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 changges of pregnancy :

Trauma asessment more difficult
Alter the patients respons to trauma injury need
modified an assessment, treatment and transportation

A Multidisciplinary approach to pregnant trauma victimis

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 %
34 %
18 %
< 1%
Trauma is often classified as
blunt vs penetrating
 Blunt Trauma
Mechanism
MVAs
Falls
Injuries
Head Injury
Hemorrhage
Obstetriccomplication(preterm labour or
abortion,premature rupture of membrane,
placental abruption, uterine rupture
 Penetrating Trauma
It usualy 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 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 matrernal injury, inadequate
uteroplacental perfusion,fetaloxygenation
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 intra pelvic
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 Physiokogy and Anatomy vs Trauma

I. Cardiovasculer and hematological:

HR , CO , Blood plasma Hyperkinetic
SVR , CVP , BP &
Supione hypotensive syndrome Hypervolemic

May complicate :
The evaluation of intravascular Volume
The assessment of Blood Loss
The diagnosis of hypovolemic shock
Maternal Physiokogy and Anatomy vs Trauma

II. Respiratory:
Diaphragma rises + 4 cm, chest diameter 2 cm
FRC , MV , TV , oxygen consumption 20 %
Supine hypotensive syndrome
- predisposerapid falls in Pa O2
- buffering capacity in the presence of acidosis
- chest tubes (thoracostomy) being misplaced

III. Tractus gastrointestinalis:

Intragastric pressure
Intragastric pH Risk of pulmonary
LES tone 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 assessment,
stabilization and transport
Resucitating 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 abd secondary 1. Evaluation for pregnancy
surveys (fetal evaluation) related complications
2. Diagnostic studies 2. Fetal monitoring
3. Definitive care 3. C-section as indicated
4. Perimortem C-section 4. OB follow-up needs
5. Subspecialty consults
Anticipated trauma related delivery

Neonatologist
(or emergency Physician if unavailable)
1. Primary and secondary surveys
2. Resucitative 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 patient, mother and foetus
Group 4 : - Maternal perimortem
- Rescucitation SC perimortem (?)
 Initial Management
Avoid distraction 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
- Left lateral 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-placental 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 (?)
ephedrine
 Secondary Survey
1. Anamnesis & Physical examination:
Assess and reassess uterine size, tenderness, tone
Vaginal/Pelvic exam
Blood
pH (vaginal-5 amniotic fluid-7) nitrazine paper
Sytation
Dilation of cervix

2. Modalities for Evaluating Abdominal Trauma

Laparotomy, CT, DPL, USG, Laparoscopy
 Secondary Survey
3. Laboratory screening
Hb, Ht, Blood group, urine analysis, Lactate, BGA,
Bicarbonate serum
Fetomaternal Blood Mixing
Kleihaure-Betke test to check fetal cells
Important in Rh negative womwn who need Rhogam (300
micrograms)

4. Radiographic studies
Obtain with the patient needs, dont hold back
Avoid repeated and unnecessary studies
0,005 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
complicvation drops to baseline
If greater then 20 % of placentalabruption
 Premortem Cesarean Section
200 succesful cases reported in the litertaure
<26 weeks gestation survival chance is 0 %
Maternal CPR > 20 minutes fetal super unlikely
Maternal CPR <5menit, 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 Excelent

5 10 minutes Good

10 15 minutes Fair

15 20minutes Poor

> 20 minutes Unlikely

 Remember

you will lose both mother

and infant if you cannot
restore blood flow to the
mothers heart .
 Summary
Anatomic and physiologic changges.
Vigorous fluid and blood replacement.
Oxygen
Treat the mother first and treat her just like any
other trauma patient.
High index of suspicion for bl;unt or penetrating
uterine trauma, abruptio placenta, amniotic fluid
embolism, isoimunization, premature rupture of
membranes
 When to Intervene and Consult

EARLY !!!

What is the Best for The Mother is

Best for The Fetus !!!