MANAGEMENT OF THE TRAUMATIZED

PREGNANT PATIENT

U. Kaswiyan

Department of Anesthesiology & Reanimation

Medical Faculty University of Padjadjaran
Hasan Sadikin General Hospital
BANDUNG

Introduction

The Committee on Trauma of The American College of Surgeons:

trauma during pregnancy 6-7% and leading non-obstetric cause
of maternal death
fetal mortality 40-70%

Anatomic and physiologic changes of pregnancy:

trauma assessment more difficult
alter the patients response to trauma injury need modified
assessment, treatment, and transportation

in

A multidisciplinary approach to pregnant trauma victim is required two

victims (mother and fetus)

The main principle:

resuscitating the mother will resuscitate the fetus

save the mother save the fetus

Causes and Types of Trauma

The

primary causes include:

42% MVCs
34% falls
18% assaults
< 1% burns

Trauma

is often classified as
blunt vs penetrating

Blunt Trauma
Mechanism

- MVAs
- Falls
Injuries

Head injury
Hemorrhage
Obtetric complications (preterm labour or
abortion, premature rupture of membrane,
placental abruption, uterine rupture)

Penetrating Trauma
It

usually the result of gunshot or knife wound

Fetal mortality
> 70%
Maternal mortality
< 5%

Probably relates to the enlarge uterus, amniotic

sac, and fetus taking the brunt of the injury while
the displaced maternal organs are preserved

Effect of trauma on the fetus

Direct

fetal injury:
Fetal mortality
Blunt trauma (in 3rd trimester)
Penetrating trauma (stabbing / gunshots)
Skull fracture and ICH

Indirect

fetal injury:
when maternal injury, inadequate
uteroplacental perfusion & fetal oxygenation

Unique Problems in the Gravid Abdomen

Placenta:

is devoid of elastic tissue,

Myometrium: very elastic predisposing to shearing

Blunt

injury Abruptio placenta

Fetal skull fractures

Supine

hypotensive syndrome 10%

Alterations in Anatomy
1st

trimester:
uterus is thick walled and intrapelvic
uterus rises out of pelvis after 12 weeks

2nd

trimester:
uterus contains large amount of amniotic fluid

3rd

trimester:
uterus is thin walled, large fetal head
engaging pelvis
at 36 weeks uterus reaches costal margin

Maternal Physiology and Anatomy vs Trauma

I. Cardiovascular and hematological:
-

HR , CO , blood plasma
SVR , CVP , BP
supine hypotensive syndrome

Hyperdynamic
&
Hypervolemic

may complicate:
- the evaluation of intravascular volume
- the assessment of blood loss
- the diagnosis of hypovolemic shock

Maternal Physiology and Anatomy vs Trauma

II. Respiratory:
-

diaphragma rises 4 cm, chest diameter 2 cm

FRC , MV , TV , oxygen consumption 20%
supine hypotensive syndrome

- predispose rapid falls in PaO2

- buffering capacity in the presence of acidosis
- chest tubes (thoracostomy) being misplaced
III. Tractus gastrointestinalis:
- intragastric pressure
- intragastric pH
- LES tone

Risk of
pulmonary aspiration

General Approach to The Pregnant Trauma Patient

Stabilize

the mothers condition

Priorities

assessing and managing are the same

to non pregnant woman
the ABCs, adequate airway, ventilatory and
circulatory support with spinal precautions,
haemorrhage control and rapid assessment,
stabilization and transport

Resuscitating

the mother is the key to survival of

both mother and fetus

Traumatic Event in Pregnancy 6

Emergency Medicine Physician:
1. Prehospital care
2. Primary and secondary surveys (fetal evaluation)
3. Resuscitative care
4. Initiate diagnostic studies
5. Perimortem C-section
6. Assess for domestic violence

Third-trimester viable infant

Catastrophic trauma

Minor trauma

Catastrophic trauma

Minor trauma

Trauma Surgeon

Obstetrician

1. Primary and secondary surveys

(fetal evaluation)
2. Diagnostic studies
3. Definitive care
4. Perimortem C-section
5. Subspecialty consults

1. Evaluation for pregnancy

related complications
2. Fetal monitoring
3. C-section as indicated
4. OB follow-up needs

Anticipated trauma related delivery

Neonatologist
(or Emergency Physician if unavailable)
1. Primary and secondary surveys
2. Resuscitative care
3. NICU-nursery requirements
4. Subspecialty consults

Classification of Pregnancy and Trauma

(Henderson & Mallon)

Group 1 :

- Pregnancy unknown
- Need pregnancy test

Group 2 :

- Pregnant < 23 weeks

- Maternal priority

Group 3 :

- Pregnant > 23 weeks

- two patients, mother and foetus

Group 4 :

- Maternal perimortem
- Rescucitation SC perimortem (?)

Initial Management

Avoid distractions and avoid the urge to

focus on the fetus
Be aggressive! But temper with common
sense.
An apparently stabile mother may be
compensating at expense of the fetus

Prehospital Trauma Care

Airway
Oxygen
Position :
- left lateral recumbent position
- leftlateral supine position
with back board

Primary Survey
1. BLS, ATLS, ACLS
Begin as you would with any other trauma patient
2. Oxygenation, Airway management
Rapid sequence induction
3. Utero-plasental blood flow
position
4. Neurological deficit
GCS, ICP control, cardiotocographic monitoring

to assess FHR and uterine activity

5. Fluid rescucitation with RL
diuresis monitoring
6. Vasopressor (?)

Secondary Survey
1. Anamnesis & Physical Examination :
Assess

tone

and reassess uterine size, tenderness,

Vaginal / Pelvic examination

- Blood
- pH (vaginal - 5 amniotic fluid - 7)
nitrazine paper
- Station
- Dilation of cervix

2. Modalities for Evaluating Abdominal Trauma :

Laparatomy, CT, DPL, USG, Laparascopy

Secondary Survey
3. Laboratory screening :
Hb, Ht, Blood group, Urine analysis, Lactate,
BGA, Bicarbonate serum
Fetomaternal Blood Mixing
- Kleihaure-Betke test to check for fetal cells
- Important in Rh negative women who need
Rhogam (300 micrograms)
4. Radiographic Studies :
Obtain what the patient needs, dont hold back
Avoid repeated and unnecessary studies
0.05 to 0.1 rad safe to fetus
- Single Pelvis X-ray is < 0.01 rad
- Abd CT is 0.05 - 0.1 rad

Secondary Survey
5. Cardiotocographic Monitoring :

FHR
- Rate (120-160)
- Beat-to-beat variability
- Baseline variability
- Decelerations, esp. late

Uterine Activity
- If < 1 contraction / 10 min. for 4 hours, risk of
complications drops to baseline.
- If greater, then 20% risk of placental abruption

Perimortem Cesarean Section

200 successful cases reported in the literature

<26 weeks gestation survival chance is 0%
Maternal CPR >20 minutes, fetal survival unlikely
Maternal CPR <5 minutes, fetal survival excellent
4 Minute Rule:
Maternal CPR for 4 minutes,
Infant should be delivered by the 5th minute

Maternal Arrest to Delivery Expected Fetal Survive

< 5 minutes

Excellent

5-10 minutes

Good

10-15 minutes

Fair

15-20 minutes

Poor

> 20 minutes

Unlikely

Example (during 2003):

1. Pregnancy + Orthopaedi

: 3 cases

2. Pregnancy + Minor trauma : 3 cases

3. Pregnancy + Head Injury

: 2 cases

Pregnancy + Fetal distress + Gemelli + Mild head injury

with subdural haematoma frontotemporoparietal dextra
(GCS=14)
Caesarean section

Craniotomy evacuation

(Neuroanesthesia technique)

Remember
... you will lose both mother
and infant if you cannot
restore blood flow to the
mothers heart

Summary
Anatomic

and physiologic changes.

Vigorous fluid and blood replacement.
Oxygen.
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, amniotic fluid
embolism, isoimmunization, premature rupture
of membranes.

When to Intervene and Consult

EARLY !!!

What is Best for The Mother

is Best for The Fetus !!!