2. • Identifies and treats the greatest threat to life first
• A universal language
• Problems treated immediately as they are found
• Continuous re-evaluation
3. To
• Understand the structured approach to major trauma in pregnancy
• Understand the management
4. What is trauma?
Types of trauma
Dual goals in managing pregnant trauma
Physiological changes in pregnancy
Types of injuries associated
Initial assessment and management
Trauma prevention in pregnancy
5. “an emotional response to a terrible event like an accident, rape, or
natural disaster” – American Psychological Association (APA)
a response to any event they find physically or emotionally
threatening or harmful
A traumatized person can feel a range of emotions both
immediately after the event and in the long term.
May feel overwhelmed, helpless, shocked, or have difficulty
processing their experiences.
Trauma can also cause physical symptoms.
6. Trauma is not just something that happens to other people.
Trauma is a disease that could affect anyone, but more importantly
it is something that we can all prevent.
7. Acute trauma: This results from a single stressful or dangerous
event.
Chronic trauma: This results from repeated and prolonged
exposure to highly stressful events. Example – repeated domestic
violence.
Complex trauma: This results from exposure to multiple traumatic
events.
8. Unique challenges
- Vulnerability of pregnant trauma patient
- Potential injuries to unborn child
Dual roles
- Provide care to mother
- Provide care to foetus
9. Leading cause of, morbidity and mortality
- 6-7% of pregnancies experience some trauma
- 1:12 injured experience significant trauma
Leading cause of non-obstetric death.
Maternal death is the common cause of foetal death.
10. Major causes
◦ Motor-vehicle collisions
◦ Falls
◦ Abuse and domestic violence
◦ Penetrating injuries
◦ Burns
Increased risk for trauma
Fainting spells
Hyperventilation
Excessive fatigue commonly associated with early pregnancy
Balance and coordination affected by changes throughout
pregnancy
Shift in the centre of
gravity as the pregnancy
advances makes the
woman prone to falls and
accidents.
11. Relative Frequency of Trauma
Falls 22%
Assault 22%
Motor Vehicle Accident
56%
Others 1%
12. Vaginal bleeding
Preterm rupture of membranes within 4 hours of injury
Uterine rupture
Placental abruption (minor trauma is low (1.6%), but in major
trauma is (37.5%) within the first 72 hours of injury
Maternal pelvic fractures
Foetal death within 7 days of the traumatic event
13. Foetal fractures, especially skull, clavicles, and long bones
Intracranial haemorrhage
Indirect injury is generally due to foetal hypoxia secondary to:
maternal hypotension, foetal hemorrhage, placental abruption or
other injury, cord injury, uterine injury
Other: spontaneous abortion, preterm delivery, Casarean delivery
and RBC isoimmunization
Rare: amniotic fluid embolus, chorionic villus embolus
14. Foetus is formed during first 3 months of pregnancy.
The uterus does not enlarge enough to rise out of pelvis until 12th
week (3 months), but then fully formed fetus and uterus grow
rapidly.
Fundal height reaches umbilicus by fifth month and epigastrium by
28 weeks.
Fundus is term for top of uterus.
Fundal height is term that describes location of top of uterus.
15. Foetus is considered viable at 24 weeks.
Viability increases significantly at 25 weeks' gestation.
However, pre-term infants have survived with less gestation.
True gestational age cannot be determined on- scene.
18. Plasma volume increases by 45-50% Reduce maternal resistance to
limited blood flow
Red cell mass Increases by 30% Dilutional anemia
Cardiac output Increases by 30-50% Relative maternal resistance to
limited blood loss
Uteroplacental blood flow 20-30% shunt Uterine injury may predispose
to increased blood loss,
increase vascularity
Uterine size Dramatic increase Change in position of
abdominal contents, supine
hypotension
Minute ventilation Increases by 25-30% Diminished PaCO2
Diminished buffering capacity
Functional residual capacity decreased Predisposition to atelectasis
and hypoxemia
Gastric emptying delayed Predisposition to aspiration
19. Diaphragm elevated due to uterine size
Decreased thoracic volume
Relative alkalosis
Predisposed to hyperventilation
Respirations are more shallow with less chest expansion.
Pregnant patient presents with rapid shallow respiration.
20. Vasoconstriction and tachycardia
Reduction of uterine blood flow by 20–30%
Foetal heart rate and blood flow decrease
Foetus becomes hypoxemic
High-flow oxygen is essential
Maternal shock has 80% foetal mortality rate
Foetus is in distress before maternal blood pressure decreases.
21. When mother compensates for early shock with vasoconstriction
and tachycardia, impact on foetus begins.
Quick review of shock response:
o Acute blood loss results in decrease in circulating blood volume.
o Cardiac output decreases as venous return falls.
o This hypovolemia causes arterial blood pressure to fall, resulting
in an inhibition of vagal tone and release of catecholamines.
o Effect to produce vasoconstriction and tachycardia.
22. Vasoconstriction profoundly affects uterus.
Reduction in uterine blood flow by 20–30%.
Mother can lose 1,500 cc without detectable blood pressure change.
Drop in foetal arterial blood pressure and decrease in foetal heart
rate.
Reduced foetal circulation results in fetal hypoxemia.
Administer 100% oxygen to mother, and administer oxygen to
foetus.
24. • Primary survey
• Immediate resuscitation from those problems
• Assess foetal well being and viability
• Secondary survey
• Definitive treatment
• +/- Transfer
25. During ITLS Primary Survey:
A quick evaluation of uterine size is done.
Foetal heart rate is better auscultated with a doppler, but can be
heard with a standard stethoscope at 20 weeks using bell side
26. Relatively minor abdominal trauma can cause foetal death.
Maternal death is most common cause of foetal death.
Have high suspicion with any abdominal trauma.
May not seem significant injury to mother, but can be significant to
foetus.
Management of maternal injuries is best management of foetus.
27. • Airway with cervical spine control
• Breathing and ventilation
• Circulation and haemorrhage control
• Disability [neurological injury]
• Environment
29. Optimize maternal and foetal outcome
High-flow oxygen rapidly administered
Foetal hypoxia occurs before maternal hypoxia
Fluid administration must be prompt
Fluid volume needed is greater
Frequent ITLS assessment
30. Mortality of foetus related to maternal treatment
Remember:
o Normal physiologic changes of pregnancy make assessment more
difficult.
o Changes in appearance and vital signs can be delayed and more
subtle.
o Therefore, ongoing ITLS assessment needs to be performed more
frequently.
31. Venous return decreases 30% in supine position with 20-week or
larger uterus
Acute hypotension
Syncope
Foetal bradycardia
Compression of vena cava:
The enlarging uterus can compress inferior vena cava when
mother is in supine position, creating a form of
mechanical/obstructive shock.
Reduces venous return and cardiac output by up to 30%.
32. Tilt or rotate backboard 15–30° to patient's left
Elevate right hip 4–6 inches (10–15 cm) with towel
Manually displace uterus to left
Better stabilized with vacuum backboard
More comfortable than standard backboard
33. Severity and type of trauma
Gestational age
Complications
Internal injuries
Severe hemorrhage
36. Abruption in 50-70% of major trauma and in 5% minor injuries
Uterine rupture in <1% major trauma but maternal death from
uterine rupture in 10% (usual for foetal death to occur)
Both cause major haemorrhage
Suspect if:
• Foetal heart abnormalities or absent
• Uterine contractions
• Amniotic fluid in the vagina
• Cervical effacement and dilatation
• Relationship of foetal presenting part to the ischial spines
• Abdominal foetal parts
38. 2/3 cases of all trauma in pregnancy.
Causes –
Motor vehicular collisions – 50-65% from steering wheel or
poor seatbelt application
Domestic violence – 20%
Assault- direct impact (blows) to abdomen
Falls
• Especially in 2nd and 3rd trimester.
• Pelvic fractures – engaged head
• Haemorrhage from dilated retroperitoneal veins can
cause massive hemorrhagic shock and death
39.
40. Knife and gunshot wounds
Fall on sharp object
- managed as in non-pregnant if point of impact is elsewhere in the
body except foetus be monitored if viable
- If abdomen is involved foetal and placental injury becomes an
issue
Penetrating abdominal injury associated with increased foetal 73%
41. The experience with electrical injury during pregnancy is limited.
Could cause delayed foetal death complicated by growth
retardation and oligohydramnios.
Serial ultrasound examinations to follow foetal growth and
amniotic fluid volume is recommended.
42. Severely burned women (more than 50 percent body surface area) in
second- and third-trimester:
- Should be delivered immediately because maternal death is almost
certain otherwise, and foetal survival is not improved by allowing
the pregnancy to continue
- Foetal mortality is approximately 63% when the body surface area
burn is 25-50% and approaches 100% when the body surface area
burn is >50%.
- Maternal and foetal deaths are usually a result of inadequate fluid
resuscitation, hypoxia or septicaemia.
43. Lab Tests
Plain Films – X-rays
Ultrasound
CT
MRI
Cardiotocographic Monitoring
DPL (Diagnostic Peritoneal Lavage )
Several invasive tests short of exploratory laparotomy
Exploratory Laparotomy
44. Goal 1 –Save the mother
Goal 2 –Save the foetus, if possible
The management of pregnant women with moderate to severe
injuries can be divided into:
Primary survey Resuscitation
Secondary survey Definitive treatment
45. Identify and treat life threatening conditions
Airway and cervical spine
- Any woman with trauma who is unconscious or has a neck injury
above the clavicle should be regarded as having a cervical neck
injury until proven otherwise
Breathing
- Oxygen should be administered at rates of at least 10 litres per
minute
Circulation and haemorrhage control
- Assess peripheral circulation, skin colour and pulse rate and
character. Control obvious external haemorrhage
46. Position woman on her left side with lateral tilt 15˚ to 30˚
- If lateral tilt is not possible because of spinal injuries or other
trauma, the uterus should be manually displaced to alleviate
aorto caval compression
Establish intravenous access with at least two large bore 16 gauge
cannulae or larger in peripheral veins. Central veins are not the first
choice of venous access
Disability
- Initial neurological assessment using Glasgow coma scale and
pupillary response
- Exposure and environmental control
The woman must be undressed to allow for a full physical
examination
The woman must always be kept warm or rarely cooled.
Hypothermia is one of the main dangers in trauma contributing
to worsening acidosis, coagulopathy and infection
47. A complete physical examination is performed to identify all other
injuries.
Orogastric tube and urinary catheter are inserted
Continue to regularly assess maternal pulse, blood pressure, urine
output as appropriate
Obstetric evaluation -Fundal height, Uterine tone, contractions, and
tenderness, Fetal heart rate, Vaginal bleeding or evidence of
spontaneous rupture of the membranes
Pelvic examination, Cardiotocography for at least 4 hours if 24 weeks or
more
Abdominal and obstetric ultrasound
48. Radiographic imaging (CT scan) as indicated when the woman is stable
Laboratory investigations for all trauma in pregnancy should include:
Complete blood picture and coagulation studies
Group and save
Biochemistry - Kleihauer test
Laboratory investigations for women with moderate to severe trauma in pregnancy:
Group and cross-match
Coagulation studies
Serum electrolytes
Renal function test
Serum glucose
AST and ALT
Amylase
Arterial blood gas analysis
Kleihauer test – quantify with flow cytometry, if the Kleihauer test indicates
significant feto-maternal haemorrhage
Urinalysis
49. Management of any further injuries should be at good Medical
Centre and Intensive Care Unit.
The pregnant woman should be retrieved or transferred as soon as
possible
In the presence of abdominal trauma (particularly with ultrasound
evidence of intra peritoneal fluid) + persistent hypotension
/tachycardia despite appropriate fluid resuscitation is an indication
for immediate MIDLINE LAPAROTOMY to definitively control
intra abdominal bleeding (abruption, uterine rupture, splenic
rupture, vascular injury etc)
50. If a Caesarean section is necessary trauma surgeons should be
present to assess and treat any maternal injuries
Consider venous thromboembolism prophylaxis
Administer Rh (D) immunoglobulin (625 IU CSL for gestation > 12
weeks) if the woman is Rh negative and has no pre-existent Rh (D)
antibodies
51. In the event of cardiac arrest, when initial resuscitation attempts
fail, delivery of the fetus by emergency caesarean section may
improve the chances of successful resuscitation of the mother and
foetus.
Caesarean section improves the chances of survival by relieving
aortocaval compression caused by the gravid uterus.
Even with lateral displacement of the uterus, maternal cardiac
output is significantly impaired during CPR.
Caesarean section be performed early, aiming for delivery within 5
minutes of cardiac arrest for pregnancy > 24/52; GA <23/52 baby
not likely to survive!!!
The neonate delivered during a peri-mortem caesarean section is
likely to be severely acidotic and hypoxic hence the attendance of a
Neonatologist
52. Motor Vehicle Accidents, falls and assaults are the commonest
traumatic mechanisms in pregnancy
Pregnant women need to wear seat belts properly
Abdominal trauma can also cause foeto-maternal haemorrhage,
uterine rupture, rupture of membranes and pre-term labour.
To deliver an intact newborn, perimortem Caesarean section should
deliver baby within 5 minutes of cessation of maternal circulation
and oxygenation
The main principle guiding therapy must be that resuscitating the
mother will resuscitate the foetus
53.
54. Anaesthetists who care for the pregnant patient
undergoing non-obstetric surgery must provide safe
anaesthesia for both mother and foetus.
To maintain maternal safety, the physiological and
anatomical changes of pregnancy must be considered,
anaesthetic technique and drug administration modified
accordingly.
Foetal wellbeing is related to avoidance of foetal
asphyxia and teratogenic drugs and preterm labour
55. A baby is something you carry inside you for nine
months, in your arms for three years and in your
heart till the day you die.
- Mary Mason
56. 1. Optimization and maintenance of normal maternal
physiological function.
2. Optimization and maintenance of uteroplacental blood flow
and O2 delivery.
3. Avoidance of unwanted drug effects on the foetus.
4. Avoidance of stimulating myometrium.
5. Avoidance of awareness during GA.
6. Using regional anaesthesia , if possible.
57. 0.75% - 2% of pregnant women undergo surgeries
75,000 – 80,000 procedures annually in USA
Centralized data unavailable in Nigeria!!!
Conditions common to this age group:
Ovarian cysts
Appendicitis
Cholelithiasis
Cervical incompetence
Breast or other malignancies
Traumatic injuries.
Commonest surgery- Appendicectomy
59. Directly related to pregnancy: Cervical circlage
Indirectly related to pregnancy: Ovarian cystectomy
Not related to pregnancy: Appendectomy, Intestinal
obstruction
61. Key to understanding the maze of the problems
associated with conduct of anaesthesia
62. First Rule of Thumb
Administer drug to the patient only if benefits clearly
outweigh the risk, both to the mother and the foetus
Planning the Anaesthesia Regimen depends on:
1. Patient’s present surgical status
2. Present gestational age of the foetus
3. Pregnancy induced physiological changes
4. Other coexisting co-morbidities
63. Emergencies will always outweigh the concern for the
unborn.
The regimen that has been chosen should cater for:
o Needs of the patient - Physical and emotional status of the
patient
o Needs of the operating Surgeon – often anaesthetic regimen
that will optimise the positioning and surgical exposure
o Needs of the Obstetrician – May need a regimen that causes
uterine relaxation
64. Both General and Regional anaesthesia have been used
successfully in pregnant patients.
No technique has been proven to have superiority over
the other in foetal outcomes.
Each technique has its own advantages and
disadvantages and the selection of technique is based on
maternal condition, site and nature of surgery
65. Advantages
Minimal amount of Local Anaesthetics
Rapid onset of anaesthesia
Definitive end point
Easy to administer
Dense Blockade
Disadvantages
Hypotension, sometimes profound
Non rectifiable dermatomal level
PDPH
Limited post op analgesia as compared to epidural
More incidence of nausea/vomiting
66. Advantages
Minimal risk of severe hypotension
Rectifiable dermatomal level
Excellent post op analgesia
Risk of meningitis and PDPH eliminated
High level of haemodynamic stability
Disadvantages
Procedure is more complex/skilled
Onset of action is slower
Amount of local anaesthetic required is more
Higher incidence of failure/partial action/sparing
Less profound block
67. Advantages
Easy to titrate the depth
Best uterine relaxation
Risk of meningitis and PDPH eliminated
High level of haemodynamic stability
Disadvantages
• Possible teratogenic effect
• Maternal risk of aspiration
• High incidence of post op pain, nausea and vomiting
68. Most serious risk during non-obstetric surgery is intrauterine
asphyxia
Causes of hypoxia:
Difficult intubation
Oesophageal intubation
Pulmonary aspiration
High levels of regional block
Systemic local anaesthetic toxicity or airway compromise from
trauma
Causes of decreased uteroplacental perfusion:
Aortocaval compression
High level of spinal or epidural blockade
Haemorrhage
Hypovolemia
Hyperventilation
High dose of ά adrenergic agents or increased circulating
catecholamines
Uterine hypertonus from ketamine >2mg/kg in early pregnancy
or Effects of anaesthesia on Foetus
69. American Society of Anaesthesiologists (ASA) and
American College of Obstetricians and Gynaecologists
(ACOG) in Oct 21, 2009 generalised that:
No currently used anaesthetic agents have been shown
to have any teratogenic effects in humans when using
standard concentrations at any gestational age.
Foetal heart rate monitoring may assist in maternal
positioning and cardio-respiratory management, and
may influence a decision to deliver the foetus.
70. It is mandatory to obtain an obstetric consultation before
performing any non obstetric surgery or any invasive
procedures
A pregnant woman should never be denied indicated
surgery, regardless of trimester.
Elective surgery should be postponed until after delivery.
If possible, non-urgent surgery should be performed in the
second trimester when preterm contractions and spontaneous
abortion are least likely
71. It depends on balance between maternal and
foetal risk urgency of the surgery
1st trimester – Organogenesis: Increased foetal risk for
teratogenesis
3rd trimester – Peak of physiological changes of
pregnancy: Increased maternal risk
Thus 2nd trimester is considered to be a ideal time for non
emergency, mandatory surgeries
72. Whilst most of the anaesthetic agents are not teratogenic,
some other agents have been implicated
Benzodiazepines/Opioids – associated with anomalies
and cleft palate
Muscle relaxants: minimal placental transfer
LA – no evidence
Cocaine – preterm delivery, increased risk of abruptio
palcenta
Ketamine - can cause preterm labour
Propofol – No evidence
Propofol + Suxa – severe maternal bradycardia
73. N2O – teratogenic in cases of abuse
Volatile anaesthetic – teratogenic in some species
74. Pregnancy is a hyper-coagulable state and the risk of
thromboembolic is further increased by postoperative
venous stasis.
Early mobilization
Maintaining adequate hydration
Pneumatic stocking gloves
Pharmacological prophylaxis
75. Adequate analgesia is important as pain will cause increased
circulating catecholamines which impair uteroplacental
perfusion.
Analgesia may mask the signs of early preterm labour.
Paracetamol and Diclofenac is pregnancy risk category B.
Ibuprofen, Morphine, Tramadol is pregnancy risk category C.
NSAIDS can cause early closure of ductus arteriosus in 3rd
trimester.
76. Using modern surgical and anaesthetic techniques, the risk of
maternal death appears to be very low.
Surgery and general anaesthesia do not appear to be major risk
factors for spontaneous abortion.
The rate of elective termination appears to be in the range of the
general population.
Non-obstetric surgical procedures do not increase the risk for major
birth defects. Hence, urgent surgical procedures should be
performed when needed.
Acute appendicitis, especially when accompanied by peritonitis,
appears to be genuine risk for surgery induced labour or foetal loss
77. Remembering the physiological and anatomical changes
of pregnancy
Prevention of foetal asphyxia by maintaining maternal
oxygenation, ventilation and haemodynamic stability
Remembering postoperative thromboprophylaxis
Remembering adequate postoperative analgesia
