TRAUMA IN PREGNANCY

CASE 1

27y G2L1(C/S)

GA:32+6

CC: flank and lumbar pain after car accident

VB,VL,LP :neg VB,VL,LP :neg

PMH: neg

PSH:C/S

CONT…

Bp:100/60 PR:88 FHR:132

V/E:1finger ext .

Cc: neg

Last sono:S/C/ANT/NL/32+5

LAB

Hb=10.3 6hr Hb=10.3

CBC

plt=189.000 6hr plt=173.000plt=189.000 6hr plt=173.000

U/A: pro : trace

PIH : NL / 233 / 3.5 / 0.8

PT,PTT,INR : NL / 375

SONO

S / C / Ant /NL

BPD = 33w + 2d

FL = 33w + 6d

AC = 33w + 4d AC = 33w + 4d

Sub chorionic hematoma : Neg

BPP SONO/NST

Fetal tone : 0/2

Respiration : 0/2

Movement : 0/2Movement : 0/2

Amniotic fluid : 2/2

NST:CLASSIII

Total score : 2/10

CASE 2

30y G1 GA:14w CC: multiple truma after car accident /multiple

fracture in limb and pelvic/vaginal bleeding. LAB test: LAB test: CBC: HB:12 plt:178000 PT,PTT,INR : NL / 320 Bp:100/60 PR:88

Sono: fetal death and subchorionic hematoma.

-Trauma affects 7% of all pregnancies- requires admission in 4 of 1000 pregnancies. - The incidence increases with advancing gestational age.- Just over half of trauma during pregnancy occurs in the

third trimester.

PRACTICE MANAGEMENT GUIDELINES FOR THE DIAGNOSIS AND MANAGEMENT OF INJURY IN THE PREGNANT PATIENT:

THE EAST PRACTICE MANAGEMENT GUIDELINES WORK GROUP./DEPARTMENT OF SURGERY, LEHIGH VALLEY HEALTH NETWORK, ALLENTOWN, PENNSYLVANIA,

USA. / J TRAUMA. 2010;69(1):211.

third trimester.

-Motor vehicle crashes comprise 50% of these traumas-falls 22%-assaults 22%.

CONT…

- Trauma during pregnancy is the leading cause of nonobstetric death and has an overall 6% to 7% maternal mortality.

-Fetal mortality has been quoted as high as 61% in major - -Fetal mortality has been quoted as high as 61% in major trauma

- -fetal mortality canbe 80% if maternal shock is present.

TRAUMA IN PREGNANCY, OBSTETRICAL OUTCOME IN A TERTIARY CENTRE IN THE NETHERLANDS

J Matern Fetal Neonatal Med. 2018 Feb;31(3):339-346. doi: 10.1080/14767058.2017.1285891. Epub 2017 Apr 11.

van der Knoop BJ1, Zonnenberg IA2, Otten VM1, van Weissenbruch MM2, de Vries JIP1.

PURPOSE:

To determine obstetrical outcome and severity of trauma.

Method:

Retrospective study in a Dutch tertiary medical center, including women admitted for trauma in pregnancy between 1995 and 2005 and infants born from these pregnancies.

adverse obstetrical outcome :

- fetal death

-placental abruption

-birth <37 weeks and/or birth weight <10th percentile

RESULTS:

-Trauma admissions occurred in 10 per 1000 deliveries.

- Injuries were non-severe in (92%). - Injuries were non-severe in (92%).

-Obstetrical symptoms and/or abnormal diagnostic tests were present in (40%).

-Adverse pregnancy outcome was encountered in 20% cases, mainly preterm births 16%.

PLACENTAL ABRUPTION

incidence of abruptio placentae after trauma varies, but is consistently higher than the rate in the general obstetrical population (0.4 to 1.3 %) %)

the rate can be much higher (40 to 66% ) in women who sustain severe trauma to the abdomen.

DIAGNOSIS OF ABRUPTION

is based upon the presence of characteristic clinical features:

- vaginal bleeding

-abdominal pain -abdominal pain

-contractions

-uterine rigidity and tenderness

-a nonreassuring fetal heart rate (FHR) tracing.

CONT…

laboratory assessments ( platelet count and fibrinogen concentration) support the diagnosis if abnormal.

Ultrasound examination is of limited usefulness Ultrasound examination is of limited usefulness in diagnosing abruption.

CT and magnetic resonance imaging are never used clinically for evaluation of abruption.

TRAUMA IN PREGNANT WOMEN: ASSESSING DETECTION OF POST-TRAUMATIC PLACENTAL ABRUPTION ON CONTRAST-ENHANCED CT VERSUS ULTRASOUND./ 2017 APR

OBJECTIVES: To evaluate detection of post-traumatic placental abruption

with contrast-enhanced CT (CECT) and comparison with Ultrasound (US).

METHODS: METHODS: trauma, and/or placental abruption over 10 years. CT was compared to US, if performed within 24 h. Two subspecialty-trained radiologists blindly reviewed the

studies. ( Lack of adverse pregnancy/fetal outcome was treated as

the absence of abruption.)

CONT…

RESULTS:

CT was performed in 36 patients.

There were three complete and eight partial abruptions. abruptions.

sensitivity for CT was 100%

specificity was 54.5% .

No sonographic abnormality was noted in both partial and complete abruption.

CONT…

False-positive reads were from: 1) misinterpretation of normal placental structures like

cotyledons. 2)age-related infarcts. 3)marginal sinus of the placenta. 3)marginal sinus of the placenta.

CONCLUSIONS: CECT identifies post-traumatic placental abruption with

high sensitivity but low specificity . CECT was better than US. US markedly underdiagnoses abruption.

COMPUTED TOMOGRAPHIC IMAGING INTERPRETATION IMPROVES FETAL OUTCOMES AFTER MATERNAL TRAUMA.

J Trauma Acute Care Surg. 2016 Dec;81(6):1131-1135. Kopelman TR1, Bogert JN, Walters JW, Gridley D, Guzman O, Davis KM, Pieri PG, Vail SJ, Pressman M.

purpose:

The purpose of this study was to demonstrate improvement in fetal survival when delivery occurs by protocol at the first sign of class III fetal heart rate tracing in pregnant trauma patients with a viable fetus on arrival and CT evidence of placental pregnant trauma patients with a viable fetus on arrival and CT evidence of placental perfusion 50% or less secondary to placental abruption.

METHODS: This is a retrospective review of pregnant trauma patients at 26 weeks' gestation or

greater who underwent abdominopelvic CT as part of their initial evaluation.

RESULTS:

Forty-one patients met inclusion criteria. Computed tomography revealed evidence of placental abruption in six patients (15%): Grade 1, one patient, Grade 2, one patient, and Grade 3, four patients. (Grade 1, >50% perfusion; Grade 2, 25%–50% perfusion; Grade 3, <25% perfusion).

Gestational ages ranged from 26 to 39 weeks. Gestational ages ranged from 26 to 39 weeks. All patients with placental abruption of Grade 2 or greater

developed concerning fetal heart tracings and underwent delivery emergently at first sign. Abruption was confirmed intraoperatively in all cases.

Apgar scores at 10 minutes were greater than 7 in 80% of infants, all of whom were ultimately discharged home. The remaining infant was transferred to an outside facility.

CONCLUSIONS:

Delivery at first sign of nonreassuring fetal heart rate tracings in pregnant trauma patients (third trimester) with placental abruption of (third trimester) with placental abruption of Grade 2 or greater can lead to improved fetal outcome.

GUIDELINES FOR THE MANAGEMENT OF A PREGNANT TRAUMA PATIENT./J OBSTET GYNAECOL CAN. 2015 JUN;37(6):553-74

.

OBJECTIVE:

Physical trauma affects 1 in 12 pregnant women and has a major impact on maternal mortality and morbidity and on pregnancy outcome. A multidisciplinary approach is warranted to optimize outcome for both the mother and her fetus. The aim of this document is to provide the obstetric care provider with an evidence-based systematic approach to the pregnant trauma patient.

EVIDENCE: Published literature was retrieved through searches of Medline, CINAHL, and The Cochrane Library

from October 2007 to September 2013 using appropriate controlled vocabulary (e.g., pregnancy, Published literature was retrieved through searches of Medline, CINAHL, and The Cochrane Library from October 2007 to September 2013 using appropriate controlled vocabulary (e.g., pregnancy, Cesarean section, hypotension, domestic violence, shock) and key words (e.g., trauma, perimortem Cesarean, Kleihauer-Betke, supine hypotension, electrical shock). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English between January 1968 and September 2013. Searches were updated on a regular basis and incorporated in the guideline to February 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES:

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care .

RESULT…

This guideline is expected to facilitate optimal and uniform care for pregnancies complicated by trauma.

1. Every female of reproductive age with significant injuries should be considered pregnant until proven otherwise by a definitive pregnancy test or ultrasound scan.

2. A nasogastric tube should be inserted in a semiconscious or unconscious injured pregnant woman to prevent aspiration of acidic gastric content.

3. Oxygen supplementation should be given to maintain maternal oxygen saturation > 3. Oxygen supplementation should be given to maintain maternal oxygen saturation > 95% to ensure adequate fetal oxygenation.

4. If needed, a thoracostomy tube should be inserted in an injured pregnant woman 1 or 2 intercostal spaces higher than usual.

5. Two large bore (14 to 16 gauge) intravenous lines should be placed in a seriously injured pregnant woman.

6. Because of their adverse effect on uteroplacental perfusion, vasopressors in pregnant women should be used only for intractable hypotension that is unresponsive to fluid resuscitation.

7. After mid-pregnancy, the gravid uterus should be moved off the inferior vena cava to increase venous return and cardiac output in the acutely injured pregnant woman. This may be achieved by manual displacement of the uterus or left lateral tilt. Care should be taken to secure the spinal cord when using left lateral tilt.

CONT…

8. To avoid rhesus D (Rh) alloimmunization in Rh-negative mothers, O-negative blood should be transfusedwhen needed until cross-matched blood becomes available.

9. The abdominal portion of military anti-shock trousers should not be inflated on a pregnant woman because this may reduce placental perfusion. (II-3B) Transfer to health care facility

10. Transfer or transport to a maternity facility (triage of a labour and delivery unit) is advocated when injuries are neither life- nor limb-threatening and the fetus is viable (≥ 23 weeks), and to the emergency room when the fetus is under 23 weeks' gestational age or considered to be non-viable. When the injury is major, the patient should be transferred or transported to the trauma unit or emergency room, regardless of major, the patient should be transferred or transported to the trauma unit or emergency room, regardless of gestational age.

11. When the severity of injury is undetermined or when the gestational age is uncertain, the patient should be evaluated in the trauma unit or emergency room to rule out major injuries.(Evaluation of a pregnant trauma patient in the emergency room)

12. In cases of major trauma, the assessment, stabilization, and care of the pregnant women is the first priority; then, if the fetus is viable (≥ 23 weeks), fetal heart rate auscultation and fetal monitoring can be initiated and an obstetrical consultation obtained as soon as feasible.

13. In pregnant women with a viable fetus (≥ 23 weeks) and suspected uterine contractions, placental abruption, or traumatic uterine rupture, urgent obstetrical consultation is recommended.

14-In cases of vaginal bleeding at or after 23 weeks, speculum or digital vaginal examination should be deferred until placenta previa is excluded by a prior or current ultrasound scan.

15. Radiographic studies indicated for maternal evaluation including abdominal computed tomography should not be deferred or delayed due to concerns regarding fetal exposure to radiation.

16. Use of gadolinium-based contrast agents can be considered when maternal benefit outweighs potential fetal risks. 16. Use of gadolinium-based contrast agents can be considered when maternal benefit outweighs potential fetal risks.

17. In addition to the routine blood tests, a pregnant trauma patient should have a coagulation panel including fibrinogen.

18. Focused abdominal sonography for trauma should be considered for detection of intraperitoneal bleeding in pregnant trauma patients.

19. Abdominal computed tomography may be considered as an alternative to diagnostic peritoneal lavage or open lavage when intra-abdominal bleeding is suspected.

20. All pregnant trauma patients with a viable pregnancy (≥ 23 weeks) should undergo electronic fetal monitoring for at least 4 hours.

21. Pregnant trauma patients (≥ 23 weeks) with adverse factors including uterine tenderness, significant abdominal pain, vaginal bleeding, sustained contractions (> 1/10 min), rupture of the membranes, atypical or abnormal fetal heart rate pattern, high risk mechanism of injury, or serum fibrinogen < 200 mg/dL should be admitted for observation for 24 hours.22. Anti-D immunoglobulin should be given to all rhesus D-negative 22. Anti-D immunoglobulin should be given to all rhesus D-negative pregnant trauma patients.

23. In Rh-negative pregnant trauma patients, quantification of maternal-fetal hemorrhage by tests such as Kleihauer-Betke should be done to determine the need for additional doses of anti-D immunoglobulin.

24. An urgent obstetrical ultrasound scan should be undertaken when the gestational age is undetermined and need for delivery is anticipated.

25. All pregnant trauma patients with a viable pregnancy who are admitted for fetal monitoring for greater than 4 hours should have an obstetrical ultrasound prior to discharge from hospital.

26. Fetal well-being should be carefully documented in cases involving violence, especially for legal purposes.

27. Management of suspected placental abruption should not be delayed pending confirmation by ultrasonography as ultrasound is not a sensitive tool for its diagnosis.diagnosis.

28. Tetanus vaccination is safe in pregnancy and should be given when indicated. 29. Every woman who sustains trauma should be questioned specifically about

domestic or intimate partner violence. 30. During prenatal visits, the caregiver should emphasize the importance of

wearing seatbelts properly at all times. Perimortem Caesarean section 31. A Caesarean section should be performed for viable pregnancies (≥ 23 weeks)

no later than 4 minutes (when possible) following maternal cardiac arrest to aid with maternal resuscitation and fetal salvage.