hemoperitoneum
Consider in setting of free fluid and high riding dead baby
Commonest is a fundal tear
Maternal mortality 10%
Fetal mortality 100%

29. Preterm Labour Abruption Fetomaternal hemorrhage Rupture of membranes
Fetal distress
Maternal Shock
Abnormal Fetal monitoring

31. Dating At 20 weeks uterus at umbilicus. At 24 weeks = umbilicus + 4 cm
At 36 weeks at xiphoid process
Symphysis to fundus in cm = # weeks
So key # is SFH>24 or
umbilicus to fundus of >4
Ultrasound: BPD, OFD, FL, HL, HC, AC

33. Fetal Monitoring
Recommended that all trauma patients > 24 weeks be monitored for 4-6 hours
If normal monitoring for 4 hours this is >90% predictive of positive fetal outcome
If patient is critical (i.e. in ICU) then continuous monitoring is indicated
Start monitoring on arrival to ED if patient badly injured /major mechanism

34. Fetal Monitoring: abnormal
Fetal heart rate outside normal range of
Greater than 3 contractions per hour
Lack of beat to beat variablity
Fetal decelerations with contractions
Indications for prolonged FM
- abnormal 4 hour FM
- uterine pain persists
- vaginal bleeding or amniotic fluid leakage
-mother unstable

35. Clinical scenarios > 24 weeks
Mother stable, Baby stable
Mother stable, Baby unstable
Mother unstable, Baby unstable
Perimortem C section

36. Mother stable, Fetus stable
1-3% of minor trauma leads to fetal death
For patients less than 24 weeks….no FM
For patients > 24 weeks…CFM for 4 hours with OB consult
Discharge criteria and advice

37. Mother stable, Fetus unstable
Less than 24 weeks….no C section
Greater than 24 weeks….C section….exact # weeks is site dependent
Obviously this is a OB decision and likely not and EP’s decision

38. Mother Unstable, Fetus Unstable
First priority is the mother
If despite good resuscitation there is fetal distress…AND… patient over 24 weeks…AND it is thought that the CS will not make the mother clinically deteriorate…consider CS
If fetus has no FHR there is no indication for emergency CS

39. Perimortem C section Indications - over 24 weeks gestation
- intact fetal heart rate on ultrasound
- maternal pulselessness or
- fetal distress in a mother with injuries that are likely to be fatal (i.e. severe head injury,)

40. Perimortem C section Procedure Incision from xiphoid to pubis
Longitudinal uterine incision
Get baby out (5 min rule…from time of maternal arrest)
Clamp cord
Give baby to infant resus. team

41. Prevention Seat belts: - Air bags: Screen for domestic violence
Educate re: increase risk of falls in 3rd trimester

42. Summary of treatment differences
Early oxygen
Intubate early
Early fetal monitoring
Place on left lat tilt position over 20 weeks
Call Ob early

43. Summary of treatment differences
Beware compensated shock can cause fetal distress
Avoid pressors
Avoid acidosis
Chest tubes higher
Neck or subclavian lines best

44. Summary of treatment differences
Don’t forget about KB test and RHIG
Do not withhold CT if it is indicated
Perimortem C section…know when to pull the trigger….and how to do it
If baby viable and minor trauma.. do 4 h fetal monitoring

45. Main take home message 2 patients Focus on resuscitating the mother
Best chance of baby doing well is the mother doing well

46. Case 1
22 year old female, 32 weeks pregnant, shot in head and chest with fetal P 50
Perimortem C section

47. Case 2
32 yr old female, 34 weeks with chest trauma, bilateral femur fractures and hypotension
Resuscitate the mother!!

48. Case 3
39 week pregnant female with moderate vehicle damage, but clinically stable
Needs 4 hour FM and then discharge if OK