The document provides information on trauma in pregnant women, including anatomical and physiological changes during pregnancy, mechanisms of injury, assessment and management of trauma, and radiation exposure risks. It discusses increased blood volume and changes to respiratory and musculoskeletal systems during pregnancy. Primary survey focuses on stabilizing the mother while also monitoring the fetus. Secondary assessment includes pelvic exams and ultrasound. Definitive care depends on specific injuries like uterine rupture or placental abruption. Radiography risks to the fetus vary by gestational age, type of imaging, and shielding used.

1. Chapter 11 Trauma in Women A: Anatomic 12 weeks - rise out of pelvis 20 weeks - at umbilicus 34-36 weeks - at the costal margin 2nd trimester - amniotic fluid embolism 3rd trimester - abruptio placentae

2. B. Blood Volume and Composition 1.Volume: 1200-1500 ml -signs of hypovolemia 2. Increased in WBC, fibrinogen , clotting factors 3. Decreased in Hb, PT, aPTT, albumin 4. Blood pressure falls 5-15 mmHg in 2nd trimester 5. CVP is variable 6. ECG: flattened or inverted T waves in leads II, III, AVF

3. C. respiratory Increased in tidal volume Decreased in residual volume Hypocapnea ( Pco2 of 30 mmHG) in late pregnancy D. Musculoskeletal 7th months: the symphysis pubis widens (4-8mm) The sacroiliac-joint space increased

4. Mechanism of Injury A. Blunt Injury 1. Direct Injury 2. Indirect Injury Abrutio Placentae & Uterine Rupture Seat belt: forward flexion and uterine compression B. Penetrating Injury Dense uterine musculature & Amnion Low incidence of maternal visceral injury

5. Assessment and Management A: Primary Survey and Resuscitation 1. Maternal: Hyperventilation 4 - 6 inches elevation of right buttock Fetus may be in shock before maternal hypovolemia shock signs Vasopressors - fetal hypoxia B: Fetus: Uterine rupture Abruptio placentae Continued fetal heart tones 20 -24 wks of gestation

6. B. Adjuncts to primary survey Maternal: Monitor on her left side after physical examination Monitor of the CVP response to fluid Maternal bicarbonate is usually low Fetus: 20-24 wks heart tones: 120- 160 beats / min Continous monitor with cardiotocodynamometry Consultation if abnormal fetal heart rates

7. C. Secondary Assessment 1. DPL: perform above the umbilicus Presence of uterine contractions 2.Vaginal Examination : Amniotic fluid with PH of 7 - 7.5 : ruptured of chorioamniotic membrane Bleeding in 3rd trimester: disruption of placenta impending fetal death The fetus may be in jeopardy even with apparent, minor maternal injury

8. D. Definite Care Uterine rupture: shock or no s/s Placental abruptio: leading cause of fetal death 30% no vaginal bleeding All pregnant Rh-negative trauma patient should considered for RH immunoglobulin therapy . Initial management is directed at resuscitation and stabilization of the pregnant patient. Perimortem c/s may be successful if it is done within 4-5 mins arrest.

9. Radiography in Pregnant Women No fetus risk: 5 - 10 rad. The maximum risk attributable to 10 rad of exposure is approx. 0.1 % After 20th weeks of gestation: cause no fetal abnormalities. Routine C-spine, CXR, Pelvis obtained with shielding: negligible fetal exposure CT beam in direct line to fetus: 3 - 9 rad. CT scan above uterus: < 3 rad to fetus.

10. Radiography to fetus varies: 1. The type of study 2. The size of patient 3. Position of the fetus 4. Type of machine 5. Method of shielding 6. The number of section obtained 7. Fetal/uterine size 8. Coned x-ray beam aimed > 10 cm away from fetus are not dangerous.

11. Estimated Radiation Dose to the Pelvic Uterus/ Radiography Type of examination Dose (mrad) Low dose group Head < 1 C- spine < 1 T-Spine < 1 CXR < 1 Extremities < 1 High Dose Group L-spine 204 - 1260 Pelvis 190 - 357 Hip and Femoral ( proximal) 124 - 450 IVP 503 - 880 Urethrocystography 1500 Abdomen ( KUB) 200 - 503

12. Upper-Limit Fetal Dose From Angiography and CT Scan Studies Type of examination Dose (mrad) Angiography Cerebral < 100 Cardiac Cath < 500 Aortography < 100 CT scanning Head ( 1 cm slices) < 50 Chest ( 1 cm slices) < 1000 Upper abdomen( 20 1-cm slices < 3000 > 2.5 cm from uterus) Lower Abdomen ( 10 1-cm slices 3000 - 9000 directly over the uterus/fetus