This document discusses trauma during pregnancy, including: 1) Trauma affects 1 in 12 pregnancies and is a leading cause of nonobstetric death, though 90% of injuries are minor. 2) Special considerations in the assessment and management of pregnant trauma patients include changes in cardiovascular, respiratory, gastrointestinal/genitourinary systems as well as injury patterns. 3) The goals in treating pregnant trauma patients are to first stabilize the mother to save the fetus, as maternal demise will lead to fetal demise in most cases. A multidisciplinary approach between trauma and obstetrics teams is important.

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