See also: [[CTG monitoring#Trauma CTG guideline|CTG]], [[Resuscitative Hysterotomy]], [[Emergency Delivery]], [[Anti-D]]
[[Pregnancy physiological changes]], [[Airway#Pregnant Airway]], [[Peri-intubation collapse#pregnancy intubation]]
- [Rosen - Trauma in Pregnancy](x-devonthink-item://C57F7072-104E-4982-B03E-BB1A04F7C060)
#ob-gyn #cram #tables
> [!key points]
> - the most common obstetric complication of trauma is uterine contractions
# History
| hx feature heading | relevance |
| :------------------- | :------------------------------------------------------------ |
| presenting complaint | abdo pain, obvious injuries, head injury |
| antinatal history | gestation, complications, Rh status |
| fetal wellbeing | fetal movements? PV bleeding? ruptured membranes? |
| PMx | co-morbidies that affect resus (eg DM, HTN, coagulopathy) |
| accident info | seatbelt use, LOC, vomiting, ambulant post? |
# Pregnancy effect on resus
see also [[Ob-Gyn#Bad things that pregnancy increases risk for|pregnancy risks]], [[Peri-intubation collapse#pregnancy intubation]], [[Pregnancy physiological changes]], [[Obesity resus considerations]]
| parameter | obstetric change | effect on resus |
| --- | --- | --- |
|Airway | - increased airway oedema<br>- decreased gastric emptying → increased aspiration risk <br>- friable tissues near airway → bleeding<br>- difficult BVM<br> <br> | - shorter handle<br>- upright RSI/NGT<br>- optimimise positioning eg ramp patient<br>- good suction |
|Breathing | - elevated diaphragm<br>- ↑ TV and ↑ minute resp <br>- reduced FRC → V/Q mismatch and reduce O2 reserves<br>- **decreased** pCO2 | - rapid O2 desaturation<br>- a pregnant patient with resp failure may have a **normal** CO2<br>- risk of diaphragm rupture with ICC |
| Circulation | - IVC compression from gravid uterus<br>- increase blood volume<br>- reduced BP and peripheral vascular resistance | - left lateral positioning<br>- may loose 1/3 of volume before signs of haemorrhagic shock appear<br>- avoid hypotensive drugs |
# Pregnant effect on assessment
> Assessment: evaluation of the patient by obtaining a history, performing a physical exam, and taking appropriate prioritised investigations
anatomical and / or physiological changes that need to be considered when assessing a pregnant trauma patient:
| feature/change | relevance for assessment |
| ---- | ---- |
| reduced lower gastro-oesophageal sphincter tone | increased risk of aspiration in pt with ↓ GCS lying flat |
| reduced FRC, ↑ O2 consumption | increased sensitivity to hypoxia |
| borderline tachycardia and increased plasma vol in pregnancy | can mask signs of blood loss |
| IVC compression can cause hypotension | spinal precautions difficult to maintain; need to do left lateral |
| gravid uterus displaces organs and stretches peritoneum | features of peritoneal irritation difficult to assess. efast difficult |
## pregnancy ECG changes
![[Pasted image 20240304133247.png]]
# Pregnancy Trauma complications
4 obstetric injuries in trauma
| injury | signs |
| ---------------------------------------------- | ------------------------------------------------------- |
| [[antepartum haemorrhage#Placental abruption]] | uterine tenderness, shock, vaginal bleeding |
| [[uterine rupture]] | shock, shoulder tip pain, severe abdo pain |
| PROM | ruptured membranes <37 weeks in absence of contractions |
| [[pre-term labour]] | contractions, cervical dilation |
## [[placental abruption]]
> [!important] Signs & Symptoms
> - uterine tenderness
> - bleeding/shock
> - Uterine tetany
> - expanding fundal height
> - evidence of fetal compromise (60% of cases)
> - Vag bleeding
> - uterine irritability
## Premature membrane rupture
- ruptured membranes <37 weeks in absence of contractions
- if mum is stable and pregnancy is viable and vaginal birth is possible, labour may be induced (not necessarily
## [[uterine rupture]]
> [!important] Signs and symptoms
> - referred shoulder tip pain
> - severe abdo pain / rebound guarding
> - oblique/transverse lie
> - hypovolaemic shock
> - fetal bradycardia
>
> **Diagnosis:**
> Ultrasound can show evidence of extrusion of the uterine contents, free fluid in pelvis and paracolic gutter region. Confirmation is by laparotomy.
> Occurs in 1% of pregnancies with blunt trauma and is **associated with a pelvic fracture**
## Uterine contractions
*Most common side effect of trauma*, due to release of prostaglandins. Whilst 70% will settle, some women may progress to labour.
labour can occur at any gestation
Labour must NOT be suppressed when there is any placental abruption, maternal complications such as [[Pre-eclampsia]], or hemodynamic instability.
# Mechanism of injury
- most common MOI is MVA (79%)
- falls
- intentional violence
- self-harm
*entrapment is more common in pregnacy due to the size and immobility of the mother*
bowel injury less common following blunt or penetrating trauma, but pregnant women have higher incidenc eof seriours abdo injuiruy and lower incidence of chest and head injury
if pelvis fracture occurs, increased vascularity of pelvis can lead ot massive pelvic or retroperitoneal haemorrhage.
# foetal injury
can be direct or indirect
note whether mum has had seatbelt on correctly or not
**direct:**
- organ ruptures, cervical and skull fracture, ICH
**indirect**
- foetal demise through [[placental abruption]], [[pre-term labour|preterm labour]], or uterine rupture
## Foetal outcome determinants
> best predictor of foetal outcome is the injury severity of the mother.
even relatively minor trauma can be associated w/ foetal injury, and fetal death can occur without any maternal injury
unrestrained pregnant patients are 2x more likely to have maternal haemorrage, 3x more likely to have fetal death
# Primary survey
## Airway
- 8x higher risk of failed intubation
## Breathing
- hypoxaemia more rapid in preg patient due to limited oxygen reserve and higher metabolic requirement
- need careful monitoring of oxygenation
- preg patients need higher partial pressure of O2 to establish same O2 sat
- NGT to ↓ risk of aspiration
- ==[[Resuscitative Thoracotomy|ICC]] 2-3 rib spaces higher due to elevated diaphragm==
> ventilation target: normal PaO2 and CO2 27-32
## Circulation
- left lateral tilt using wedge improve systolic BP
- IV access above diaphrag so IV therapy not obstructed by gravid uterus
- order Kleihauer if Rh D negative
# Obstetric exam and history
- estimated delivery date
- date of last menstral period
- prior preg complications and current issues
## Gestational age
- *20-22 weeks when uterus around level of umbilicus*
# Traumatic arrest
Same [[Traumatic arrest]] algorithm as for non-pregnant trauma patient , but including [[Resuscitative Hysterotomy]]
# EFAST
- sensitivity / specificity high in first trimester (90%/89%)
- sensitivity <50% in 2nd and 3rd trimester, but specificity same
# Ix and interventions
- **negative efast, minor injuries, no foetal distress**
- 4 hours CTG before discharge
- worsening advise re: preterm labour, bleeding, abdo pain
- **negative eFAST, complex injuries**
- admission
- CTG at least 4 hours
- **positive eFAST, no peritoneal signs, stable**
- abdo CT scan
- **positive eFAST, peritoneal signs, unstable**
- urgent laparotomy
# patient warming
- if temp <36.5 deg C
- any major trauma patient suggestive of major bleeding
- includes all fluids being infused through warming devices and external warming devices
# Radiation for radiology
see [[Trauma in pregnancy radiology]]
[Diagnostic imaging during pregnancy and lactation - first10EM](cubox://card?id=7126247982034321620)
- most diagnostic radiology pose no substantial risk ot mum or fetus, including plain XR
- radiation risk related to fetal effective dose and to stage of pregnancy
- most risk 2-8 weeks after fertilisation
# transfusion
- both fetal suceptibility to CMV due to immature immune system, and risk of Rh isoimmunisation
> ensure CMV antibody negative
> only Rh negative RBC and platelets should be used for pregnant women
> ppx anti-D requred for Rh negative females who are pregannt or of chiod bearing potential who recieve Rh positive platelets
> pregnant women who are Kell blood group negative should receive kell negative RBCs where possible
## fetomaternal haemorrhage assessment
## Anti-D administration
see also: [[Anti-D]]
haemolytic disease of newborn may arise if mum develop satni RBC abs against fetal red cell antigens
mums who are Rh negative require ppx Rh immunoglobulin therapy
# Related Questions
## cardiac arrest in pregnancy
- [x] 8Q: [Resuscitative Hysterotomy](x-devonthink-item://7E9EF652-F67B-42C5-A536-2EE85BA1954F?page=3) -- [Answer](x-devonthink-item://2DE5FACA-6D8F-41A2-8EAA-8DFE1E76FA61?page=1)
## physiology changes in pregnancy
- [x] 9Q: [Pregnant Lady Who Fell Down Stairs](x-devonthink-item://CDB16617-3785-40E5-B8BE-5668D2D7A3E7?page=10) -- [Answer](x-devonthink-item://A6CA01E8-9551-45E7-8617-441BE3DBB5D7?page=9)
## resuscitative hysterotomy
- [x] DUPLICATE Q: [Resuscitative Hysterotomy](x-devonthink-item://7E9EF652-F67B-42C5-A536-2EE85BA1954F?page=3) -- [Answer](x-devonthink-item://2DE5FACA-6D8F-41A2-8EAA-8DFE1E76FA61?page=1)
## trauma in pregnancy
- [x] 13Q: [Trauma + pregnancy](x-devonthink-item://85167CB5-A7B5-4BF3-9BC7-AC46D5538A42?page=6) -- [Answer](x-devonthink-item://5B03E66C-E043-4EB7-A5F6-7389CB927BD7?page=8)
- [ ] 14Q: [Trauma in Pregnancy](x-devonthink-item://92A26505-5B6B-4ADD-995F-6AAA2E05C637?page=2) -- [Answer](x-devonthink-item://0808A030-AF19-4671-BE84-3E8BCBEC6124?page=2)
- [ ] 15Q: [Trauma in Pregnancy](x-devonthink-item://662C8511-01CD-4659-B57D-5A01CF74D69B?page=6) -- [Answer](x-devonthink-item://79A95C0A-634E-4B38-9131-78949F63D56F?page=4)
- [x] DUPLICATE Q: [Pregnant Lady Who Fell Down Stairs](x-devonthink-item://CDB16617-3785-40E5-B8BE-5668D2D7A3E7?page=10) -- [Answer](x-devonthink-item://A6CA01E8-9551-45E7-8617-441BE3DBB5D7?page=9)