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48. CARE OF THE PREGNANT TRAUMA PATIENT The Trauma Manual 48.

CARE OF THE PREGNANT TRAUMA PATIENT Glen Tinkoff

Introduction Anatomic changes and potential clinical consequences Physiologic changes or potential clinical consequences Mechanisms of injury Management Hospital Cesarean section and trauma Specific problems unique to pregnancy Placental abruption Disseminated intravascular coagulation Fetomaternal transfusion Premature labor Intrauterine fetal death Medications in pregnancy Axioms Bibliography I. Introduction. Injury occurs in 6% to 7% of all pregnancies and is the leading nonobstetric cause of maternal death. Furthermore, maternal compromise and injury severity are the principal factors in trauma-related fetal demise. Accordingly, optimal early management of the pregnant trauma victim yields the best possible outcome for the fetus; thus, the tenet, save the mother, save the fetus. Although initial treatment priorities remain the same, anatomic and physiologic changes that accompany pregnancy are important modifiers of trauma care in all settings. II. Anatomic changes and potential clinical consequences A. Uterus 1. Increased size (7 cm/70 g 36 cm/1,100 g) 2. Intraabdominal location after 12th week (Fig. 48.1)

FIG. 48.1. Uterine size. (From Knudson MM. Trauma in pregnancy. In: Blaisdell FW, Trunkey DD, eds. Abdominal trauma, 2nd ed. New York: Thieme, 1993:326, with permission.)

3. Thinning of muscular wall 4. Increased blood flow (60 mL/minute 600 mL/minute) 5. Potential clinical consequences a. Increased susceptibility to injury b. Increased bleeding c. Compression of inferior vena cava in supine position (supine hypotension syndrome) B. Placenta 1. Lack of elasticity 2. Catecholamine sensitivity 3. Potential clinical consequences a. Prone to separation from uterus wall (abruption) b. Decreased placental blood flow, with stress leading to fetal compromise C. Pelvis 1. Venous engorgement 2. Ligamentous relaxation 3. Potential clinical consequences

a. Increased severity of hemorrhage b. Gait instability and increased risk of falls c. Altered radiologic appearance and misdiagnosis D. Genitourinary 1. Dilated collecting system 2. Displaced bladder intraabdominal 3. Potential clinical consequences a. Altered radiologic appearance and misdiagnosis b. Increased risk for injury E. Gastrointestinal 1. Intestinal displacement into upper quadrant 2. Alteration in gastroesophageal junction 3. Peritoneal stretching 4. Potential clinical consequences a. Altered injury pattern b. Decreased peritoneal sensitivity and misleading physical examination c. Increased risk for reflux and aspiration F. Diaphragm 1. Elevated (4 cm)

2. Increased excursion (12 cm) 3. Potential clinical consequence a. Altered anatomic landmark (e.g., misplaced chest tube) b. Decreased functional residual capacity (FRC) G. Heart 1. Displaced cephalad 2. Potential clinical consequences a. Electrocardiographic (ECG) changesleft axis deviation; T-wave flattening, or inversion in leads III and AVF H. Pituitary 1. Enlarged by 135% 2. Increased blood flow demands 3. Potential clinical consequences a. Shock can cause necrosis of the interior pituitary gland, resulting in pituitary insufficiency (Sheehan's syndrome). III. Physiologic changes or potential clinical consequences A. Cardiovascular 1. Increased cardiac output 2. Increased heart rate 3. Increased blood pressure (second trimester) 4. Decreased central venous pressure

5. Decreased peripheral vascular resistance 6. Increased ectopy 7. Potential clinical consequences a. Altered vital signs b. Preexisting hyperdynamic condition B. Hematologic 1. Increased blood volume predominantly caused by increased plasma volume 2. Decreased hematocrit (32% to 36%) caused by an increase in plasma greater than red blood cell (RBC) volume 3. Increased white blood cell (WBC) count (1825 WBC/mm3) 4. Increased factor I, VII, VIII, IX, and X 5. Decreased plasminogen activator levels 6. Potential clinical consequence a. Altered hematologic parameters b. Physiologic anemia; physiologic hypervolemia c. Signs of ongoing hemorrhage delayed; one third of the mother's blood volume can be lost without change in heart rate or blood pressure. d. Increased volume requirement with hemorrhage e. Hypercoagulability; increased risk for venothromboembolism

C. Respiratory 1. Increased minute ventilation 2. Increased tidal volume 3. Decreased functional residual capacity 4. Potential clinical consequence a. Chronic respiratory alkalosis b. Decreased respiratory buffering capacity c. Altered response to inhalation, anesthetics d. Propensity for rapid oxygen desaturation e. Decreased tolerance of hypoxemia D. Renal 1. Increased renal blood flow 2. Increased creatinine clearance 3. Increased glomerular filtration rate 4. Decreased glucose resorption 5. Potential clinical consequences a. Decreased blood urea nitrogen b. Decreased serum creatinine

c. Glucosuria E. Gastrointestinal 1. Decreased gastric emptying 2. Increased gastric acid production 3. Impaired gallbladder contraction 4. Potential clinical consequence a. Increased risk for acid reflux or aspiration b. Bile stasis or increased gallstone formation F. Endocrine 1. Increased placental lactogen 2. Increased progesterone 3. Increased estrogen 4. Increased parathormone 5. Increased calcitonin a. Insulin resistance or pregnancy-induced diabetes b. Lower esophageal sphincter relaxation c. Delayed gastric emptying d. Increased calcium absorption G. Neurologic

1. Pregnancy-induced hypertension (eclampsia) a. Increased risk for intracranial hemorrhage b. Increased risk for seizures c. Mimics head injury IV. Mechanisms of injury A. Blunt 1. Motor vehicle collisions (MVC) >falls >assaults 2. MVC are the leading nonobstetric cause of maternal and fetal mortality. 3. Placental abruption is the most common cause of fetal death when the mother survives. 4. Pelvic fractures are the most common maternal injury associated with fetal death. 5. The most common fetal injury is skull fracture, with intracranial hemorrhage. 6. Uterine rupture is associated with ejection from the vehicle and presents with maternal shock and uterine tenderness. 7. Utilization and proper application of seatbelt is the most important factor in preventing maternal injury and associated fetal death. 8. Pelvic ligamentous laxity and the protuberant abdomen contribute to gait instability and increased incidents of falls in pregnancy. B. Penetrating 1. Gunshot wounds (GSW) >stab wounds 2. Often associated with domestic violence 3. Risk of uterine injury is increased in the second and third trimester.

4. Fetal injury associated with uterine injury is common and carries a high mortality rate (40% to 65%). 5. Maternal mortality is rare. 6. Upper abdominal penetrating injury is often associated with extensive gastrointestinal and vascular injuries. V. Management A. General considerations 1. Consider the potential for pregnancy in all female trauma victims of appropriate age. Routinely perform beta-human growth hormone (hCG) testing. 2. Although two patients are being managed, the initial treatment priorities remain the same (i.e., Advanced Trauma Life Support [ATLS] protocol). The best early treatment of the fetus is optimal resuscitation of the mother. 3. Early obstetric consultation and fetal assessment is mandatory. Subsequent care may require neonatal specialists. B. Prehospital 1. As the fetus is exquisitely sensitive to hypoxia and hypovolemia, prehospital management of the pregnant trauma victim should include administration of supplemental oxygen and intravenous fluid as soon as possible. 2. In late pregnancy, extrication, immobilization, and transport can be complicated by anatomic factors. Supine hypotension syndrome can be prevented by positioning the pregnant patient to avoid uterine compression of the inferior vena cava, such as, left lateral decubitus position, or with the right hip elevated and the uterus manually displaced. If a spinal injury is suspected, immobilize the gravid patient on a long backboard, which is tilted 15 to the left. 3. The pneumatic antishock garments (PASG) can be used to stabilize fractures or control hemorrhage. However, inflation of the abdominal compartment of the PASG is contraindicated because the increased intraabdominal pressure further compromises venous return. 4. Field triage and interhospital transfer protocols must account for pregnancy. Assuming comparable transport times, transport pregnant patients to the facility best equipped to deal with the patient's injuries and simultaneously provide obstetric

and neonatology expertise. Notify the receiving facility as early as possible to allow for timely preparation and response. 5. Do not attempt fetal assessment in the field. Rapid extrication, proper immobilization, and prompt transport are the best measures applied to safeguard mother and child. C. Hospital 1. Primary survey a. Simultaneous resuscitation of vital signs, and identification and management of lifethreatening injuries are the same as for other trauma patients b. Consider early intubation and mechanical ventilation in any pregnant trauma patient with marginal airway or ventilatory status to avoid fetal hypoxia. c. Because of physiologic hypervolemia, the pregnant trauma patient can lose a significant amount of blood volume (1,500 mL) without manifesting any signs of hypovolemia. Even if the mother's vital signs are normal, the fetus can inadequately be perfused. d. Venous access in the upper extremities is preferred. Initiate prompt and vigorous volume resuscitation. Consider early red blood cell transfusion. Use type O, Rhnegative red blood cell transfusions to avoid Rh isoimmunization. Vasopressors reduce placental blood flow and should be avoided as an initial measure to correct maternal hypotension. 2. Secondary survey a. Obstetric history 1. Date of last menstrual period 2. Expected date of delivery 3. First perception of fetal movement 4. Status of current and previous pregnancies

b. Determine uterine size (Fig 48.1) by assessing fundal height as measured in centimeters from the symphysis pubis, which provides a rapid measure of fetal age (1 cm = 1 week of gestational age). c. Examination of the gravid abdomen must include assessment of uterine tenderness and consistency, presence of contractions, and determination of fetal lie and movement. Perform internal pelvic examination with special attention to the presence of vaginal blood or amniotic fluid, and to cervical effacement, dilation, and fetal station. The presence of amniotic fluid (pH = 7) can be confirmed by the change in Nitrazine paper from blue-green to deep blue. (Normal amniotic fluid has a pH >7; normal vaginal fluid has a pH of 5.) 3. Fetal assessment a. Beyond 20 weeks gestation, fetal heart tones can be auscultated with a fetoscope or stethoscope to determine fetal heart rate. The normal range is from 120 to 160 beats/minute. Fetal bradycardia is indicative of fetal distress. b. Institute continuous electronic fetal monitoring for gravid patients at or beyond 20 to 24 weeks as the fetus may be viable if delivered. Obstetric personnel experienced in cardiotocography must be available to interpret fetal heart rate tracings for signs of fetal distress. These signs include an abnormal baseline rate, repetitive decelerations, especially after uterine contractions; and absence of accelerations or beat-to-beat variability. c. High-resolution, real-time ultrasonography is excellent for evaluating the fetus for gestational age, cardiac activity, and movement. As with cardiotocography, properly trained and credentialed personnel must be available to perform and interpret this study. 4. Diagnostic modalities a. Perform essential radiologic studies, including computed tomography. Whenever possible, shield the lower abdomen with a lead apron and avoid duplicating studies. b. Radiation exposure to the preimplantation embryo (<3 weeks) is lethal. During organogenesis (27 wks), the embryo is most sensitive to the teratogenic, growth retarding and postnatal neoplastic effects of radiation. Radiation exposure of <0.1 Gy is generally safe (Table 48.1).

Table 48.1 Absorbed radiation doses from radiation study

c. Indications for diagnostic peritoneal lavage (DPL) or focused abdominal sonography for trauma (FAST) are the same as for the nonpregnant patient. For patients in their second or third trimester, perform DPL above the umbilicus and in an open manner. d. FAST can be a helpful, noninvasive method of determining the presence of free fluid in the abdomen after trauma. Location of the transducer must be changed to allow for the anatomic displacement of structures. 5. Definitive care a. Proceed with urgent operative intervention as dictated by physical findings and diagnostic studies. b. Pregnant trauma patients who are critically ill should be managed in the appropriate surgical or trauma intensive care unit. Onsite obstetric care and bedside fetal monitoring must be available. c. Stable gravid trauma patients requiring hospitalization should be obstetrically observed for 24 to 48 hours. Those patients whose fetus is beyond 20 to 24 weeks' gestation should have continuous cardiotocographic monitoring (CTM). A minimum of 24 hours is recommended for patients who present with frequent uterine activity (more than five contractions per hour), abdominal or uterine tenderness, vaginal bleeding, rupture of amniotic membranes, or hypotension. d. Asymptomatic gravid patients whose fetus is >20 to 24 weeks gestation with minor injuries not requiring hospitalization with normal findings on CTM of at least 4 hours' duration can be released with appropriate instructions and follow-up care. VI. Cesarean section and trauma A. Indications 1. Fetal factors a. Risk of fetal distress exceeds risk of prematurity b. Placental abruption

c. Uterine rupture d. Fetal malposition with premature labor e. Severe pelvic or lumbosacral spine fractures 2. Maternal factors a. Inadequate exposure for control of other injuries b. Disseminated intravascular coagulation (DIC) B. Perimortem cesarean section can be considered in situations of fetal gestational age 26 weeks, and the interval between maternal death and delivery can be minimized (<15 minutes). Maternal cardiopulmonary resuscitation must be continued throughout cesarean section and neonatal intensive care support should be immediately available. C. Technique 1. Vertical midline abdominal incision 2. Incise the uterus vertically. 3. Expose the infant's head, and suction oropharynx with a bulb syringe. 4. Deliver the infant. 5. Clamp and divide the umbilical cord. 6. Manually remove the placenta. 7. Inspect the endometrial surface to ensure removal of all membranes. 8. Close the uterus in layers with absorbable suture. 9. Administer oxytocin (usual dosage = 20 U intravenously) to treat postpartum uterine

bleeding. D. Cesarean section prolongs operative time and increases blood loss by at least 1,000 mL. VII. Specific problems unique to pregnancy A. Placental abruption (abruptio placenta) is the most common cause of fetal death with maternal survival. In late pregnancy, even minor injury can be associated with abruption. Placental separation from the uterine wall of >50% generally results in fetal death. Clinical findings include abdominal pain, vaginal bleeding, leakage of amniotic fluid, uterine tenderness and rigidity, expanding fundal height, and maternal shock. Minor degrees of placental separation are compatible with fetal survival in utero and should be carefully followed by serial ultrasound, external fetal monitoring, and observation for fetomaternal transfusion (see VII. C). B. Disseminated intravascular coagulation is caused by either the release of thromboplastic substances during placental abruption or amniotic fluid embolism. Maternal shock and death can occur precipitously. Treatment includes emergency evacuation of the uterus and blood component therapy to reverse the coagulopathy. C. Fetomaternal transfusion, fetal hemorrhage into the maternal circulation, is common after trauma (~26%). Fetomaternal transfusion can result in fetal anemia and death, as well as isoimmunization of an Rh-negative mother. The KleihauerBetke (K-B) test measures fetomaternal hemorrhage. This test has been used to determine the need for Rh immunoglobulin in Rh-negative mothers and as an indicator of placental abruption. However, the amount of fetomaternal transfusion sufficient to sensitize Rh-negative mothers is far below the sensitivity of the K-B test. Therefore, it is recommended to treat all Rh-negative mothers who present with abdominal trauma with Rh immune globulin (50 mg if <16 weeks' gestation; 300 mg if >16 weeks). Furthermore, use cardiographic monitoring and high-resolution, realtime ultrasound in patients suspected of abruption, rather than relying on the K-B test. D. Premature labor, defined as onset of uterine contractions before 36 weeks' gestation that are forceful enough to cause cervical dilation and effacement, is a common complication of maternal trauma. Most of these premature contractions stop without tocolysis. Tocolytics (usually b-adrenergic agonist or magnesium sulfate) are generally used to allow adequate time for complete evaluation of the preterm fetus. Administer these agents under the direction of an obstetrician and experienced personnel. Tocolysis is contraindicated with fetal distress, vaginal bleeding, suspected placental abruption, maternal shock or hypotension, cervical dilation >4 cm, or maternal comorbidities (e.g. diabetes, pregnancy-induced hypertension, cardiac disease, maternal hyperthyroidism). E. Intrauterine fetal death does not necessitate immediate operative intervention. Labor usually ensues within 48 hours. Monitor coagulation studies closely if observation is entertained, as once DIC develops maternal shock and death can occur precipitously as mentioned above. VIII. Medications in pregnancy A. Analgesics 1. Administer narcotics (fetal respiratory depression) and nonsteroidal antiinflammatory drugs (NSAID; prostaglandin and platelet inhibition) with caution (lower dosing and appropriate monitoring). B. Antibiotics

1. Penicillins, cephalosporins, erythromycin, and clindamycin are safe. 2. Administer aminoglycoside (fetal ototoxicity), sulfonamide (neonatal kernicterus), quinolone, and metronidazole with caution. 3. Chloramphenicol (maternal and fetal bone marrow toxicity), and tetracycline (inhibition of fetal bone growth) are contraindicated. C. Anticoagulants (Chapter 51) 1. Heparin is indicated as it does not cross the placenta, has a short half-life, and is immediately reversible with protamine. Low molecular weight heparin is also considered safe for use in pregnancy. 2. Warfarin is contraindicated as it crosses the placenta, and has a long half-life and takes significant time to reverse. D. Anticonvulsants 1. Administer benzodiazepines and barbiturates (fetal respiratory depression) with caution. 2. Phenytoin (teratogenic) is contraindicated. E. Antiemetics 1. Metoclopramide and prochlorperazine are safe. F. Because local anesthetics cross the placenta, administer them with caution and avoid large doses. G. General anesthesia and neuromuscular blockers are considered safe. H. Stress prophylaxis 1. Sucralfate is safe. 2. Use H2 blockers with caution I. Administer tetanus prophylaxis according to the standard guidelines. Axioms

Save the mother, save the fetus.

Perform a routine beta-HCG test on all women of childbearing age.

In transporting trauma patients in late pregnancy, take measures to displace the uterus to the left side.

The fetus can be in jeopardy, even with apparent minor maternal injury.

Although two patients are being managed, the initial treatment priorities remain the same.

The best early treatment of the fetus is optimal resuscitation of the mother.

Significant blood loss can occur in the pregnant patient without change in vital signs.

Placental abruption is the leading cause of fetal death in patients where the mother survives.

Fetal death is not an indication for cesarean section.

Under no circumstances should maintaining a pregnancy compromise the management of maternal wounds. Bibliography Knudson MH. Trauma in pregnancy. In: Blaisdell FW, Trunkey DD, eds. Abdominal trauma. New York: Thieme, 1993:324339. Rozyck GS, Knudson MM. Reproductive system trauma In: Feliciano DV, Moore EE, Mattox KL, eds. Trauma. Stamford: Appleton & Lange; 1996:695709. Trauma in women. In: Subcommittee on Advanced Life Support of the American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors. Chicago: American College of Surgeons, 1997:315332. Vaizey CJ, Jacobsen MJ, Cross FW. Trauma in pregnancy. Br J Surg 1994;81: 1406 1415. Wilson RF, Vincent C. Gynecologic and obstetric trauma. In: Wilson RF, Walt AS, eds. Management of trauma's pitfalls and practice. Baltimore: Williams & Wilkins 1996:21640.