Asessment of pregnant trauma patient.Cal

ASSESSMENT AND PREOPERATIVE CARE IN PREGNANT TRAUMA PATIENT : 

ASSESSMENT AND PREOPERATIVE CARE IN PREGNANT TRAUMA PATIENT Yard. Doç. Dr. Eray Çaliskan Kocaeli University, School of Medicine Department of Obstetrics and Gynecology

BACKGROUND : 

BACKGROUND Leading non-obstetric cause of death in pregnancy, 6-7% of maternal deaths For innercity socioeconomic and ethnic groups 20-46% of maternal deaths 1 in 14 pregnant women will experience some sort of trauma 3-4 out of 1000 pregnant women will require ICU for their injuries Connolly et al, Am J Perinatol, 1997, Hill et al, Am Fam Physician, 1996

BACKGROUND - CAUSE : 

BACKGROUND - CAUSE 22-35% of women presenting with any complaints to emergency have in fact injuries related to physical abuse Domestic violence should be screened in blunt trauma patient via questionnaires

FIRST TRIMESTER : 

FIRST TRIMESTER Uterus: Intrapelvic and thick-walled Fetus protected from direct injury Risks Abortion Isoimmunization

SECOND TRIMESTER : 

SECOND TRIMESTER Uterus: Extrapelvic Large volume of amniotic fluid Risks Abruptio placenta Amniotic fluid embolism Isoimmunization

THIRD TRIMESTER : 

THIRD TRIMESTER Uterus: Thin walled Maternal abdominal viscera displaced Inferior vena cava compression

THIRD TRIMESTER : 

THIRD TRIMESTER Risks Pelvic fractures with maternal hemorrhage and direct fetal injury Abruptio placenta Amniotic fluid embolism Isoimmunization

IMPORTANT MATERNAL PHYSIOLOGICAL HINTS : 

IMPORTANT MATERNAL PHYSIOLOGICAL HINTS Systolic blood pressure: Decreased by 5-15 mmHg Diastolic blood pressure: Decreased by 5 to 15 mmHg Electrokardiogram: Flat or inverted T waves in leads II, V1 and V2 Q waves in leads III and aVF Blood volume: increased by 30 to 50% White Blood Cell: May be increased 5000-15000/mm3 Fibrinogen: Increased; 264 to 615 mg/dL D-dimer: Frequently positive

IMPORTANT MATERNAL PHYSIOLOGICAL HINTS : 

IMPORTANT MATERNAL PHYSIOLOGICAL HINTS Respiratory rate: Increased by 40-50% Oxygen consumption: Increased by 15-20% at rest Partial pressure of O2: Increased 100 to 108 mmHg Partial pressure of CO2: Decreased 27 to 32 mmHg Bicarbonate: Decreased 19 to 25 mEq per L Base excess: Present; 3 to 4 mEq/L Blood urea nitrogen: Decreased 3 to 3.5 mg/dL Serum creatinine: Decreased 0.6 to 0.7 mg/dL

IMPORTANT MATERNAL PHYSIOLOGICAL HINTS : 

IMPORTANT MATERNAL PHYSIOLOGICAL HINTS Kidneys: Mild hydronephrosis Gastrointestinal tract: Decreased gastric emptying, decreased motility, increased risk of aspiration Muskuloskeletal system: Widened symphisis pubis and sacroiliac joints Diaphragm: Higher position in pregnancy; chest tubes should be placed one or two interspaces higher Peritoneum: Small amounts of intraperitoneal fluid is normally present

TRAUMA PREVENTION : 

TRAUMA PREVENTION Correct positioning of seat belts Use shoulder harness Enlarged abdomen, decreased exercise capacity, increase the frequency of falls Screen all pregnant women for domestic violence Use questionnaires Consult social service Consult law enforcement agencies

INITIAL ASSESSMENT : 

INITIAL ASSESSMENT Stabilize the patient standart ABC Rapid maternal respiratory support Prevent aspiration; nasogastric emptying, intubation Prevent supine hypotension syndrome: place patient on a backborad with 15º angle to the left or 30º lateral tilt beyond 24 weeks of gestation, Avoid femoral access: distribution of medication may be altered by the compression of gravid uterus

REFER TO TRAUMA CENTER : 

REFER TO TRAUMA CENTER Glascow Coma Score less than 14 Respiratory rate <10 or >29 per minute Systolic blood pressure < 90 mmHg Revised trauma score less than 11 Penetrating injury, mechanism of injury Specific for pregnancy Pulse >110 beat/minute Chest pain, loss of conciousness Third trimester of pregnancy

ESTIMATION OF GESTATIONAL AGE : 

ESTIMATION OF GESTATIONAL AGE Ask the patient or the partner Last menstrual period Search patient files, previous ultrasound exams Symphisis to uterine fundus height Obstetric ultrasound Number of fetuses Viability Hemorrhage Fetal age

FACTORS ASSOCIATED WITH INCREASED FETAL MORTALITY AFTER TRAUMA : 

FACTORS ASSOCIATED WITH INCREASED FETAL MORTALITY AFTER TRAUMA Maternal hypotension High maternal injury severity score Ejection from a motor vehicle Maternal pelvic fracture Automobile vs pedestrian accidents Maternal history of alcohol use Young maternal age Motorcycle crashes Maternal smoking history Uterine rupture

THE FETUS : 

THE FETUS Continue O2 and iv fluid supplementation until hypovolemia, hypoxia and fetal distress resolve Replace blood loss with blood whenever possible to increase O2 delivery to the fetus Both depolarizing and non-depolarizing muscle relaxants cross placenta Considerable fetal and intrauterine bleeding may occur without external bleeding

ASESSMENT IN THE REFERRAL CENTER : 

ASESSMENT IN THE REFERRAL CENTER Pre-alerted multispeciality team should receive the patient Revise ABC Diagnostic studies Operative interventions Decision making on the faith of pregnancy fetal resuscitation >24 weeks of gestation

MULTIDISIPLINARY APPROACH : 

MULTIDISIPLINARY APPROACH Emergency Physician Neonatologist Trauma Surgeon Obstetrician Fetal monitoring Complications C-section Fetal viability Rudloff U, Trauma in pregnancy, Arch Gynecol Obstet, 2007

FETAL SAFETY FOR RADIATION INDUCED TERATOGENESIS : 

FETAL SAFETY FOR RADIATION INDUCED TERATOGENESIS Patel SJ et al, RadioGraphics, 2007

FETAL SAFETY - CT : 

FETAL SAFETY - CT Radiation exposure at CT is low when the fetus is outside the field of view CT of the head, neck or extremity can be safely performed at any trimester of pregnancy Chest CT is a low risk procedure when the fetus is avoided from the primary beam Abdominal and pelvic CT are high risk procedures- consider risk and benefit

FETAL SAFETY : 

FETAL SAFETY No known harmful effects at 1.5 Tesla or lower magnetic fields Intravenous contrast imaging should be avoided After maternal trauma concerns about fetal radiation exposure should neither deter nor delay radiologic evaluation Counselling the pregnant patient is improtant to decrease anxiety

Slide 22: 

Pregnant patient post trauma (blunt or penetrating) Maternal stabilization (ABC of resuscitation) Assess Maternal Injury Obstetric USG as soon as possible - Assess fetal viability - Placental abruption Head & Neck Injury Chest Injury CT head & Cervical spine Abdominal Injury Pelvic Injury MRI for subtle injury Portable chest X-ray Chest CT with contrast if vascular inj. Abdominal USG Abd. CT with iv or oral contrast Uretheral injury Pelvic X-ray for fractures Conventional retrograde cystography not CT CT pelvis if needed

EVALUATION OF THE FETUS : 

EVALUATION OF THE FETUS Speculum examination; vaginal bleeding, fetal to maternal hemorrhage, premature rupture of the membranes Kleihauer Betke test for testing the amount of fetal Hb in the maternal circulation External fetal monitoring: fetal heart rate Obstetric ultrasound: fetal viability, placental abruption, uterine rupture, pelvic hematoma

PENETRATING ABDOMINAL TRAUMA : 

PENETRATING ABDOMINAL TRAUMA Gun shot wounds: 19% risk of visceral injury, 3.9% maternal death Fetal mortality is 70% Enlarged uterus, shielding half of the abdominal cavity Penetrating injury involving upper part of the peritoneal cavity; increased frequency of multiple visceral injuries

Slide 25: 

Penetrating abdominal trauma in pregnancy Hemodynamically unstable Stable vital signs Viable Fetus Entrance wound below umbilicus and no peritoneal signs Explorative Laparotomy Continuous fetal monitoring Delivery if =36 wks of gestation Damage control and delivery Acidosis, coagulopathy, hypothermia + - Dead Fetus Distressed Fetus Expectant management Expectant management Explorative laparotomy and delivery

LEGAL CONSIDERATIONS : 

LEGAL CONSIDERATIONS Maternal and paternal consent should be obtained for all interventions Teratogenicity Anesthesia Surgery Termination of pregnancy For all interventions maternal well being is utmost importance in overall decision making

PERIMORTEM DELIVERY : 

PERIMORTEM DELIVERY Consider in women beyond 24 wks of gestation Start within 4 min of maternal arrest Good results within 20 min of dynamic arrest 60% fetal survival with favorable neurologic outcome Large Vertical midline incision should be preferred Paternal consenting is not necessary

CONCLUSION : 

CONCLUSION Multidisciplinary approach is mandatory Maternal well being is the priority Maternal and paternal consenting for all interventions is important Domestic violence screening is one the most important preventive measure