MANAGING THE PREGNANT TRAUMA PATIENT ALAN H. TYROCH, MD, FACS, FCCM PROFESSOR & CHAIR OF SURGERY TRAUMA MEDICAL DIRECTOR

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1 MANAGING THE PREGNANT TRAUMA PATIENT ALAN H. TYROCH, MD, FACS, FCCM PROFESSOR & CHAIR OF SURGERY TRAUMA MEDICAL DIRECTOR

2 INTRODUCTION Trauma impacts 1 in 12 pregnancies Trauma is one of the primary cause of non-obstetrical maternal deaths 20% of maternal deaths Maternal health takes precedence over the fetus Best initial treatment for the fetus is to provide optimal resuscitation to the mother

3 UMC at EL PASO ( : 32 patients) <1% of total trauma admissions Mean age: 25 (range: 16-36) Mean: ISS: 11.5 (range: 1-50) Mean LOS: 4.8 days (range: 1-67) Mortality: Mother: 3 (9.4%) Fetus: 3 (9.4%)

4 INJURY TYPE 9% 91% BLUNT PENETRATING

5 MECHANISM OF INJURY 13% 9% 16% 6% 3% 3% 50% MVC Fall MCC Assault GSW SW A-Ped

6 TRAUMA ACTIVATION LEVEL 22% 28% 50% LEVEL I LEVEL II LEVEL III

7 TRIMESTER 1 st : < 14 weeks 2 nd : weeks 3 rd : weeks 32 % 42% FIRST 26 % SECOND THIRD

8 ADMISSION STATUS 22% 50% 28% 1 2 3

9 OUTCOME FETUS MOTHER 9% PG intact 9% 6% 19% 72% Delivered Fetal Death 84% Home Morgue Rehab

10 ANATOMIC & PHYSIOLOGIC ALTERATIONS OF PREGNANCY

11 SOCIETY OF OBSTETRICIANS & GYNECOLOGISTS OF CANADA J Obstet Gynaecol Can 2015: 37(6): Quality of Evidence Assessment I: At least one properly randomized trial II-1:Well-designed controlled trials II-2: Well-designed cohort or casecontrol studies II-3: Obtained from comparisons between times or places with/without intervention III: Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees Classification of Recommendations A: Good evidence to recommend B: Fair evidence to recommend C: Existing evidence is conflicting & does not allow to make a recommendation for or against D: Fair evidence to recommend against

12 UTERUS 70gms to 1kg 12 wks: pelvic brim 20 wks: umbilicus wks: costal margin 23 wks: viable fetus

13 CARDIOVASCULAR Plasma volume increases by 50% & red blood cell volume increases by 18%-30% physiologic anemia Heart Rate: Slight tachycardia (15% increase) Blood Pressure: Decrease in BP during the second trimester with normalization near term Cardiac Output: Increases to 6-7 L/min at term

14 CARDIOVASCULAR Mother can lose >35% of blood before signs Fetal distress (bioassay for the Mom) If Mom is in shock, high fetal mortality (80%) By mid-pregnancy, the uterus compresses IVC to decrease cardiac output by 30% Manually displace uterus to the left (II-1B) Vasopressors should be used only for intractable hypotension (II-3B)

15 PULMONARY Respiratory rate is slightly increased Tidal volume is increased (40%) Decreased residual volume Slight respiratory alkalosis Decreased pco2 (32 mmhg) Decreased bicarbonate (22 mmhg) Increased minute ventilation Elevated diaphragm

16 PULMONARY Supplemental Oxygen! 8X more difficult to intubate Smaller ETT size Insert chest tube 1-2 higher intercostal spaces Adjust ventilator to keep pco 2 slighter lower

17 HEMATOLOGIC Leukocytosis Hypoalbuminemia Hypercoagulable state Fibrinogen (400 mg/dl) fibrinogen level (III-C) Increase in erythrocyte 2,3 DPG Transfuse O- blood until crossmatch (I-A) Type & Screen

18 FETOMATERNAL HEMORRHAGE 0.01cc of Rh+ fetal blood can sensitize Mom Rhogam to all Rh- Moms after injury (III-B) One dose provides protection up to 30cc of fetal blood Administer up to 72 hrs after injury

19 KLEIHAUER-BETKE BLOOD TEST Does not exclude minor degrees of hemorrhage (III-B)

20 GASTROINTESTINAL Stomach: Decreased motility & delayed emptying Intestine: Decreased motility & upward displacement Liver: No alteration in size Gallbladder: Stasis

21 GENITOURINARY Marked dilatation of renal pelvis & ureters Reduced ureteral peristalsis Bladder becomes an abdominal organ Glomerular filtration rate accelerates Renal blood flow accelerates Creatinine clearance enhanced Glucosuria is common Proteinuria may be present

22 MUSCULOSKELETAL Man: 4.40 mm Woman: 4.10 mm Gravid: 7.90 mm

23 DIAGNOSTICS

24 No single diagnostic procedure results in a radiation dose that threatens the well-being of the developing embryo & fetus. American College of Radiology Fetal risk is considered to be negligible at < 5rad when compared to other risks of pregnancy, and the risk of malformations is significantly increased above control levels only at doses > 15rad. National Council on Radiation Protection Women should be counseled that radiation exposure from a single diagnostic procedure does not result in harmful fetal effects. Exposure to < 5rad has not been associated with an increase in fetal anomalies or pregnancy loss. American Council of Obstetrics & Gynecology

25 Radiologic studies should not be deferred due to concerns regarding fetal exposure (II-2B) < 5 wks: Increased risk of miscarriage 5-10 wks: Teratogenic wks: Growth restriction or CNS effects > 20 wks:

26 ELECTRONIC FETAL MONITORING All pregnant patients > 23 wks should undergo monitoring for at least 4 hrs (III-3B) If adverse factors, monitor for 24 hrs (III-B) High risk mechanism of injury Uterine tenderness Abdominal pain Vaginal bleeding Sustained contractions (>6/hr) Membrane rupture Atypical or abnormal fetal heart rate pattern Serum fibrinogen < 200 mg/dl

27 ULTRASOUND Complements the EFM Recommended if EFM > 4 hrs (III-C) Purpose: Determine gestational age Demonstrate fetal HR ( ) & rhythm Placental localization Assess amniotic fluid volume Assess cervical length Confirm fetal demise Identify fluid in the abdomen (FAST)

28 PLACENTAL ABRUPTION Associated with Vaginal hemorrhage (70%) Uterine tenderness Uterine contractions Uterine tetany Uterine irritability Atypical EFM tracing

29 PLACENTAL ABRUPTION Typically occurs 2-6 hrs after injury Almost always within 24 hrs of injury Management of suspected abruption should not be delayed for ultrasound confirmation since it is not a sensitive tool (II-3D) 50% to 80% will be missed on ultrasound Those that will be identified are clinically apparent.

30 UTERINE RUPTURE High maternal mortality Fetal mortality is almost universal. Associated with: Maternal shock Abdominal tenderness, guarding or rigidity Abnormal fetal lie Inability to palpate uterine fundus Palpation of fetal parts

31 PERIMORTEM CESAREAN DELIVERY Recommended for viable pregnancies no later than 4 minutes following maternal cardiac arrest to aid with maternal resuscitation & fetal salvage. (III-B)

32 MATERNAL CONSIDERATIONS Perimortem cesarean delivery may improve maternal outcome: Reduction of placental demand. Improvement of venous return. Evacuation of the uterus increases the functional residual capacity of the lungs.

33 FETAL PROGNOSIS Delivery within minutes of cardiac arrest. Infant survival increases dramatically when the infant passes weeks of gestational age. Infants have survived when no fetal heart tones were detectable; DO NOT waste time to evaluate the condition of the fetus (JUST DO IT!). The cause of maternal death is related to fetal prognosis.

34 MEDICOLEGAL RISKS Injury to the healthcare provider(s) Delivering an infant with neurologic damage Performing the procedure on a woman with the inappropriate diagnosis of cardiopulmonary arrest Performing the procedure & the fetus is too premature > 23 weeks: May help both the mother & fetus 20 to 23 weeks: May help the mother < 20 weeks: No benefit to the mother Legal No U.S. physician has ever been successfully sued.

35 TECHNIQUE Midline incision from pubis to above the umbilicus (linea nigra) Incision carried through the fascial (linea alba) & peritoneal layers Vertical incision via the lower uterine segment Extend cephaled with scissors Remove the infant & clamp the cord Assess the infant for the need for ventilatory assistance, intubation and other resuscitative measures Simultaneous maternal resuscitative thoracotomy Do NOT cross-clamp descending thoracic aorta

36 SUMMARY Follow ATLS protocol Remember that 2 patients exist Best treatment for the fetus is to stabilize the mother Approach should be more aggressive, not less aggressive Fetal heart rate may be first indicator of inadequate resuscitation Respect minor trauma, especially in the 3rd trimester

Caring for Mom and Child: Trauma in the Pregnant Patient

Caring for Mom and Child: Trauma in the Pregnant Patient George Koenig DO, FACS Assistant Professor of Surgery, Division of Trauma & Critical Care Associate Medical Director JeffSTAT Thomas Jefferson University