Trauma in pregnancy and the ED delivery Rebecca Burton-MacLeod Oct 30, 2003.

Trauma in pregnancy and the ED delivery

Rebecca Burton-MacLeod

Oct 30, 2003

Background Trauma in 6-7% of pregnancies accounts for nearly half deaths in

pregnancy (46.3%) most commonly due to MVC (>50%),

assault, fall

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

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

Case 28 y.o. female G1P0 30wks GA. MVC.

Unconscious when arrives in ED. Sats 88%. Decreased A/E right side

Airway/breathing management…what considerations in pregnant patient?

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)

Case cont’d 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

Secondary survey Complete hx obstetrical hx physical exam evaluating/monitoring fetus

Obstetrical hx LMP EDC problems/complications of current

pregnancy problems/complications past pregnancies determination of fetal GA (uterine size)

– GA >24wks, wt >500gm (survival 20-30%)

Estimation of GA Rough estimate--

any fundus palpable above umbilicus is viable!

Physical exam Rectal exam pelvic exam:

– speculum for signs of vaginal trauma, cervical dilation, source of vaginal fluid…do swabs for GBS, chlamydia/gonorrhea if leakage of amniotic fluid, slide for ferning of amniotic fluid

– bimanual exam for bony pelvic trauma, advanced labour

Fetal evaluation FHR and Fetal movement!!! If <24wks then intermittent FHR

monitoring if >24wks then continuous external FHR

monitoring

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)

FHR strips Variability

Decelerations

Labs Routine trauma bloodwork blood type and Rh status coagulation studies if abruption

suspected ABG for maternal hypoxia and acidosis

Imaging questions What options exist for diagnostic

imaging modalities?

Imaging options Plain films CT/MRI U/S

Imaging questions Any concerns with radiation exposure?

Radiography Major effects of exposure to radiation for fetus:

– congenital malformations (small risk b/w 2-15wks GA if rads>100 mrad)

– growth retardation (15% risk of small head size)

– postnatal neoplasia (0.2-0.8% for CT pelvis)– death(<1% during first 2wks after conception)

Radiography exposure1000 mrad = 1 rad

Low exposure group (<1 mrad):

– head

– c-spine

– s-spine

– extremities

– chest

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)

Radiography

exposure of <5-10 rad causes no significant increases in fetal complications

take precautions--shield abdomen, focus beams

naturally occurring rad during 9mos is 50-100 mrad

CT scans Head/chest CT-- <1 rad abdo above uterus -- <3 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

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

Imaging questions Will this affect what studies are

ordered?

Imaging Bottom line: radiation deemed

necessary for maternal evaluation should not be withheld on basis of potential problems for fetus

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

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 (>30ml FMH)

– less than 1% trauma, and 3.1% major trauma pts

KB not necessary <16wk GA as circulating blood volume <30ml

Types of trauma Blunt penetrating fetal injury placental injury uterine injury

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

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%

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

Fetal injury Leading causes fetal death: maternal

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

Predictors of fetal death/preterm birth

Predictors fetal death:– Higher Injury Severity

Scores (ISS>25, 50% incidence fetal death)

– lower GCS– lower admitting

maternal pH– low serum bicarbonate– FHR <110 bpm

Predictors preterm birth:– ROM– placental abruption– not associated with

abdo tenderness or uterine contractions

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 <50% of cases best indicator--fetal distress (60% of cases), thus

FHR monitoring immediately

Abruption If mother/fetus stable--expectant mgmt

if <32wk GA, otherwise, C/S delivery recommended

54x more likely to have coagulopathies if abruption

DIC directly proportional to amount of abruption

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

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

Disposition

Mother/fetus stable Minimum 4h continuous FHR monitoring if >3 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!

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!

Mother stable/ fetus unstable

If GA >24wks and FHR unstable = C/S stat

If FHR present and GA >26wks then 75% survive

other indications for C/S--uterine rupture, fetal malpresentation during premature labor, and uterus mechanically limits maternal repair

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

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 >24wks by best estimate 70% of fetus that survive are delivered within

5min of ED arrival 4min for maternal resuscitation, 1min for C/S!!

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

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)

Stages of labour

First stage Latent phase—slow cx dilation up to

4cm Active phase—rapid dilation Lasts 8h in primip, 5h in multip Examine cx for effacement, dilation,

position, station, presentation

Second stage Full dilation of cx and urge to push with

contractions 50min primip, 20min multip FHR monitoring and U/S useful—

viability, lie, presentation

Delivery Equipment:Sterile 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

Delivery cont’d 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

Third stage Delivery of placenta Uterus firm and globular, gush of blood,

umbilical cord protrudes from vagina 5-20min in duration

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

Risks/benefits of adjuncts

procedure Risk Benefit Useful in ED?

NPO and IV’s 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

Risk/benefits of adjuncts cont’d

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

Complications of delivery

Dystocia—shoulder dystocia (1/300 live births)

Malpresentation—breech delivery (1/25 live births)

Breech presentations A—frank breech B—complete breech C—incomplete

breech

Breech delivery Identification—Leopolds maneuvers (not

useful in ED), U/S, vaginal exam Complications—head entrapment, umbilical

cord prolapse Mgmt—generous episiotomy, knee flex and

sweep out legs, pull out 10-15cm of cord after umbilicus clears perineum, use pelvis to hold infant, mauriceau maneuver

Shoulder dystocia Identification—”turtle sign”, shoulders vertically aligned Mgmt—

– H—help (obs, neonat, anaesth)– E—generous episiotomy– L—legs flexed (McRoberts maneuver)– P—pressure (suprapubic and shoulder pressure)– E—enter vagina (Rubin’s or Wood’s maneuver)– R—remove posterior arm (splint, sweep, grasp, and

pull to extension)

McRoberts maneuver

Rubins maneuver

Summary Most importantly, get obstetrical help

ASAP!

References Marx: Rosen’s 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. Oct;20(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. Jul;49(1):18-24 Stallard et al. Emergency delivery and perimortem C-section. Emerg Med Clin North Am.

2003. Aug;21(3):679-93. Shah et al. trauma in pregnancy. Emerg Med Clin North Am. 2003. Aug;21(3):615-29. Rogers et al. A multi-institutional study of factors associated with fetal death in injured

pregnant patients. Arch Surg 1999. Nov;134(11):1274-7. Pak et al. Is adverse pregancy outcome predictable after blunt abdominal trauma? Am J

Obstet Gynecol 1998. Nov;179(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 19:1349-1357. Goodwin et al. Abdominal ultrasound examination in pregnant blunt trauma patients. J

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