Two for One: Caring for the Pregnant Trauma Patient Nabil Alzadjali FRCP III McGill University

 CASE 1 25 Yrs F, 35 wks Preg. PC : MVC PMH : nil, Rh +ve, HPI : Driver, belted, rear ended by another car, air bag deployed Complaining of occasional abdominal pain, ?cramping. Unsure about fetal movements. Very concerned regarding fetal well being. ABC stable. BP 120/70 HR 88 RR 15 No signs of injuries on exam. FHR 140, No uterine contractions palpable. No guarding. No lap belt sign. No PV bleeding. Os Closed  How do we manage this patient?

 CASE 2 20 Yrs F, 30 weeks gestation Struck by truck across the street from hospital. Cardiac arrest at scene. U/G Technician have intubated and started CPR. Down time about 5 minutes. Arrival in ER, Pulseless Electrical Activity.  How do we manage this patient?

 Incidence  Physiological Alterations  Anatomical Alterations  Unique Problems in the Gravid Abdomen  Prehospital Considerations  Diagnostic Studies  Management of trauma  Unstable Mother  Stable Mother  Perimortem Cesarean Section

Incidence  The Leading cause of non-obst. mortality - 46%  Trauma during pregnancy - 7%  Causes of Trauma (1)  MVA 54.6 %  Domestic abuse & Assault 22.3 %  Falls21.8 %  Penetrating inj.1.3 %  < 1% of trauma admissions are pregnant  Preterm Labor in 11.4 % & P. Abruption in 1.58 % (1) Connolly A, Katz VL, Bash KL, et al: Trauma and pregnancy. Am J Perinatol 14: , 1997

Physiological Changes During Pregnancy

Hemodynamic Changes of Pregnancy (Mean Values) Non P.Trim. 1Trim. 2Trim. 3 HR Sys. BP Dias. BP C. Output CVP Bld V (ml) Hct with Fe (%) WBC (cell/mm 3 )

Supine Hypotensive Syndrome (1) (1) Milson I, Forssman L: Factors influencing aortocaval compressionin late pregnancy, Am J Obtst Gynecol 148: , 1984

 Respiratory  Respiratory alkalosis  Reduce oxygen reserve (reduced FRC 20% & increased O2 consumption by 15 %)  Residual volume decreased by 40%  Respiratory rate increased  Impaired buffering capacity

 GI  Intestine are concentrated in upper abdomen  Decrease GI motility  Decrease peritoneal irritation  GU  Bladder is displaced upward >10 wks  Dilitation of renal pelvis and ureters

Alterations in Anatomy  1st trimester uterus is thick walled and intra- pelvic  Out of pelvis > 12 wks.  Second trimester uterus contains large amount of amniotic fluid  Third trimester uterus is thin walled, large Fetal head engaging pelvis  At 36 weeks uterus reaches costal margin

Injuries unique to pregnancy  Premature Contractions  Rarely progress to preterm delivery  Tocolysis is not proven in trauma. (1)  Abruptio Placentae  Different elastic properties in uterus & placenta “shearing”  3 % of minor trauma and upto 50 % in severe trauma (1) GoodwinTM, Breen MT: Pregnancy outcome and fetomaternal hemorrhage after noncatastrophic trauma, Am J Obstet Gynecol162: , 1990.

 Uterine Rupture  Rare, 0.6 % of severe abdominal trauma (1)  Direct trauma after 12 wks of gestation  Prior Surgery (C/S or Myomec.) the risk  Maternal-Fetal Hemorrhage  Trimesters 1 3%, T2 12%, T3 45%  4-5 X more common in injured pregnant women  Causes isoimmunization & fetal death  Kleihauer-Betke test - volume of fetal blood  cc sensitize, 5 cc +ve KB Test.  To determine amount of Rhogam needed 1. Pearlman MD, Tintinalli JE, Lorenz RP: Blunt trauma during pregnancy, N Engl J Med 323:1609, 1990

Special Considerations  Blunt Abdominal Trauma  Penetrating Abdominal Trauma  Stabbing injury  Gunshot injury

Blunt Trauma  Injuries  Head injury most common  Retroperitoneal hemorrhage  Abruptio placenta  DIC  Uterine Rupture  Seatbelts – 3 Points Restraints  1/3 – ½ improperly or don’t use belts  Unbelted is at 2.3X to give birth <48 hrs & 4.1X fetal death

Penetrating Injury GSW’s  Gravid uterus alter injury pattern to the mother.  If missile enter upper abdomen; increased probability of harm (upto 100%).  If enters below uterine fundus visceral injury less likely (0%)  Awwad et al (1)  Fetal death rate is 67%  38 % for injuries above the uterus. (1) Awwad JT et al: High-velocity penetrating wounds of the gravid uterus: Review of 16 years of civil war, Obstet Gynecol 83:259, 1994.

 Stabbing Injury  Rare rare, only 19 cases reported in literature  Morbidity 93 % - Mortality 50 %  Many advocate exploratory laprotomy since uterus laceration is devastating b/c of its enlarged circulation.  Meizner et al (1)  An injury to uterus can rapidly change to a hypotensive emergency.  It is difficult to know the size and depth of uterine rupture (1) Meizner I, Potashnik G: Sharpnel penetration in pregnanc resulting in fetal death, Isr J Med Sci 24:431, 1988.

Pre-hospital Consideration  Oxygen  Shock should be anticipated  ED should be notified early, GA >24 wks  Transport in L lateral position (GA > 20 wks) National Association of EM Physician, 1997 “PASG – class III intervention” worsen the supine hypotension

Diagnostic Studies

Modalities for Evaluating Trauma  Plain Films – X-rays  Ultrasound  CT & MRI  Cardiotocographic Monitoring  DPL  Laparotomy

Plain Films  Risk of 1 rad to fetus is approx  < 5-10 rads causes  No risk on congenital malformation, abortions or intra-uterine growth ret.  Smaller risk of increase in childhood cancer  Radiation doses > 10 rads  6 % chance of severe mental ret.  < 3 % chance childhood cancer.

Radiographic examination Dose to Ovary/Uterus-mrad Low Dose Group: Head C-Spine Thoracic Spine Chest Extremities <1 High Dose Group: Lumbar Spine Pelvic Hip Intravenous pyelogram Urethrocystogram KUB 204 – – – – – 503 Rosenstein M:Handbook of selected organ doses for projections common in diagnostic radiology. HEW publication(FDA) Rockville, MD. US Dept. Of Health And Human Services, Centre For Devices And Radiologic Health, 1988.

Ultrasound  Best modality to assess both fetus and mother  Not sensitive:  Colonic lesions  Biliary tree lesions  Sub-placental hematoma  Safe procedure

CAT SCAN  Complementary to U/S & DPL  Penetrating wounds of flank & back  Can miss diaphragmatic and bowel injuries  Portability  Spiral CT reduces radiation exposure by %

Radiographic examinationDose (mrad) Computed Tomography Head (1 cm slice) Chest (1 cm slice) Upper Abdomen (20 slices 2.5 cm above uterus) Lower Abdomen (10 1 cm slices over the uterus/fetus) < 50 < 1000 < – 9000 Angiography Cerebral Cardiac Catheterization Aortography < 100 < 500 < 100 Rosenstein M:Handbook of selected organ doses for projections common in diagnostic radiology. HEW publication(FDA) Rockville MD,. US Dept. Of Health And Human Services, Centre For Devices And Radiologic Health, 1988.

Cardiotocographic Monitoring  FHR  Rate ( )  Beat-to-beat variability  Baseline variability  Decelerations, esp. late

Cardiotocographic Monitoring Variability:

Cardiotocographic Monitoring Decelerations: Early and Late

Cardiotocographic Monitoring Decelerations: Variable

Diagnostic Peritoneal Lavage  CT & U/S are better in stable patient.  Hypotensive unstable pt and if bedside U/S is not available  Can be performed in any trimester  Gravid uterus does not reduce the accuracy of DPL for OR  Limited in detecting bowel perforation and does not assess retroperitoneal hemorrhage or intra- uterine pathology

Diagnostic Peritoneal Lavage  Rothenberger et al (1)  n=12 (4 Supra umbilical & 8 infra umbilical)  Sensitivity 100 % (8 internal bleeding confirmed by lapratomy),  Specificity 100 % ( 4 no bleeding)  No Complications from the procedure  Esposito et al (2)  n=40, 13 had DPL  PPV = 100 % (1)Rothenberger DA, et al:Diagnostic peritoneal lavage for blunt trauma in pregnant women, Am J Obstet Gyneco 129:479-48,1977. (2)Eposito TJ, et al: Evaluation of blunt abdominal trauma occurring during pregnancy, J Trauma 29: , 1989.

Management  Avoid distractions and avoid focus on the fetus  Be aggressive! But temper with common sense.  An apparently stable mother may be compensating at expense of the fetus  If < 24 weeks, intermittent fetal doppler  If > 24 weeks, then continuous cardiotocographic monitoring to assess FHR and uterine activity

I. Initial maternal Resuscitation Airway Assess & control Preoxygenate and sellick’s maneuver is important before intubation Breathing Assess and manage Place CT in 4 th intercostal space Circulation Assess maternal circulation IV access Telt to left if > 20 wks

Management  The hemodynamically unstable mother  The hemodynamically stable mother

II. The hemodynamically unstable mother

Fetal Viability Weeks gestation 6-month survival (%) Survival with no severe abnormalities (%) Data from Morris JA Jr et al: Ann Surg 223:481, 1996.

III. The hemodynamically stable mother Stable fetus  Minor trauma does not exclude significant fetal injury; 1-3 % of all minor trauma results in fetal loss from placenta abruption. (1)  Asymptomatic mother or with no obvious abdominal injury needs monitoring for feto- placental pathology (1) Pearlman MD, Philip ME: Safety belt use during pregnancy, obstet Gynecol 88: 1026, 1996

1. Pearlman MD, Tintinalli JE, Lorenz RP: Blunt trauma during pregnancy, N Engl J Med 323:1609, 1990 Pearlman et al (1)  Minimum 4 hrs CTG monitoring  Extended to 24 hrs if :. >3 contractions per hour. Persistent uterine tenderness. Non reassuring fetal monitor strip. Vaginal bleeding. ROM. Serious maternal injury present  All placental abruption were detected within 4 hrs  70 % of pt required admission.  All discharged home subsequently had live birth.

III. The hemodynamically stable mother Unstable fetus  Fetal death rates are 3-9 times higher than mat.  No infant survive if there is no fetal heart tone before C/S  Morris et al (1)  Heart tone is best survival marker for f. to undergo C/S  If fetal heart tone is present and the GA is > 26 wks the survival is 75%  60 % of fetal death occurs with under use of CTG and delay recognition of fetal distress.

Perimortem Cesarean Section  ~200 successful cases reported in the literature  Maternal CPR <5 minutes, fetal survival excellent  <23 weeks gestation survival chance is 0%  Maternal CPR >20 minutes, fetal survival unlikely

Fetal Viability Weeks gestation 6-month survival (%) Survival with no severe abnormalities (%) Data from Morris JA Jr et al: Ann Surg 223:481, 1996.

Perimortem Cesarean Section  4 Minute Rule: Maternal CPR for 4 minutes, Infant should be delivered by the 5 th minute.

Perimortem Cesarean Section  Technique:  Make sure it is indicated first and that resuscitative team is ready  Vertical incision from xyphoid to pubis  Continue straight down through abdominal wall and peritoneum  Cut through uterus and placenta (if anterior)  Bluntly open uterus and remove fetus  Cut and clamp cord

Summary  Anatomic and physiologic changes  Vigorous fluid and blood replacement  Treat the mother first and treat her just like any other trauma patient  High index of suspicion for blunt or penetrating uterine trauma & abruptio placenta.  Consider perimortem C/S in unstable women or cardiac arrest with viable fetus after 24 wks.

When to Intervene and Consult EARLY !

What is Best for the Mother is Best for the Fetus! Remember

Questions ?