Baby on Board! The Pregnant Trauma Patient Gillian Schmitz, MD, FACEP
BabyonBoard!ThePregnantTraumaPatient
GillianSchmitz,MD,FACEP
OBJECTIVES
1. Maternal-fetal anatomy & physiology2. Approach to Resuscitation3. Uterine pathology4. Fetal Monitoring5. Perimortem cesarean delivery (PMCD)6. Evidence based approach for disposition
AnatomicChanges
AnatomicChanges
PhysiologicChanges
• HRincreases10-20bpm• BPdecreasesby10-15mmHG
• Canlose30-35%circulatingbloodvolumebeforemanifestingclinicalsignsofshock!
Increasedminute
ventilation
Respiratoryalkalosis
Fasterdesaturation
Respiratory
• Tidal volume• Respiratory rate• O2 consumption• PCO2
• Arterial pH
• é (by 25%)• é (40-50%)• é (15-20%)• ê (27-32)• é (7.40-7.45)
Relative hypocapnea & faster desaturation
Renal / GI
• Kidneys• Bicarbonate• Base excess• Creatinine• Gastric emptying
• hydronephrosis• ê (19-25)*• ê (3-4) • ê
• ê
SupineHypotensionSyndrome
Labs
ApproachtoResuscitation:PrimarySurvey
ADEQUATERESUSCITATIONOFMOTHER
Airway:earlyRSI
• é riskdifficultintubation• Failedintubation8xé– éWeightgain(aspirate)– éRespiratorytractmucosaledema• Smallertube
– é Airwayresistance– ê Respiratorysystemcompliance– é Oxygenrequirements
No. 325, June 2015 Guidelines for the Management of a Pregnant Trauma Patient
Vital Signs in Pregnancy
–Normal is NOT normal –Up to 30% (2 L) loss of blood volume
before vital signs change–Maternal shock = fetal survival 20%
ApproachtoResuscitation:SecondarySurvey
• Headtotoeexam• Abdominalexam/fetalviability• GUexam• Fetalmonitoring/earlyOBconsultation• EarlyNGtubeplacement/IVF/blood
• ADEQUATERESUSCITATIONOFMOTHER
ImaginginPregnancy
PlacentalAbruption
PlacentalAbruption
FetalMonitoring
UterineRupture
PenetratingTrauma
Intimate Partner Violence
• Focus is on the fetus–Abdomen (60%)
• éPreterm delivery• éFetal demise
DomesticViolence
• Thinkaboutit• Askwhenpatientisalone• Socialservicesevaluationorreferral
InjuryPrevention
Expectantmomwithseaton
© Mark Pearlman MD
ResuscitativeHysterotomy
SurvivingInfantswithTimeofMaternalArrestin
Perimortem CSection
KatzV,Balderston K,DeFreest M.Perimortem cesareandelivery:wereourassumptionscorrect?.AmJObstet Gynecol.2005Jun.192(6):1916-20;discussion1920-1.
MaternalImprovementafterCsection
KatzV,Balderston K,DeFreest M.Perimortem cesareandelivery:wereourassumptionscorrect?.AmJObstet Gynecol.2005Jun.192(6):1916-20;discussion1920-1.
Considerations
• EstimatedGestationalAge
• Adequacyofresuscitativeefforts
• ElapsedTime
WhatdoIneed?
TreatmentAlgorithm>20weeks
Unstable Stable
Resuscitate
TransfertoOR
PerimortemCsection
TreatmentAlgorithm>20weeksStable
FASTExam/Ultrasound
+ -
Serialexams
ConsiderCT
FetalMonitoringOBconsultation
SurgicalandOBconsultation
CTvs OR
FetalMonitoringADMIT
Unstable
TreatmentAlgorithm>20weeksStable
CTneg
TocodynamometerMonitoring
• Monitoringfor4hoursissufficienttoruleoutmajortrauma-relatedcomplicationsinlowriskpatients
FetalMonitoring
HospitalizationanduterineactivitymonitoringbyEFMfor24hoursforpatientswith:
• uterinetenderness,vaginalbleeding• contractionsduringamonitoringperiodof4hours
• ruptureofthemembranes• atypicalorabnormalfetalheartrate• highriskmechanismofinjury(motorcycle,pedestrian,
• highspeedcrash)
Fetomaternal Hemmorhage
• Apttest• Kleihauer-Betke (KB)test• Rhogam• Tetanus
TakeHomePoints
• Focusresuscitationonmom• Notallminortraumaisminor!• Vitalsignsnotreliableindicators• Imaginginpregnancy• PMCSnowResuscitativeHysterotomy
Questions?