1. Two for One: Caring for the Pregnant Trauma Patient Nabil Alzadjali FRCP III McGill University

2.  CASE 1 25 Yrs F, 35 wks Preg. PC : MVC PMH : nil, Rh +ve, HPI : Driver, belted, rear ended by another car, air bag deployed Complaining of occasional abdominal pain, ?cramping. Unsure about fetal movements. Very concerned regarding fetal well being. ABC stable. BP 120/70 HR 88 RR 15 No signs of injuries on exam. FHR 140, No uterine contractions palpable. No guarding. No lap belt sign. No PV bleeding. Os Closed  How do we manage this patient?

3.  CASE 2 20 Yrs F, 30 weeks gestation Struck by truck across the street from hospital. Cardiac arrest at scene. U/G Technician have intubated and started CPR. Down time about 5 minutes. Arrival in ER, Pulseless Electrical Activity.  How do we manage this patient?

4.  Incidence  Physiological Alterations  Anatomical Alterations  Unique Problems in the Gravid Abdomen  Prehospital Considerations  Diagnostic Studies  Management of trauma  Unstable Mother  Stable Mother  Perimortem Cesarean Section

5. Incidence  The Leading cause of non-obst. mortality - 46%  Trauma during pregnancy - 7%  Causes of Trauma (1)  MVA 54.6 %  Domestic abuse & Assault 22.3 %  Falls21.8 %  Penetrating inj.1.3 %  < 1% of trauma admissions are pregnant  Preterm Labor in 11.4 % & P. Abruption in 1.58 % (1) Connolly A, Katz VL, Bash KL, et al: Trauma and pregnancy. Am J Perinatol 14:331-336, 1997

6. Physiological Changes During Pregnancy

7. Hemodynamic Changes of Pregnancy (Mean Values) Non P.Trim. 1Trim. 2Trim. 3 HR70788285 Sys. BP115110102114 Dias. BP70606370 C. Output4.5 66 CVP9.07.54.03.8 Bld V (ml)4000420050005600 Hct with Fe (%)40363436 WBC (cell/mm 3 )7200910097009800

8. Supine Hypotensive Syndrome (1) (1) Milson I, Forssman L: Factors influencing aortocaval compressionin late pregnancy, Am J Obtst Gynecol 148: 764-771, 1984

9.  Respiratory  Respiratory alkalosis  Reduce oxygen reserve (reduced FRC 20% & increased O2 consumption by 15 %)  Residual volume decreased by 40%  Respiratory rate increased  Impaired buffering capacity

10.  GI  Intestine are concentrated in upper abdomen  Decrease GI motility  Decrease peritoneal irritation  GU  Bladder is displaced upward >10 wks  Dilitation of renal pelvis and ureters

11. Alterations in Anatomy  1st trimester uterus is thick walled and intra- pelvic  Out of pelvis > 12 wks.  Second trimester uterus contains large amount of amniotic fluid  Third trimester uterus is thin walled, large Fetal head engaging pelvis  At 36 weeks uterus reaches costal margin

12. Injuries unique to pregnancy  Premature Contractions  Rarely progress to preterm delivery  Tocolysis is not proven in trauma. (1)  Abruptio Placentae  Different elastic properties in uterus & placenta “shearing”  3 % of minor trauma and upto 50 % in severe trauma (1) GoodwinTM, Breen MT: Pregnancy outcome and fetomaternal hemorrhage after noncatastrophic trauma, Am J Obstet Gynecol162: 665-671, 1990.

13.  Uterine Rupture  Rare, 0.6 % of severe abdominal trauma (1)  Direct trauma after 12 wks of gestation  Prior Surgery (C/S or Myomec.) the risk  Maternal-Fetal Hemorrhage  Trimesters 1 3%, T2 12%, T3 45%  4-5 X more common in injured pregnant women  Causes isoimmunization & fetal death  Kleihauer-Betke test - volume of fetal blood .01-.03 cc sensitize, 5 cc +ve KB Test.  To determine amount of Rhogam needed 1. Pearlman MD, Tintinalli JE, Lorenz RP: Blunt trauma during pregnancy, N Engl J Med 323:1609, 1990

14. Special Considerations  Blunt Abdominal Trauma  Penetrating Abdominal Trauma  Stabbing injury  Gunshot injury

15. Blunt Trauma  Injuries  Head injury most common  Retroperitoneal hemorrhage  Abruptio placenta  DIC  Uterine Rupture  Seatbelts – 3 Points Restraints  1/3 – ½ improperly or don’t use belts  Unbelted is at 2.3X to give birth <48 hrs & 4.1X fetal death

16. Penetrating Injury GSW’s  Gravid uterus alter injury pattern to the mother.  If missile enter upper abdomen; increased probability of harm (upto 100%).  If enters below uterine fundus visceral injury less likely (0%)  Awwad et al (1)  Fetal death rate is 67%  38 % for injuries above the uterus. (1) Awwad JT et al: High-velocity penetrating wounds of the gravid uterus: Review of 16 years of civil war, Obstet Gynecol 83:259, 1994.

17.  Stabbing Injury  Rare rare, only 19 cases reported in literature  Morbidity 93 % - Mortality 50 %  Many advocate exploratory laprotomy since uterus laceration is devastating b/c of its enlarged circulation.  Meizner et al (1)  An injury to uterus can rapidly change to a hypotensive emergency.  It is difficult to know the size and depth of uterine rupture (1) Meizner I, Potashnik G: Sharpnel penetration in pregnanc resulting in fetal death, Isr J Med Sci 24:431, 1988.

18. Pre-hospital Consideration  Oxygen  Shock should be anticipated  ED should be notified early, GA >24 wks  Transport in L lateral position (GA > 20 wks) National Association of EM Physician, 1997 “PASG – class III intervention” worsen the supine hypotension

19. Diagnostic Studies

20. Modalities for Evaluating Trauma  Plain Films – X-rays  Ultrasound  CT & MRI  Cardiotocographic Monitoring  DPL  Laparotomy

21. Plain Films  Risk of 1 rad to fetus is approx. 0.003  < 5-10 rads causes  No risk on congenital malformation, abortions or intra-uterine growth ret.  Smaller risk of increase in childhood cancer  Radiation doses > 10 rads  6 % chance of severe mental ret.  < 3 % chance childhood cancer.

22. Radiographic examination Dose to Ovary/Uterus-mrad Low Dose Group: Head C-Spine Thoracic Spine Chest Extremities <1 High Dose Group: Lumbar Spine Pelvic Hip Intravenous pyelogram Urethrocystogram KUB 204 – 1260 190 – 357 124 – 450 503 – 880 1500 200 – 503 Rosenstein M:Handbook of selected organ doses for projections common in diagnostic radiology. HEW publication(FDA) 89-8031. Rockville, MD. US Dept. Of Health And Human Services, Centre For Devices And Radiologic Health, 1988.

23. Ultrasound  Best modality to assess both fetus and mother  Not sensitive:  Colonic lesions  Biliary tree lesions  Sub-placental hematoma  Safe procedure

24. CAT SCAN  Complementary to U/S & DPL  Penetrating wounds of flank & back  Can miss diaphragmatic and bowel injuries  Portability  Spiral CT reduces radiation exposure by 14-30 %

25. Radiographic examinationDose (mrad) Computed Tomography Head (1 cm slice) Chest (1 cm slice) Upper Abdomen (20 slices 2.5 cm above uterus) Lower Abdomen (10 1 cm slices over the uterus/fetus) < 50 < 1000 < 3000 3000 – 9000 Angiography Cerebral Cardiac Catheterization Aortography < 100 < 500 < 100 Rosenstein M:Handbook of selected organ doses for projections common in diagnostic radiology. HEW publication(FDA) 89- 8031. Rockville MD,. US Dept. Of Health And Human Services, Centre For Devices And Radiologic Health, 1988.

26. Cardiotocographic Monitoring  FHR  Rate (120-160)  Beat-to-beat variability  Baseline variability  Decelerations, esp. late

27. Cardiotocographic Monitoring Variability:

28. Cardiotocographic Monitoring Decelerations: Early and Late

29. Cardiotocographic Monitoring Decelerations: Variable

30. Diagnostic Peritoneal Lavage  CT & U/S are better in stable patient.  Hypotensive unstable pt and if bedside U/S is not available  Can be performed in any trimester  Gravid uterus does not reduce the accuracy of DPL for OR  Limited in detecting bowel perforation and does not assess retroperitoneal hemorrhage or intra- uterine pathology

31. Diagnostic Peritoneal Lavage  Rothenberger et al (1)  n=12 (4 Supra umbilical & 8 infra umbilical)  Sensitivity 100 % (8 internal bleeding confirmed by lapratomy),  Specificity 100 % ( 4 no bleeding)  No Complications from the procedure  Esposito et al (2)  n=40, 13 had DPL  PPV = 100 % (1)Rothenberger DA, et al:Diagnostic peritoneal lavage for blunt trauma in pregnant women, Am J Obstet Gyneco 129:479-48,1977. (2)Eposito TJ, et al: Evaluation of blunt abdominal trauma occurring during pregnancy, J Trauma 29:1628-1632, 1989.

32. Management  Avoid distractions and avoid focus on the fetus  Be aggressive! But temper with common sense.  An apparently stable mother may be compensating at expense of the fetus  If < 24 weeks, intermittent fetal doppler  If > 24 weeks, then continuous cardiotocographic monitoring to assess FHR and uterine activity

33. I. Initial maternal Resuscitation Airway Assess & control Preoxygenate and sellick’s maneuver is important before intubation Breathing Assess and manage Place CT in 4 th intercostal space Circulation Assess maternal circulation IV access Telt to left if > 20 wks

34. Management  The hemodynamically unstable mother  The hemodynamically stable mother

35. II. The hemodynamically unstable mother

36. Fetal Viability Weeks gestation 6-month survival (%) Survival with no severe abnormalities (%) 2200 23152 245621 257969 Data from Morris JA Jr et al: Ann Surg 223:481, 1996.

37. III. The hemodynamically stable mother Stable fetus  Minor trauma does not exclude significant fetal injury; 1-3 % of all minor trauma results in fetal loss from placenta abruption. (1)  Asymptomatic mother or with no obvious abdominal injury needs monitoring for feto- placental pathology (1) Pearlman MD, Philip ME: Safety belt use during pregnancy, obstet Gynecol 88: 1026, 1996

38. 1. Pearlman MD, Tintinalli JE, Lorenz RP: Blunt trauma during pregnancy, N Engl J Med 323:1609, 1990 Pearlman et al (1)  Minimum 4 hrs CTG monitoring  Extended to 24 hrs if :. >3 contractions per hour. Persistent uterine tenderness. Non reassuring fetal monitor strip. Vaginal bleeding. ROM. Serious maternal injury present  All placental abruption were detected within 4 hrs  70 % of pt required admission.  All discharged home subsequently had live birth.

39. III. The hemodynamically stable mother Unstable fetus  Fetal death rates are 3-9 times higher than mat.  No infant survive if there is no fetal heart tone before C/S  Morris et al (1)  Heart tone is best survival marker for f. to undergo C/S  If fetal heart tone is present and the GA is > 26 wks the survival is 75%  60 % of fetal death occurs with under use of CTG and delay recognition of fetal distress.

41. Perimortem Cesarean Section  ~200 successful cases reported in the literature  Maternal CPR <5 minutes, fetal survival excellent  <23 weeks gestation survival chance is 0%  Maternal CPR >20 minutes, fetal survival unlikely

42. Fetal Viability Weeks gestation 6-month survival (%) Survival with no severe abnormalities (%) 2200 23152 245621 257969 Data from Morris JA Jr et al: Ann Surg 223:481, 1996.

43. Perimortem Cesarean Section  4 Minute Rule: Maternal CPR for 4 minutes, Infant should be delivered by the 5 th minute.

44. Perimortem Cesarean Section  Technique:  Make sure it is indicated first and that resuscitative team is ready  Vertical incision from xyphoid to pubis  Continue straight down through abdominal wall and peritoneum  Cut through uterus and placenta (if anterior)  Bluntly open uterus and remove fetus  Cut and clamp cord

45. Summary  Anatomic and physiologic changes  Vigorous fluid and blood replacement  Treat the mother first and treat her just like any other trauma patient  High index of suspicion for blunt or penetrating uterine trauma & abruptio placenta.  Consider perimortem C/S in unstable women or cardiac arrest with viable fetus after 24 wks.

46. When to Intervene and Consult EARLY !

47. What is Best for the Mother is Best for the Fetus! Remember

48. Questions ?