Trauma in Pregnancy:: Get One Buy One

TRAUMA IN PREGNANCY:
Get one buy one

Judi Januadi Endjun
Department of Obstetrics and Gyneco;ogy

Gatot Soebroto Army Central and Teaching Hospital
Jakarta
2010
OBJECTIVES
Review aspects of trauma
related to pregnancy
Describe indications and

technique of perimortem
cesarean delivery
ALSO (advanced life support in obstetrics), 2005
http://www.dtimcrowe.com/hemorrhage_page.jpg
Hanya untuk Pendidikan dan Kesehatan JJE-2010/03/07
Trauma and Pregnancy
ATLS Protocol the same
Physiologic and Anatomic changes of

pregnancy change the pattern of injury
and the physiologic response to injury
Two patients requiring treatment!!!

William Schecter, MD
BACKGROUND
The pregnant trauma patient presents a unique challenge
because care must be provided for two patients—the
mother and the fetus.
Anatomic and physiologic changes in pregnancy can
mask or mimic injury, making diagnosis of trauma-
related problems difficult.
Care of pregnant trauma patients with severe injuries
often requires a multidisciplinary approach involving
an emergency clinician, trauma surgeon, obstetrician,
and neonatologist. (Andrew K. Chang, 2009)1
1. http://emedicine.medscape.com/article/796979-overview
BACKGROUND
Cardiac arrest occurs in 1/30,000 pregnancies
(ALSO, 2005)2
Many maternal deaths occur from potentially
treatable causes (ALSO, 2005)
Maternal physiology influences resuscitative

evaluation and efforts (ALSO, 2005)
Fetal outcome is directly related to well being of the
mother (ALSO, 2005)

Hemodynamic Susceptibility
Uterine blood flow determined by perfusion
pressure and decreases with drop in maternal
BP
Uterus receives 20 – 30% of cardiac output
Aortocaval compression causes 30% of
cardiac output to be sequestered
Uterine displacement increases cardiac
output by 25%
Uterine Size by Trimester
Third Trimester
Second Trimester
First Trimester
http://craniosacral-therapy.ca/baby.jpg
Anatomic Changes
16 weeks 24 weeks 32weeks

http://www.bellaonline.com/articles/art7113.asp
William Schecter, MD
Maternal Physiology in Trauma
Masking of signs of hypovolemia up to
1,500 cc of blood loss
Increased oxygen consumption – Maintain
oxygen saturation > 90%; PaCO2 of 35 – 40
mmHg could mean respiratory failure
Assume stomach full – early gastric
decompression
BUN and creatinine decreased
PATHOPHYSIOLOGY1
To evaluate the pregnant patient, the various
physiologic changes that occur during pregnancy must
be understood.
Because balance and coordination are most adversely
affected during the third trimester, the frequency of
accidental injury is greatest during this period.
Although the pregnant patient's blood pressure
decreases during pregnancy, changes may not be as
great as traditionally thought.
http://emedicine.medscape.com/article/796979-overview

PATHOPHYSIOLOGY1
Systolic blood pressure changes by only 2-4 mm
Hg, while diastolic pressure decreases by 5-15
mm Hg in mid-trimester.
In addition, the resting heart rate usually
increases by only 10-15 beats per minute.
Thus, tachycardia or hypotension in the pregnant
trauma patient should not be attributed solely to
the gravid state.
http://g-na.org/misc/pregnancy.jpg
Figure 1
Trauma in Pregnancy
Criddle, Laura M.
AJN The American Journal of Nursing.
109(11):41-47, November 2009.
doi: 10.1097/01.NAJ.0000363352.52097.d5
Figure 1. Anatomical Changes in the Third

Trimester of Pregnancy.In the assessment
and treatment of pregnant trauma patients,
it's important to understand the anatomical
changes typically experienced by pregnant
women. Seen here is a patient in the third
trimester of pregnancy. The growing fetus
pushes on internal organs, displacing them,
which makes some of them (such as the
bladder) more prone to rupture and some
assessments (such as the auscultation of
bowel sounds) more difficult. Illustration by
Anne Rains.
Hanya untuk Pendidikan dan Kesehatan

Hemodynamic Changes of Pregnancy (Mean Values)
Non P. Trim. 1 Trim. 2 Trim. 3

HR 70 78 82 85
Sys. BP 115 110 102 114
Dias. BP 70 60 63 70
C. Output 4.5 4.5 6 6
CVP 9.0 7.5 4.0 3.8
Bld V (ml) 4000 4200 5000 5600
Hct with Fe (%) 40 36 34 36
WBC (cell/mm3 ) 7200 9100 9700 9800
Nabil Alzadjali, McGill University

Supine Hypotensive Syndrome(1)
(1) Milson I, Forssman L: Factors influencing aortocaval compressionin late pregnancy, Am J Obtst
Gynecol 148: 764-771, 1984
Modalities for Evaluating
Trauma
 Plain Films – X-rays
 Ultrasound
 CT & MRI
 Cardiotocographic
Monitoring
 DPL
 Laparotomy
Hanya untuk Pendidikan dan

JJE-2010/03/07 Kesehatan
IMAGING STUDIES1
As a general rule, abdominal CT should be avoided in
early pregnancy because other diagnostic modalities, such
as ultrasonography and diagnostic peritoneal lavage, are
acceptable alternatives.
CT does, however, allow for better visualization of

retroperitoneal and intrauterine injuries.
Head and chest CT may be used when indicated because
the amount of radiation is much less and because few, if
any, alternative diagnostic modalities exist.

IMAGING STUDIES1
Ultrasonography
Assess fetal viability and for multiple gestations.
Assess the size, gestational age, and position of the fetus.
Ultrasonography can depict free intraperitoneal fluid or hemorrhage in the
mother.
The focused assessment with sonography for trauma (FAST) examination
has become routine in many trauma centers and has been shown to
have high sensitivity and accuracy in the hands of emergency clinicians
and trauma surgeons.
MRI: No reports of adverse effects (but few data) exist.
Ventilation-perfusion (V/Q) scanning: No reports of adverse effects
(but few data) exist.

TREATMENT1
Pre hospital care
Emergency department care
REMEMBER:
THE PREGANT PATIENT CAN LOSE A LOT OF

BLOOD BEFORE ABNORMAL BP AND PULSE!!!

Four Minute Rule
Maternal apnea associated with rapid
declines in arterial pH and PaO2
Fetus of an apneic and asystolic mother has

≤ 2 minutes of oxygen reserve
After 4 minutes without restoration of

circulation, dramatic action must occur
Pregnancy-Related Maternal Death
Hypertension 24%
Embolism 23%
Hemorrhage 21%
Infection 12%
Cardiomyopathy 6%
Anesthesia 3%
Other causes 11%
Etiology of Cardiac Arrest
DISEASE ASSOCIATED COMPLICATIONS
PIH and Eclampsia Seizures, cerebral edema

Embolism DVT, DIC
Hemorrhage Hypovolemia, hypotension
Tocolytic therapy Arrhythmias, hypermagnesemia,
hypokalemia
Trauma Hemorrhage, hypovolemia

Previous uterine scar Uterine rupture, placenta accreta
Hanya untuk Pendidikan dan ALSO (advanced life support in obstetrics), 2005
Kesehatan JJE-2010/03/07
Etiology of Cardiac Arrest
DISEASE ASSOCIATED COMPLICATIONS
Infection Septic shock, chorioamnionitis

Anesthesia Malignant hyperthermia, arrhythmias
Cardiac Impaired cardiac output, arrhythmias
Substance abuse Overdose, arrhythmias, abruption
Polyhydramnios AFE, uterine rupture

Endocrine Thyroid storm, CVA
Hanya untuk Pendidikan dan JJE-2010/03/07

Kesehatan
Primary ABCDs
Airway: open the airway
Breathing: provide positive-pressure ventilations
Circulations: give chest compressions
Defibrilation: assess for and shock VF or
pulseless VT, up to 3 times

Primary Maternal Survey
Supplemental oxygen
Ventilatory support
Fluid support
Blood replacement

Primary Fetal Survey
Fundal height and fetal position
Uterine activity
Fetal heart rate pattern
Presence of vaginal bleeding
Membrane status
Cervical assessment

Maternal Secondary Assessment
Appropriate x-ray studies
Uterine ultrasound
Diagnostic peritoneal lavage
Urine output
Consider CVP
Labs: Hemoglobin, electrolytes, and
coagulation studies
Secondary ABCDs
Airway
Breathing
Circulation
Differential Diagnosis

Secondary ABCDs
Airway
Place as son as possible
Breathing
Confirm placement
Secure device
Confirm adequate oxygenation

Secondary ABCDs
Circulation
Establish IV access
Identify rhythm and monitor
Administer appropriate drugs
Differential Diagnosis
Search for, treat identified reversible
causes
Drugs for Fib or Pulseless V-
Tach

Management of Blunt Trauma
Primary maternal and fetal survey
Labs include blood type and Rh,
hemoglobin, coagulation studies and
Kleihauer Betke (KB)
Consider of obstetrical ultrasound
If, Rh negative, give full dose Rh
immune globulin (more if KB indicates)
Discharge after Blunt Trauma
Monitor for contractions if GA > 20 wks
If < 3 per hour, monitor 4 hours then D/C
If 3 – 7 per hour, monitor 24 hours, then D/C
Discharge criteria:
Resolution of contractions
Reassuring FHT’s with intact membranes
No uterine tenderness or vaginal bleeding
Automobile Accidents
Seatbelt use declines in pregnancy
Seatbelt use in pregnancy decreases severe injury
and death by 50%
Proper seatbelt positioning important:
Lap belt passes below abdomen, across anterior
superior iliac spines
Shoulder belt should be between breasts
Airbag deployment not associated with increased
maternal or fetal injury
http://www.vahealth.org/Injury/safetyseat/images/Pregnancy_Seatbelts_clip_image003.jpg
The American College of Obstetricians and Gynecologists recommends
proper seat belt use by all pregnant women (Brown, Haywood L, ACOG, 2009)
http://www.smartmotorist.com/images/news/ideal_seat_belt_position_during_pregnancy.jpg
http://www.health.com/health/static/hw/media/medical/hw/h9991085.jpg
Maternal Cardiac Arrest
Airway
Human Wedge
Chest Compression
27% left tilt
A
L
S
O
(
Pre-requisites for Perimortem
Cesarean
Skilled personnel and equipment
No spontaneous maternal circulation
for four minutes
Potential fetal viability: singleton @ ≥ 23 –
24 weeks
Facilities and personnel available to care
for mother and infant postoperatively
Steps in Perimortem Cesarean
Personal protective devices
Modified sterile technique
Midline vertical or modified Joel-Cohen
abdominal incision
Vertical uterine incision
Dry and warm infant
Pack uterus, remove lateral tilt, continue CPR
Repair anatomically, when stable
Perimortem Cesarean Delivery Kit
Obstetrics supplies Obstetrics supplies
Knife handle, # 10 scalpel Hemostats
blade Needle driver
Bladder blade retractor Finger forceps or
Bandage scissors pickups
Laparotomy sponges 0-Chromic sutures
Medium Richardson 1-Vicryl sutures
retractors Sterile gloves
Kocher clamps
Perimortem Cesarean Delivery Kit
Pediatric supplies Pediatric supplies
Pediatric blankets Bulb syringe
Self inflating bag: DeLee suction
infant, child Cord clamps
Face masks:
neonate, infant

PROGNOSIS1
Penetrating injury has a perinatal mortality rate of 40-70%,
although the maternal mortality rate is less than that in the
nonpregnant patient because of the protective effects of the
large, muscular uterus on the maternal visceral organs.
In one urban study, violence accounted for 57% of maternal
deaths (48% homicides, 9% suicides).
Investigators in one study reported a 7% maternal mortality
rate in serious automobile injuries and a 14% injury rate in
surviving mothers.

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.

Remember
What is Best for

the Mother is
Best for the
Fetus!
REFERENCES
 ALSO Course (advanced life support in obstetrics), 2005
 The MOET Course Manual. Managing obstetric emergencies
and trauma, 2nd Ed, 2007
 Nabil Alzadjali. Two for One: Caring for the Pregnant Trauma
Patient. McGill University. Diunduh pada tanggal 28 Februari
2010 dari
www.mcgill.ca/files/emergency/Trauma_in_pregnancy.ppt
 William Schecter. Trauma and Pregnancy. Diunduh pada
tanggal 28 Februari 2010 dari
medschool.ucsf.edu/sfgh_surgery/education/ppt/.../lecture11.ppt

THANK YOU
judijanuadi@hotmail.com ; http//www.scribd.com ; facebook

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TRAUMA IN PREGNANCY:

Get one buy one

Department of Obstetrics and Gyneco;ogy

Describe indications and

ALSO (advanced life support in obstetrics), 2005

Physiologic and Anatomic changes of

Two patients requiring treatment!!!

Maternal physiology influences resuscitative

Hanya untuk Pendidikan dan Kesehatan JJE-2010/03/07

16 weeks 24 weeks 32weeks

Hanya untuk Pendidikan dan Kesehatan JJE-2010/03/07

Figure 1. Anatomical Changes in the Third

Hanya untuk Pendidikan dan Kesehatan

Non P. Trim. 1 Trim. 2 Trim. 3

Nabil Alzadjali, McGill University

Hanya untuk Pendidikan dan

CT does, however, allow for better visualization of

Hanya untuk Pendidikan dan Kesehatan JJE-2010/03/07

Hanya untuk Pendidikan dan Kesehatan JJE-2010/03/07

THE PREGANT PATIENT CAN LOSE A LOT OF

Hanya untuk Pendidikan dan Kesehatan JJE-2010/03/07

Fetus of an apneic and asystolic mother has

After 4 minutes without restoration of

PIH and Eclampsia Seizures, cerebral edema

Trauma Hemorrhage, hypovolemia

Infection Septic shock, chorioamnionitis

Cardiac Impaired cardiac output, arrhythmias

Substance abuse Overdose, arrhythmias, abruption

Polyhydramnios AFE, uterine rupture

Hanya untuk Pendidikan dan JJE-2010/03/07

Breathing: provide positive-pressure ventilations

Circulations: give chest compressions

Defibrilation: assess for and shock VF or

pulseless VT, up to 3 times

ALSO (advanced life support in obstetrics), 2005

Hanya untuk Pendidikan dan Kesehatan JJE-2010/03/07

ALSO (advanced life support in obstetrics), 2005

Hanya untuk Pendidikan dan Kesehatan JJE-2010/03/07

Hanya untuk Pendidikan dan Kesehatan JJE-2010/03/07

ALSO (advanced life support in obstetrics), 200

Hanya untuk Pendidikan dan Kesehatan JJE-2010/03/07

ALSO (advanced life support in obstetrics), 200

ALSO (advanced life support in obstetrics), 200

ALSO (advanced life support in obstetrics), 2005

Hanya untuk Pendidikan dan Kesehatan JJE-2010/03/07

Hanya untuk Pendidikan dan Kesehatan JJE-2010/03/07

What is Best for

Hanya untuk Pendidikan dan Kesehatan JJE-2010/03/07

judijanuadi@hotmail.com ; http//www.scribd.com ; facebook

Hanya untuk Pendidikan dan Kesehatan JJE-2010/03/07

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