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Disclosures Celmatix Advisor or Reviewer (spouse) Mindchild Advisor - - PowerPoint PPT Presentation

Nov 04, 2022 302 likes •439 views

6/11/2016 Disclosures Celmatix Advisor or Reviewer (spouse) Mindchild Advisor or Reviewer (spouse) Bobs Red Mill Grant/Research Support (spouse) Management of Maternal Trauma During Pregnancy Susan Tran, MD Assistant Professor

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6/11/2016 1

Management of Maternal Trauma During Pregnancy

Susan Tran, MD Assistant Professor Maternal-Fetal Medicine June 11, 2016

Celmatix Advisor or Reviewer (spouse) Mindchild Advisor or Reviewer (spouse) Bob’s Red Mill Grant/Research Support (spouse)

Disclosures

2

Case

OB team called emergently to ED for 32 yo visibly pregnant unrestrained passenger in MVC

  • Vitals: Temp 98F, BP 70/42, P 136, RR 36, O2

sat 95% on 100% facemask

  • No major deformities visible; abdomen gravid,

bruised; Pupils equal, round, reactive; Doesn’t

  • pen eyes or respond to painful stimuli
  • Currently being transfused blood products

3

Poll

The next course of action is:

  • A. Move immediately to CT scanner
  • B. Monitor the fetus
  • C. Intubate
  • D. Perimortem cesarean

4

24% 4% 10% 62%

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6/11/2016 2

Outline

  • Epidemiology
  • Maternal physiology
  • Motor vehicle crashes (MVCs)
  • Blunt and penetrating abdominal trauma

– Falls

  • Evaluation and management

– CPR and perimortem cesarean delivery

5

EPIDEMIOLOGY

6

Epidemiology

  • Trauma is the leading cause of

nonobstetric maternal death

7

Trauma

  • Affects 6 - 8% of pregnancies

– ~2/3 motor vehicle crashes (MVCs) – Falls and abdominal trauma – Domestic violence

  • Most incidents are considered minor
  • 0.4% pregnancies require hospitalization for trauma

– 5 – 38% delivered during trauma hospitalization

8

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6/11/2016 3

Fetal death from trauma

  • ~3.7 fetal deaths per 100,000

live births

  • Can occur with apparently minor trauma
  • Placental abruption occurs

– Severe trauma: 40 - 50% – Minor trauma: 1 - 5% – Responsible for ~70% of fetal deaths after trauma

9

Petrone P et all, 2015

Complications of OB trauma

  • Preterm labor
  • Placental abruption
  • Emergency cesarean
  • Fetal loss
  • Premature rupture of membranes
  • Spontaneous abortion
  • Uterine rupture

10

MATERNAL PHYSIOLOGY

11

Physiologic adaptations

  • Heme

– Plasma volume increases ~40% – Fibrinogen < 200 is abnormal in pregnancy – WBC normal 6k-16k in pregnancy

  • Cardiovascular

– Increased cardiac output

  • Pulmonary

– Decrease in functional residual capacity – Increase in tidal volume – Decrease in pCO2

  • GI

– Lower esophageal sphincter relaxes

  • Renal

– GFR increases 50%

12

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6/11/2016 4

Special considerations

  • Gravid uterus more likely to sustain injury
  • Aortocaval compression

– Can result in a 25-30% reduction in cardiac output – Maternal positioning

  • Left lateral tilt

– Can limit CPR efforts

  • At best, CPR generates ~10% cardiac output in term patients

13

MOTOR VEHICLE CRASHES (MVCS)

14

MVCs

  • 207 cases per 100,000 pregnancies
  • Mortality rates related to MVCs

– Maternal 1.4 per 100,000 pregnancies – Fetal 3.7 per 100,000 pregnancies

  • Substance use a risk factor

– 40 - 45% tested positive for intoxicant(s)

15

Seat belts

  • 3 point restraint seat belts save lives!
  • ~1/3 pregnant women DON’T wear them

– Discomfort – Inconvenience – Fears of hurting fetus / misinformation

  • ~50% no prenatal seat belt counseling

16

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6/11/2016 5

MVC mechanism of injury

  • Blunt abdominal trauma
  • Shearing forces

– Coup-contrecoup

17

abruption BLUNT ABDOMINAL TRAUMA

18

Blunt abdominal trauma

  • Bowel less likely to be injured
  • Traumatic uterine rupture

– Fundal or posterior uterus – Fetal mortality approaches 100%

  • Pelvic fractures

– Risk factor for fetal head injury – Not a contraindication to vaginal delivery

  • Fetomaternal hemorrhage
  • Abruption

19

Petrone P et al, 2015

Abruption

  • Up to 2/3 severe

abdominal traumas

  • Doesn’t always

correlate injury severity

  • Ultrasound sensitivity

~25%

– A normal ultrasound does not rule out abruption!

20 www.mayoclinic.com

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6/11/2016 6

Fetomaternal hemorrhage: Kleihauer Betke (KB) Testing

  • To determine Rhogam amount in Rh neg
  • Protocols vary

– Give Rhogam to all Rh neg women with trauma – KB test in ALL pregnant trauma patients?

  • 46 of 71 pregnant trauma patients had positive KB tests *

– 44 of those 46 had PTL compared to 0 patients with negative KB – EAST‡ recommendation: routine KB testing in ALL trauma >12w GA

* Muench et al. J Trauma. 2004 Nov;57(5):1094-8.

‡ Eastern Association for the Surgery of Trauma

21

PENETRATING ABDOMINAL TRAUMA

22

Penetrating abdominal trauma

  • Gun shot wounds (GSWs)
  • Stab wounds
  • Associated with assault or suicide attempts

23

Penetrating abdominal trauma: Injury

  • Enlarged uterus
  • Fetus: Usually less favorable prognosis

– 40 – 70% mortality rates (injury below fundus)

  • Maternal: Usually more favorable prognosis

– Visceral injury ~19% (vs 82% nonpregnant) – Mortality 3.9% (vs 12.5% nonpregnant)

24

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6/11/2016 7

EVALUATION OF THE OBSTETRIC TRAUMA PATIENT

25

ATLS™ Assessment

Advanced Trauma Life Support™

– American College of Surgeons (ACS)

  • Primary survey
  • Resuscitation
  • Secondary survey
  • Re-evaluation
  • Definitive care

26

Assessment of the pregnant trauma patient

PRIMARY EVALUATION

  • Evaluate mother and

stabilize

– ABCDE – IV’s – O2 – Displace uterus

SECONDARY EVALUATION

  • Maternal injuries
  • Abruption
  • Preterm labor
  • Fetal distress
  • Fetomaternal

hemorrhage

  • Fetal injuries

27

Primary evaluation – Rapid!

  • Similar to nonpregnant patients

– Do not withhold needed interventions because of fetus

  • Simultaneous stabilization and assessment
  • > 20w GA, displace uterus off IVC & aorta

– 15 degree left lateral tilt

28

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6/11/2016 8

Primary evaluation – ABCs

  • Airway
  • Breathing
  • Circulation
  • Disability
  • Exposure

29

Secondary evaluation

  • Systematic evaluation for traumatic injury
  • FETAL ASSESSMENT

– Gestational age – Assess for vaginal bleeding, membrane rupture, labor – Fetal monitoring generally > 20w GA

  • Remember pregnancy physiology

– Aortocaval compression – Expanded circulating blood volume – Normal lab values

30

Diagnostic studies

Pregnancy should not preclude the use

  • f indicated diagnostic studies
  • Radiation exposure of <5 rads

– No associated fetal abnormalities or pregnancy loss

31

Estimated fetal radiation exposure

Radiologic examination Fetal radiation exposure (mrad)† Chest radiograph (PA, lateral) <1 Abdomen plain film 200 - 300 C-spine radiograph <1 Hip / femur radiograph 100 - 400 CT chest 30 CT abdomen 250

  • MRI does NOT produce ionizing radiation

†Bentur Y. Ionizing and nonionizing radiation in pregnancy. In: Maternal-fetal toxicology,

2nd ed, Koren G (Ed), Marcel Dekker, New York, 1994

32

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A COMMON SCENARIO…

33

Case

  • 29 yo G2 P1001 @ 33w4d who was the

belted driver in an MVC in which she was rear ended by a car going ~ 20 mph

– C/o mild contractions – Reports normal FM and denies LOF/VB – Exam: NAD; minimal TTP over seatbelt region; UCs q3”; category 1 FHRT

34

Poll

How long do you monitor the fetus?

  • A. 1 hour
  • B. 2 hours
  • C. 4 hours
  • D. 6 hours
  • E. 24 hours

35 3% 5% 37% 22% 32%

L&D eval after maternal trauma

Monitoring

  • If no contractions or bleeding, monitor 4 hr
  • Concern for abruption?

– Monitor / observe for 24 hours and reassess

36

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6/11/2016 10

Other evaluations

  • At least 4 hours of monitoring
  • Physical exam

– Abdomen, pelvis, SSE

  • Ultrasound for fetal assessment
  • Labs

– CBC – Blood type / Rh – Coags including fibrinogen – +/- KB – Consider toxicology / blood alcohol screen

37

CARDIOPULMONARY RESUSCITATION (CPR) AND PERIMORTEM CESAREAN

38

CPR in the pregnant patient

  • <24 weeks: similar to nonpregnant
  • >24 weeks: consider 4 minute rule

– Unwitnessed arrest deliver after 1 minute if no response

  • 20 – 30% blood volume to uterus
  • Cardiac output from chest compressions

– Nonpregnant ~33% – Third trimester ~10%

39

AHA: ACLS modifications for pregnant women

  • Tilt the patient
  • Early intubation
  • Cricoid pressure
  • Do not use femoral access site
  • No modifications to medications
  • Remove fetal monitors prior to defibrillation

40

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Other CPR Key Points

  • Start the clock
  • Prepare for perimortem CS as you initiate CPR
  • Get help

– Anesthesia – NICU – Nursing – Surgical

  • Aggressive fluid replacement, anticipate DIC
  • Do not worry about continuous fetal monitoring

41

The “4 Minute Rule”

  • Perimortem cesarean decision after 4 minutes:

– Imminent maternal death – Properly performed CPR has been ineffective

  • Deliver at 4 minutes to:

– Improve maternal resuscitation efforts – Improve neonatal outcomes – Potentially avoid permanent anoxic CNS damage

42

Key points: Perimortem cesarean

  • Do not move patient to the OR
  • Continue maternal resuscitation
  • Anesthesia not necessary
  • Abdominal prep not necessary
  • Use incision with which you are most comfortable
  • ? Aorta palpation to assess pulse/effectiveness of CPR

– May compress aorta to redirect CO cepahalad

  • Close uterus while ACLS/CPR continues
  • Reevaluate to determine if patient should be moved to

OR or ICU setting

43

Outcomes

  • Multicenter retrospective cohort study *

– 114,952 trauma admissions including 441 pregnant women – 32 emergency cesarean sections

  • 45% fetal and 75% maternal survival
  • Review of published cases 1985-2004†

– 38 perimortem cesareans between 25-40w GA – 30/38 (79%) delivered surviving infants – Spontaneous return of maternal circulation or improvement in maternal hemodynamic status in 12 of 20 cases

* Morris JA Jr et al, Ann Surg, 223 (1996), pp. 481–488 † Katz et al, AJOG 192 (2005), pp. 1916–1920 44

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6/11/2016 12

RECOMMENDATIONS

45

Recommendations

  • Mom first; fetus second
  • Displace uterus to one side
  • FAST scan is reliable in pregnancy
  • Consider perimortem cesarean at 4 minutes
  • Encourage patients to use seatbelts properly
  • Screen: domestic violence, substance abuse
  • Monitor viable patients for a minimum of 4 hours

– Admit for further monitoring if UCs > q10 min after 4 hours

  • Rhogam if Rh negative

46

CASE REVISITED

47

Case

OB team called emergently to ED for 32 yo visibly pregnant unrestrained passenger in MVC

  • Vitals: Temp 98F, BP 70/42, P 136, RR 36, O2

sat 95% on 100% facemask

  • No major deformities visible; abdomen gravid,

bruised; Pupils equal, round, reactive; Doesn’t

  • pen eyes or respond to painful stimuli
  • Currently being transfused blood products

48

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6/11/2016 13

Poll

The next course of action is:

  • A. Move immediately to CT scanner
  • B. Monitor the fetus
  • C. Intubate
  • D. Perimortem cesarean

49

41% 8% 41% 10%

  • Primary focus is always maternal stability

50

QUESTIONS?

51