Trauma is the leading cause of non-obstetric death in pregnant women. MVAs and intimate partner violence account for most cases. 

Let’s first discuss the physiological changes to consider when managing a pregnant patient in a trauma.

  • AIRWAY:
    • Progesterone: floppier airway with more edema
      • Predict a more difficult tube
    • Decreased esophageal tone and -> higher risk for aspiration
      • Decompress early with NG or OG tube
  • BREATHING:
    • Increase in respiratory drive -> hyperventilation -> chronic respiratory alkalosis -> fall in bicarb
    • Decrease in functional residual capacity due to upward displacement of diaphragm.
      • Less reserve when intubating! Preoxygenation and apneic oxygenation are extra important.
  • CIRCULATION:
    • Cardiac output increases by up to 50%, due to increase in blood volume (increases preload), decrease in SVR (progesterone -> decreased afterload), and increase in HR.
      • Vitals may not readily reflect significant blood loss.
      • Replace volume liberally (O negative blood).
    • Gravid uterus can compress the IVC and displace the diaphragm
      • Position in left lateral decubitus
      • Displace uterus to the left during compressions
      • Chest tube 1-2 IC spaces above

Management:

  • Fetal FAST: number of fetuses and position, placental location (exclude placenta previa before vaginal exam!), amniotic fluid volume, fetal cardiac activity, and femur length (> 4cm may survive ex-utero)
  • Vaginal exam: look for bleeding, amniotic fluid, cervical dilation or effacement
  • Immunization:
    • Anti-D immune globulin for rhesus D negative patients
      • Kleihauer-Betke: quantifies maternal-fetal hemorrhage to de
    • Tetanus vaccine is safe in pregnancy
  • Antenatal corticosteroids: typically viable 23 to 34 weeks gestation
  • Don’t forget to screen for intimate partner violence
  • Admit at least 24 hours: uterine tenderness, vaginal bleeding, contractions at least once every 10 minutes, rupture of membranes, abnormal FHR, high risk mechanism, hypofibrinogenemia
  • Resuscitative hysterotomy aka Perimortem cesarean (> 24 wk): Initiate WITHIN FOUR MINUTES. Patient codes, no ROSC at first pulse check -> start gathering supplies for C-section. You mostly just need betadine, a 10-blade scalpel, and scissors. The thoracotomy tray also has everything you need (scissors, retractors, clamps).
    • Call OB, Peds, NICU, Trauma, RT
    • Primary benefit is saving mom’s life by both redirecting blood flow, reducing demand, and relieving pressure from the IVC and aorta
    • Secondary benefit to deliver baby (the faster, the better chances)
      • Prep neonatal resuscitation supplies, including warmer

Love, Julie

Resources:

https://www.uptodate.com/contents/initial-evaluation-and-management-of-major-trauma-in-pregnancy

https://www.east.org/education-career-development/practice-management-guidelines/details/pregnancy-and-trauma

https://www.jogc.com/article/S1701-2163(15)30232-2/pdf

https://www.ajog.org/article/s0002-9378(13)00068-9/fulltext

http://www.emdocs.net/resuscitation-of-the-pregnant-trauma-patient-pearls-pitfalls/

June 2024
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