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Trauma and Pregnancy

Douglas J.E. Schuerer M.D.Associate Professor of Surgery

Director of TraumaBJH

October 4, 2014.

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Is Mom Injured?

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Patient VH

25 yo F, 8 months pregnant, front-seatrestrained passenger in head-on MVC withheavy damage. Transported via ARCH to ED.+LOC, c/o neck, back and abdominal pain.

LLD position, 2 L crystalloid complete at 21:32

Fetal heart rates (twins) in 140s.

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History and Exam

History TL spinal fusion for scoliosis, C-section

ExamAlert and oriented x 3

+C-spine TTP w/ collar in place

Right clavicle TTP Diffuse abdominal TTP with intermittent

firmness, no seat belt sign.

No vaginal bleeding or fluid leakage.

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FAST

Performed in left lateral decubitus and

supine positions, no free fluid seen

except ?trace fluid in the pelvis. +fetal

heart motion in both fetuses.

Performed by resident physician and

ED attending.

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Labs and Imaging

Labs

H/H 10.6/32.4. INR 1.08. Cr 0.62

Imaging

CXR clear

Displaced R clavicle fracture

C-spine XR limited but negative

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Assessment

Pt initially hypotensive but responded to IVF.

Abdominal pain increased and evolved fromintermittent (and corresponding to

contractions) to constant during evaluation inED.

Given increasing abdominal pain and firmuterus, concern for evolving placental

abruption. Pt admitted to labor and delivery for fetal

monitoring and evaluation, with plan for fulltrauma evaluation once stabilized from OB

standpoint.

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Hospital Course

Fetal heart tracings: Initially reassuring, thenwith frequent decelerations and change in

variability from moderate to minimal. Given change in tracings and increasing

abdominal pain with more frequent contractions,taken to OR for suspected placental abruption.

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Trauma and Pregnancy

ABCs of Trauma

Primary and Secondary Survey

Special TopicsFetal Monitoring

Minor Trauma

Radiation / FAST

Abruption

Surgery/ Splenic Artery Aneurysm/ Other

How to make improvements?

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Trauma in Pregnancy

Trauma complicates 1 in 12 pregnancies

MVC 55%

Falls 22%

Assaults 22%

Burns 1%

Patient stratification

Women unaware they are pregnantWomen < 26wks gestation

Women > 26wks gestation

Maternal peri-mortem state

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Anatomic Changes

Uterine size

12wksuterus becomes intra-abdominal organ

20wksvertex of uterus palpable at umbilicus

36wksuterus reaches the costal margin

In late pregnancy, majority of GI tract may be found

above inferior costal margins

Diaphragm elevated 4cm

Mediastinum may appear enlarged on radiographs

Descent in late pregnancy make fetus susceptible to

head injury with maternal pelvic trauma

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How are pregnant patients leveled?

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Pregnancy as Criteria?

Single institution study of Level II trauma patients

57 had only pregnancy as criteria for Level II

28 also had physiologic criteria

The pregnancy only patients had a significantly

lower incidence of c-section2 vs. 5.

Authors conclude that pregnancy itself may not be

a necessary criteria. Other would argue that the resources needed for

these patients may still be greater.

Aufforth et al.Am Jour Surg 2010

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Primary Survey

ABCs

A- Airway with cervical spine control

B- Breathing

C- Circulation

D- Disability or neuro status

E- Exposure (undress)

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Airway

Can patient talk, are they hoarse or

breathless or not awake?

Are they agitated (could be hypoxia) Is there blood in the airway?

Intubation

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Breathing and Ventilation

Deliver oxygen, facemask or nasal cannulae

if not intubated.

Follow pulse-ox.

Check ABG if unsure (vasoconstriction or

CO poisoning e.g.)

Inspection, palpation, auscultation. Make sure chest is rising and falling.

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Breathing and Ventilation

Decreased breath sounds?

Pneumothorax (tension), hemothorax.

Paradoxical chest movement?Flail chest

Sucking sound?

Open pneumothorax

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Circulation with Hemorrhage

Control

2 large bore IVs

Short and wide is better (no triple lumen

CVPs)

Cover wounds and hold pressure

Assess pulses

Check blood pressure Roll patient to the left

Is the patient in shock?

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Circulation

2 liters crystalloid

Then use blood.

Tailor based on hemodynamic response.

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Disability: Neuro Status

Determine level of consciousness and

pupillary size and reaction.

A Alert

V Responds to verbal stimuli

P Responds to painful stimuli

U Unresponsive

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Neuro Status

Glasgow Coma Scale

GCS 15 points

Eye opening 1- 4 points

Verbal Response 1- 5 points

Motor Response 1- 6 points

GCS < 8 should be intubated. Other outcomes/ treatments based on GCS.

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Exposure

Remove clothes especially wet/cold items.

Examine for all injuries.

Keep patient warm.

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Dont be distracted

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Secondary Survey

A Allergies

M Medications

P Past illness and operations

L Last meal

E Events/ Environment related to the injury

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Secondary Survey

Head

Neck

Chest

Abdomen

Musculoskeletal

Neurologic

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Special Considerations

Primary focus remains maternal assessment andresuscitation using ATLS protocols

Early gastric decompression

Supplemental oxygen for all pregnant patients

If thoracostomy tube drainage required, place 1-2interspaces higher than usual

Avoid supine hypertensionleft lateral decubitus

positioning, manual uterine displacement to left, or15 backboard tilt

Avoid vasopressors unless absolutely indicated

Tetanus vaccination is safe in pregnancy

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Special Considerations

HCT

BP

HR Blood Volume

Functional Residual Capacity

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Primary Survey of Fetus in Secondary

Survey

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ED C-Section

Ideally by most experienced physician (OB, Trauma, EP)

Midline Vertical epigastrium to symphysis pubis

Quick Facts

1) No infant survives if there is no fetal heart tone before emergency

cesarean section commences.2) If fetal heart tones are present and the gestational age is 26 weeks or

more, then infant survival is 75%

3) Sixty percent of fetal deaths result from underuse ofcardiotocographic monitoring and delayed recognition of fetaldistress

4) 70% of children who survive perimortem cesarean sections aredelivered in less than 5 minutes of emergency department arrival

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Fetal Monitoring

Performed once maternal life-threatening injuriesidentified and treated

Fetal heart tones discernable with Doppler by 10th

wk gestation Assess uterine size, contractions, vaginal

lacerations or bleeding, amniotic fluid leak (pH =7, ferning)

Continuous monitoring in all pregnancies of > 20wks gestation. Premature labor in 25% of traumacases after 22-24 wks. Duration of monitoringremains controversial.

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Duration of Fetal Monitoring

Initiate for a minimum of 4hrs and during any

operation

At end of 4hr period, may discontinue electronic

monitoring if contractions less frequent thanq15min and no signs of placental abruption

Perlman et al,N Engl J Med, 323, 1990.

Continue monitoring 24hrs for injuries related to

motorcycle accidents, ejected MVC, ped vs MVC,and patients with maternal tachycardia or

abnormal fetal heart rate Curet et al,J Trauma, 49, 2000.

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Is all that really needed?

Minor Trauma

Cahill et al.

Evaluated 317 patients with minor trauma

(ISS=0)

9 had positive KB test

1 of 256 with delivery information had

abruptionAbruption and pregnancy mortality could not

be predicted

Cahill et al. Am Jour Ob Gyn 2008

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Minor Trauma

No patients had nonreassuring fetal

parameters

14% had > 5 contractions per hour

Prediction index did not help predict who

would abrupt.

Suggest no need for intensive workup forminor trauma.

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Radiation

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A Typical Case

22 y/o WF trauma packaged on NRB just movedover to bed

Flight reports VSS

13wks preg restrained front seat passenger

head on by drunk driver, driver of pts car

deceased (her fianc)

no LOC, +prolonged extrication but pt compartment

relatively preserved traction splint to left leg for closed thigh deformity,

+jaw pain/HA/thigh/abd pain

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Primary Survey

C-collar in place, reports name clearly, left jaw pain whenasked to open mouth, +dried blood in OP (teeth/mucosa intact)with active slow ooze from bilat nares, +raccoon eyes, nogross midface instability but painful with frontal incisormanipulation--- 100% on NRB

CTA bilat, no flail, trach midline +radial, no muffled heart sounds, no active extremity

hemorrhage, 151/96 99, 2-18ga bilat AC (rcd 500ml NS)

GCS 15 PERRL, moves all 4 (moves toes left foot)

97.4, left leg in traction with closed thigh deformity/TTP, ableto move toes and intact palpable left DP but faint vs. rightwarm blankets placed

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Secondary Survey

VSS, HR

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East Guidelines

Level I

There are no level I standards.

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Recommendations

Level II

a. All pregnant women >20-week gestation who

suffer trauma should have cardiotocographic

monitoring for a minimum of 6 hours. Monitoringshould be continued and further evaluation should

be carried out if uterine contractions, a

nonreassuring fetal heart rate pattern, vaginal

bleeding, significant uterine tenderness orirritability, serious maternal injury, or rupture of

the amniotic membranes is present.

R d i

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Recommendations

Level II

b. Kleihauer-Betke analysis should be

performed in all pregnant patients >12

week-gestation.

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Recommendations

c. Concern about possible effects of high-

dose ionizing radiation exposure should not

prevent medically indicated maternal

diagnostic X-ray procedures from beingperformed. During pregnancy, other

imaging procedures not associated with

ionizing radiation should be consideredinstead of X-rays when possible.

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Recommendations

d. Exposure to

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Recommendations

e. Ultrasonography and magnetic resonance

imaging are not associated with known

adverse fetal effects. However, until more

information is available, magneticresonance imaging is not recommended for

use in the first trimester.

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Recommendations

f. Consultation with a radiologist should be

considered for purposes of calculating

estimated fetal dose when multiple

diagnostic X-rays are performed.

g. Perimortem cesarean section should be

considered in any moribund pregnant

woman of 24-week gestation.

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Recommendations

h. Delivery in perimortem cesarean sections

must occur within 20 minutes of maternal

death but should ideally start within 4

minutes of the maternal arrest. Fetalneurologic outcome is related to delivery

time after maternal death.

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Recommendations

i. Consider keeping the pregnant patient

tilted left side down 15 degrees to keep the

pregnant uterus off the vena cava and

prevent supine hypotension syndrome.

j. Obstetric consult should be considered in

all cases of injury in pregnant patients.

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CT or not to CT?

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Decisions

Standard care IV/O2/Monitor/Analgesics

Toco if viable (>24wks)

CT Head/neckCXR & pelvis

FAST & Pelvic US

Panscan OR

+

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CT for Pregnant Trauma Patients

ATLS?

1) Support the mom and you support the

baby

2) Less likely to have uterine/fetal trauma if 1st

trimester d/t still in pelvis

3) 2nd

/3rd

Trimester increase risk to fetus withmaternal abdominal organ protection

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Radiation Dosing

Dose (rad or Gy)

StrengthQuality Factor of ionizing

radiation (i.e. photons/beta QF=1 vs. alpha

QF= 20)

Final Product/Tissue Damage= One Sv

=100 rem

1 mGy = 100 mrad

100 mGy= 10 Rads

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November 2007. RadioGraphics, 27, 1705-1722.

Estimated mean fetal

absorbed dose

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Whats acceptable for my children?(Brigham Website)

Latent leukemia and cancers manifest years after theexposure

The fetus mimics child radiocarcinogenic effects which run2 to 3 timeshigher than the adult risk

A study of prenatal and childhood cancer studies showed arelative risk (RR) of 1.4 (40% increase above the normalincidence) following a fetal dose of ~ 10 mGy (1 Rad).

The normal incidence of childhood cancer is ~ 0.2-0.3 %,so a 10 mGy (1 Rad) fetal dose would increase thisincidence to ~0.35%.

A fetal dose of 10-20 mGy(1-2 Rads) raises the incidenceof childhood leukemiato 5/10,000 from a baseline rate of3.6/10,000.

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Early Radiation Effects

Gestational Age 100mGy (10 Rads)

15 wks I II

I =negligible riskII=potential association with adverse birth outcome,

especially with other

teratogenic risk factors

III=highest risk At 0-2 weeks post-conception, doses 100 mGy have an "all or none effect"potentially causing embryologic demise, surviving fetus will progress to term

without associated effects

At 3-8 weeks post-conception, doses 100 mGy have potential for organ malformation

100 mGy threshold dose for mental effects

United Nations Scientific Committee on the Effects of Atomic Radiation. Sources and Effects of Ionizing

Radiation. New York, NY: United Nations; 1977

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Future?

Next generation scanners

May decrease the radiation exposure

128 slice double helix scanners can scan entire

patient in 2 seconds

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What about FAST?

Focused Abdominal Sonography for

Trauma

Four views (Each flank, cardiac, pelvis) to

evaluate for fluid in the abdomen

Does not evaluate what is bleeding, just

evaluates for fluid

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FAST in Pregnancy(Rosens 6thEd)

Sensitivity Specificity +LR -LR

Intra-abdominal

injury

88 99 88 0.12

Free fluid 83 98 42 0.17

False neg usually d/t bowel perforation or

liver/spleen lacs w/o FF

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FAST

Use of FAST in pregnancy

2001

http://www.east.org/index.asp

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FAST

Use of FAST in pregnancy

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FAST

Use of FAST in pregnancy

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FAST

Use of FAST in pregnancy

Retrospective study at a Level 1 trauma center, evaluating all

female pts 10-50 years of age, who sustained blunt abdominal

trauma and underwent FAST. 1995-2002, n= 2319.

Non pregnant pts

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Non-pregnant pts

N=1804

90.6% no FF

3.7% (n=67) hadinjuries

Pregnant pts

N=299

91% no FF

3% (n=9) had injuries

Bowel injury (1)

Abruption (2)

Liver lac w/abruption (1)

Splenic lac (1)

Abruption with

emergent C-sxn (4)

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FAST

Likely of benefit

Must be used as a serial test

Cannot make definitive decisions on thestatus of the abdomen based on 1

evaluation.

Relatively easy to perform

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Placental Abruption

Second most common cause of fetal death in

trauma

Clinical Diagnosis

Occurs in ~5% (or less) of minor & ~50% major

injuries

Fetal mortality can be > 60%

Symptoms are similar to any trauma with

abdominal pain.

Ultrasound can miss up to 50%

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CT for Abruption

Wei et al Emerg Radiol, 2009

44 trauma and 22 non-trauma CTs with

contrast evaluated

All 7 placental abruptions were identified

by senior reviewers, but not by initial reads

Concluded that with training CT with

contrast can be a good evaluation tool.

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CT for Abruption

Manriquez et al. Am J OB Gyn, 2010

Reviewed 61 pregnant patients with

abdominal trauma and CT with contrast

Images reviewed by trained radiologist

Abruption defined as delivery within 36

hours with symptoms of abruption

Confirmed by placental abruption

Identified 6 of 7 abruptions.

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CT for Abruption

Manriquez et al. Am J OB Gyn, 2010

Claim sens of 86% and spec of 98%, but

there is no true evaluation of false

negatives.

My thoughtImproving CTs obtained for

trauma reasons maybe more helpful than

US for abruption.

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Surgery

Keep right side bumped up or rotate table to

the left

If non-abdominal operation, can perform

continuous monitoring in the OR

Always plan on possibility of urgent

section.

If known or suspected trauma injuriesuse

vertical incision.

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Potential Surgical Catastrophes

Splenic Artery AneurysmsUsually presents as sudden unexpected shock or

death

of all cases in pregnant women, most commonly

3rdtrimester or laborIf found prior to rupture, treat with splenectomy

and arterial resection, aneurysm exclusion, orangiographic embolization

I have removed two spleens in the OB suite for thisindication due to bleeding at the time of statsection.

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Uterine Rupture

Rare

Most common if previous c-section

Usually result of direct abdominal trauma in

2ndor 3rdtrimester

Maternal mortality ~10%

Fetal mortality ~100%

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Back to our Case

Hemoperitoneum after Pfannenstiel incision Packs placed in RUQ by OB

Midline incision performed by Unit III

Large amount of blood and clot in LUQ

Grade 2 splenic laceration (2-3 cm), active bleeding fromsplenic hilum, splenectomy performed with oversewingof short gastric vessel

No liver deformity palpated

LUQ packed, temporary abdominal closure

EBL 3.5 L, received 4 u pRBC, 1uFFP, 1L coll, 2L cryst

Fetal demise x 1, one neonate critical

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Postop Course

CT Imaging: C-spine negative

Grade 2 liver laceration

Nondisplaced right rib fractures Small right PTX and pulmonary contusion

Taken back POD 1 for abdominalexploration and closure. Minor oozingfrom tail of pancreas controlled with sutureligation and cautery. Drain left in splenicbed.

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Postop Course

C-spine cleared

Non-operative management for claviclefracture.

Postoperative ileus Tolerating diet by POD 8.

Drain output serous, fluid amylase 88

Discharged to home POD 9. Seen in follow-up 2 weeks postop, doing

well, drain removed.

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Discussion

Patients with significant abdominal pain

CANNOT have their c-spine cleared.

Involve trauma anesthesia attending if

needed.

Consider doing any such case in the OR

instead of the OB floor.

Perhaps surgery resident can do follow up

FASTs.

Biggest issue is with communication.

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Summary

Always remember that the fetus cannot live

if the mom has expired.

FAST is a useful adjunct in the initial

resuscitation, but is not the end word on

abdominal injuries.

Team communication critical for all trauma

patients, especially when there are two (ormore) patients.

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Thank You