Trauma x Two: The Pregnant Victim

Douglas S. Ander, MDEmory University School of MedicineProfessor of Emergency MedicineAssistant Dean for Medical Education

Disclosures “I, Douglas Ander, have no real or

perceived vested interests that relate to this presentation nor do I have any relationships with pharmaceutical companies, biomedical device manufacturers, and/or other corporations whose products or services are related to pertinent therapeutic areas.”

Frequently Asked Questions What are the statistics? What is the role of domestic violence? How do the physiologic changes of pregnancy

affect management? How to I recognize the possibility of fetomaternal

injuries? How do I recognize abruptio placenta? What do I need to know about fetal monitoring? Should pregnant women wear seatbelts? What do I do when my patient codes? What is the significance of fetomaternal

hemorrhage? What xrays should I do?

What are the statistics?

Introduction Accidental injury occurs in 6-7% of all

pregnancies Trauma is the leading cause of maternal

death, 46.3% Overall 6-7% maternal mortality Fetal mortality 61% in major trauma, 80% if

cases of maternal shock < 1% of trauma admissions are pregnant

Peckham CH et al. Am J Ob Gyn 1963;87:609Fildes J et al. J Trauma 1992;32:643Connolly A et al. Am J Perinatol 14:331-336, 1997

Causes of Trauma

MVC64%

Burns16%

Assault8%

Falls8%

Penetrat-ing4%

Drost et al. J Trauma 1990;30:574.

What is the role of intimate partner violence?

Domestic Violence 154 acts of violence per 1000 pregnant

women during first 4 months, increases to 170 per thousand during the 5-9th months.

Only 8 of 24 sought medical care May lead to increased complications

41.8% vs. 11.8%, P<.01 17.1% (assault) vs. 7.1% (MVC)

1985 National Family Violence Study, Helton AS et al. Am J Public Health 1987;77:1337Pak LL et al. Am J Ob Gyn 1998;179:1140

Goodwin and Breen. Am J Ob Gyn 1990;162:665

How do the physiologic changes of pregnancy effect management?

Cardiovascular Plasma volume increases by 50% Heart rate increases by 10-15 bpm Cardiac output increases by 40-50% Total peripheral resistance decreases Oxygen consumption increases by 20% Decrease in venous return

Cardiovascular 30-35% decrease in maternal blood flow

can cause a 10-20% decrease in uterine blood flow prior to detectable hemodynamic changes in the mother

Warm and pink shock patient

Respiratory Decrease in functional residual capacity Decreased oxygen reserve

Increased risk of maternal hypoxemia during RSI

Gastrointestinal Decreased motility and tone

Increased risk of aspiration Stretching of abdominal wall

Decreased response to peritoneal irritation

Anatomic Diaphragm rises 4cm

Perform thoracotomy 1-2 interspaces higher

Compartmentalization of the small intestine into the upper abdomen Increased risk injury

Uterus may shield the intestines

Increased cardiac output to uterus Increased risk for

significant hemorrhage

Supine Hypotensive Syndrome

Milson I, Forssman L: Am J Obtst Gynecol 148: 764-771, 1984

How to I recognize the possibility of fetomaternal injuries?

Major Trauma 24% of the women died

All fetuses expired Average gestational age 22.4 weeks

Of the 31 who survived 6 fetal deaths

4/6 of abruptio placenta 8/10 women in shock had fetal demise

Rothenberger et al. J Trauma 1978;18:173

Minor Trauma Pearlman

75/75 no fetal death, 3 abruptio placentae Goodwin

5 abruptio placentae Schiff

Relative risk for abruption in non-severe trauma, 3.7 (1.3-7.9)

Morris 3/5 infants considered salvageable died from

mothers with mild to moderate injury, ISS < 16

Cahill 317 patients, ISS 0, only 1 abruptio placentae

which was unrelated to the trauma

How do I recognize abruptio placenta?

Recognition of abruptioplacentae - >20 wks Pearlman et al

No women had an abruption if no uterine contractions were detected or if their frequency was less than every 10 minutes during 4 hours of monitoring after trauma was sustained

Pearlman et al. Am J Obstet Gynecol 1990;162:1502-1510.

Monitoring Recommendations All women >20-week gestation:

Minimum 6 hours monitoring Extended to 24 hours if :

. >3 contractions per hour

. Persistent uterine tenderness

. Non reassuring fetal monitor strip

. Vaginal bleeding

. Rupture of membranes

. Serious maternal injury Controversy based on the minor trauma

literature

What do I need to know about fetal monitoring?

Fetal MonitoringHeart rate

Bradycardia <110 bpm Tachycardia >160 bpm

VariabilityPresence of decelerations

Variability

Fetal Monitoring: Late Decelerations Onset is 30 seconds or more after onset of the

contraction, nadir well after the peak contraction and returns to baseline after the contraction is over

Fall of 10-20 bpm Always believed to indicate fetal distress

Seatbelts in pregnancy?

Seatbelt Statistics Most wore restraints before pregnancy, but

increased restraint use during pregnancy (79% vs. 86%, chi squared, p = 0.02)

Only 52% - 72.5% used restraints properly 55.3% reported that restraints would

protect their baby, 10.7% harm and 34.0% unsure

If they felt restraints were beneficial they were more likely to always wear restraints ( 84.4% vs. 64.6%, p<0.0001)

Only 21% - 36.9% of women were educated on proper restraint use during pregnancy.

Tyroch et al. J Trauma 1999;46:241Mcgwin et al. J Trauma 2004;56:670

Seatbelt EvidenceRisks Fetal Death Placental

AbruptionOdds Ratio

95% CI Odds Ratio

95% CI

Ejection 32.8 7.5-144.5 6.1 1.1-33.5

Restrained

0.230 0.071-0.742

NS NS

Curet MJ et al. J Trauma 2000;49:18

Proper seatbelt use is key

Air bag had no effect on force transmission.

What do I do when my pregnant trauma patient codes?

Resuscitation Mom first

Most common cause of fetal demise is maternal demise

B-HCG on all child bearing age patients

Perimortem Cesarean Section Survival

Maternal CPR <5 minutes, fetal survival excellent

<23 weeks gestation survival chance is 0%

Maternal CPR >20 minutes, fetal survival unlikely

Technique

Technique Ideally

started within 4 minutes

What is the significance of fetomaternal hemorrhage?

Fetomaternal Hemorrhage As little as 5 cc can sensitize Rh-negative

women Increased risk of abruptio placentae and

predictor of preterm labor – some controversy KB analysis all patients >12 week-gestation Rhogam for all Rh-negative pregnant patients

As a rule can give 300mcg of Rhogam for every 30cc of fetal blood detected in maternal circulation

Dahmus MA et al. AM J Ob Gyn 1993;169:1054.Goodwin TG et al. Am J Ob Gyn 1990;162:665Rose PG et al. Am J Ob Gyn 1985;153:844Dhanraj d et al. Amer J Ob Gyn 2004;190:1461Pearlman et al. Am J Obstet Gynecol 1990;162:1502-1510Meunch et al. J Trauma 2004;57:1094-1098

What xrays should I do?

Radiology Perform clinically indicated studies Below 5 rads (50 mGy) exposure no

significant risk Shielding of the abdomen provides

additional protection by as much as 75%

Radiology Most common fetal malformation caused

by high-dose radiation are CNS changes 2-15 weeks gestation At least 20 – 40 rad

Slight increase in leukemia Background rate of leukemia in children is

about 3.6 per 10,000 Exposure to 1-2 rad increases this rate to

5 per 10,000

0 1 2 3 4 5 6

ChestUpper or lower extremity

CT HeadBackground radiation

VQ ScanAbdomen (multiple views)

LS SpineCT AbdomenCT LS Spine

MaximumRad

iatio

n so

urce

Fetal exposure

US for Trauma in Pregnancy

Richards et al. Radiology 2004; 233:463–470

Negative FAST is valuable

US for Abruptio Placentae

Glantz et al. J Ultrasound Med 21:837–840, 2002

Specific not sensitive

Xrays to perform?

Those that are clinically relevant

Radiation Safety Poster From 1947

Trauma in PregnancyKey Points

Remember domestic violence Consider physiologic changes Early monitoring and a minimum of 4 hours Seat belt education Resuscitate the mother Rhogam and KB testing Failed resuscitation consider c-section Use radiologic procedures appropriately Ultrasound has value in trauma evaluation

Questions?Douglas Ander, MDdander@emory.edu