EMCrit.org
Trauma
in Pregnancy
In the 2nd trimester, normal Bicarb is 18-20
Place chest tubes higher than in non-preg
Normal HR 90-95
Sys/Dia decreased by 10-15
Can lose 2 L of blood s any signs
HCT 32-34%
WBC can range from 5-18000 at baseline,
but function of WBCs is decreased
Hypercoaguable state
Kleihaeur-Beiker (KB) staining to establish and estimate
fetal to maternal bleeding. Need rhogam 50
mcg if <12 weeks
300 mcg if >12 weeks
KB testing is not necessary for anything but major
trauma. If there is major trauma, don’t
need rhogam for 72 hours so let the admission team worry about it.
Fundus at umbilicus at 20 weeks, 24 weeks is a viable fetus
Watch for 4 hours, if stable, can DC.
Chest tube should be 1-2 ICS higher
Perimortem C-Section:
Cut from epigastrum to pubis, then open peritoneum. You have 4 minutes from loss of pulse.
PREGNANCY PROBLEMS
| TRUAMA IN PREGNANCY — Francis L. Counselman, MD, Eastern
Virginia Medical School Distinguished Professor of Emergency Medicine, and
Chairman/Program Director, Department of Emergency Medicine, Eastern
Virginia Medical School, Norfolk, Virginia |
| Incidence: 6% to 7%; “at no other time in a woman’s
adult life is she more at risk for trauma than the third trimester of
pregnancy” |
 |
Motor vehicle accidents: number one cause of
trauma during pregnancy; incidence distributed equally throughout pregnancy
|
|
Falls: second most common cause of trauma
during pregnancy; most occur during 20 to 30 wk gestation; patients have
altered center of gravity, respiratory alkalosis (causing lightheadedness
and dizziness), and laxity of pelvic ligaments, predisposing them to falls
|
|
Domestic abuse: third leading cause of trauma
during pregnancy; tends to be associated with significant fetal injury
because trauma almost always directed toward abdomen and uterus |
|
Trauma: leading cause of nonobstetric death in
women and leading cause of death in women of childbearing age; maternal
survival leading predictor of fetal survival |
| Normal changes during pregnancy: all systems involved;
cardiac output increases by almost 40% by 10 wk gestation and remains
elevated until term; heart rate increases 10 to 15 beats/min by term (80-95
beats/min normal during pregnancy); systemic vascular resistance decreases;
widened pulse pressure (due to larger drop in diastolic than in systolic
blood pressure), low blood pressure |
|
Supine hypotensive syndrome: gravid uterus
resting on inferior vena cava decreases venous return, can decrease cardiac
output by up to 30%; placing patient in left lateral decubitus position
increases blood pressure; if changing patient’s position contraindicated,
manually displace uterus to left |
|
Blood volume: increases by 50% by 28 wk
gestation; red blood cell mass increases 18% to 30%, resulting in dilutional
physiologic anemia of pregnancy (obtaining previous medical records
helpful); hemoglobin and hematocrit (H&H) lowest at 30 to 34 wk; pregnant
women can lose 10% to 20% of blood volume acutely without change in vital
signs, 33% if blood loss gradual (fetus probably will not survive; increased
blood volume needed to feed fetus) |
|
Leukocytosis of pregnancy: hormonally
mediated; average white blood cell count 12,000 to 18,000/mm3
(almost all polymorphonuclear leukocytes, making it difficult
to assess infection), reaching up to 25,000/mm3
during labor |
|
Hypercoagulable state: prevents or decreases
effects of maternal hemorrhage; predisposes patients to thromboembolic
disease (highest risk in third trimester and first month postpartum);
prothrombin time (PT) and partial thromboplastin time (PTT) shortened;
fibrinogen almost doubles (normal reading probably early indicator of
disseminated intravascular coagulation [DIC]) |
|
Pulmonary changes: minute ventilation
increases up to 40%; normal PCO
2 of woman in third trimester approximately 30 mm Hg (bagging
patient to 40 mm Hg will cause fetal and maternal acidosis and fetal
distress) |
|
Diaphragm: abdominal contents pushed cephalad;
decreased functional residual capacity; chest tube should be placed 1 to 2
intercostal spaces higher than usual; diaphragm can rise as much as 4 cm;
bowel motility and gastric emptying decreased (general relaxation of gut);
decreased lower esophageal sphincter pressure (effect of progesterone;
causes reflux); increased gastric acid production; empty stomach using
nasogastric (NG) tube to decrease risk for aspiration; alkaline phosphatase
markedly increased (placental origin); uterus largest intra-abdominal organ
by third trimester (not problem in blunt trauma but significant injuries
possible with penetrating trauma); due to stretched peritoneum and abdominal
muscles, patients often show minimum signs of peritoneal irritation despite
as much as liter of blood in abdomen |
|
Genitourinary system: uterus can increase to
1200 g by third trimester (normally 60-80 g); blood flow increases from 60
mL/min to 600 mL/min (every 10 min, entire circulating blood volume of
mother goes through uterus; patient can exsanguinate in approximately 10
min); always admit pregnant patients with pyelonephritis because natural
hydroureter and hydronephrosis increase risk of seeding blood stream;
glomerular filtration rate increases by 50%, blood urea nitrogen (BUN) and
creatinine drop by approximately 50%; in pregnant trauma victim, borderline
or high creatinine indicates significant renal injury until proven otherwise
|
| History: last menstrual period (always obtain pregnancy
test on every woman of childbearing age in trauma); estimate length of
pregnancy; if fetus not viable, direct all resuscitative measures to mother;
if fetus viable, must alter treatment; patients with history of cesarean
delivery at increased risk for uterine rupture |
| Physical examination: estimate fundal height (if
greater than or equal to 2 finger breadths above umbilicus, fetus probably
viable); look for uterine tenderness, uterine contour, and contractions
(signs of abruption or uterine rupture); check for fetal heart rate by
stethoscope (by 18-20 wk), Doppler imaging (10-14 wk), or transabdominal or
transvaginal ultrasonography (6-7 wk); normal fetal heart rate 120 to 160
beats/min (if outside this range, fetal distress until proven otherwise);
fetal hemodynamics most sensitive indicator of maternal hemodynamics |
| Pelvic examination: contraindicated in patients in
third trimester with vaginal bleeding; if no contraindications, perform
sterile speculum examination looking for perineal and vaginal lacerations
and urethral injury; examine vagina for open os, light urethral dilation,
crowning; measure pH (alkaline pH suggests ruptured membranes; ferning in
fluid sample from posterior fornix more specific for amniotic fluid) |
| Blood: obtain blood type and screen on all pregnant
patients beyond 12 wk gestation; complete blood count (CBC) and H&H low |
| Kleihauer-Betke test: no longer recommended for all
pregnant trauma patients; identifies presence and estimates gross amount of
fetal red blood cells in maternal circulation (no relation to severity of
injury); obtain only on Rh-negative mothers to quantify how much RhoGAM (RhO
[D] immune globulin) to give; 300 µg of RhoGAM protects mother
from 30 mL of fetal-maternal hemorrhage; Kleihauer-Betke test can help
determine whether more RhoGAM needed) |
| Coagulopathy studies: if mother has significant trauma,
draw baseline blood sample to determine whether she is going into DIC (clue
to abruption) |
| Imaging studies: “if the woman was not
pregnant and she needed the x-rays, get the x-rays”; “the risk of missing
the injury is much, much greater than any risk of radiation exposure to the
fetus”; no significant risk of increased teratogenic effect if fetus exposed
to <10 rads, significant risk if exposed to >15 rads; fetus most vulnerable
in weeks 2 to 7; unlikely x-rays cause harm to fetus at >20 wk gestation;
shield pelvis and limit number of views if possible (eg, to clear
C-spine, use only lateral, anteroposterior, and odontoid views, omit oblique
view); routine pelvic films no longer indicated in trauma patients |
|
Ultrasonography: key to evaluation; determine
fetal heart rate (good indicator of how fetus and mother are doing);
determine fetal age; only 50% sensitive for detecting abruption |
|
Abdominal ultrasonography: perform focused
assessment with sonography for trauma (FAST) examination; should not have
fluid in cul de sac or between liver and peritoneum; if FAST examination
positive and patient hemodynamically unstable, send patient to operating
room (OR); if FAST positive and patient stable, send patient for computed
tomography (CT); if FAST negative, observe or scan again in 30 min |
|
Cranial CT: be sure to shield fetus |
|
CT of abdomen and pelvis: causes more
radiation exposure; reduce radiation by performing 3-cm cuts instead of 1-cm
cuts (some sensitivity lost but not enough to significantly alter
interpretation of examination); can see uterine rupture and abruption; not
good for detecting fetal injury |
|
Angiography: performed for therapeutic as well
as diagnostic reasons; contrast not contraindicated in pregnancy |
|
Diagnostic peritoneal lavage (DPL): indicated
only when CT and ultrasonography not available; use supraumbilical open
approach; does not detect retroperitoneal injuries |
|
Fetal monitoring: if fetus <23 wk, check fetal
heart rate intermittently for distress; if fetus >23 wk, use continuous
cardiotocographic monitoring |
|
Cardiotocographic monitoring: measures fetal
heart rate and uterine contractions; best test for abruption (100%
sensitive); have low threshold for performing this test (reassures mother);
if no uterine contractions in 2 hr, can send patient home safely; if even
one contraction, monitor for another 2 hr |
| Management: administer high-flow 100% O2
(benefits fetus; fetus has O2
-hemoglobin dissociation curve different from that of mother); if
fetus >20 wk gestation, place mother in left lateral decubitus position if
not contraindicated; if contraindications present, displace uterus to left;
no role for military antishock trousers (MAST; inappropriate and may be
harmful); cardiac monitor for mother, intermittent monitoring for fetus if
<23 wk and cardiotocographic monitoring if >23 wk |
|
Fluids: 2 large-bore intravenous (IV) lines
(use upper extremities if possible); restoring circulating volume initial
goal; Ringer’s lactate preferred over normal saline; give blood transfusion
early (fetus will die if physician waits for signs of shock) |
|
NG tube: empty stomach; pregnant patients at
increased risk for aspiration |
|
Vaccinations: tetanus toxoid and tetanus
immune globulin safe in pregnancy; indicated if vaccinations not up-to-date
|
|
Medications: RhoGAM for Rh-negative mothers
(give if >12 wk gestation); safe to give penicillin, Timentin (ticarcillin
and clavulanate), Augmentin (amoxicillin and potassium clavulanate),
cephalosporins, erythromycin, clindamycin, nitrofurantoin; stay away from
tetracyclines (can cause teeth and bone problems in fetus, maternal
toxicity), fluoroquinolones (can cause cartilage problems and arthropathy in
fetus), sulfa agents (in third trimester; cause kernicterus), trimethoprim (folate
inhibitor), chloramphenicol; Tylenol (acetaminophen) safe; make sure patient
not taking aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs; can
cause premature closure of ductus arteriosus); narcotics safe in pregnancy,
but avoid codeine in first trimester (associated with increased incidence of
cleft palate); can give Demerol (meperidine) or morphine |
| Abruption: 1% to 5% incidence in minor trauma, 20% to
50% in major trauma; second leading cause of death in fetuses (death of
mother most common cause); patients classically present with vaginal
bleeding and abdominal pain; not all have classic presentation (bleeding may
be hidden behind placenta; pain may be minimal or patient may have
distracting injuries); consider abruption if mother has hypotension and no
apparent sign of blood loss (uterus can hold 2 L of blood), fundal height
much higher than expected for dates, or uterus expanding; cardiotocographic
monitoring best test; increasing use of D-dimer test to detect early DIC;
fetus with <25% separation has good chance of doing well with conservative
management; fetus with >50% separation unlikely to survive unless delivered
immediately; obstetric specialist must make decision on what to do with
abruptions of 25% to 50%; do not let absence of vaginal bleeding prevent
diagnosis of abruption |
| Uterine rupture: rare (incidence <1%); usually occurs
in late pregnancy; patients almost always have had previous uterine surgery
(cesarean delivery most common); patients typically have had multiple
gestations; polyhydramnios and abdominal pain also risk factors for rupture;
signs include loss of normal uterine contour, palpable fetal parts, vaginal
bleeding, fetal distress |
| Traumatic cardiac arrest: if fetus <23 wk gestation, do
not worry about patient being pregnant (direct all resuscitative measures
toward mother); if fetus >23 wk gestation, obtain obstetric consult and
consider early resuscitative thoracotomy; do not cross-clamp aorta |