1. Trauma x Two: The Pregnant Victim Douglas S. Ander, MD Emory University School of Medicine Professor of Emergency Medicine Assistant Dean for Medical Education

2. Disclosures  “I, Douglas Ander, have no real or perceived vested interests that relate to this presentation nor do I have any relationships with pharmaceutical companies, biomedical device manufacturers, and/or other corporations whose products or services are related to pertinent therapeutic areas.”

3. Frequently Asked Questions  What are the statistics?  What is the role of domestic violence?  How do the physiologic changes of pregnancy affect management?  How to I recognize the possibility of fetomaternal injuries?  How do I recognize abruptio placenta?  What do I need to know about fetal monitoring?  Should pregnant women wear seatbelts?  What do I do when my patient codes?  What is the significance of fetomaternal hemorrhage?  What xrays should I do?

4. What are the statistics?

5. Introduction  Accidental injury occurs in 6-7% of all pregnancies  Trauma is the leading cause of maternal death, 46.3%  Overall 6-7% maternal mortality  Fetal mortality 61% in major trauma, 80% if cases of maternal shock  < 1% of trauma admissions are pregnant Peckham CH et al. Am J Ob Gyn 1963;87:609 Fildes J et al. J Trauma 1992;32:643 Connolly A et al. Am J Perinatol 14:331-336, 1997

6. Causes of Trauma Drost et al. J Trauma 1990;30:574.

7. What is the role of intimate partner violence?

8. Domestic Violence  154 acts of violence per 1000 pregnant women during first 4 months, increases to 170 per thousand during the 5-9th months.  Only 8 of 24 sought medical care  May lead to increased complications  41.8% vs. 11.8%, P<.01  17.1% (assault) vs. 7.1% (MVC) 1985 National Family Violence Study, Helton AS et al. Am J Public Health 1987;77:1337 Pak LL et al. Am J Ob Gyn 1998;179:1140 Goodwin and Breen. Am J Ob Gyn 1990;162:665

9. How do the physiologic changes of pregnancy effect management?

10. Cardiovascular  Plasma volume increases by 50%  Heart rate increases by 10-15 bpm  Cardiac output increases by 40-50%  Total peripheral resistance decreases  Oxygen consumption increases by 20%  Decrease in venous return

11. Cardiovascular  30-35% decrease in maternal blood flow can cause a 10-20% decrease in uterine blood flow prior to detectable hemodynamic changes in the mother  Warm and pink shock patient

12. Respiratory  Decrease in functional residual capacity  Decreased oxygen reserve  Increased risk of maternal hypoxemia during RSI

13. Gastrointestinal  Decreased motility and tone  Increased risk of aspiration  Stretching of abdominal wall  Decreased response to peritoneal irritation

14. Anatomic  Diaphragm rises 4cm  Perform thoracotomy 1-2 interspaces higher  Compartmentalization of the small intestine into the upper abdomen  Increased risk injury  Uterus may shield the intestines  Increased cardiac output to uterus  Increased risk for significant hemorrhage

15. Supine Hypotensive Syndrome Milson I, Forssman L: Am J Obtst Gynecol 148: 764-771, 1984

16. How to I recognize the possibility of fetomaternal injuries?

17. Major Trauma  24% of the women died  All fetuses expired  Average gestational age 22.4 weeks  Of the 31 who survived  6 fetal deaths  4/6 of abruptio placenta  8/10 women in shock had fetal demise Rothenberger et al. J Trauma 1978;18:173

18. Minor Trauma  Pearlman  75/75 no fetal death, 3 abruptio placentae  Goodwin  5 abruptio placentae  Schiff  Relative risk for abruption in non-severe trauma, 3.7 (1.3-7.9)  Morris  3/5 infants considered salvageable died from mothers with mild to moderate injury, ISS < 16  Cahill  317 patients, ISS 0, only 1 abruptio placentae which was unrelated to the trauma

19. How do I recognize abruptio placenta?

20. Recognition of abruptio placentae - >20 wks  Pearlman et al  No women had an abruption if no uterine contractions were detected or if their frequency was less than every 10 minutes during 4 hours of monitoring after trauma was sustained Pearlman et al. Am J Obstet Gynecol 1990;162:1502-1510.

21. Monitoring Recommendations  All women >20-week gestation:  Minimum 6 hours monitoring  Extended to 24 hours if :. >3 contractions per hour. Persistent uterine tenderness. Non reassuring fetal monitor strip. Vaginal bleeding. Rupture of membranes. Serious maternal injury  Controversy based on the minor trauma literature

22. What do I need to know about fetal monitoring?

23. Fetal Monitoring  Heart rate  Bradycardia <110 bpm  Tachycardia >160 bpm  Variability  Presence of decelerations

24. Variability

25. Fetal Monitoring: Late Decelerations  Onset is 30 seconds or more after onset of the contraction, nadir well after the peak contraction and returns to baseline after the contraction is over  Fall of 10-20 bpm  Always believed to indicate fetal distress

26. Seatbelts in pregnancy?

27. Seatbelt Statistics  Most wore restraints before pregnancy, but increased restraint use during pregnancy (79% vs. 86%, chi squared, p = 0.02)  Only 52% - 72.5% used restraints properly  55.3% reported that restraints would protect their baby, 10.7% harm and 34.0% unsure  If they felt restraints were beneficial they were more likely to always wear restraints ( 84.4% vs. 64.6%, p<0.0001)  Only 21% - 36.9% of women were educated on proper restraint use during pregnancy. Tyroch et al. J Trauma 1999;46:241 Mcgwin et al. J Trauma 2004;56:670

28. Seatbelt Evidence RisksFetal DeathPlacental Abruption Odds Ratio 95% CIOdds Ratio 95% CI Ejection32.87.5-144.56.11.1-33.5 Restrained0.2300.071-0.742NS Curet MJ et al. J Trauma 2000;49:18

29. Proper seatbelt use is key Air bag had no effect on force transmission.

30. What do I do when my pregnant trauma patient codes?

31. Resuscitation  Mom first  Most common cause of fetal demise is maternal demise  B-HCG on all child bearing age patients

33. Perimortem Cesarean Section Survival  Maternal CPR <5 minutes, fetal survival excellent  <23 weeks gestation survival chance is 0%  Maternal CPR >20 minutes, fetal survival unlikely

35. Technique

36.  Ideally started within 4 minutes

37. What is the significance of fetomaternal hemorrhage?

38. Fetomaternal Hemorrhage  As little as 5 cc can sensitize Rh-negative women  Increased risk of abruptio placentae and predictor of preterm labor – some controversy  KB analysis all patients >12 week-gestation  Rhogam for all Rh-negative pregnant patients  As a rule can give 300mcg of Rhogam for every 30cc of fetal blood detected in maternal circulation Dahmus MA et al. AM J Ob Gyn 1993;169:1054. Goodwin TG et al. Am J Ob Gyn 1990;162:665 Rose PG et al. Am J Ob Gyn 1985;153:844 Dhanraj d et al. Amer J Ob Gyn 2004;190:1461 Pearlman et al. Am J Obstet Gynecol 1990;162:1502-1510 Meunch et al. J Trauma 2004;57:1094-1098

39. What xrays should I do?

40. Radiology  Perform clinically indicated studies  Below 5 rads (50 mGy) exposure no significant risk  Shielding of the abdomen provides additional protection by as much as 75%

41. Radiology  Most common fetal malformation caused by high-dose radiation are CNS changes  2-15 weeks gestation  At least 20 – 40 rad  Slight increase in leukemia  Background rate of leukemia in children is about 3.6 per 10,000  Exposure to 1-2 rad increases this rate to 5 per 10,000

43. US for Trauma in Pregnancy Richards et al. Radiology 2004; 233:463–470 Negative FAST is valuable

44. US for Abruptio Placentae Glantz et al. J Ultrasound Med 21:837–840, 2002 Specific not sensitive

45. Xrays to perform?  Those that are clinically relevant Radiation Safety Poster From 1947

46. Trauma in Pregnancy Key Points  Remember domestic violence  Consider physiologic changes  Early monitoring and a minimum of 4 hours  Seat belt education  Resuscitate the mother  Rhogam and KB testing  Failed resuscitation consider c-section  Use radiologic procedures appropriately  Ultrasound has value in trauma evaluation

47. Questions? Douglas Ander, MD dander@emory.edu