International Trauma Life Support, 7e Trauma in Pregnancy 19 Key Lecture Points Cover the general information included in the lecture slides, including the information associated with the various trimesters. Note should be made that the status of the fetus generally depends on the well-being of the mother. Therefore, if the mother has adequate blood volume, blood pressure, and circulation, then the fetus will do well. Use the quote: “Death of the fetus in the trauma situation is most often associated with the death of the mother.” Mention that the treatment of shock is the same for pregnant patients as for other patients. Emphasize that the physiologic changes of pregnancy may cause delay in the diagnosis of the shock state in the mother. Stress that uterine obstruction of venous blood flow may cause hypotension in the supine patient (“supine hypotension syndrome”), and thus must be prevented by rolling the patient or backboard to the left. Note that there is an increased rate of fetal demise 2 or 3 days following major trauma to the mother. Mention that short backboard-type device may be ineffective as an SMR device in the pregnant patient because of the difficulty with adequately securing the straps. This concern also applies to the very obese patient.

Trauma in Pregnancy Courtesy of Bonnie U. Gruenberg

Overview Dual goals in managing pregnant trauma Physiological changes of pregnancy Response to hypovolemia Types of injuries most commonly associated Initial assessment and management Trauma prevention in pregnancy

Trauma in Pregnancy Unique challenges Dual roles Vulnerability of pregnant trauma patient Potential injuries to unborn child Dual roles Provide care to mother Provide care to fetus Major goals in caring for the pregnant trauma are evaluation and stabilization. All prehospital interventions directed toward optimizing both fetal and maternal outcome. Optimal care for fetus is appropriate treatment of mother.

Trauma in Pregnancy Leading cause of morbidity and mortality 6–7% of pregnancies experience some trauma 1 in 12 injured experience significant trauma Major causes Motor-vehicle collisions Falls Abuse and domestic violence Penetrating injuries Burns Because minor injuries rarely present problems for EMS providers, ITLS focuses on more severe traumatic injuries to pregnant patient. Leading cause of morbidity and mortality: 6–7% of pregnancies are complicated by accidental trauma. Approximately 8% (1 in 12) of those are significant. MVCs are most common cause (65–70%).

Pregnant Patient Increased risk for trauma Fainting spells, hyperventilation, excess fatigue commonly associated with early pregnancy Balance and coordination affected by changes throughout pregnancy The pregnant patient is often at risk for a higher incidence of accidental trauma. Increase in fainting spells, hyperventilation, and excess fatigue are commonly associated with early pregnancy. Physiological changes that affect balance and coordination.

Fetal Development IMAGE: Figure 19-1 Anatomy of pregnancy. Fetus is formed during first 3 months of pregnancy. The uterus does not enlarge enough to rise out of pelvis until 12th week (3 months), but then fully formed fetus and uterus grow rapidly. Fundal height reaches umbilicus by fifth month and epigastrium by seventh month. Fundus is term for top of uterus. Fundal height is term that describes location of top of uterus.

Viability Assessment NOTE: Table 19-1 Assessment of a pregnancy. Fetus is considered viable at 24 weeks. Viability increases significantly at 25 weeks' gestation. However, pre-term infants have survived with less gestation. True gestational age cannot be determined on- scene.

Physiologic Changes IMAGE: Table 19-2 Physiologic Changes During Pregnancy. During pregnancy, dramatic physiological changes occur. The changes that are unique to pregnant state affect and alter physiological response by both mother and fetus. More fluid is needed to resuscitate if patient develops shock. Increase in both red blood cells and plasma with increase of plasma greater than red blood cells. Appears to be anemic (physiological anemia of pregnancy). Many women with poor nutrition also have an absolute anemia and are less able to compensate for hemorrhagic shock. Always assume stomach of a pregnant patient is full. Always guard against vomiting and aspiration.

Physiologic Changes Respiratory system Diaphragm elevated due to uterine size Decreased thoracic volume Relative alkalosis Predisposed to hyperventilation Respirations are more shallow with less chest expansion. Pregnant patient presents with rapid shallow respiration.

Vital Signs in Pregnancy Do not mistake normal vital signs for signs of shock. Normal pulse: 10–15 beats faster Blood pressure: 10–15 mmHg lower 30–35% blood loss before significant blood pressure change Be alert to all signs of shock Frequent ITLS Ongoing Exams Normal pregnancy vital signs make early diagnosis of shock more difficult.

Response to Hypovolemia Vasoconstriction and tachycardia Reduction of uterine blood flow by 20–30% Fetal heart rate and blood flow decrease Fetus becomes hypoxemic High-flow oxygen is essential Maternal shock has 80% fetal mortality rate Fetus is in distress before maternal blood pressure decreases. When mother compensates for early shock with vasoconstriction and tachycardia, impact on fetus begins. Quick review of shock response: Acute blood loss results in decrease in circulating blood volume. Cardiac output decreases as venous return falls. This hypovolemia causes arterial blood pressure to fall, resulting in an inhibition of vagal tone and release of catecholamines. Effect to produce vasoconstriction and tachycardia. Vasoconstriction profoundly affects uterus. Reduction in uterine blood flow by 20–30%. Mother can lose 1,500 cc without detectable blood pressure change. Drop in fetal arterial blood pressure and decrease in fetal heart rate. Reduced fetal circulation results in fetal hypoxemia. Administer 100% oxygen to mother, and administer oxygen to fetus.

Trauma in Pregnancy ITLS Primary and Secondary Surveys Optimize maternal and fetal outcome High-flow oxygen rapidly administered Fetal hypoxia occurs before maternal hypoxia Fluid administration must be prompt Fluid volume needed is greater Frequent Ongoing Exams Mortality of fetus related to maternal treatment Remember: Normal physiologic changes of pregnancy make assessment more difficult. Changes in appearance and vital signs can be delayed and more subtle. Therefore, Ongoing Exams need to be performed more frequently.

Pregnant Trauma Arrest Treated same as for other victims Defibrillation settings are same Drug dosages are same Fluid volume needed increases 4 liters normal saline rapid infusion during transport If mother unsalvageable: Continue CPR Notify hospital of possible cesarean section Treatment is same as for other patients, except for fluid resuscitation. Fluid resuscitation during transport (same as other patients).

Supine Hypotension Venous return decreases 30% in supine position with 20-week or larger uterus Acute hypotension Syncope Fetal bradycardia IMAGE: Figure 19-3 Compression of vena cava. The enlarging uterus can compress inferior vena cava when mother is in supine position, creating a form of mechanical/obstructive shock. Reduces venous return and cardiac output by up to 30%.

Supine Hypotension Transport position Tilt or rotate backboard 15–30° to patient's left Elevate right hip 4–6 inches (10–15 cm) with towel Manually displace uterus to left Remember: SMR needs to be in an anatomically neutral position specific for each patient to be neutral for spinal cord and airway. Although texts often recommend age ranges (including ITLS), SMR is principle-driven. Appropriate padding should be used for all age groups and situations (elderly, American football shoulder pads, infants, obesity, etc.). If uterus is up to umbilicus, you should tilt backboard using one of these methods. Carefully secure backboard when tilting so patient does not flip over onto floor of ambulance. Courtesy of Louis B. Mallory, MBA, REMT-P

Supine Hypotension Transport position Better stabilized with vacuum backboard More comfortable than standard backboard © Pearson

Evaluation of Uterine Size IMAGE: Table 19-3 ITLS Primary Survey Brief Evaluation of Uterine Size. Fetal heart rate is better auscultated with a Doppler, but can be heard with a standard stethoscope at 20 weeks. Using bell side may improve auscultation.

Fetal Death Relatively minor abdominal trauma can cause fetal death. Maternal death is most common cause of fetal death. Have high suspicion with any abdominal trauma. May not seem significant injury to mother, but can be significant to fetus. Management of maternal injuries is best management of fetus.

Types of Trauma Motor-vehicle collisions Penetrating injuries Domestic violence Falls Burns

Motor-Vehicle Collisions 65–75% of pregnancy-related trauma <1% injured when minor vehicle damage Seatbelts significantly decrease mortality Have not shown any increase in uterine injury Head injury is the most common cause of death in pregnant patients involved in MVCs. This is closely followed by uncontrolled hemorrhage. Courtesy of Louis B. Mallory, MBA, REMT-P

Motor-Vehicle Collisions Maternal death Head injury Most common Uncontrolled hemorrhage Second most common Assess pelvis Fetal injury Fetal distress Fetal death Placental abruption Uterine rupture Preterm labor Maternal pelvic fracture can hold 4 or more liters of blood (uncontrolled hemorrhage) with few clinical signs. Unless there is high-index of suspicion and clear understanding of physiologic changes of pregnancy, seriousness of a pelvic fracture can be overlooked.

Abdominal Trauma Physiologic changes Clinical presentation Decreased sensitivity Gradual stretching Hormonal changes Uterus very vascular Clinical presentation Guarding, rigidity, rebound response absent Abdominal trauma requires ED evaluation IMAGE: Figure 19-5 Picture of placental abruption and uterine rupture. Can have significant occult intrauterine or abdominal bleeding. May not have abdominal tenderness early, even with significant bleeding. Emergency Department evaluation and monitoring is recommended for even minor abdominal trauma during pregnancy.

Penetrating Injuries Gunshot wounds and stabbings Entry below fundus Uterus absorbs force, protects maternal organs High fetal mortality rate: 40–70% Lower maternal mortality rate: 4–10% Entry above fundus Bowel injury due to displacement Gunshot wounds and stabbings are most common injuries encountered. Definitive care will depend on several factors, involving degree of shock, associated organ injury, and time of gestation.

Domestic Violence 10% experience abuse during pregnancy Proximal and midline injuries Face and neck most common Low birth weight Abused by spouse or boyfriend: 70–85% (U.S.) Large percentage of pregnant women experience domestic violence. Frequency appears to worsen as pregnancy progresses. Through second and third trimesters, estimated that 1 in 10 pregnant women experience abuse during pregnancy.

Falls Injury from falls Increase with progression of pregnancy Center of gravity altered Proportionate to force and body part impacted Pelvic injuries Placental separation Fetal fractures Emergency Department evaluation and monitoring is recommended for even minor abdominal trauma.

Burns Fluid volume needed increases Mortality and morbidity Maternal mortality same as non-pregnant Fetal mortality increases with >20% BSA Of 2.2 million patients who suffer burn injuries in United States annually, less than 4% are pregnant. Fluid requirement for pregnant patient is greater than that of nonpregnant. BSA – Burn Surface Area.

Trauma Prevention Proper seat-belt use Report domestic violence Counseling for domestic violence Patient education Multiple changes associated with pregnancy Physiological, anatomical, emotional Some patients get very little, if any, prenatal care, and even less prenatal education. If situation is not critical, you should not hesitate to educate your pregnant patients.

Summary Trauma in pregnancy Fetal care depends on maternal care Knowledge of physiological changes Hypotension and hemorrhage easily overlooked Rapid evaluation and interventions to stabilize Aggressive oxygen administration Aggressive fluid resuscitation Prevent supine hypotension Fetal care depends on maternal care Due to difficulty in early diagnosis, you should have a low threshold for load-and-go. Pregnant trauma with serious injuries should be directly transported to facility (trauma center) capable of managing these complex patients.