Trauma in pregnancy: Difference between revisions
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*For maternal vitals see [[Maternal Vitals and Labs in Pregnancy]]
*For maternal vitals see [[Maternal Vitals and Labs in Pregnancy]]


===Risk Factors for Severity(ATLS)===
===Risk Factors for Severity ([[ATLS]])===
*Maternal heart rate > 100
*Maternal heart rate > 100
*Injury  Severity Score > 9
*Injury  Severity Score > 9
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*Motorcycle or pedestrian collisions
*Motorcycle or pedestrian collisions


==Clinical Features==
==Assessment==
*Airway
**Prepare for potentially difficult airway
***Increased soft tissue edema, breast enlargement, weight gain
**Pregnant women at increased risk of aspiration due to delayed gastric emptying
**Failed intubations 8 times more likely in pregnant trauma patients


==Differential Diagnosis==
*Breathing
**Increased basal O2 requirement
**Fetus is highly sensitive to maternal hypoxia
***Keep maternal SpO2 >95%
**Some recommend placement of thoracostomy tube 1-2 intercostal spaces higher than usual, when indicated<ref>Tsuei B. Assessment of the pregnant trauma patient. Injury 2006; 37(5)367-373</ref>
 
*Circulation
**Fluid and blood product resuscitation should proceed according to ATLS
**Placenta is highly responsive to vasopressors and can result in decreased placental perfusion
**Compression of IVC by gravid uterus can decreased CO by 30%
***If must be kept supine, allow patient to lay in left lateral position
***May also manually displace uterus to the left if patient must be kept on backboard
**Fetal risks from defibrillation of mother are small
 
==Complications==
*[[Uterine rupture]]
**more common with direct abdominal trauma in second half of pregnancy
**Occurs in severe MVAs resulting in pelvic fractures, penetrating trauma
**Signs and Sx
***maternal [[shock]]
***abdominal distension
***abnormal uterine contour
***abnormal fetal lie (oblique or transverse)
***palpable fetal parts
***sudden abnormal FHR pattern
***Ascent of fetal presenting part
 
*[[Placental Abruption]]
**Most common cause of fetal demise in blunt trauma
**US on not sensitive → do not delay treatment for [[ultrasound]] if abruption suspected
**Signs and Sx
***abdominal pain
***uterine tenderness
***vaginal bleeding (70%, may be absent if retroplacental)
***Uterine contractions or hypertonicity
***Signs of fetal distress on toco monitor are often the earliest indicator
****decelerations, tachycardia, bradycardia, and loss of variability


==Diagnosis ([[Abruption]])==
*[[Preterm labor]]
Symptoms
**Trauma in pregnancy is associated with 2x higher risk of preterm delivery
*Vag bleed 70% (may be absent if retroplacental)
*Cramps/contractions
*Uterine tenderness
*Hypovolemia
*Abnl fetal HR


US only 50% accurate
==Differential Diagnosis==
{{Abdominal trauma DDX}}


Signs of fetal distress on toco monitor are often the earliest indicator
==Evaluation==
*decelerations, tachycardia, bradycardia, and loss of variability
*Trauma labs
*Rh factor
*Coag studies
*[[D-dimer]]
*Fibrinogen
*[[FAST]] - sensitivity similar to non-pregnant trauma population
*Radiographic imaging as directed by [[ATLS]] assesment<ref>Edmonton V, Edmonton R, Maslovitz S, et al. Guidelines for the Management of Pregnant Trauma Patient.  J Obset Gynaecol Can 2015. 37(6):553-571</ref>
**Radiographic imaging should not be delayed or deferred due to concern for fetal radiation exposure in the trauma setting
*Tocographic and fetal monitoring - '''VEAL CHOP'''
**'''V'''ariable - '''C'''ord compression
**'''E'''arly - '''H'''ead compression
**'''A'''ccelerations - '''O'''kay
**'''L'''ate - '''P'''lacental insufficiency


==Treatment & Disposition==
==Treatment & Disposition==
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*Nonviable fetus (<23-24wks)
*Nonviable fetus (<23-24wks)
**Standard treatment for trauma
**Standard treatment for trauma
**Consider RhoGAM 50mcg in rh neg
***No obstetric intervention will alter the outcome of a pre-viable fetus
**Consider [[RhoGAM]] 50mcg in Rh negative patients
*Viable fetus (>23-24wks)
*Viable fetus (>23-24wks)
**Consider RhoGAM 300mcg in rh neg
**Consider RhoGAM 300mcg in Rh negative patients
**Avoid pressors - compromises blood flow to uterus leading to decreased fetal O2 delivery  
**Avoid pressors - compromises blood flow to uterus leading to decreased fetal O2 delivery  
**Monitor (fetal) all for 4-6hrs -->
**Fetal monitoring (continuous cardiotocographic monitoring)
**Extend Monitoring to 24hrs, if abnormal 6hr monitoring
***If no risk factors for fetal loss, minimum 4-6 hours
***The duration of cardiotocographic monitoring should be extended to 24 hours if, during the first 4 hours, she develops > 4 contractions per hour, persistent uterine tenderness, a worrisome fetal monitor strip, vaginal bleeding, or rupture of the membranes. <ref>Pearlman MD, Tintinalli JE, Lorenz RP. A prospective controlled study of outcome after trauma during pregnancy. Am J Obstet Gynecol. 1990;162:1502–10.</ref>
***If risk factors for fetal loss/abruption, monitor for 24 hours
 
****The duration of cardiotocographic monitoring should be extended to 24 hours if, during the first 4 hours, she develops > 4 contractions per hour, persistent uterine tenderness, a worrisome fetal monitor strip, vaginal bleeding, or rupture of the membranes. <ref>Pearlman MD, Tintinalli JE, Lorenz RP. A prospective controlled study of outcome after trauma during pregnancy. Am J Obstet Gynecol. 1990;162:1502–10.</ref>
* Allow patient to roll onto left side to unload uterine compression of IVC -> increases venous return to heart


* Abdominal CT imaging should be delayed or deferred due to concern for fetal radiation exposure in the setting of trauma.
*Allow patient to roll onto left side to unload uterine compression of IVC → increases venous return to heart
*In the setting of maternal cardiac arrest, consider [[Perimortem cesarean delivery|Perimortem Cesarean delivery]] if no ROSC within 4 minutes


===Abnormal Monitoring===
===Abnormal Monitoring===
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*Persistent uterine TTP
*Persistent uterine TTP
*Worrisome strip
*Worrisome strip
*Vag bleed
*Vaginal bleeding
*PROM
*PROM
*Serious maternal injury
*Serious maternal injury


Partial abruption w/ stable mom/fetus and <32wk may have expectant care (with easy access to emergent C-section)
Partial abruption with stable mom/fetus and <32wk may have expectant care (with easy access to emergent C-section)


Abruption = risk DIC
[[Abruption]] = risk [[DIC]]


*Frequent uterine activity more predictive of abruption than US
*Frequent uterine activity more predictive of abruption than US
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*[[Abruption]]
*[[Abruption]]
*[[Maternal Vitals and Labs in Pregnancy]]
*[[Maternal Vitals and Labs in Pregnancy]]
*[[Trauma (main)]]
*[[Pregnancy (main)]]


==References==
==References==

Revision as of 23:57, 6 March 2021

Background

  • Concern for trauma, premature labor, and abruption
  • Viable = >23-24wk (~fundus above umbilicus)
  • nl FHR = 110-160 beats/min
  • The leading cause of death in women during their reproductive years
  • The leading non-obstetric cause of death and disability in pregnant women
  • Trauma or accidental injury complicates up to 7% of all pregnancies
  • For maternal vitals see Maternal Vitals and Labs in Pregnancy

Risk Factors for Severity (ATLS)

  • Maternal heart rate > 100
  • Injury Severity Score > 9
  • Evidence of placental abruption
  • Fetal heart rate > 160 or <120
  • Ejection during a motor vehicle crash
  • Motorcycle or pedestrian collisions

Assessment

  • Airway
    • Prepare for potentially difficult airway
      • Increased soft tissue edema, breast enlargement, weight gain
    • Pregnant women at increased risk of aspiration due to delayed gastric emptying
    • Failed intubations 8 times more likely in pregnant trauma patients
  • Breathing
    • Increased basal O2 requirement
    • Fetus is highly sensitive to maternal hypoxia
      • Keep maternal SpO2 >95%
    • Some recommend placement of thoracostomy tube 1-2 intercostal spaces higher than usual, when indicated[1]
  • Circulation
    • Fluid and blood product resuscitation should proceed according to ATLS
    • Placenta is highly responsive to vasopressors and can result in decreased placental perfusion
    • Compression of IVC by gravid uterus can decreased CO by 30%
      • If must be kept supine, allow patient to lay in left lateral position
      • May also manually displace uterus to the left if patient must be kept on backboard
    • Fetal risks from defibrillation of mother are small

Complications

  • Uterine rupture
    • more common with direct abdominal trauma in second half of pregnancy
    • Occurs in severe MVAs resulting in pelvic fractures, penetrating trauma
    • Signs and Sx
      • maternal shock
      • abdominal distension
      • abnormal uterine contour
      • abnormal fetal lie (oblique or transverse)
      • palpable fetal parts
      • sudden abnormal FHR pattern
      • Ascent of fetal presenting part
  • Placental Abruption
    • Most common cause of fetal demise in blunt trauma
    • US on not sensitive → do not delay treatment for ultrasound if abruption suspected
    • Signs and Sx
      • abdominal pain
      • uterine tenderness
      • vaginal bleeding (70%, may be absent if retroplacental)
      • Uterine contractions or hypertonicity
      • Signs of fetal distress on toco monitor are often the earliest indicator
        • decelerations, tachycardia, bradycardia, and loss of variability
  • Preterm labor
    • Trauma in pregnancy is associated with 2x higher risk of preterm delivery

Differential Diagnosis

Abdominal Trauma

Evaluation

  • Trauma labs
  • Rh factor
  • Coag studies
  • D-dimer
  • Fibrinogen
  • FAST - sensitivity similar to non-pregnant trauma population
  • Radiographic imaging as directed by ATLS assesment[2]
    • Radiographic imaging should not be delayed or deferred due to concern for fetal radiation exposure in the trauma setting
  • Tocographic and fetal monitoring - VEAL CHOP
    • Variable - Cord compression
    • Early - Head compression
    • Accelerations - Okay
    • Late - Placental insufficiency

Treatment & Disposition

Assessment and stabilization of the mother should take first priority

  • Nonviable fetus (<23-24wks)
    • Standard treatment for trauma
      • No obstetric intervention will alter the outcome of a pre-viable fetus
    • Consider RhoGAM 50mcg in Rh negative patients
  • Viable fetus (>23-24wks)
    • Consider RhoGAM 300mcg in Rh negative patients
    • Avoid pressors - compromises blood flow to uterus leading to decreased fetal O2 delivery
    • Fetal monitoring (continuous cardiotocographic monitoring)
      • If no risk factors for fetal loss, minimum 4-6 hours
      • If risk factors for fetal loss/abruption, monitor for 24 hours
        • The duration of cardiotocographic monitoring should be extended to 24 hours if, during the first 4 hours, she develops > 4 contractions per hour, persistent uterine tenderness, a worrisome fetal monitor strip, vaginal bleeding, or rupture of the membranes. [3]
  • Allow patient to roll onto left side to unload uterine compression of IVC → increases venous return to heart
  • In the setting of maternal cardiac arrest, consider Perimortem Cesarean delivery if no ROSC within 4 minutes

Abnormal Monitoring

  • >3 contractions/hr
  • Persistent uterine TTP
  • Worrisome strip
  • Vaginal bleeding
  • PROM
  • Serious maternal injury

Partial abruption with stable mom/fetus and <32wk may have expectant care (with easy access to emergent C-section)

Abruption = risk DIC

  • Frequent uterine activity more predictive of abruption than US
    • >8 contractions/hr for 4hrs - high risk for abruption
    • 3-7 contractions/hr for 4hrs - extend monitoring for 24hrs
    • <3 contractions/hr for 4hrs - safe for discharge

External Links

See Also

References

  1. ↑ Tsuei B. Assessment of the pregnant trauma patient. Injury 2006; 37(5)367-373
  2. ↑ Edmonton V, Edmonton R, Maslovitz S, et al. Guidelines for the Management of Pregnant Trauma Patient. J Obset Gynaecol Can 2015. 37(6):553-571
  3. ↑ Pearlman MD, Tintinalli JE, Lorenz RP. A prospective controlled study of outcome after trauma during pregnancy. Am J Obstet Gynecol. 1990;162:1502–10.
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