TRAUMA AND SURGERY IN THE PREGANANT PATIENT IN THE PREGANANT PATIENT PRINCIPLES OF SURGERY-2009 NICHOLAS LEYLAND,BASc,MD,MHCM,FRCSC CHIEF OF OBSTETRICS

TRAUMA AND SURGERYTRAUMA AND SURGERY IN THE PREGANANT IN THE PREGANANT PATIENTPATIENT

PRINCIPLES OF SURGERY-PRINCIPLES OF SURGERY-20092009NICHOLAS LEYLAND,BASc,MD,MHCM,FRCSCCHIEF OF OBSTETRICS AND GYNAECOLOGY, MEDICAL DIRECTOR OF THE WOMEN’S, CHILDREN’S AND FAMILY HEALTH PROGRAMST.JOSEPH’S HEALTH CENTRE,ASSOCIATE PROFESSOR OF OB/GYN,UNIVERSITY OF TORONTO

Surgery and Trauma in the Surgery and Trauma in the Pregnant PatientPregnant PatientLearning objectives:

1)TRAUMA IN PREGNANCY

2)THE ACUTE ABDOMEN IN PREGNANCY

3)CASES

5) UPDATE LEYLAND

Trauma in Pregnancy-Incidence:Trauma in Pregnancy-Incidence:

Maternal mortality rate

• 3.5%– Mortality rate is similar for

non-pregnant women

Fetal mortality rate

• 1% in minor trauma

• 15% in major trauma

• Overall fetal death rate from trauma = 1/30000 pregnancies

• Trauma occurs in 6-7% of pregnancies• 4.6-8.3% of Traumas are complicated by pregnancy

““THERAPEUTIC PARALYSIS”THERAPEUTIC PARALYSIS”

Maternal Physiology:Maternal Physiology:Surgical Implications:Surgical Implications:

• Cardiovascular Changes; CO ^ 50%,Blood Vol^ 50%• Maternal rbc ^ 30% ‘Dilutional Anaemia’• WBC ^ 12000, Labour 20,000• GI: Appendix (localization), Progesterone Decreased motility,^ alk

phosphatase, no change in Transaminases• Respiratory Changes: e.g. Decreased pCO2

General Management PrinciplesGeneral Management PrinciplesMaternal AssessmentMaternal Assessment

• Primary Survey– ABCs…Fetus

• Lateral Tilt– Supine position can cardiac output by 30%

– 15° tilt is appropriate

– Can decrease effect of CPR

General Management PrinciplesGeneral Management PrinciplesFetal AssessmentFetal Assessment

• Ultrasound– GA– Placentation/Abruption– Fetal viability– Extent of fetal trauma/demise– BPP?

• Celestone as indicated• Initiate FHM after patient is stabilized• Vaginal exam to rule out PROM


• Rhogam:– Administer within 72 hrs– 10-30% of trauma have evidence of admixture– Betke-Kleihaurer test to determine quantity of

hemorrhages – 90% of hemorrhages are < 30 cc

• Anterior placed placentas have higher risk


• Exploratory Laparotomy– usually necessary in penetrating trauma

– C/S may be required to attain adequate surgical exposure

• Tetanus– As usual

Imaging & RadiationImaging & Radiation

Harmful effects:1. Cell death and teratogenesis

– High doses of radiation before implantation is likely lethal

– In humans, high dose growth restriction, microcephaly, mental retardation

– Effects are greatest at 8-15 wks gestation– No proven effects before 8 wks or after 25 wks– Risks are not increased until radiation exposure = 5

rad

Fetal Radiation Exposure in typical trauma

Fetal Exposure

CXR (2 views) 0.02-0.07 mrad

Abdo XR (3 views) 100 mrad

CT Head/Chest <1 rad

CT Abdo 3.5 rad

Total 4.8 radACOG guidelines suggest that imaging is

safe when exposure is ≤ 5 rad

Imaging & RadiationImaging & Radiation

Blunt TraumaBlunt Trauma

• MVAs and abuse most common• Fetal death can follow direct blunt trauma or

maternal death– Specifically head trauma and ejection from vehicle

• Abdominal contents shifted in pregnancy– Retroperitoneal & splenic injury more frequent – GI injuries less frequent

Blunt Trauma - ConsequencesBlunt Trauma - Consequences• Placental Abruption

– In up to 40% of severe blunt trauma– In up to 3% of minor blunt trauma– Contractions q10min = 20% risk of abruption– Abruption confers 50% fetal mortality

• Uterine rupture– Increases with force and gestation– Fetal death frequent here, but maternal death 10%

• Pelvic Fracture– Consider fetal skull fracture– MAST trousers contraindicated– If stable vaginal delivery still feasible

• Pre-Term Labour …

Blunt Trauma – Pre Term LabourBlunt Trauma – Pre Term Labour

Can PTL be predicted after blunt abdominal trauma?• 85 patients over 3 yrs with non-catastrophic trauma

Findings• Preterm Labour in 13 (15%)• Presence of Abdo pain or Contractions do not predict

PTL• Domestic abuse victims were more likely to have

repeated trauma

(Pak 1998)

MVAsMVAs

Frequency

• In USA, 2% of all live births have been exposed to a reported MVA

Seatbelts

• Up to 25% of pregnant drivers are unrestrained.

• Seatbelts positioned improperly cause a 3-4 fold increase in energy transmission through the uterus

MVAsMVAsAirbags

• No large scale data of airbags in pregnancy

• Pregnancy is not an indication for deactivation of airbags

Pregnant Crash Test Dummy:

Penetrating TraumaPenetrating Trauma

• Uterus may serve to protect maternal organs– Visceral injury from penetrating trauma in pregnancy =

38% vs 90%– Of GSWs to abdomen, death in pregnancy is 1/3 rate of

non-pregnant– Fetal death rate: 71% of GSWs, 42% stabs

• Penetrating trauma is generally an indication for exploratory laparotomy

• Half the women had perinatal deaths due to either maternal shock, uteroplacental injury, or direct fetal injury.

A Unified ApproachA Unified Approach

Is there a need for a standardized protocol for obstetrical patients who experience trauma?

The low incidence of trauma during pregnancy leaves trauma teams at risk of ignoring steps that may prevent adverse outcomes. An organized approach of stabilizing the injured gravida and then initiating ultrasound and EFM in pregnancies beyond 24 wks will ensure the best outcome for the mother and her unborn child. It is now a requirement in Australia for a level 1 trauma centre to have a protocol detailing the management of pregnant patients after trauma.

A Unified ApproachA Unified Approach

Issues to consider• Delayed monitoring during primary survey and imaging

– Average time to clear c-spine estimated at 36 minutes

• Access to FHR monitor in ER may not be available– Estimated that 15% of ERs in USA have this

• Other activities in resuscitation room may preclude continuous access to FH, or hinder ability to hear it

• Patients transferred to labour floor for ongoing monitoring may not receive optimal management of non-obstetrical issues– Eg. Soft tissue injury, Physiotherapy, occupational therapy, etc.

TRAUMA IN PREGNANCY- TRAUMA IN PREGNANCY- Key Points:Key Points:

• Trauma occurs in 6-7% of pregnancies• Physiologic changes of pregnancy may confuse the

picture• ABCs should not be abandoned in managing a pregnant

trauma patient• Consider Rhogam, Celestone, PROM, and initial FH

monitoring• Education regarding proper use of seatbelts in pregnancy is

paramount• Consideration of a standardized trauma protocol or record

for obstetrical use may be warranted.

TRAUMA IN PREGNANCY-TRAUMA IN PREGNANCY- Key Points: Key Points:

• Investigations ….LEYLAND’S AXIOM… “IF AN INVESTIGATION IS INDICATED DO IT”

• Fetal viability….24 weeks• Fetal monitoring….OBS/PERINATOLOGY• Transfer to regional center ONLY after

maternal stabilization

TRAUMA IN PREGNANCY:TRAUMA IN PREGNANCY:Head TraumaHead Trauma

• Dead Mother = Dead Fetus

CaseCase

• ID: 21 y/o G1 P0 @ 18/40

• HPI:– Sudden onset of colicky right sided pain– Anorexia– No BM x 3 days, emesis x 1– Warmth x 2 days– No dysuria, no gross hematuria, no PV bleeding

CaseCase

• O/E:– BP: 110/55; HR: 110 regular; RR: 18; Temp:

37.9– Abdo: uterine height of 20 cm, tender over right

side of abdomen w/ rebound– V/E: N

CaseCase

• DDx:– Appendicitis

– UTI

– Renal calculi

– Cholecystitis

– Ovarian cyst / torsion

– Ligamentous pain

– Cecal diverticulitis

– Acute iliitis

CaseCase

• Investigations?• Labs:

– Hb 130, WBC 14, Plt 350– Lytes, Cr, liver tests all normal– Urine R&M – trace protein, no leuks, no bacteria, trace

blood

• Imaging:– Fetal U/S – BPP 8/8– RLQ U/S - compressible blind-ended tubular structure

w/ a maximal diameter of 9 mm, wall thickened to 5 mm

Appendicitis - BackgroundAppendicitis - Background

• Of the most common causes of the acute abdo

• Peaks in 2nd and 3rd decades of life, M>F• Anatomy:

– Lies in the RLQ of the abdomen– Exceptions:

• Malrotation (LUQ)• Pregnancy (RLQ-RUQ)

EpidemiologyEpidemiology

• Incidence – 0.05-0.07%

• Perforation – 20-55% (versus 4-19% in general population)

• Fetal mortality – 1.5-9% w/o perf (up to 36% w/ perf)

• Overall correct diagnosis 50-86%

ClinicalClinical

• Symptoms non-specific initially• Initially dull, poorly localized periumbilical

pain• Localizes to McBurney’s point• Nausea/vomiting• Low grade fever ~38 (if rupture, fever

higher)• Eventually +/- peritoneal signs

Labs/ImagingLabs/Imaging

• Labs: elevated WBC, no abnormalities that indicated an alternate dx (liver functions, B-HCG, etc)

• CT: 95% spec and sens

• U/S: 81% spec, 86% sens

ManagementManagement

• Surgical• Preop

– Hydration– Abx prophylaxis

• Non-perfed: cefazolin 1 g IV, metronidazole 500 mg IV• Perfed: ceftriaxone 1 g IV, metronidazole 500 mg IV

• Delaying intervention for >24 hrs, risks perfs• Risk of preg comps (SA or prematurity) w/

laparotomy decrease with gestational age• May do laparotomy or laparoscopy

G.I. DISEASE IN PREGNANCY:G.I. DISEASE IN PREGNANCY:APPENDICITISAPPENDICITIS

• Fetal Mortality and Maternal Morbidity rates are directly correlated to the delay in diagnosis and treatment******

Acute cholecystitis - BackgroundAcute cholecystitis - Background

• A syndrome with:– RUQ pain– Fever– Leukocytosis– Assoc w/ GB inflammation usually due to

gallstone (in preg – 90%)

EpidemiologyEpidemiology

• Incidence of <0.1% in pregnancy

• Maternal mortality 0-1%– 15% with pancreatitis

• Fetal mortality 10-20%– 60% with pancreatitis

ClinicalClinical

• RUQ/epigastric pain, steady and severe >4-6 hours

• Nausea/vomiting, anorexia• Fatty food ingestion exacerbates pain 1

hour after intake• Ill looking, tachycardic, febrile, lie still,

peritoneal signs, +ve Murphy’s sign (inspiratory arrest) +/- jaundice

PathophysiologyPathophysiology

• Pregnancy predisposes to accumulation of GB stones by:– Increasing viscosity of bile– Increasing the number of micelles on which

cholesterol crystals precipitate– Relaxing the GB leading to stasis

• Increased risk of cholelithiasis stays for up to 5 years postpartum

Labs/ImagingLabs/Imaging

• Labs:– Elevated WBC w/ left shift– Elevated bili and ALP, +/- high AST/ALT/amylase

• U/S:– Cholelithiasis– Wall thickening >4.5 mm– Sonographic Murphy’s sign– Dilation of GB– Sens 88%, spec 80%

• HIDA scan – Sens 97%, spec 90%


• IV hydration• Analgesia

– Demerol preferred over morphine (morphine may produce spasm of sphincter of Oddi)

• NPO• Abx

– Metronidazole 500 mg IV q8h– Ceftriaxone 1 g IV q24h


• Surgery is safest to perform during TM2• Laparoscopic cholecystectomy has been

performed during pregnancy but safety is uncertain

• Patients w/ choledocholithiasis or pancreatitis can be mx w/ ERCP w/ sphincterotomy

• If preg and have gallstones but asymptomatic – no surgery

• Pre-preg if have symptoms consistent w/ gallstones consider cholecystectomy

G.I. DISEASE IN PREGNANCY:G.I. DISEASE IN PREGNANCY:BOWEL OBSTRUCTIONBOWEL OBSTRUCTION

• Morbidity and Mortality related to the delay in diagnosis*

• Previous Surgery and Adhesions--3d TM

• Volvulus, Hernia, Intussusception

• Signs and Symptoms =

• Diagnosis Serial Assessments and Serial AXRs

• Management?

CASE 2CASE 2

• “THE MOOSE STORY”

CASE 2CASE 2


• NOW IN THE NEUROSURGICAL ICU

• CONSULTS OBS RE CT, ANGIOGRAPHY

• CONSIDERATION OF TERMINATION?

CASE 2CASE 2


• THE HAPPY ENDING……….

CASE 3CASE 3

• 30 YR OLD WOMAN AT 24 WEEKS GESTATION MVA HIT FROM BEHIND

• HAD SEAT BELT ON, NO HEAD INJURY• O/E VSS, BRUISED AND TENDER

ABDOMEN• FETAL HEART TONES HEARD• WHAT ARE THE ISSUES HERE?

CASE 3CASE 3

• MATERNAL CONSIDERATIONS FIRST!

• FETUS SECONDARY

• MONITORING IF FETUS VIABLE

• FETAL MATERNAL TRANSFUSION

BETKE-KLEIHAUER

• SURGICAL DELIVERY IF FETAL DISTRESS AND MOTHER IS STABLE

SURGERY IN THE SURGERY IN THE PREGNANT PATIENTPREGNANT PATIENT

Learning objectives:

1)TRAUMA IN PREGNANCY

2)THE ACUTE ABDOMEN IN PREGNANCY

3)CASES

THANKS!

SURGERY IN THE SURGERY IN THE PREGNANT PATIENTPREGNANT PATIENT

• AVOID “THERAPEUTIC PARALYSIS”• IF AN INVESTIGATION IS INDICATED

FOR DIAGNOSIS ---DO IT!• NEVER COMPROMIZE THE MATERNAL

CARE FOR THE SAKE OF THE FETUS!• THERE ARE VERY FEW DRUGS OR

INVESTIGATIVE TESTS WHICH CAUSE SERIOUS FETAL DAMAGE

Documents

TRAUMA AND SURGERY IN THE PREGANANT PATIENT IN THE PREGANANT PATIENT PRINCIPLES OF SURGERY-2009 NICHOLAS LEYLAND,BASc,MD,MHCM,FRCSC CHIEF OF OBSTETRICS