Trauma in Pregnancy - •Discuss the prevalence and risk factors of trauma in pregnancy...

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  • Trauma in Pregnancy

    Kayla E Ireland, MD Maternal Fetal Medicine Fellow Department Obstetrics and Gynecology

  • Financial Disclosure

    No relevant financial relationships with commercial interests to disclose

  • Objectives Discuss the prevalence and risk factors of

    trauma in pregnancy Describe the perinatal complications

    associated with trauma in pregnancy Describe the management of pregnant

    women with minor and major trauma at the time of event as well as subsequent prenatal care

  • Trauma in Pregnancy

    Occurs 6-7% pregnancies (1 in 12 women)

    Leading cause of non-obstetric maternal mortality

    Fildes 1992 J Trauma

    MacDorman 2016 Obstet Gynecol

    Adjusted maternal mortality rates, Texas, 20002014

  • Trauma in Pregnancy

    Presence of gravid uterus alters the pattern of injury

    Two patients mother and fetus both require evaluation and management

    Critical Care and Trauma, Williams Obstetrics, 24e

  • Mechanism of injury

    NTDB 1994 2001, 895 pregnant women with trauma

    Ikossi et al 2005 J Am Col Surgeons

  • Physiologic Changes in Pregnancy Cardiovascular

  • Physiologic Changes in Pregnancy Hemostasis

    Parameter Non-pregnant Term Pregnant Activated PTT (sec) 31.6 4.9 31.9 2.9 Fibrinogen (mg/dL) 256 58 473 72 Factor VII (%) 99.3 19.4 181.4 48.0 Factor X (%) 97.7 15.4 144.5 20.1 Plasminogen (%) 105.5 14.1 136.2 19.5 tPA (ng/mL) 5.7 3.6 5.0 1.5 Antithrombin III (%) 98.9 13.2 97.5 33.3 Protein C (%) 77.2 12.0 62.9 20.5 Total protein S (%) 75.6 14.0 49.9 10.2

  • Physiologic Changes in Pregnancy Respiratory

    Total Lung Capacity

    Decreased 5%

    Vital Capacity No Change

    Inspiratory Capacity

    Increased 15%

    Expiratory Reserve Volume

    Decreased 25%

    Residual Volume Decreased 15%

    Functional Residual Capacity

    Decreased 20%

    Closing Capacity No change

  • Uterine Blood Flow: 10% of CO

  • Is Pregnancy protective in trauma???

    National Trauma Data Bank (NTDB) 2001-2005 - compared non-pregnant to pregnant women Non- pregnant women (N = 214,394), 98.28% pregnant women (N = 3,763) 1.72%

    Among women of similar age groups who are equivalently injured, pregnant women exhibit lower mortality

    John et al 2011 Surgery

  • MVC and pregnancy 207 per 100,000 pregnancies

    92,500 women injured annually Fetal mortality

    1.4/100,000 Maternal mortality


    87% receive medical care, majority admission >20 weeks gestation

    Risk factors: use of intoxicants, improper seat belt use pts reported having received

    proper seat belt use from prenatal care provider Critical Care and Trauma, Williams Obstetrics, 24e

  • Seat Belt Use in Pregnancy County Prenatal Clinical

    Survey, n=450, 92% response rate

    73% rate of correct use Reasons for lack of use:

    Discomfort (53%) Forgetfulness (37%)

    10% believed seatbelts are harmful

    1/3 unsure of effects seatbelt on fetus

    McGwin 2004 J Trauma

  • MVC and pregnancy Obstetrical concern

    Strain on uterus placental abruption

    Contrecoup and shear-force strain

    among severely injured women (ISS >12), placental abruption occurs in as many as 40% of cases

    Critical Care and Trauma, Williams Obstetrics, 24e

  • Slips/Falls in Pregnancy Increased joint laxity and

    weight gain affects gait predispose to falls

    1 in 4 women will fall at least once in pregnancy

    Complications proportional to force and body part impacted Fracture lower extremity

    most commonly associated injury when hospitalized (40%)

    3% fetal loss due to falls

    Overall 49 per 100,000 deliveries

    Of 639 hospitalized pregnant women after fall PTL, RR 4.4 Abruption, RR 8 Fetal distress, RR 2.1 Fetal hypoxia, RR 2.9

    Mendez-Figueroa 2013 AJOG Schiff BJOG 2008

  • Domestic Partner Violence/Intimate Partner Violence and Pregnancy

    >60 studies from >20 countries: rates 1-57% (22% in general female population)

    Risk factors: substance abuse, low

    maternal education level, low socioeconomic status, unintended pregnancy, h/o DV in prior pregnancy, h/o witnessed violence as child, unmarried

    Adverse pregnancy outcomes: SAB, NICU admission, PTB,

    low birthweight Strong association between

    peripartum depression and antenatal DV Prospective cohort

    13,617mom/baby dyads 42 months pp Antenatal depression OR 4.02 Postpartum depression OR


    Mendez-Figueroa 2013 AJOG Flach 2011 BJOG

  • Penetrating Trauma

    Altered pattern of injury Visceral injury 15-40% (compared to 80-90% non-pregnant) Below fundus

    High fetal mortality rate: 40-70% Lower maternal mortality rate: 4-7%

    Above fundus Bowel and solid organ injury

    Of 321 women with abdominal trauma 9% Penetrating injuries 77% GSW, 23% stab wounds

    Petrone 2011 Injury

  • Minor Trauma

    Prospective cohort 3 yrs, n=317 Minor trauma excluded life-threatening injuries, any injuries

    greater than bruising/lacs/contusions = ISS 0 Falls (48%), MVC (29%), assaults (87%) 14% patients with regular contractions 1st 4 hrs 1 abruption = 35 wks, fall from standing abruption 41 wks Of the predictors no single variable sensitive/specific to

    predict clinical outcomes.. Cahill 2008 AJOG

  • Uterine Rupture 0.6% injuries during

    pregnancy More likely in prior scarred

    uterus, associated with direct impact significant force

    75% cases involve the fundus

    Fetal mortality approaches 100%

    Maternal mortality 10% (usually due to severity of injuries) Woldeyes 2015 Case Rep Obstet Gynecol

  • Abruption Catastrophic events with blunt

    trauma: include abruption and placenta tear

    Deformation elastic myometrium around inelastic placenta

    1-6% minor injuries, 50% major injuries

    Considerable force placental fracture

    More likely to be concealed (no VB) with increased risk of coagulopathy compared to non-traumatic abruption

    Si/sxs: VB, uterine TTP, fetal tachycardia, late decelerations, acidosis, fetal death

    Critical Care and Trauma, Williams Obstetrics, 24e

  • Preterm Labor Incidence following trauma

  • Fetal Deaths Related to Maternal Injury Retrospective study of fetal deaths 16 states (55% of US live births),

    15,000 Fetal Deaths 240 traumatic fetal deaths, 3.7 per

    100,000 live births Causes:

    MVC (20%); firearm (6%); falls (3%)

    27 maternal deaths (11%)

    Weiss 2001 JAMA

  • Management of Trauma in Pregnancy RULE #1

    Mother first fetus second Maternal Death is the most common cause of

    fetal demise Minor Maternal Trauma is associated with fetal


  • Management of Trauma in Pregnancy

    Maternal and fetal outcomes directly related to severity of injury

    Not specific pregnancy scoring system ISS does not take into account abruption and pregnancy outcomes

    Schiff et al 582 pregnancies hospitalized after injury, ISS did not accurately predict adverse pregnancy outcomes and MINOR injuries associated with PTL and abruption

  • Management of Trauma in Pregnancy With few exceptions, treatment priorities in

    injured pregnant women are directed as they would be in non-pregnant patients

    DONT BREAK THE ROUTINE Basic rules of resuscitation ABCs

    LEFT LATERAL TILT ensure large uterus is positioned off the great vessels to diminish its affect on vessel compression and decreased cardiac output

  • Primary Survey

    ABCs A B C D E

    Increased Aspiration Risk Raised intra-abdominal pressure

    Decreased LES pressure Slow gastric emptying

    Displaced Bowel

    Pregnancy itself is a risk for failed intubation

  • Primary Survey

    ABCs A B C D E

    Oxygen consumption increases 20% Elevated diaphragms

    Decreased FRC by 20% Physiologic compensated respiratory

    alkalosis (dec buffering capacity)

  • Primary Survey

    ABCs A B C D E

    Normal: - pulse: 10-15 beats faster

    - Blood pressure: 10-15 mmHg lower

    Supine Hypotension

    Massive blood loss with minimal si/sxs

    Hypotension fetal hypoperfusion

  • Primary Survey

    ABCs A B C D E

    Exam - Glasgow Coma Scale

    - Pupillary Reflex

    Traumatic Brain Injury - Independent predictor of fetal loss

    - HPA axis dysregulation hypopituitarism 40% with mod-severe TBI

  • FAST exams in pregnancy

    177 pregnant trauma patients 85% in 2nd/3rd Trimester FAST

    sensitivity: 83% Specificity: 98%

    May decrease use of CT

    Goodwin 2001 J Trauma

  • Secondary Survey

    Obstetrical Exam Fetal gestational age/position Evaluate vaginal bleeding/PROM/cervical


    Kleihauer-Betke Detection of transplacental hemorrhage in Rh

    negative Guide Rh immunoglubin therapy to prevent Rh


  • Kleihauer-Betke Testing KB used detect FMH in Rh neg, may

    reflect uterine injury and risk of PTL FMH: KB 0.01 mL fetal blood in

    maternal circulation 46/71 patients KB 0.01 mL (FMH)

    44/46 contractions, 25/46 PTL Neg KB (n=25) no PTL or contractions

    Likelihood ratio +KB for PTL: 20.8, NPV 92.6%

    Muench 2004 J Trauma

    In retrospective review 125 women with blunt trauma, KB sensitivity 56%, specificity 71%, accuracy 27% diagnose FMH

    Fetal monitoring, ultrasound were more useful in detecting fetal and pregnancy complications

    Concluded: little value in acute trauma management

    Towery 1993 J Trauma

  • Fetal Monitoring At viability continuous fetal monitoring should

    be initiated Ideal duration not established Fetal well-being reflects maternal well-being =

    additional VITAL SIGN

    Obstetrical Hemorrhage, Williams Obstetrics, 24e

  • Fetal Monitoring Pearlman (1990) prospective

    study n=85 adverse pregnancy outcome 1st

    4 hours CTX Q2-5 minutes No one with contractions occurring

    less than >q15 min adverse outcome

    Sensitive but no specific for detecting immediate adverse perinatal outcome

    Connolly (1997) no adverse outcomes in women with normal fetal heart rate tracings

    Dahmus 1993 AJOG summarized data, n=605 adverse pregnancy outcome

    frequent uterine contractions occurring greater than 6 times per hour in the 1st 4 hours

  • Fetal Monitoring RECCOMENDATIONS:

    At viability, external electronic fetal heart rate monitoring and cardiotocographic monitoring minimum 4-6 hours

    Extend 24 hours: contractions > Q10 minutes within 4 hours Si/sxs abruption: persistent uterine tenderness, vaginal

    bleeding Non-reassuring fetal monitoring ROM Serious maternal injury maternal vital sign Uterine hypoperfusion ARDS, cardiac arrhythmia

  • Radiation in Pregnancy

    CO #656 Radiation in Pregnancy Obstet Gynecol 2016

  • Delivery Dependent on fetal gestation age, fetal

    condition, extent of injury and when delivery would improve maternal well-being (large uterus hinders adequate treatment or evaluation of intraabdominal injury)

    C-section Viable fetus in distress Uterine trauma

    IUFD vaginal delivery preferred Trauma laparotomy does not mandate C-section

  • Infant survival after C-section for trauma Multi-institution (9 Level 1 trauma center), 1986 -

    1994 retrospective cohort 32 emergent C-sections of 441 pregnant women

    admitted after trauma Mean GA 33 wks at delivery (22-40) No FHT (n=13) = no survival Survival 75% when GA >26 wks Most common reason for preventable fetal loss

    delayed recognition of fetal distress Morris 1996 Annals of Surgery

  • Perimortem C-section within 4 minutes of maternal cardiac

    arrest assume cardiopulmonary resuscitation ineffective 3rd TM due to aortocaval compression fetal and perhaps maternal outcomes would be optimized by timely delivery brain damage begins at 5 minutes of

    anoxia Katz et al 2005 AJOG review of 38

    cases in literature SELECTION BIAS 13/20 resuscitated and discharged

    from hospital 12/18 improved hemodynamic stability

    after C-section No case of deterioration with c-delivery

  • Perimortem C-section Time Arrest Delivery % newborns neurologically intact

  • Pregnancy Complications after Trauma Women hospitalized for trauma 9 months preceding delivery (N=7822)

    OR 9% CI

    Placental abruption 1.6 (1.3-1.9)

    Preterm labor 2.7 (2.5-2.9)

    Maternal Death 4.4 (1.4 14)

    Retrospective cohort study CA ICD-9. El Kady 2004 Am J Obstet Gynecol

    Sperry et al 10 year retrospective cohort at UTSW Level 1, n=773 women discharge home after trauma with viable fetus

    Preterm Delivery RR 1.9 (1.1-1.3), Low Birthweight RR 1.8 (1.04 1.32) with higher risk with increasing ISS score and earlier gestation

    Trauma during pregnancy is risk factor for poor pregnancy outcome El Kady 2004 AJOG

    Sperry 2006 Am J Surgery