Trauma in Pregnancy

Kayla E Ireland, MD Maternal Fetal Medicine Fellow Department Obstetrics and Gynecology

Financial Disclosure

No relevant financial relationships with commercial interests to disclose

Objectives • Discuss the prevalence and risk factors of

trauma in pregnancy • Describe the perinatal complications

associated with trauma in pregnancy • Describe the management of pregnant

women with minor and major trauma – at the time of event as well as subsequent prenatal care

Trauma in Pregnancy

• Occurs 6-7% pregnancies (1 in 12 women)

• Leading cause of non-obstetric maternal mortality

Fildes 1992 J Trauma

MacDorman 2016 Obstet Gynecol

Adjusted maternal mortality rates, Texas, 2000–2014

Trauma in Pregnancy

• Presence of gravid uterus alters the pattern of injury

• Two patients – mother and fetus – both require evaluation and management

Critical Care and Trauma, Williams Obstetrics, 24e

Mechanism of injury

• NTDB 1994 – 2001, 895 pregnant women with trauma…

Ikossi et al 2005 J Am Col Surgeons

Physiologic Changes in Pregnancy Cardiovascular

Physiologic Changes in Pregnancy Hemostasis

Parameter Non-pregnant Term Pregnant Activated PTT (sec) 31.6 ± 4.9 31.9 ± 2.9 Fibrinogen (mg/dL) 256 ± 58 473 ± 72 Factor VII (%) 99.3 ± 19.4 181.4 ± 48.0 Factor X (%) 97.7 ± 15.4 144.5 ± 20.1 Plasminogen (%) 105.5 ± 14.1 136.2 ± 19.5 tPA (ng/mL) 5.7 ± 3.6 5.0 ± 1.5 Antithrombin III (%) 98.9 ± 13.2 97.5 ± 33.3 Protein C (%) 77.2 ± 12.0 62.9 ± 20.5 Total protein S (%) 75.6 ± 14.0 49.9 ± 10.2

Physiologic Changes in Pregnancy Respiratory

↓ ↓

↓

↑

Total Lung Capacity

Decreased 5%

Vital Capacity No Change

Inspiratory Capacity

Increased 15%

Expiratory Reserve Volume

Decreased 25%

Residual Volume Decreased 15%

Functional Residual Capacity

Decreased 20%

Closing Capacity No change

Uterine Blood Flow: 10% of CO

Is Pregnancy protective in trauma???

• National Trauma Data Bank (NTDB) 2001-2005 - compared non-pregnant to pregnant women – Non- pregnant women (N = 214,394), 98.28% – pregnant women (N = 3,763) 1.72%

• Among women of similar age groups who are equivalently injured, pregnant women exhibit lower mortality

John et al 2011 Surgery

MVC and pregnancy • 207 per 100,000 pregnancies

– 92,500 women injured annually – Fetal mortality

• 1.4/100,000 – Maternal mortality

• 3.7/100,000

• 87% receive medical care, majority admission >20 weeks gestation

• Risk factors: use of intoxicants, improper seat belt use – ½ pts reported having received

proper seat belt use from prenatal care provider Critical Care and Trauma, Williams Obstetrics, 24e

Seat Belt Use in Pregnancy • County Prenatal Clinical

Survey, n=450, 92% response rate

• 73% rate of correct use • Reasons for lack of use:

– Discomfort (53%) – Forgetfulness (37%)

• 10% believed seatbelts are harmful

• 1/3 unsure of effects seatbelt on fetus

McGwin 2004 J Trauma

MVC and pregnancy • Obstetrical concern Æ

Strain on uterus Æ placental abruption

• “Contrecoup” and shear-force strain

• among severely injured women (ISS >12), placental abruption occurs in as many as 40% of cases

Critical Care and Trauma, Williams Obstetrics, 24e

Slips/Falls in Pregnancy • Increased joint laxity and

weight gain Æ affects gait Æ predispose to falls

• 1 in 4 women will fall at least once in pregnancy

• Complications proportional to force and body part impacted – Fracture lower extremity

most commonly associated injury when hospitalized (40%)

– 3% fetal loss due to falls

• Overall 49 per 100,000 deliveries

• Of 639 hospitalized pregnant women after fall – PTL, RR 4.4 – Abruption, RR 8 – Fetal distress, RR 2.1 – Fetal hypoxia, RR 2.9

Mendez-Figueroa 2013 AJOG Schiff BJOG 2008

Domestic Partner Violence/Intimate Partner Violence and Pregnancy

• >60 studies from >20 countries: rates 1-57% (22% in general female population)

• Risk factors: – substance abuse, low

maternal education level, low socioeconomic status, unintended pregnancy, h/o DV in prior pregnancy, h/o witnessed violence as child, unmarried

• Adverse pregnancy outcomes: – SAB, NICU admission, PTB,

low birthweight • Strong association between

peripartum depression and antenatal DV – Prospective cohort

13,617mom/baby dyads 42 months pp • Antenatal depression OR 4.02 • Postpartum depression OR

1.7

Mendez-Figueroa 2013 AJOG Flach 2011 BJOG

Penetrating Trauma

• Altered pattern of injury – Visceral injury 15-40% (compared to 80-90% non-pregnant) – Below fundus

• High fetal mortality rate: 40-70% • Lower maternal mortality rate: 4-7%

– Above fundus • Bowel and solid organ injury

• Of 321 women with abdominal trauma – 9% Penetrating injuries – 77% GSW, 23% stab wounds

Petrone 2011 Injury

Minor Trauma

• Prospective cohort 3 yrs, n=317 • “Minor” trauma excluded life-threatening injuries, any injuries

greater than bruising/lacs/contusions = ISS 0 • Falls (48%), MVC (29%), assaults (87%) • 14% patients with regular contractions 1st 4 hrs • 1 abruption = 35 wks, fall from standing Æ abruption 41 wks • Of the predictors – no single variable sensitive/specific to

predict clinical outcomes.. Cahill 2008 AJOG

Uterine Rupture • 0.6% injuries during

pregnancy • More likely in prior scarred

uterus, associated with direct impact significant force

• 75% cases involve the fundus

• Fetal mortality approaches 100%

• Maternal mortality 10% (usually due to severity of injuries) Woldeyes 2015 Case Rep Obstet Gynecol

Abruption • Catastrophic events with blunt

trauma: – include abruption and placenta tear

• Deformation elastic myometrium around inelastic placenta

• 1-6% “minor injuries”, 50% “major injuries”

• Considerable force Æ placental fracture

• More likely to be concealed (no VB) with increased risk of coagulopathy compared to non-traumatic abruption

• Si/sxs: VB, uterine TTP, fetal tachycardia, late decelerations, acidosis, fetal death

Critical Care and Trauma, Williams Obstetrics, 24e

Preterm Labor • Incidence following trauma <5% • Causes

– Uterine injury Æ destabilization of lysosomal enzymes Æ PG production

– Premature rupture of membrane – Abruption

Fetal Deaths Related to Maternal Injury • Retrospective study of fetal deaths • 16 states (55% of US live births),

15,000 Fetal Deaths • 240 traumatic fetal deaths, 3.7 per

100,000 live births • Causes:

– MVC (20%); firearm (6%); falls (3%)

– 27 maternal deaths (11%)

Weiss 2001 JAMA

Management of Trauma in Pregnancy RULE #1

Mother first – fetus second Maternal Death is the most common cause of

fetal demise… Minor Maternal Trauma is associated with fetal

demise

Management of Trauma in Pregnancy

• Maternal and fetal outcomes directly related to severity of injury

• Not specific pregnancy scoring system – ISS does not take into account abruption and pregnancy outcomes

• Schiff et al 582 pregnancies hospitalized after injury, ISS did not accurately predict adverse pregnancy outcomes and MINOR injuries associated with PTL and abruption

Management of Trauma in Pregnancy • With few exceptions, treatment priorities in

injured pregnant women are directed as they would be in non-pregnant patients

• DON’T BREAK THE ROUTINE… – Basic rules of resuscitation ABCs…

• LEFT LATERAL TILT… ensure large uterus is positioned off the great vessels to diminish its affect on vessel compression and decreased cardiac output

Primary Survey

ABCs A B C D E

Increased Aspiration Risk – Raised intra-abdominal pressure

– Decreased LES pressure – Slow gastric emptying

– Displaced Bowel

Pregnancy itself is a risk for failed intubation

Primary Survey

ABCs A B C D E

Oxygen consumption increases 20% Elevated diaphragms

Decreased FRC by 20% Physiologic compensated respiratory

alkalosis (dec buffering capacity)

Primary Survey

ABCs A B C D E

Normal: - pulse: 10-15 beats faster

- Blood pressure: 10-15 mmHg lower

Supine Hypotension

Massive blood loss with minimal si/sxs

Hypotension Æ fetal hypoperfusion

Primary Survey

ABCs A B C D E

Exam - Glasgow Coma Scale

- Pupillary Reflex

Traumatic Brain Injury - Independent predictor of fetal loss

- HPA axis dysregulation – hypopituitarism 40% with mod-severe TBI

FAST exams in pregnancy

• 177 pregnant trauma patients – 85% in 2nd/3rd Trimester – FAST

• sensitivity: 83% • Specificity: 98%

– May decrease use of CT

Goodwin 2001 J Trauma

Secondary Survey

• Obstetrical Exam – Fetal gestational age/position – Evaluate vaginal bleeding/PROM/cervical

effacement

• Kleihauer-Betke – Detection of transplacental hemorrhage in Rh

negative – Guide Rh immunoglubin therapy to prevent Rh

isoimmunization

Kleihauer-Betke Testing • KB used detect FMH in Rh neg, may

reflect uterine injury and risk of PTL • FMH: KB ≥ 0.01 mL fetal blood in

maternal circulation • 46/71 patients KB ≥ 0.01 mL (FMH)

– 44/46 contractions, 25/46 PTL – Neg KB (n=25) – no PTL or contractions

• Likelihood ratio +KB for PTL: 20.8, NPV 92.6%

Muench 2004 J Trauma

• In retrospective review 125 women with blunt trauma, KB sensitivity 56%, specificity 71%, accuracy 27% diagnose FMH

• Fetal monitoring, ultrasound were more useful in detecting fetal and pregnancy complications

• Concluded: little value in acute trauma management

Towery 1993 J Trauma

Fetal Monitoring • At viability Æ continuous fetal monitoring should

be initiated • Ideal duration not established… • Fetal well-being reflects maternal well-being =

additional VITAL SIGN

Obstetrical Hemorrhage, Williams Obstetrics, 24e

Fetal Monitoring • Pearlman (1990) prospective

study n=85 – adverse pregnancy outcome Æ 1st

4 hours CTX Q2-5 minutes – No one with contractions occurring

less than >q15 min adverse outcome

– Sensitive but no specific for detecting immediate adverse perinatal outcome

• Connolly (1997) no adverse outcomes in women with normal fetal heart rate tracings

• Dahmus 1993 AJOG summarized data, n=605 – adverse pregnancy outcome Æ

“frequent uterine contractions” occurring greater than 6 times per hour in the 1st 4 hours

Fetal Monitoring RECCOMENDATIONS:

• At viability, external electronic fetal heart rate monitoring and cardiotocographic monitoring minimum 4-6 hours

• Extend 24 hours: – contractions > Q10 minutes within 4 hours – Si/sxs abruption: persistent uterine tenderness, vaginal

bleeding – Non-reassuring fetal monitoring – ROM – Serious maternal injury Æ maternal vital sign – Uterine hypoperfusion Æ ARDS, cardiac arrhythmia

Radiation in Pregnancy

CO #656 Radiation in Pregnancy Obstet Gynecol 2016

Delivery • Dependent on fetal gestation age, fetal

condition, extent of injury and when delivery would improve maternal well-being (large uterus hinders adequate treatment or evaluation of intraabdominal injury)

• C-section – Viable fetus in distress – Uterine trauma

• IUFD – vaginal delivery preferred • Trauma laparotomy does not mandate C-section

Infant survival after C-section for trauma • Multi-institution (9 Level 1 trauma center), 1986 -

1994 retrospective cohort • 32 emergent C-sections of 441 pregnant women

admitted after trauma • Mean GA 33 wks at delivery (22-40) • No FHT (n=13) = no survival • Survival 75% when GA >26 wks • Most common reason for preventable fetal loss –

delayed recognition of fetal distress Morris 1996 Annals of Surgery

Perimortem C-section • within 4 minutes of maternal cardiac

arrest Æ assume cardiopulmonary resuscitation ineffective 3rd TM due to aortocaval compression Æ fetal and perhaps maternal outcomes would be optimized by timely delivery – brain damage begins at 5 minutes of

anoxia • Katz et al 2005 AJOG Æ review of 38

cases in literature… SELECTION BIAS… – 13/20 resuscitated and discharged

from hospital – 12/18 improved hemodynamic stability

after C-section – No case of deterioration with c-delivery

Perimortem C-section Time Arrest Æ Delivery % newborns neurologically intact

<5 minutes 98%

6-15 minutes 84%

16-25 minutes 33%

26-35 minutes 25%

Adapted from Clark SL, Cotton DB, Hankins GDV, et al. Critical Care Obstetrics, 3rd Ed. 1997

“these goals rarely can be met in actual practice... For example, most cases of cardiac arrest occur in uncontrolled circumstances, and thus, the time to CPR initiation alone would exceed the first 5 minutes. Thus “crash” cesarean delivery would supersede resuscitative efforts, be necessarily done without appropriate anesthesia or surgical equipment, and more likely than not, would lead to maternal death…”

Pregnancy Complications after Trauma Women hospitalized for trauma 9 months preceding delivery (N=7822)

OR 9% CI

Placental abruption 1.6 (1.3-1.9)

Preterm labor 2.7 (2.5-2.9)

Maternal Death 4.4 (1.4 – 14)

Retrospective cohort study CA ICD-9. El Kady 2004 Am J Obstet Gynecol

• Sperry et al 10 year retrospective cohort at UTSW Level 1, n=773 women discharge home after trauma with viable fetus

• Preterm Delivery RR 1.9 (1.1-1.3), Low Birthweight RR 1.8 (1.04 – 1.32) with higher risk with increasing ISS score and earlier gestation

• Trauma during pregnancy is risk factor for poor pregnancy outcome El Kady 2004 AJOG

Sperry 2006 Am J Surgery