Trauma in Pregnancy - Ob Hospitalist Group · Trauma impacts 5-9% of all pregnancies ... Murphy et...

Trauma in PregnancyOb Hospitalist Group

Background

Trauma impacts 5-9% of all pregnancies

Trauma is the leading cause of non-obstetric maternal mortality in the United States

Causes 46% of maternal deaths

#1 cause of fetal death is maternal death Primary cause of maternal death is due to blunt trauma

Intracranial injuries

Fetal death approaches 40-50% in life threatening trauma

Pregnancy related trauma: 19.6% associated with Illicit drugs

12.9% associated with alcohol

Brown, HL. Trauma in Pregnancy. Obstet Gynecol 2009;114:147-60Schiff MA. Pregnancy outcomes following hospitalisation for a fall in Washington State from 1987 to 2004. BJOG 2008;115:1648-1654Kady, D et al. Trauma during pregnancy: An analysis of fetal outcomes in a large population. Am J Obstet Gynecol 2004;190:1661-8Schiff MA et al. The effect of Air Bags on Pregnancy outcomes in Washington State. Obstet Gynecol 2010;115(1):85-92Vivian-Taylor J et al. Motor vehicle accidents during pregnancy: a population-based study. BJOG 2012;119:499-503Raptis et al. Imaging of Trauma in the pregnant patient. RadioGraphics 2014;34:748-63Murphy et al. Trauma in Pregnancy: assessment, management, and prevention. Am Fam Physician 2014;90(10):717-24.Mirza et al. Trauma in pregnancy: A systemic approach. Am J Perinatol 2010;27:579-86.Oxford et al. Trauma in pregnancy. Clin Obstet Gynecol 2009;52(4):611-629

Background

Trauma in pregnancy: MVA 49% (other sources indicate up to 80%)

Falls 25%

Assault 18%

GSW, homicide, or penetrating injury 4%

Suicide 3%

Burns 1%

The majority of fetal losses occur after MINOR injury Fetal loss occurs at a much lower rate from minor injuries (1-

5%), but minor injuries are much more common, so the net result is higher fetal loss

90% of traumatic injuries are minor

60-70% of trauma related fetal injuries are a result of minor injuries

Background

5-29% of pregnant patients are delivered during the hospitalization for trauma

70% by Cesarean delivery

Most delivered in 24 hours

1 in 12 pregnancies are complicated by trauma

Intimate Partner Violence in up to 31.5% of pregnancies 20% (or more) of nonfatal violent crimes are experienced by

women

First trimester pregnancy loss when occurs is usually due to hypovolemia and hypotension

Types of Trauma

Blunt Trauma (MVA, falls)

Penetrating Trauma

Toxic exposures

Burns

Drowning

Motor Vehicle Accidents

Motor Vehicle Accidents account for 70-80% of major trauma events in pregnancy

82% of fetal trauma losses result from MVA

Responsible for 1300-3900 fetal losses each year

5.9% fetal death rate

368 maternal fatalities due to MVA yearly (2.2% maternal deaths)

Blunt trauma is the #1 cause

Motor Vehicle Accidents

Perinatal death rate associated with MVA of 3-6/100,000 live births in high income countries

2.8% of women experience a crash during pregnancy

Intoxicants are involved 45%

Only 34-64% of pregnant patients involved in MVA are restrained

Penetrating Trauma

GSW or stab wounds

More likely to cause uterine or direct fetal injury

Fetal demise up to 65% (40-65%)

Fetal injuries in 70%

Can cause direct fetal injury or injury to uterine vasculature, placenta, or umbilical cord

Upper abdominal injuries likely to cause bowel injury due to superiorly displaced bowel by gravid uterus

Falls

Nearly 27% of pregnant women will experience a fall

Falls account for 24% of maternity injury hospitalizations

Majority of falls (79%) occur in the third trimester

2.3x more likely to be hospitalized for a fall during pregnancy compared to non-pregnant reproductive age women

Increased risk of falling in pregnancy due to: Increased joint laxity

Weight gain

Change in center of gravity

Other anatomical changes

Falls

Types of falls: Stumbling, slipping,

tripping from the same level: 35%

Falls on stairs or steps: 17%

Fall from one level to another: 5%

Other types: 13%

Unspecified falls: 31%

Maternal Anatomic and Physiological Considerations

During first trimester, uterus is protected by the bony pelvis

Heart Rate Blood Pressure Blood Volume


Heart is rotated by 15 to 20 degree left axis deviation

Respiratory alkalosis with compensatory metabolic acidosis Secondary to physiologic hyperventilation

Maternal values with lower PaCO2, increased PaO2, and lower bicarbonate concentration

Hematological changes Dilutionial anemia (normal Hgb 10.5)

Plasma volume increases 45%

Leukocytosis can be normal with WBC up to 16,000 normal in first and second trimesters (and can be elevated up to 30,000 in labor)

Normal fibrinogen >200


Gastrointestinal changes: increased risk of aspiration Increased intraabdominal pressure

Relaxation of lower esophageal sphincter

Delayed gastric emptying

Gravid uterus can result in IVC compression At 20w gestational age, in supine position the uterus can

compress the IVC resulting in 30% decrease in cardiac output

Left lateral tilt of 15 to 30 degrees (most authors recommend 25 to 30 degrees)

Risks to Pregnancy

Trauma is associated with: First trimester loss

Preterm delivery

Preterm labor

Premature rupture of membranes

Placental abruption

Uterine rupture

Stillbirth

Pregnancy Specific Injury Considerations: Placental Abruption

Placenta relatively inelastic and more rigid than uterine wall

65-75% fetal mortality for post trauma abruption

Placental abruptions: 1-5% occurrence with minor trauma

20-50% with major trauma

Difficult to diagnose by imaging Unless significant retroplacental clot

In one study, 8 or more contractions were present in the first 4h in 100% of patients with the final diagnosis of placental abruption (Murphy and Quinlan)

Pregnancy Specific Injury Considerations: Uterine Rupture

Uterine rupture and lacerations are rare Complicate about 1% of traumas

Traumatic uterine rupture Almost 100% fetal mortality

10% maternal mortality

Best diagnosed by CT 75% involve fundus

Increased risk if prior C/S

Blood flow to the uterus approximately 600ml per minute

Typically present with wide spectrum of clinical findings Severe abdominal pain, shock, no FHT noted

Consider uterine trauma with significant force blunt trauma: recognize it!

Pregnancy Specific Injury Considerations: Uterine Lacerations

Penetrating injuries more likely to injure uterus (and fetus) during pregnancy

GSW to abdomen:

70% result in fetal injuries

Fetal mortality rate 40-65%

Pregnancy Specific Injury Considerations: Pelvic Fractures

Pelvic and acetabular fractures rare but carry significant morbidity and mortality

Maternal mortality with pelvic fracture: 9%

Fetal mortality with pelvic fracture: 35%

Pelvic fractures: 73% from MVA

14% from falls

13% from pedestrian vs MV

Pregnancy Specific Injury Considerations:Other Injuries

Retroperitoneal hemorrhage Ovarian and other pelvic veins are engorged, increasing the risk of

hemorrhage with blunt or penetrating injuries

Genitourinary System Hydronephrosis in later pregnancy increases risk to collecting system

Bladder increased risk of injury as displaced superiorly later in pregnancy

Vaginal lacerations

Splenic rupture or hepatic injury Spleen enlarged

Gravid uterus displaces spleen and liver closer to rib cage in pregnancy which increases chance of injury

Up to 25% risk of significant splenic or hepatic injury after severe blunt trauma in pregnancy

Pregnancy Specific Injury Considerations:Other Injuries

Bowel injury Bowel displaced superiorly

Increased risk of injury from upper abdominal penetrating wound, lower risk of injury from lower abdominal penetrating wound

Direct fetal injury <1% from blunt trauma

Skull fracture

Up to 70% from penetrating injury

Fetomaternal hemorrhage Reported in 2.6 to 30% of pregnant trauma patients

Evaluate by Kleihauer-Betke test Measures percent of fetal red blood cells containing

fetal hemoglobin in maternal blood

Assists in calculation of anti-D immune globulin dose

Positive KB doesn’t predict adverse outcome (significant FMH will be accompanied by FHR changes)

Population studies:

What does the literature say about trauma in pregnancy?

Kady et al. Trauma During Pregnancy: An analysis of maternal and fetal outcomes in a large population. Am J Obstet Gynecol2004;190:1661-1668.

Retrospective cohort study

Large study, reviewed all maternal trauma admissions in CA hospitals from 1991-1999

Traumas included falls, MVA, assaults

MVA led to majority of admissions

Falls were the most common mechanism of injury leading to delivery

10,316 deliveries identified in 4,833,286 total deliveries

24% delivered during initial trauma admission

Highest risk of maternal death: Intracranial injuries

Internal injuries (intraabdominal hemorrhage)

Highest rate of fetal injuries: Open injuries

Internal maternal trauma

Kady et al.

Delivery at hospitalization at time of trauma admission

9-fold increase in abruption

42-fold increase in uterine rupture

69-fold higher maternal death

2-fold increase risk of PTD

4.6-fold increase in fetal death

3-fold increase in neonatal death

Delivered at hospitalization subsequent to trauma

20% increase risk of PTD

56% increase in abruption rate

38% increase in low birth weight

2.7-fold increase risk of PTL

4-fold increase in maternal death

No significant increased risk of fetal or neonatal mortality

Kady et al.

Non-severe Injuries(X-fold increase)

Abruption: 7.7

Uterine Rupture: 16

Maternal Death: 4.9

Fetal Death: 2.7

Severe Injuries(X-fold increase)

Abruption: 23

Uterine Rupture: 233

Maternal Death: 555

Fetal Death: 17

Kady et al.

These authors conclude that women sustaining trauma during pregnancy, even if not delivered at the inciting event, continue to have increased risks of maternal morbidity and should be monitored closely during the remainder of the pregnancy

Schiff MA et al. Maternal and Infant outcomes after injury during pregnancy in Washington state from 1989 to 1997. J Trauma Inj Infect Critical Care 2002;53:939-945.

Retrospective cohort study of term patients

Evaluated maternal and infant outcomes after trauma injury documented in WA from 1989-1997

Only included women delivering at the trauma admission

Compared patients considered “severely injured” to those considered “non-severely injured”

Based on ISS (Injury Severity Score)

Schiff et al.

“Severely injured” term patients compared to “non-severely injured”

Increased relative risk: Abruption 15.8

C/S 4.3

Non-reassuring FHR 3.9

“Non-severely injured” term patients

Increased relative risk: Abruption 4.2

Infant hypoxia 4.6

Fetal death 13.6

Schiff MA et al. Pregnancy outcomes following hospitalisation for motor vehicle crashes in Washington state from 1989 to 2001. Am J Epidemiol2005;161:503-510.

Subsequent follow-up study of statewide pregnancy outcomes in WA

Specifically evaluated patients in MVA from 1989-2001

82.9% discharged home undelivered, 17.1% delivered during index hospitalization for MVA

Found the ISS didn’t correlate with adverse pregnancy outcomes

Concluded that women hospitalized for MVA at increased risk of adverse pregnancy outcomes, regardless of the presence (or absence) of identifiable physical injuries

Including:

PTL

Abruption

Meconium at delivery

Neonatal respiratory distress

Vivian-Taylor et al. Motor vehicle accidents during pregnancy: a population-based study. BJOG2012;19:499-503

Population based study in New South Wales, Australia

Looked at MVA in a 7 year inclusive time period (2000-2007)

Out of 604,380 women giving birth, 2,147 were admitted after a MVA

Ratio of 3.5 admissions per 1000 maternities

Type of MVA: Vehicle occupant: 88.6%

Pedestrian: 3.4%

Motorcycle riders: 0.9%

Bicycle riders: 0.8%

Unknown: 6.9%

Vivian-Taylor et al.

Most were considered to have only minor injuries 77.9% admitted for one day or less

Pregnancy outcome data (available for 95.2%) 0.4% SAB <20w

3.5% delivered at >20w during the same hospitalization

96% were undelivered at the time of discharge

Had similar delivery outcomes to women not involved in MVA

Injury profile: 19% with bruising to abdomen, pelvis, or lower back

7% pelvic fracture

8% intraabdominal injuries

10% admitted to ICU

11% transfusion

4% maternal death

Vivian-Taylor et al.

Low overall perinatal mortality: 1.4%

If delivery required at the admission for MVA: 33% perinatal death

20.8% fetal demise

61% delivered by C/S

Increased risk of PTD

Antepartum hemorrhage

>25% abruption

Contrary to other studies, if the MVA didn’t precipitate delivery at the index hospital admission, there was no increased risk of PTD, perinatal death, or other pregnancy or delivery adverse outcomes during the remainder of the pregnancy

Schiff et al. The effect of air bags on pregnancy outcomes in Washington state. Obstet Gynecol2010;115(1):85-92.

Several case reports suggested increased rates of uterine rupture, abruption, and ROM following air bag deployment

Previous study by Klinich et al refuted these case reports (small study)

Suggested appropriate 3-point seat belt use in conjunction with air bags associated with fewer adverse pregnancy outcomes

Prior study by Metz et al (small study) 1 abruption with fetal death in 30 air bag deployed crashes

73% with post MVA contractions

20% with abnormal FHR tracing

Lack of population based cohort study

Schiff et al.

Airbags typically deploy: Moderate to severe frontal crash

Specified threshold determined by velocity change

Airbags deploy with >1200# force at speeds averaging 230 mph

Schiff et al.

Study looking at effects of air bag use on pregnancy outcomes in Washington state from 2002-2005

Studied 3348 non-rollover MVA with pregnant front seat occupant

Frequency of 10.3 MVA per 1000 deliveries

42.9% 2nd trimester

31% 3rd trimester

Nonsignificant increase in PTL and fetal death with air bag deployment

When controlling for various factors, authors found maternal and perinatal outcomes were similar between air bag equipped and unequipped vehicles

Appears that for the majority of maternal and perinatal outcomes, there are no increased risks associated with air bag deployment

Schiff MA. Pregnancy outcomes following hospitalization for a fall in Washington state from 1987 to 2004. BJOG2008;115(1):1648-1654

Schiff et al.

Authors evaluated pregnancy outcomes following a fall

Retrospective study of 693 pregnant women hospitalized after a fall from 1987-2004

Of those patients evaluated: 67.1% discharged home

undelivered

32.9% delivered during same hospitalization

79.3% in 3rd trimester

11.3% in 2nd trimester

Schiff et al.

Schiff et al.

Of those hospitalized for a fall, there were increased risks of:

PTL: 4.4 fold

Abruption: 8 fold

IOL: 90%

C/S: 30%

Fetal distress: 2.1 fold

Fetal hypoxia: 2.9 fold

Weiss HB et al. Fetal death related to maternal injury. J Am Med Assn 2001;286:1863-1868

Reviewed fetal death certificates from 1995 through 1997

Study encompassed 16 states, representing 55% of the United States population

240 injury related fetal deaths

11% (27 deaths) associated maternal deaths

Injury related rate of 3.7 fetal deaths per 100,000 live births

Highest rate of injury related fetal deaths was in 15-19 year-old gravid patients

9.3 fetal deaths per 100,000 live births

Dannenberg et al. Obstetrics: homocide and other injuries as causes of maternal death in New York City, 1781 through 1991. Am J Obstet Gynecol1995;172:1557-1564

Reviewed medical examiner records from 1987 through 1991 in New York

First study to outline homicide as a leading cause of intentional injury-related deaths in an urban population

Majority of patients were nonviable 20 of 115 included patients were viable

10 were within 6 months postpartum

Types of maternal injuries Homicide: 63%

GSW: 51%

Stabbing: 17%

Strangulation: 14%

Others: Burns: 7%, Blunt force: 7%, Unspecified: 1%

Suicide: 13%

MVA: 12%

Overdose: 7%

Other authors have noted high rates of interpersonal violence during pregnancy (31.5%)

Cahill et al. Minor trauma in pregnancy-is the evaluation unwarranted? Am J Obstet Gynecol2008;198:208.e1-208.e5

3-year prospective cohort study of noncatastrophic trauma

Delivery information available for 236 of 317 patients evaluation

Of the 317 patients: Evaluated with standardized protocol

Detailed documentation of event

Complete physical examination

Fetal ultrasound

Laboratory evaluation

Blood type, CBC, PT, PTT, fibrinogen, and KB test

If admitted, KB repeated at discharge

Evaluation of pregnancy outcome data

Cahill et al.

Standardized monitoring protocol of 4 hours of continuous monitoring

If more than 5 contractions in any hour, admitted for 24h continuous monitoring

13.9% had >5 contractions per hour and required extended monitoring

2.8% had positive KB at presentation However, none of the 13.9% requiring additional

monitoring had a positive KB at admission or discharge

One patient with a fall at 35w delivered at 41w and was noted to have a partial abruption at delivery

Likely not related to the trauma

Cahill et al.

Study by Dhanraj and Lambus Compared KB results from 151 pregnant trauma patients to

100 gestational age matched controls

No statistically significant difference in positive KB results

Of the patients with a positive KB, none were associated with placental abruption or fetal distress

Cahill et al considers in light of these studies together, suggest in the absence of maternal injury or other clinically concerning signs

Recommend adopting practice of a “physical exam, brief fetal well-being assessment, and patient counseling” is adequate assessment after a minor traumatic event

Imaging of the Pregnancy Trauma Patient

Raptis et al. Imaging of Trauma in the Pregnant Patient. RadioGraphics 2014;34:748-763.American College of Obstetricians and Gynecologists. Guidelines for Diagnostic imaging During

Pregnancy and Lactation. ACOG Committee Opinion No. 656. Obstet Gynecol 2016;127:e75-80.

Imaging

Imaging critically important: early diagnosis of maternal injuries is paramount as maternal decompensation with shock results in poor maternal and fetal outcome

Fetal death rates approach 80% with maternal shock victims

Intracranial injuries are the major cause of maternal deaths, followed by intraabdominal injuries

Remember left lateral tilt

Imaging: Ultrasound

Fetal assessment Estimate gestational age Quantify AFI Evaluate placenta

FAST scan (Focused Assessment with Sonography in Trauma)

Advantages: Safe Readily available Portable No preparation required

Disadvantages: Difficult to detect small amounts of intraperitoneal fluid Poor detection of solid and hollow organ injury 50-80% false negative rate of detecting abruption

US is not a substitute for a clinically needed diagnostic CT examination

Imaging: Conventional Radiology

“Workhorse” modality of trauma imaging includes conventional radiology and CT

Per American College of Radiology 2008 practice guidelines and supported by ACOG

Fetal radiation doses of <50 mGy are not associated with increased fetal anomalies or fetal loss

Very early pregnancy (<2w): “all or none”

2-20w risk of teratogenesis (threshold 50-150mGY)

Increased baseline risk of cancer Exposure to 50 mGY: risk 2-fold

Borderline risk of 1:2000. New risk is 1:1000

Increased overall fetal lifetime risk of cancer increased by 2%

Imaging: Conventional Radiology

Estimated fetal radiation doses: C-spine (AP, lateral) <0.001 mGY

CXR (PA, lateral) 0.002 mGY

Abdomen (AP) 1-3 mGY

Head CT 0 mGY

Chest CT (PE protocol) 0.2 mGY

Abdomen and pelvis 25 mGY

Imaging: Computed Tomographic Examination

Modality of choice for: Intracranial pathology

Chest, abdominal, and pelvic injuries

Bladder injuries (CT cystogram)

IV contrast is FDA Category B medication Improves detection of maternal and fetal injuries by providing

vascular contrast in organs and opacification of vascular structures including the placenta

Radiologist detection of abruption is practitioner dependent

Imaging: Magnetic Resonance Imaging

Excellent choice for specific situations Spinal injuries

Complex spinal or spinal cord injuries

Complex neurological injuries

Soft tissue injuries

Also option for follow up testing

Although no evidence of harmful fetal effects: Potential effects of energy deposition, resultant tissue

heating in the fetus, and potential effects of acoustic noise.

Gadolinium FDA Category C

What is the expert consensus?

Suggested Reading

Brown HL. Trauma in Pregnancy. Obstet Gynecol 2009;114(1):147-160

Mirza et al. Trauma in Pregnancy: A Systematic Approach. Am J Perinatol 2010;27:579-586

Oxford CM and Ludmire J. Trauma in Pregnancy. Clin ObstetGynecol 2009;52(4):611-629

Murphy NJ and Quinlan JD. Trauma in Pregnancy: Assessment, Management, and Prevention. Am Fam Physician 2014;90(10):717-724.

Kilpatrick, SJ. Trauma in Pregnancy. In: UpToDate Post TW (Ed), UpToDate, Waltham, MA. Accessed on February 12, 2016.

Expert Opinion and Recommendations

First focus: primary assessment for major trauma Airway, Breathing, Circulation

Transfer to major trauma center if appropriate

Adequate IV access

Then complete secondary assessment Labs if major trauma:

CBC, CMP, KB, UA, urine toxicology, blood type and screen, crossmatch, PT/PTT, fibrinogen

Recommendations vary by source

Remember left lateral tilt (25 to 30 degrees)

Thorough physical examination


Initiate fetal monitoring in viable fetus as soon as patient is stabilized and continue for at least 4h (4 to 6h)

80% of abruptions will occur in first 4-6h, remaining abruptions usually detected within 24h

No adverse outcomes noted directly related to trauma when monitoring is normal and there are no early warning signs (vaginal bleeding, abdominal pain) and less than 6 contractions per hour (1 every 10 minutes)

Monitor for 24h if concerning symptoms or if frequent contractions (>1 every 10 minutes), regardless of perceived intensity of trauma

Non-reassuring FHR, vaginal bleeding, uterine tenderness, serious maternal injury, or positive KB warrant additional monitoring

20% risk of abruption if more frequent contractions


Although abnormal monitoring and early warning signs of vaginal bleeding, contractions, uterine or abdominal tenderness, and positive KB don’t necessarily predict PTL or adverse pregnancy outcome they do warrant increased surveillance and attention

Consider: Abnormal FHR not seen until 30% abruption

Fetal demise occurs at about 50% abruption

Sinusoidal FHR pattern suggestive of fetal anemia

Recognize concerning FHR pattern early


Perform Ultrasound Imaging for fetal assessment and gestational age

Perform other imaging and testing as indicated CT, XRay, MRI

Open peritoneal lavage

Give Rhogam if indicated 300mcg dose will neutralize 15ml fetal RBCs

Give antenatal corticosteroids if anticipate possibility of PTD

Exploratory laparotomy doesn’t necessarily require concurrent cesarean delivery


If patient is in preterm labor: Tocolysis not contraindicated

Avoid beta-mimetic agents because the associated tachycardia can mask signs of concealed hemorrhage and maternal clinical deterioration

Management with tocolytic agents, antibiotics, and antenatal corticosteroids

DVT prophylaxis


Thorough and detailed documentation on initial and subsequent exam findings

Carefully and accurately document because records likely to be revisited if significant maternal or fetal morbidity or mortality

For example, documenting urgent need for C/S within few hours after MVA is likely to be secondary to the MVA


Cardiopulmonary Resuscitation At best, CPR only provides 30% of normal cardiac output

CPR is less effective in pregnancy

Decreased maternal chest compliance

Aortocaval compression in supine further complicates CPR

Manually displace uterus to left


Perform perimortum C/S if viable gestational age Initiate within 4 minutes, deliver by 5 minutes

IMMEDIATE and DECISIVE decision for perimortum C/S if any hope of intact neonate

Don’t waste time going to the OR, cut at bedside with stat knife

Consider vertical laparotomy and classical uterine incision, transecting placenta if necessary for rapidity of delivery

Optimal fetal survival if delivery by 5 minutes

Intact Fetal survival becomes unlikely if more than 15-20 minutes have passed since the loss of maternal vital signs

67% intact survival if delivered in less than 15 minutes

Need to evacuate significantly gravid uterus for effective CPR


Aggressive volume replacement at 3:1 ratio to blood loss

Consider DIC and dilutionial coagulopathy with need for aggressive blood and factor repletion

Coagulopathy also seen with hypothermia

Maternal symptoms after 20-25% EBL (1.2-1.5L) Tachycardia, vasoconstriction, hypotension with above

Above plus tissue hypoxia, oliguria, hypotension with 25-35% EBL (1.5-2L)

Above plus hemorrhagic shock, altered consciousness, anuria, DIC with >30% EBL (>2L)


Provide education on seatbelt use

Lap belt should be placed low under the protruding abdomen

Shoulder belt should be displaced off the side of the uterus

If the lap belt is placed over the dome of the uterus, the increased pressure is transmitted to the uterus and increases the risk of significant injury


Screen for Intimate Partner Violence More than 1 out of 3 women have experienced IPV in lifetime but

true prevalence unknown

May be increased during pregnancy with increased severity of violence

Associated with poor pregnancy outcomes:

Poor weight gain, infection, anemia, tobacco use, stillbirth, pelvic fracture, placental abruption, fetal injury, PTD, LBW

Can include:

Physical injury, psychological abuse, sexual assault, progressive isolation, stalking, deprivation, intimidation, reproductive coercion

References

Brown HL. Trauma in Pregnancy. Obstet Gynecol 2009;114(1):147-160

Oxford CM and Ludmire J. Trauma in Pregnancy. Clin Obstet Gynecol 2009;52(4):611-629

Murphy NJ and Quinlan JD. Trauma in Pregnancy: Assessment, Management, and Prevention. Am Fam Physician 2014;90(10):717-724.

Schiff MA. Pregnancy outcomes following hospitalisation for a fall in Washington State from 1987 to 2004. BJOG 2008;115:1648-1654

Kady, D et al. Trauma during pregnancy: An analysis of fetal outcomes in a large population. Am J Obstet Gynecol 2004;190:1661-1668

Schiff MA et al. The effect of Air Bags on Pregnancy outcomes in Washington State. ObstetGynecol 2010;115(1):85-92

Vivian-Taylor J et al. Motor vehicle accidents during pregnancy: a population-based study. BJOG 2012;119:499-503

Raptis et al. Imaging of Trauma in the pregnant patient. RadioGraphics 2014;34:748-763

Mirza et al. Trauma in pregnancy: A systemic approach. Am J Perinatol 2010;27:579-586.

Kilpatrick, SJ. Trauma in Pregnancy. In: UpToDate Post TW (Ed), UpToDate, Waltham, MA. Accessed on February 12, 2016.

Cahill AG et al. Minor trauma in pregnancy-is the evaluation unwarranted? Am J ObstetGynecol 2008;198:208.e1-208.e5

Intimate partner violence. Committee Opinion No. 518. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;119:412-417

Critical care in pregnancy. Practice Bulletin No. 158. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e21-28

Guidelines for diagnostic imaging during pregnancy and lactation. Committee Opinion No. 656. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e75-80

Additional Resources

Recommended reading resources include several trauma assessment and evaluation algorithms

UNC algorithm: http://www.mombaby.org/PDF/TraumaInPregnancy.pdf

Thank You!

Trauma in Pregnancy - Ob Hospitalist Group · Trauma impacts 5-9% of all pregnancies ... Murphy et...

Documents

Transcript of Trauma in Pregnancy - Ob Hospitalist Group · Trauma impacts 5-9% of all pregnancies ... Murphy et...