2018 UF ED/Trauma Symposium

1. Pregnancy and Trauma
Brian K. Yorkgitis, PA-C, DO, FACS
Assistant Professor
Division of Acute Care Surgery

2. Background
• Trauma affects 1 in 12 pregnancies
• MVC 48%
• Falls 25%
• Assault/IPV 17%
• Suicide 3.3%
• GSW 4%
• Leading cause of nonobstetric death
• 9 in 10 injuries are minor
• 1-5% rate of fetal loss
• Represents 60-70% of total fetal loss

3. Background
• Pregnancy related trauma:
• 19.6% associated with Illicit drugs
• 12.9% associated with alcohol
• 5-29% delivered during the hospitalization for trauma
• 70% by cesarean delivery
• Most delivered in 24 hours

4. Cardiovascular Changes
• Increased cardiac output (CO=SV x HR)
• 30-50% increased blood volume
• Dilutional anemia (Hgb ~10g/dL)
• HR increase ~15%
• Gravid uterus compress the IVC resulting in 30% decrease in CO
• Pregnancy may induce a hypercoagulable state
• Increased activity of clotting factors
• Decreased fibrinolysis
• Venous hypertension due to uterine pressure on venous system
• Incidence of DVT of 0.1-0.2%

5. Respiratory Changes
• 40-50% increased respiration rate> increased minute ventilation
• Increased oxygen consumption
• PaCO2 decrease with decreased plasma bicarbonate levels
• Thoracic cavity diameter increases
• Diaphragm rises
• Decreased FRC

6. GI/GU Changes
• Inhibit GI motility
• Delayed gastric emptying
• Decreased LES tone
• Clinical signs of peritoneal irritation are less evident
• 25-50% increase renal blood flow
• Reduced BUN/Cr
• Kidney hypertrophy

7. Orthopedic changes
• Symphysis pubis widens by the 7th month
• Sacroiliac joint spaces increase
• May create confusion in interpretation of pelvic X-rays
• Joint/ligament laxity

9. Shock Classification
• Maternal changes occur to assist with blood loss at delivery
• Natural 500cc
• C-section 1000cc
• Physiologic changes may result in later presentation of hypotension
• Up to 40% volume loss prior to maternal shock signs

10. Change in Injury Pattern
• Spleen enlarges
• Gravid uterus displaces intrabdominal contents
• Spleen and liver to positions closer to the rib cage
• Chest tubes placed in 3/4th intercostal space
• Increases the possibility of injury
• 25% risk of significant splenic or hepatic injury after severe blunt trauma
• Bowel is displaced superiorly
• Increases the potential for complex and multiple intestinal injuries from penetrating
trauma
• Hydronephrosis increases the risk for collecting-system injury

12. Changes in Injury Pattern
• Pelvic and acetabular fractures rare
• Carry significant morbidity and mortality
• Maternal mortality with pelvic fracture: 9%
• Fetal mortality with pelvic fracture: 35%
• No difference for fetal demise among simple or complex fractures
• Pelvic fractures not always preclude vaginal delivery
• Ovarian and other pelvic veins engorge
• Increase the risk for retroperitoneal hemorrhage
• Bladder is compressed uterus
• Displaced at greater risk of injury
• Vaginal lacerations

13. Goal
• STABLIZE MOTHER
• MATERNAL DEMISE WILL LEAD TO FETAL DEMISE
• Maternal shock results in fetal death rate ~80%

14. Primary Assessment
• A- airway
• Ensure patent airway
• Failed intubation 8x more likely
• Protect again aspiration
• B- breathing
• Supplemental oxygen- prevent maternal and fetal hypoxia
• Symptomatic pneumothorax
• C- circulation
• Establish IVs (above diaphragm)
• Type and cross (Rh status)
• Volume resuscitation- limit crystalloids
• Pulse exam
• Turn to Left side- compression on IVC from gravid uterus
• D- disability
• GCS
• Gross motor and sensation
• E- exposure
• Look at the entire body
• Maintain normothermia

15. Adjuncts to Primary Survey
• E-FAST
• Looking for free fluid, pericardial fluid, pneumo/hemothorax
• FHT and fetal movement
• Chest X-ray
• Pelvic x-ray

16. Secondary Survey
• Complete history
• Medical, surgical social, medications, allergies
• Obstetric hx: last menstruation, expected date of delivery, problems or complications
of the current and previous pregnancies
• Head to toe evaluation
• Look, listen, feel, move
• Fundal Examination
• Height (estimated gestational age)
• Shape
• Tone
• Tenderness
• Vaginal examination
• Bleeding present r/o placenta previa by US first
• Exclude vaginal laceration as cause for bleeding in pelvic fracture

17. Electrofetal Monitoring
• > 23 weeks initiate as soon as possible
• Minimum of 4 hours
• High risk admission for 24 hours
• Pain, tenderness, bleeding, frequent contractions <10 min, ROM, abnormal FHR patterns, high risk MOI,
fibrinogen<200
• <23 weeks
• Brief assessment
• Uterine contractions occur in 40%
• 90% resolve with no adverse outcome
• Elevated uterine tone = concern for abruptio placentae
• Contractions >6/hour concerning
• Normal EFM and physical exam reassuring
• Discontinued after 4 hours if:
• Contractions 1/10 minutes
• FHT reassuring
• No maternal abdominal pain or vaginal bleeding

18. US
• Compliment EFM
• Less sensitive than EFM for AP
• Assess
• Gestational age
• FHR
• Placental localization
• Amniotic fluid volume
• Cervical length
• Biophysical profile
• HR, breathing, movement, tone, AFI
• Middle cerebral artery evaluation
• Fetal injury detection, detect fetal demise

19. Imaging with Ionized Radiation
• Studies indicated for maternal evaluation should not be deferred or delayed due
to concerns regarding fetal exposure to radiation
• Obtain the right test the first time
• Contrast study- IV iodinated contrast material FDA category B drug
• Shield abdomen when able
• Imaging studies to exclude injuries or to detect injuries that can be managed nonoperatively
is beneficial
• Imaging studies allows clinical team to be aggressive and proactive in addressing injuries to
avoid the consequences of delayed treatment
• Rad (radiation absorbed dose)
• Grey(100 rads = 1 Gy, 0.1 rad =1mGy)
• Fetal radiation doses of less than 50 mGy (5rad) are not associated with increased
fetal anomalies or fetal loss throughout pregnancy
• MRI study when stable to examine specific injuries/complaints
2008 ACR/ACOG/NCRPM

21. Radiation Risks
• Greatest effects of radiation exposure between conception and week 25
• Radiation injury during weeks 1-3 results in death of the implant or embryo
• 5-10 weeks highest teratogenic potential
• Threshold below which teratogenesis does not occur is not known
• Thought to be between 50 and 150 mGy
• Radiation during weeks 8-25 affect CNS
• 10 rads may result in decreased IQ
• 100 rads may result in severe mental retardation
• Fatal childhood cancer after fetal exposure to 50 mGy relative risk 2
• Represents increase in the baseline risk from 1 in 2000 to 1 in 1000.
• Fetal radiation dose of 50 mGy increases overall lifetime risk of cancer by 2%

22. Risks of Laparotomy
• Nonobstetrical laparotomy
• 26% incidence of preterm labor in the second trimester
• 82% incidence of preterm labor in the third trimester

23. Evaluation for Maternal-Fetal Hemorrhage
• 10-30% of traumas
• Rh antigen developed by 6 weeks
• Minor trauma can cause sensitization
• Rhogam given to all Rh neg pregnant trauma patients
• Kleihauer-Betke test- measures fetal hgb transferred
• Quantify MFH
• >30mL = more Rhogam needed
• Magnitude of MFH reflects severity of injury
• Flow cytometry

24. Placental Abruption
• Placenta is more rigid than the uterine wall
• May allow shearing forces to separate the placenta and uterus
• Most common cause of fetal death in cases where the mother
survives
• 67%–75% rate of fetal mortality for AP incurred by trauma
• More common after 16 weeks of gestation
• Up to 1%–5% of minor traumas
• 20%–50% of major traumas
• Fetal death can be prevented with emergency cesarean delivery
• Most occur 2-6 hours after injury, rarely after 24hr

25. • US
• CT

26. Types

31. Uterine Rupture
• <1% of pregnant trauma patients
• –0.6% of blunt abdominal trauma in pregnancy
• Near 100% fetal mortality
• Up to 10% maternal mortality
• Pain, shock, irregular uterine contour, palpable fetal part,
absent/abnormal FHT, ascent of fetal presenting part, peritonitis
• Extent of uterine damage is difficult to predict at presentation
• Often not discovered until imaging or surgery is performed
• Laparotomy to control bleeding, delivery

32. Preterm Labor
• Trauma patients 2-fold higher risk of preterm labor
• Eval for signs of preterm labor in every patient
• ROM
• EFM- regular contractions
• Fetal fibronectin
• Cervical length assessment

33. Burns
• Airway
• CO poisoning evaluation
• >50% TBSA
• Delivery if 2nd or 3rd trimester

34. Intimate Partner Violence
• 3-9% of pregnant females
• Rates as high as 50% in low-income, single women
• Victims less likely to get prenatal care until 3rd trimester
• Poor weight gain risk factor
• Pregnancy-associated suicide 2.0 deaths per 100,000 live births
• 54.3% of pregnancy-associated suicides involved intimate partner conflict attributable to
suicide
• Pregnancy-associated homicide 2.9 deaths per 100,000 live births
• 45.3% of pregnancy-associated homicides were associated with IPV
• Delivery in the same hospital stay as the assault 8-fold increased risk of fetal
death (aOR=8.13, 95% CI=4.6–14.3)
• Assess for depression and suicidality

36. Primortem Cesarean
• Cesarean performed in the face of maternal cardiac arrest
• >23 weeks
• Imminent maternal death
• 4 min of resuscitation
• If no FHT on initial assessment, unlikely survival
• Retrospective multicenter study
• 75% maternal survival
• 45% fetal survival

37. Direct Fetal Injury
• <15% of blunt trauma
• Uterus, amniotic fluid and mother diminish force delivered to fetus
• Fetal skull and brain

38. Seat Belts in Pregnancy
• 2.8% of women experience a crash during pregnancy
• Intoxicants are involved 45%
• Only 34-64% of pregnant patients involved in MVA are restrained
• 4 out of 5 unborn babies that die in maternal crashes could survive if
seat belt was used

39. • Do not turn off the air bags
• Seat position
• Chest >10 inches from steering wheel or dashboard

40. • GOAL 1
• SAVE MOTHER
• GOAL 2
• SAVE FETUS
• Joint evaluation by trauma and OB when possible

41. Questions?
@UFJaxTrauma @DrBYork
Brian.yorkgitis2@jax.ufl.edu