Trauma in pregnancy and the ED delivery

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Trauma in pregnancy and the ED delivery

• Rebecca Burton-MacLeod
• Oct 30, 2003

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Background

• Trauma in 6-7 of pregnancies
• accounts for nearly half deaths in pregnancy
  (46.3)
• most commonly due to MVC (gt50), assault, fall

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10 physiological changes.that exam question!

• Dec BP first trimester (dec sys 2-4mmHg, dec dias
  5-15mmHg)
• inc HR (by 10-15bpm)
• CVP 4cm (instead of 7.5cm)
• blood volume inc 48-58
• CO inc 40
• inc clotting factors
• FRC dec by 20
• oxygen consumption inc by 15
• dec gastric motility
• inc gastric acid production

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10 anatomical changes.that other question!

• diaphragm rises 4cm with rib flaring resulting
• inc size uterus
• bladder displaced upwards
• bowel displaced and modified peritoneal
  irritation signs
• sympheseal distraction (7.7-7.9cm)
• ureteral dilation
• dec gastroesophageal sphincter response
• supine hypotensive syndrome
• blood flow to uterus inc 10x
• inc peripheral venous pressure

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Case

• 28 y.o. female G1P0 30wks GA. MVC. Unconscious
  when arrives in ED. Sats 88. Decreased A/E right
  side
• Airway/breathing managementwhat considerations
  in pregnant patient?

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Airway/Breathing

• Oxygen promptly (dec oxygen reserve, inc
  consumption)
• RSI (high risk of aspiration)
• adjust mechanical respirators (inc TV)
• Chest tube insertion 1-2 IC spaces above normal
  (raised diaphragm)

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Case contd

• Circulation issues in pregnancy?
• High index of suspicion for shock (inc blood
  volume, but uterine blood flow compromised first)
• avoid vasopressors, if possible (dec uterine
  blood flow even more)
• use RL (more physiologic and less acidotic)
• tilt pt 15-30 degrees, or elevate right hip

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Secondary survey

• Complete hx
• obstetrical hx
• physical exam
• evaluating/monitoring fetus

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Obstetrical hx

• LMP
• EDC
• problems/complications of current pregnancy
• problems/complications past pregnancies
• determination of fetal GA (uterine size)
• GA gt24wks, wt gt500gm (survival 20-30)

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Estimation of GA

• Rough estimate--any fundus palpable above
  umbilicus is viable!

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Physical exam

• Rectal exam
• pelvic exam
• speculum for signs of vaginal trauma, cervical
  dilation, source of vaginal fluiddo swabs for
  GBS, chlamydia/gonorrhea if leakage of amniotic
  fluid, slide for ferning of amniotic fluid
• bimanual exam for bony pelvic trauma, advanced
  labour

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Fetal evaluation

• FHR and Fetal movement!!!
• If lt24wks then intermittent FHR monitoring
• if gt24wks then continuous external FHR monitoring

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FHR strips

• A--accelerations
• B--baseline (120-160bpm), beat to beat
  variability (loss indicates fetal distress)
• C--contractions
• D--decelerations (late decels indicates fetal
  hypoxia)

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FHR strips

• Variability
• Decelerations

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Labs

• Routine trauma bloodwork
• blood type and Rh status
• coagulation studies if abruption suspected
• ABG for maternal hypoxia and acidosis

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Imaging questions

• What options exist for diagnostic imaging
  modalities?

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Imaging options

• Plain films
• CT/MRI
• U/S

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Imaging questions

• Any concerns with radiation exposure?

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Radiography

• Major effects of exposure to radiation for fetus
• congenital malformations (small risk b/w 2-15wks
  GA if radsgt100 mrad)
• growth retardation (15 risk of small head size)
• postnatal neoplasia (0.2-0.8 for CT pelvis)
• death(lt1 during first 2wks after conception)

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Radiography exposure1000 mrad 1 rad

• High exposure group
• l-spine (204-1260 mrad)
• pelvis (190-357 mrad)
• hip (124-450 mrad)
• IVP (503-880 mrad)
• UCG (1500 mrad)
• KUB (200-503 mrad)

• Low exposure group (lt1 mrad)
• head
• c-spine
• s-spine
• extremities
• chest

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Radiography

• exposure of lt5-10 rad causes no significant
  increases in fetal complications
• take precautions--shield abdomen, focus beams
• naturally occurring rad during 9mos is 50-100 mrad

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CT scans

• Head/chest CT-- lt1 rad
• abdo above uterus -- lt3 rad
• pelvic -- 3-9 rad
• spiral CT reduce radiation exposure by 14-30
• fetal assessment--CT will NOT show fetal injury,
  but will show uterine rupture, placental
  separation, placental ischemia

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U/S

• Best modality for assessment of mother and fetus
  (GA, placental location, fetal demise)
• sensitivity 83-88, specificity 98-99
• similar ability to detect intraperitoneal fluid
  in pregnant pts as compared to non-pregnant
• less sensitivity for evaluating kidneys /
  pancreas / bowel / biliary tree than CT
• safe for fetus, therefore firstline imaging

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Imaging questions

• Will this affect what studies are ordered?

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Imaging

• Bottom line radiation deemed necessary for
  maternal evaluation should not be withheld on
  basis of potential problems for fetus

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Other procedures

• Kleihauer-Betke test
• FMH (8-30 after trauma)
• complications--Rh sensitization, fetal anemia,
  fetal distress, or fetal death from
  exsanguination
• acid elution on maternal blood--adult cells
  colourless, fetal cells purple ratio calculated

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Kleihauer-Betke test

• only sensitive for over 5ml, but as little as 1ml
  can sensitize 70 of Rh neg mothers
• thus, all Rh neg mothers should receive one 300
  mcg Rhogam within 72h
• KB test only done on pts at risk for massive FMH
  which would require more than one dose of Rhogam
  (gt30ml FMH)
• less than 1 trauma, and 3.1 major trauma pts
• KB not necessary lt16wk GA as circulating blood
  volume lt30ml

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Types of trauma

• Blunt
• penetrating
• fetal injury
• placental injury
• uterine injury

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Blunt trauma

• MVC, abuse, falls
• Seatbelt use--no belts inc fetal death 4.1x,
  3-point belt best as long as positioned correctly
• physical abuse--4-17 (perpetrator usually known
  to pt) only 3 of pts tell MD what happened
• falls--2 of pts fall more than once during
  pregnancy

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Penetrating trauma

• Organs most likely involved if upper abdomen
  affected (dec order) sm bowel, liver, colon,
  stomach
• uterus almost exclusively during third trimester
  (fetal injury 60-90)
• GSW--maternal mortality 7-9, fetal mortality 70

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Penetrating trauma

• GSW
• above uterus injuries require exploration
• laparotomy for uterine wounds

• Stab
• if above uterus then operative intervention based
  on clinical findings/imaging results
• laparotomy for uterine wounds

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Fetal injury

• Leading causes fetal death maternal death,
  maternal shock/hypoxia, placental abruption,
  direct fetal injury (intracranial hemorrhage,
  skull )

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Predictors of fetal death/preterm birth

• Predictors fetal death
• Higher Injury Severity Scores (ISSgt25, 50
  incidence fetal death)
• lower GCS
• lower admitting maternal pH
• low serum bicarbonate
• FHR lt110 bpm

• Predictors preterm birth
• ROM
• placental abruption
• not associated with abdo tenderness or uterine
  contractions

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Placental injury

• Abruption occurs 2-4 minor trauma, 38 major
  trauma
• can occur with no signs of inj to abdominal wall
• s/s--vaginal bleeding, abdominal cramps, uterine
  tenderness, amniotic fluid leakage, maternal
  hypovolemia, or a change in FHR
• also associated uterine contractions--if less
  than 1/10min then unlikely abruption
• U/S only accurate in lt50 of cases
• best indicator--fetal distress (60 of cases),
  thus FHR monitoring immediately

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Abruption

• If mother/fetus stable--expectant mgmt if lt32wk
  GA, otherwise, C/S delivery recommended
• 54x more likely to have coagulopathies if
  abruption
• DIC directly proportional to amount of abruption

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Uterine injury

• 27y.o. 33wk GA had fall. Presents with
  contractions. Cx long, hard, posterior.
• Use of tocolytics indicated?
• Not routinely as 90 stop spontaneously and those
  that do not are often pathological in origin and
  tocolytics contraindicated

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Uterine rupture

• Caused by severe MVC, penetrating injuries
• s/s--maternal shock, abdominal pain, easily
  palpable fetal anatomy, fetal demise
• mgmt--either suture tear or hysterectomy

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Disposition
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Mother/fetus stable

• Minimum 4h continuous FHR monitoring
• if gt3 uterine contractions/hour, persistent
  uterine tenderness, abnormal FHR strip, vaginal
  bleeding, ROM, any serious maternal injury
  (ejections, motorcycle/ped collisions, no
  seatbelts) 24h minimum monitoring
• all pts settled and d/c within 24h had live
  births!

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Monitoring

• One survey showed FHR monitoring often does not
  take place during first hour of maternal work-up
  (68)
• in survey only 15 of departments had adequate
  FHR monitoring equipment
• often inadequate FHR monitoring despite fact
  fetal distress without overt clinical signs!

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Mother stable/ fetus unstable

• If GA gt24wks and FHR unstable C/S stat
• If FHR present and GA gt26wks then 75 survive
• other indications for C/S--uterine rupture, fetal
  malpresentation during premature labor, and
  uterus mechanically limits maternal repair

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Mother unstable/ fetus unstable

• 32y.o. 30wk GA by dates. MVC. P110, BP 80/45. FHR
  72. Splenic rupture. Which first--operative
  splenic mgmt or C/S?
• Mother before fetus!
• Repair of injuries that are life/limb saving for
  mother first
• then if fetus still viable, consider C/S

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Maternal arrest/ fetus unstable

• Within 4min of maternal arrest, if no response to
  advanced cardiac life support consider
  perimortem C/S
• Potential for fetal and maternal survival
• No MD in US ever found liable for performing
  perimortem C/S
• GA gt24wks by best estimate
• 70 of fetus that survive are delivered within
  5min of ED arrival
• 4min for maternal resuscitation, 1min for C/S!!

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Perimortem C/S

• Call for help (obs, peds)
• continue CPR during procedure, consider
  thoracotomy with OCM
• midline vertical incision from epigastrium to
  symphysis pubis through all layers to peritoneal
  cavity, using large scalpel
• vertical incision through anterior uterus from
  fundus to bladder reflection, using large
  scalpel/scissors if bladder encountered, rupture
• if placenta encountered on opening uterus, it
  should be incised to reach fetus
• clamp and cut cord after delivery of fetus

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ED deliveries

• ED suboptimal location
• Consider transfer if in periphery and pt not in
  active labour
• Call for obstetrical help if available
• Perinatal mortality 8-10 for ED deliveries
• ED selected by pts with complications
  (hemorrhage, PROM, eclampsia, PTL, abruptions,
  precipitous delivery, psychosocial complicating
  factors)

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Stages of labour
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First stage

• Latent phaseslow cx dilation up to 4cm
• Active phaserapid dilation
• Lasts 8h in primip, 5h in multip
• Examine cx for effacement, dilation, position,
  station, presentation

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Second stage

• Full dilation of cx and urge to push with
  contractions
• 50min primip, 20min multip
• FHR monitoring and U/S usefulviability, lie,
  presentation

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Delivery

• EquipmentSterile gloves, Towels, Cord clamps
  (2), Hemostats, Placenta basin, Surgical
  scissors, Rubber bulb syringe, Neonatal airways,
  Syringes, needles (small gauge), Gauze sponges
• Lithotomy position
• Once crowning, finger sweep to ensure cord not
  wrapped around neck
• Modified Ritgen manoeuver used for delivery of
  head

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Delivery contd

• Suction nares/mouth
• Downward traction on head for delivery of
  anterior shoulder
• Upward pull subsequently will allow posterior
  shoulder to pass
• Clamp cord and cut

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Third stage

• Delivery of placenta
• Uterus firm and globular, gush of blood,
  umbilical cord protrudes from vagina
• 5-20min in duration

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Fourth stage

• First hour post-delivery of placenta
• PPH most likely to occur during this time
• Uterine exploration to ensure expulsion of entire
  placenta
• Pack uterus with 4-inch gauze using ring forceps
• Uterine artery embolization or hysterectomy
• Repair of lacerations
• Oxytocin 20-40 u/l at 200ml/h

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Risks/benefits of adjuncts
procedure Risk Benefit Useful in ED?
NPO and IVs Fluid overload, A-B disturb Venous access, dec risk of aspiration Yes
Enemas Time consuming Less pain by constipation No
Pubic shaving Infection / irritation None No
Nitrous oxide analgesia Incomplete pain control Self-admin, few fetus SE Yes
Narcotics Fetal depression Good paincontrol PRN
Regional anesthesia Technically difficult, incomplete pain control Good pain control when technically correct PRN
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Risk/benefits of adjuncts contd
Procedure Risks Benefits Useful in ED?
FHR monitoring Inc surgical intervention Early dx fetal distress Variable
U/S None Adds to database Yes
Amniotomy Augmented labour, prolapsed cord None No
Episiotomy Poor maternal outcomes None if uncomplicated No
Ritgen maneuver None Decreased trauma yes
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Complications of delivery

• Dystociashoulder dystocia (1/300 live births)
• Malpresentationbreech delivery (1/25 live births)

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Breech presentations

• Afrank breech
• Bcomplete breech
• Cincomplete breech

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Breech delivery

• IdentificationLeopolds maneuvers (not useful in
  ED), U/S, vaginal exam
• Complicationshead entrapment, umbilical cord
  prolapse
• Mgmtgenerous episiotomy, knee flex and sweep out
  legs, pull out 10-15cm of cord after umbilicus
  clears perineum, use pelvis to hold infant,
  mauriceau maneuver

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Shoulder dystocia

• Identificationturtle sign, shoulders
  vertically aligned
• Mgmt
• Hhelp (obs, neonat, anaesth)
• Egenerous episiotomy
• Llegs flexed (McRoberts maneuver)
• Ppressure (suprapubic and shoulder pressure)
• Eenter vagina (Rubins or Woods maneuver)
• Rremove posterior arm (splint, sweep, grasp, and
  pull to extension)

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McRoberts maneuver
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Rubins maneuver
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Summary

• Most importantly, get obstetrical help ASAP!

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References

• Marx Rosens Emergency Medicine Concepts and
  clinical practice. 5th ed. 2002. Mosby Inc.
• Kolb et al. Blunt trauma in the obstetric
  patient monitoring practices in the ED. Am J
  Emerg Med 2002. Oct20(6)524-7.
• Curet et al. Predictors of outcome in trauma
  during pregnancy identification of patients who
  can be monitored for less than 6 hours. J Trauma
  2000. Jul49(1)18-24
• Stallard et al. Emergency delivery and
  perimortem C-section. Emerg Med Clin North Am.
  2003. Aug21(3)679-93.
• Shah et al. trauma in pregnancy. Emerg Med Clin
  North Am. 2003. Aug21(3)615-29.
• Rogers et al. A multi-institutional study of
  factors associated with fetal death in injured
  pregnant patients. Arch Surg 1999.
  Nov134(11)1274-7.
• Pak et al. Is adverse pregancy outcome
  predictable after blunt abdominal trauma? Am J
  Obstet Gynecol 1998. Nov179(5)1140-4.
• Desjardins. Management of the injured pregnant
  patient. Trauma.org trauma in pregnancy.
  http//www.trauma.org/resus/pregnancytrauma.html
• Goldman et al. Radiologic ABCs of maternal and
  fetal survival after trauma when minutes may
  count. Radiographics 1999 191349-1357.
• Goodwin et al. Abdominal ultrasound examination
  in pregnant blunt trauma patients. J Trauma 2001.
  Apr50(4)689-93.