Pregnant trauma patients - NYSORA

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Pregnant trauma patients

Pregnant trauma patients

Learning objectives

  • Discuss the potential for obstetric complications after trauma
  • Outline the complex management challenges of trauma during pregnancy

Definition and mechanisms

  • Trauma is the leading cause of nonobstetric mortality and affects 7% of all pregnancies
  • The most common traumatic injuries are motor vehicle crashes, assaults, falls, or partner violence
  • Major trauma has been associated with 7 percent of maternal and 80 percent of fetal mortality
  • Placental abruption is the most common cause of fetal death:
    • First trimester: the thick-walled uterus is protected from trauma by the pelvic girdle
    • Second trimester: the fetus is protected by relatively abundant amniotic fluid volume
    • Third trimester: the thin-walled uterus is exposed to blunt and penetrating abdominal trauma
  • Pregnant trauma patients should be approached and managed like any other trauma patient using a standard ABCD approach
  • Clinical decision-making is complicated by:
    • The needs of both mother and fetus must be considered
    • Anatomical and physiological changes in pregnancy can mask or mimic injury
    • Life-threatening obstetric complications can occur even after seemingly minor trauma and may require urgent delivery of the fetus
    • Fetal injury can predominate of that the mother
  • Establishing maternal stability may not be possible without obstetric intervention

Complications

Injury severity score

Physiological changes of pregnancy

SystemChangesImplications
Pulmonary system

↑ Tidal volume
The respiratory rate is unchanged
↓ FRC
↑ Oxygen consumption
↑ Minute ventilation
↓ Arterial CO2 tension
↓ Thoracic compliance
Elevated diaphragm
Apply supplementary oxygen to avoid hypoxia
Consider desaturation
Bag mask ventilation may be difficult
Place chest drains higher (3rd or 4th intercostal space)
Airway↑ Airway edema
↑ Vascular engorgement
↑ Tissue friability
↑ Breast size and neck adiposity
↑ Aspiration risk
Difficult intubation
Consider cricoid pressure
insert early NGT
Cardiovascular system↑ Plasma volume (40-50%)
↑ Heart rate (15-25%)
↑ Cardiac output (50%)
↓ SVR (20%)
Increased blood volume may initially mask the shock
Supine hypotension due to IVC compression may reduce CO
Hematological changesHypercoagulability
Anemia
Thrombocytopenia
↑ Factors VII, VIII, IX, X, XII, von Willebrand, and fibrinogen
↓ aPTT, PT, and INR
All Rhesus-negative mothers should receive anti-D within 72 hours of injury
Consider rhesus status when initiating blood product transfusion
Renal system↑ Renal blood flow
↑ Glomerular filtration rate (60%)
↓ Serum creatinine and bicarbonate
Gastrointestinal system↓ Esophageal sphincter tone
Cephalad displacement of the stomach
↑ Intra-gastric pressure
Delayed gastric emptying
Perform early gastric decompression with NGT
The bladder becomes an intra-abdominal organ after 1st trimester
Other abdominal organs are displaced by the uterus

See also physiological changes during pregnancy

Management

Discharge criteria:

  • Resolution of contractions
  • A reassuring fetal heart tracing
  • Intact membranes
  • No vaginal bleeding
  • No uterine tenderness
  • Administer Rh immune globulin therapy to all Rh-negative patients unless the injury is remote from the uterus

Anesthetic management

Suggested reading

  • Irving, T., Menon, R., Ciantar, E., 2021. Trauma during pregnancy. BJA Education 21, 10–19.
  • Huls CK, Detlefs C. Trauma in pregnancy. Semin Perinatol. 2018;42(1):13-20.
  • Jain V, Chari R, Maslovitz S, et al. Guidelines for the Management of a Pregnant Trauma Patient. J Obstet Gynaecol Can. 2015;37(6):553-574.

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