Trauma is a leading cause of non-obstetric death in pregnancy and can complicate 6-7% of pregnancies. The most common causes of trauma during pregnancy are motor vehicle collisions, assaults, falls, and domestic violence. Managing trauma in pregnancy requires a multidisciplinary approach and care of both the mother and fetus. The priorities are resuscitation of the mother to also resuscitate the fetus, assessment of fetal well-being, and treatment of maternal injuries while minimizing risks to the fetus. Diagnostic imaging such as ultrasound and CT scans can be used judiciously as long as radiation exposure is minimized. Timely delivery via c-section may be needed if the mother or fetus are critically unstable.

1. Trauma in Pregnancy

2. • Trauma is not just something that happens to other
people. Trauma is a disease that could affect
anyone, but it is more importantly it is something
that we can all prevent.

3. • Complicates 6-7% of
pregnancies.
• Leading cause of non- obstetric
death.
• Maternal death is the common
cause of fetal death.

4. Relative Frequency of Trauma
Severity and Mortality

5. RTA
Assault
Causes
domestic violence
Intimitate partner violence
Fall
Accidents
pedestrian collision
Penetrating injury
gun shot injury
Suicide/homicide
substance abuse
Burns /electrical injury

6. Relative Frequency of Trauma

7. • Shift in the centre of
gravity as the
pregnancy advances
makes the woman
prone to falls and
accidents.

10. UNIQUE
CHALLENGE
CARE OF TWO
PATIENTS
ALTERED
PHYSIOLOGY

11. Predictors of Mortality
• Severity and type of trauma
• Gestational age
• Complications
• Internal injuries
• Severe hemorrhage

12. Keel et al reported the major killers in polytrauma
 head injury (66%).
 hemorrhagic shock (21%).
 sepsis and multiorgan failure (13%)
 coagulopathies (dilutional and
consumption).

13. ANATOMICAL & PHYSIOLOGICAL CHANGES
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

14. Injury specific
considerations

15. BLUNT TRAUMA
• 2/3 cases of all trauma in pregnancy.
• CAUSES
- Motor vehicular collisions
- Assault
- Falls
• Especially in 2nd and 3rd trimester.
• PELVIC FRACTURES – engaged head
• Haemorrhage from dilated retroperitoneal
veins can cause massive hemorrhagic shock
and death

16. • MVA - Passenger
restraint system
decreases
maternal/fetal injury.
• Crosby & Costilee
- 33% maternal
mortality with no
restraints
- 5% using seat belts

17. Penetrating trauma
• Primarily -stabbing or gunshot wounds
• The gravid uterus in 2nd & 3rd trimester provides
protection to maternal internal organs.
• Maternal mortality lower than the non-pregnant
women – 3.9% vs 12.5%
• Awwad and colleagues, observed fetal death rates 70-
90%- direct injury to uterus and 38% for injuries
above uterus.

18. BURNS
• BURNS -6.8% to 7.8% of all pregnancies
• Fetal loss is 56% -if 15-25% of body surface area(BSA)
involved.
63% - If 25-50% BSA involved.
100%- If >50% BSA involved.
• Maternal and fetal deaths are often a result of
inadequate fluid resuscitation, prolonged hypotension,
shock, hypoxia, septicemia and hyponatremia.
• Potential for carbon monoxide poisoning

19. Assessing and managing the
pregnant patient with trauma

20. MULTIDISCIPLINARY APPROACH
Trauma Surgeon
Obstetrician
Anaesthesiologist
Neonatologist

22. Primary Survey
Maternal assessment
„ Fetal age assessment & presence of life
If CPR unsuccessful consider Perimortem CS
Minimize effect of uterine compression on maternal
resuscitation
Fetal resuscitation

23. Maternal Resuscitation
The main principle guiding
therapy must be that
resuscitating the mother will
resuscitate the fetus.

24. PRIMARY SURVEY

25. CIRCULATION
• Position- 30 degrees to left.
• Volume resuscitation.
Crystalloid- 3:1 replacement
Blood transfusion
• Maternal B.P,H.R- not a reliable indicator of maternal and
fetal well being.
• Uterus not critical organ- after acute blood loss- uterine
blood flow decreased to maintain normal maternal B.P.
• When signs of shock appear- fetal compromise far advanced

26. Supine hypotension syndrome

27. GOALS OF INITIAL RESUSCITATION
• Systolic blood pressure - 80 to 100 mmHg.
• PaCO2 > 90%
• Hematocrit - 25% to 36%.
• Platelet count >50,000/cu mm.
• Normal serum calcium.
• Core body temperature > 35°C.
• Avoiding an increase in serum lactate level and
metabolic acidosis.
• Adequate analgesia

28. SECONDARY SURVEY
• ‘Top to bottom’ physical assessment .
• More extensive fetal evaluation ; specific fetal evaluation
• Identify - vaginal bleeding
- ruptured fetal membranes
- abruption
- PTL
- Direct uterine injury or fetal injury
- fetal distress
• Assess the extent of feto-maternal hemorrhage.

29. FETAL EVALUATION
• Continuous fetal
monitoring
• CTG changes of
bradycardia ,
deceleration,
tachycardia will
indicate
complications and
also reflects maternal
status.
• USG - to assess
liquor, abruption

30. Laboratory
• CBC
• Serum electrolytes, blood sugar
• Blood group &Type and Cross match,
• PT/aPTT, fibrinogen,
• Kleihauer-Betke(KB)
• urinalysis (and HCG if needed).
• ABG

31. Diagnostic Imaging
Investigations During
Pregnancy

32. IMAGING STUDIES
• Do not avoid or delay necessary exams due to
concerns about fetal radiation exposure.
• Fetal adverse effects are unlikely if radiation dose less than
5 rads or distance more than 10 cm.
• Relative risk of childhood cancer greatest before 8 weeks.
• Lesser than 1% of trauma patients are exposed to more
than 3 rads.
• Fetal effects of radiation depend upon gestational age at
the time of exposure.

33. • Ultrasound (US)
- simultaneous assessment of mother and fetus.
- Fluid or air collections in the abdomen
- ultrasound has a sensitivity of only 50% in detecting
abruption .

34. FAST (focused assessment with
sonography in trauma)
• Reduces the need for x-ray or CT scan.
• shortens the time to surgery.
• 96% of gravid trauma patients required no tests using
ionizing radiation
• sensitivity of 61% to 83% & specificity of 94% to 100%.

35. • CT scan
- Head and chest CT- 1 rads
- abdomen above uterus- 3 rads
- pelvic CT- 3 to 9 rads
• MRI – no documented fetal effects reported including
mutagenic.

36. DIAGNOSTIC PERITONEAL LAVAGE
• DPL is an invasive, rapid, and highly accurate test for
evaluating intraperitoneal haemorrhage or a ruptured
hollow viscus.
• Performed less frequently; replaced by FAST and helical
computed tomography (CT).

37. Anesthesia in OB trauma
• Maintain good anesthesia, oxygenation, normotension,
normothermia, normocarbia (PaCO2 = 30) and left uterine
displacement.
• Avoid ketamine > 2 mg /kg (uterine hypertonus).
• Monitor FHTs if practical. Loss of variability is normal, but
fetal tachy or bradycardia may mean hypoxia.
• Avoid benzodiazepines and N2O early in gestation

38. MOTHER STABLE, FETUS STABLE
• Once mother is stabilized, focus on fetus.
• Direct impact – not necessary for feto placental
pathology.
• No obvious abdominal trauma- still needs
monitoring.
• 4hr- CTG monitoring recommended.(Pearlman
et al.)

39. MOTHER STABLE, FETUS UNSTABLE
• CESAREAN SECTION
- Fetal distress despite optimizing mother.
- uterine rupture.
- placental rupture
- Fetal malpresentation during preterm labor.
- uterus mechanically limits maternal repair

40. MOTHER UNSTABLE FETUS UNSTABLE
• Primary repair of maternal injuries- best course
• Even in fetal distress, as critically injured mother will not
withstand cesarean section.
• Early restoration of maternal physiology – best initial action
for fetus.
• If mother can withstand- cesarean section can be
performed

41. When to Salvage Fetus ?

42. PERIMORTEM CS
• Maternal resuscitation as per ACLS guidelines.
• If no response- decision for perimortem cesarean section.
• No return of spontaneous circulation after resuscitation for
four minutes.
• Delivery within 5 min carries the best chance of fetal and
maternal survival.

44. CONCLUSION
• Most diagnostic and therapeutic modalities relating to
trauma care should not be modified or avoided during
pregnancy.
• Co-management /multidisciplinary approach , function to
insure appropriate care of the trauma victim and her fetus.