Management of the Pregnant Trauma Patient

Transcription

1 Management of the Pregnant Trauma Patient Yasser Y. El-Sayed, M.D. Associate Professor and Associate Chief Maternal-Fetal Medicine and Obstetrics Stanford University

2 Trauma in Pregnancy Historical Perspective Etiologies and Scope of the Problem Physiologic Considerations in Pregnancy General Approach to Pregnant Trauma Patient Catastrophic Trauma Noncatastrophic Trauma Causes and Sites of Injury

3 Trauma in Pregnancy Etiology Motor vehicle accidents 55% Assaults -22% Falls 22% Burns 1%

4 Trauma in Pregnancy Scope of the problem Leading cause of non-obstetric obstetric maternal death in the U.S. Accounts ~20 % of maternal deaths 8-10% of pregnancies 0.4% of all pregnant patients require hospitalization to treat trauma

5 Trauma in Pregnancy scope of the problem Risk of Spontaneous abortion Stillbirth Stillbirth Placental Placental Abruption Preterm Preterm Labor PPROMPPROM Fetal loss exceeds maternal loss by >3 to 1 Fetal death - maternal shock/death & abruption Direct fetal injury complicates <1% of trauma

6 Trauma in Pregnancy Fetal Mortality Risk Factors Maternal acidosis, hypoxia, shock High Maternal Injury Severity Score Severe head injury Major injury to thorax, abdomen Maternal pelvic fracture Direct utero-placental injury

7 Catastrophic and Non-catastrophic Trauma Catastrophic Trauma life-threatening e.g. Maternal shock, head injury resulting in coma, emergency laparotomy 40-50% fetal loss Noncatastrophic Minor, non-life life-threatening 1-5% fetal loss >50% of all fetal losses from minor trauma

8 Management of the Pregnant Trauma Patient Physiologic Changes

9 Physiologic Changes-Genitourinary First Trimester-- --Bladder and Uterus are PELVIC organs REDUCED risk for injury Second and Third Trimester-- ABDOMINAL organ INCREASED risk for injury

10 Physiologic Changes-Gastrointestinal Tract Dominant Progesterone Effect DECREASED Gastric Motility DELAYED Gastric Emptying Time INCREASED Risk for Aspiration REDUCED Lower GI Injury INCREASED Upper Abdominal Bowel Injury

11 Physiologic Changes - Pulmonary System INCREASED Tidal Volume INCREASED Minute Ventilation by 50% DECREASE in Expiratory Reserve and Residual Volumes DECREASED Functional Residual Capacity ATELECTASIS AND HYPOXEMIA

12 Physiologic Changes - Cardiovascular System Cardiac Output (CO) INCREASES 50% by second trimester Pulse increases 10-15% 15% SUPINE Position DECREASES CO in second and third trimesters Stroke volume 30% normal supine

13 Physiologic Changes - Cardiovascular System Blood volume INCREASES by 50% GREATER increase in plasma than in RBCs Physiologic anemia of pregnancy INCREASED tolerance of blood loss, ie, cc prior to need for tranfusion

14 Physiologic Changes - Cardiovascular System BP maintained at expense of splanchnic and uteroplacental flow Alterations of P and BP may be late findings SVR is DECREASED-- --skin may remain warm and pink

15 Physiologic Changes - Hematologic System Fibrinogen, factors II, VII, VIII, and X are INCREASED by 20 to 200 percent are INCREASED REDUCED fibrinolytic activity HYPERCOAGULABLE STATE

16 General Approach to Pregnant Trauma Patient Catastrophic Trauma

17 General Approach to the Pregnant Catastrophic Trauma Patient Priority is Mother Cardiopulmonary Stability Then fetal assessment Fetal health, as a rule, is maximized when maternal medical condition is optimized

18 In The Field Educate pre-hospital personnel Backboard tilted to LEFT with spine immobilization Information on length of Gestation Gross Gross uterine size assessment 2 large bore IVs Volume Replacement

19 Primary Survey A Airway with C-spine C protection cricoidcricoid pressue cuffed cuffed endotracheal tube B Breathing C- Circulation Control Control hemorrhage Restore Restore Volume preferable to vasopressors D- Disability (Neurologic( Status) E- Exposure

20 Injury Scoring Systems Revised Trauma Score (RTS) Abbreviated Injury Score (AIS) Injury Severity Score (ISS)

21 Trauma scoring in pregnancy Poorly predictive of fetal outcome Even minor maternal injury can be associated with fetal loss Morris et al, Ann Surg 1996 Schiff et al, J Trauma, 2002 Schiff et al, Am J Epid,, 2004

22 Primary Survey Fetal Assessment Gestational age assessment Palpable contractions Vaginal Bleeding Doptones

23 Secondary Survey Maternal Evaluation Radiographic imaging Fetal monitoring if viable fetus Diagnostic modality necessary for maternal evaluation should NOT be withheld Mann et al. J Trauma 2000

24 Secondary Survey Maternal Evaluation Laboratory tests CBC, CBC, platelets Liver Liver function tests Metabolic Metabolic panel Coagulation profile Type Type and crossmatch Rh Immunoglobulin Tetanus toxoid

25 Secondary Survey Fetal Assessment Ultrasonography Fetal Monitoring Preterm Labor Non-reassuring Fetal Status Examination PPROM

26 Maternal Cardiac Arrest Perimortem Cesarean Section Proceed with delivery minutes after arrest Aortocaval decompression 50-70% fetal survival

27 General Approach to Pregnant Trauma Patient Non-Catastrophic Trauma

28 General Approach to the Pregnant Noncatastrophic Trauma Patient Abruption can occur with minor injuries Majority Majority symptomatic on presentation Contractions Vaginal Vaginal bleeding Abdominal pain Symptoms poorly predictive of adverse outcome

29 Noncatastrophic Trauma Patient Absent symptoms and normal monitoring 100% negative predictive value No benefit to prolonged monitoring Connolly et al 1997, AM J Perinatol Delayed abruption case reports Up to five - six days after traumatic event Lavin et al J Reprod Med 1986 Higgins et al Obstet Gynecol 1984

30 Noncatastrophic Trauma Patient Asymptomatic women and normal tracing Discharge after hours Symptoms contractions, bleeding, pain, FHR abnormalities Monitor until symptoms abate Minimum 24 hours Curet et al, J Trauma, 2000 ACOG 1998

31 Noncatastrophic Trauma Patient Laboratory Studies CBC Type and Screen Kleihauer-Betke in Rh positive patient Unhelpful Goodwin et al Am J Obstet Gynecol 1990 Preterm Labor Muench et al J Trauma 2004

32 Management of the Pregnant Trauma Patient Causes of Injury

33 Cause of Injury MVA most common Maternal/fetal mortality reduced with restraint Severe (ISS>9) Nonsevere (ISS 1-8) 1 n=84 n=309 Preterm labor 13.1% 24.6%* Abruption 13.1%* 7.4%* Fetal distress 20.2%* 12.0% Fetal death 2.5%* 1.6% *values significantly different from controls Schiff et al Am J Epidem 2005

34 Assaults Cause of Injury 1-20% suffer violence in pregnancy ASSLT-Del SUBSQ- Del PTL 16.4%* 10.5%* Abruption 5.4%* 2.1%* Uterine Rupture 0.71%* 0.11% Maternal Death 0.71%* 0.17% Fetal Death 9.3%* 0.9% *values significantly different from controls El Kady et al Obstet Gynecol 2005

35 Trauma in Pregnancy TRAUMA-DEL SUBSQ-DEL PTL* 14.4% 18.4% Abruption* 8% 1.5% Distress* 16.7% 11.5% *values significantly different from controls El Kady et al Am J Obstet Gynecol 2004

36 Cause of Injury Burns and Thermal Injury 4% of burn victims are pregnant Total Total Body Surface Area <50% 50% Fetal mortality up to 50% Maternal mortality ~ 5% > 80% Maternal and Fetal mortality nearly 100%

37 Management of the Pregnant Trauma Patient Site of Injury

38 Site of Injury Pelvic and Urinary tract Trauma Pelvic fractures Retroperitoneal bleeding Hypovolemic shock Bladder Bladder injuries Urethral Urethral disruption Laceration of perineum, vagina and rectum Degree of hematuria DOES NOT correlate well with extent of injury Fetal death and skull fracture

39 Site of Injury Blunt Abdominal Trauma Retroperitoneal injury/hematomas from increased vascularity Marked dilation of uterine veins Risk of massive blood loss with abdomino- pelvic injury

40 Blunt Abdominal Trauma Bowel relatively protected due to uterine displacement 25% hepatic or splenic injuries Risk of uterine rupture increases with advanced gestation 0.6%

41 Blunt Abdominal Trauma Evaluation for intraperitoneal fluid Ultrasound sensitivity and specifity for intraperitoneal fluid similar to non-pregnant Goodwin H et al. J Trauma, 2001 CT CT scan Stable Stable patient Open Open Diagnostic Peritoneal Lavage Largely Largely replaced

42 Blunt Abdominal Trauma Placental abruption Severe injury to abdomen 50-60% Minor injury 1-5% 1

43 Penetrating Abdominal Trauma Gunshot Wounds Maternal mortality 4% Fetal Mortality 70% Stab wounds Maternal mortality <5% Fetal mortality 40% Visceral injury 16-38% (80-90% non-pregnant)

44 Penetrating Abdominal Trauma Midline Laparotomy exploration of all abdominal organs C-section versus repair without delivery Uterus involved Gestational age Fetal condition Interference with exploration and repair of peritoneal cavity and organs

45 Site of Injury Chest Trauma Information scant in pregnancy Fetal Fetal loss may be due to maternal and fetal hypoxia Aortic Aortic rupture most common cause of sudden death after MVA or fall from a height. Diaphragm may be elevated by as much as 4 cm - chest tubes should be placed one or two interspaces higher

46 Site of Injury Head Trauma 50% of all trauma deaths 10-15% 15% of maternal trauma deaths Fildes et al J Trauma, 1992 Closed head injury Externally unapparent Coup and contracoup Laceration of subdural vessels Increased susceptibility in pregnancy

47 Head Trauma Protect the airway & oxygenate Ventilate to normocapnia Correct hypovolemia and hypotension Maintain adequate Cerebral Perfusion Pressure CT Scan when appropriate Neurosurgery if indicated Intensive Care for further monitoring and management Trauma.org