Trauma in pregnancy praneel
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TRAUMA IN PREGNANCY
Praneel Kumar Bundaberg Hospital Emergency
Department
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Outline
Introduction Take home point A & P changes in pregnancy and clinical
significance Emergency management Traumatic Complications Of Pregnancy
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Introduction
7% of all pregnancies 8% of women age 15-40 admitted to
trauma centre do not know they are pregnant
Order of frequencies – MVA – Interpersonal Violence and falls
Viable fetus – 24 to 26 weeks of gestation or extimated fetal weight of 500gram
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Take Home Points
Maternal Life takes Priority The best chance of fetal survival is
maternal survival Initial management – ATLS protocol with
some caveats Imaging should not be withheld if it
provides significant diagnostic information
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Anatomical Changes
Uterus – 12 weeks intrapelvic / 20 weeks umbilicus and costal margin by 34 to 36weeks
Diaphragm rises as pregnancy progress – significance
Abdominal viscera are pushed upward by enlarging uterus
Stretching abdominal wall modifies normal response to peritoneal irritation – guarding /rebound can be blunted despite significant bleeding and injury
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Anatomical Changes
Bladder displaced into abdominal cavity after 12weeks
Baseline diastasis of the pubic symphysis may exist – can be mistaken for pelvic disruption on a radiograph
AND REMEMBER SUPINE HYPOTENSION SYNDROME
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Physiological Changes CVS
BP – declines in the first trimester/ level out in 2nd trimester and return to no pregnant level in the 3rd Trimester ( Systolic decline of 2-4mg and diastolic decline of 5-15mg ) ?? Significance
HR – does not rise by more than 10-15 beats per minute
Blood volume – may increase to as much as 45% peaking at 32 -34weeks of gestation with 25% increase in RBC – physiological anemia
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Physiological ChangesCVS
Marked venous congestion in the pelvic and lower extremities in the 3rd trimester – increasing potentional of hemorrage from both bony and soft tissue pelvic injuries
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Physological changes Pulmonary
Reduced oxygen reserve – due to decrease FRC caused by Diaphragm and increase in O2 consumption
Minute ventilation increases leading to hypocapnea
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Physiological Changes GI
Gastro esophageal sphincter response is reduced and GI motility is deceased
Increased risk of aspiration
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EMERGENCY MANAGEMENT
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Primary SurveyABCDEF
GET YOUR TEAM READY Airway - Intervene as early as possible- Prolong bag mask ventilation increase risk of
aspiration ( already increased abdominal pressure and decreased lower esophageal tone
- Difficult airway – proportion of Mallampati class 4 increase by 34% from 12 to 38weeks
- NG decompression – to be performed to minimize the risk of ongoing Aspiration
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Breathing -Supplemental oxygen in all patient –Fetus
vulnerable to hypoxia -Apnoeic oxygenation during RSI - Remember the diaphragm during
thoracostomy – use ultrasound to confirm where diaphragm is
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Circulation - Significant blood loss before hypotension - Displace uterus to the Lt after 20weeks of
gestation – either manually or tilting the backboard with wedge or pillow
- RH Neagtive blood should be used - AVOID VASSOPRESSORS – decrease
uterine blood flow
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Disability/Dextrose- Same as non pregnant – GCS /Pupil and
gross motor function and sensation Exposure and Environment- Examine all areas of the body - Log roll
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F- FAST /FINGER / FOLEYS / FAMILY + FETUS
- EFAST - Finger – check every orifice for bleeding - Foleys – IDC if indicated - Family
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FETUS - Use bedside ultrasound –HR and
movement - CTG ideal –minimum observation is
4hours- HR 120 -160 - Be-aware Very Angry Doctor Coming - Fetal distress can be sign of occult
maternal distress
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Secondary Survey
Similar in general to non pregnant patient Specific emphasis on abdominal and
Vaginal examination - Abdomen : fundal height – age / decrease
may suggest traumatic PPROM - Vaginal: preferably by obstetric
specialist / evaluate vaginal lac or bony fragment and fluid
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IMAGING
Use it if needed Radiation risk – teratogencity,birth defect and
increase life time risk of malignancy Loss of viability – risk greatest in the first 2
weeks post conception /risk with failure to implant at 50rad
Radiation induced malformation at 2-15weeks - Small head size / mental retardation/ organ
malformation - Afer 25 weeks – lifetime increase in malignancy Risk negligible < 5 rads exposure Risk increases > 15 rads exposure
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Approximate Fetal Radiation Dose
Study Dose (rads)
Chest X-ray <0.001
Pelvis 0.04
CT Head <0.05
CT Chest 0.01-0.2
CT Abdomen 0.8-3.0
CT Pelvis 2.5-7.9
Spine series 0.37
9 month background dose
0.1
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Complications
Placental Abruption- Most common cause of fetal death - Vaginal bleeding / abdominal cramps /
uterine tenderness/ fetal distress- Ultrasound – 50% sensitive - 3.9 fold increase in Preterm labour - More likey to have DIC
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Uterine Injury-Rare, but always consider in significant
trauma-Associate with near 100% fetal death rae-Cause:Pelvic fractures striking uterus:Penetrating trauma:Inappropriate seatbelt placement, too high-can lead to uterine contractions
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Fetomaternal Hemorrage - Rh –ve mum /Rh positive baby- All RH –ve women sustaining abdo
trauma should receive RH immune globulin
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Mother stable/Fetus stable Mother stable / Fetus Unstable Mother Unstable /Fetus Unstable
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Take Home Points
Maternal Life takes Priority The best chance of fetal survival is
maternal survival Initial management – ATLS protocol with
some caveats Imaging should not be withheld if it
provides significant diagnostic information
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