Trauma in Pregnancy, What if …?

The Pregnant Trauma Patient

Trauma is the leading non-obstetric cause of maternal death. Optimal management of the pregnant trauma patient requires a multidisciplinary approach. The anaesthetist and critical care physician play a pivotal role in the entire continuum of fetomaternal care, from initial assessment, resuscitation and intraoperative management, to postoperative care that often involves critical care support and patient transfer. Primary goals are aggressive resuscitation of the mother and maintenance of uteroplacental perfusion and fetal oxygenation by the avoidance of hypoxia, hypotension, hypocapnia, acidosis and hypothermia. Recognizing and understanding the mechanisms of injury, the factors that may predict fetal outcome, and the pathophysiological changes that can result from trauma, will allow early identification and treatment of fetomaternal injury. This in turn should improve morbidity and mortality. A framework for the acute care of the pregnant trauma patient is presented.

Trauma in pregnancy

The anatomic and physiologic changes make treatment of the pregnant trauma patient complex. The fetus is the challenge, because, in pregnancy, trauma has little effect on maternal morbidity and mortality. Aggressive resuscitation of the mother, in general, is the best management for the fetus, because fetal outcome is directly related to maternal outcome. Recent literature has attempted, with little success, to identify factors that may predict poor fetal outcomes. Cardiotocographic monitoring should be initiated as soon as possible in the emergency department to evaluate fetal well-being. Other key points include: Maternal blood pressure and respiratory rate return to baseline as pregnancy approaches term. Initial fetal health may be the best indicator of maternal health. Inferior vena cava compression in the supine patient may cause significant hypotension. Maternal acidosis may be predictive of fetal outcome. Kleihauer-Betke testing is not necessary in the emergency department. Early ultrasonographic evaluation can identify free intraperitoneal fluid and assess fetal health. Necessary radiographs should not be withheld at any period of gestation. Radiation beyond 20 weeks' gestation is safe. Patients with viable gestations require at least 4 hours of CTM monitoring after even minor trauma.

Trauma in pregnancy

Serious trauma in pregnancy is an uncommon event but is particularly challenging to the physician, due to the presence of a potential second patient. Responding to the challenge requires a knowledge of the physiological changes which may alter the maternal response to injury, as well as an understanding of the maternal-fetal relationship. Fetal outcome is dependent on maternal well-being, and thus timely and appropriate resuscitation of the mother is the first priority. Initial management of the pregnant trauma patient includes attention to the airway-breathing-circulation (ABC). Certain injuries are more common in pregnancy and are influenced by the presence of the gravid uterus. The physician needs an awareness of the common complications of pregnancy and additional skills may be required to diagnose and assess fetal viability. The principles of the perimortem section should be understood, as well as the social implications of domestic violence towards pregnant women.

Gastrointestinal surgery during pregnancy

Gastrointestinal surgical problems often mimic symptoms and signs of nonsurgical conditions that occur during pregnancy. This mimicry presents a particular challenge to diagnosis because avoiding a delay in treatment is critical to successful management. Some of these conditions, such as acute appendicitis and biliary colic, are common in younger women; however, the anatomic and physiologic changes of pregnancy can alter their usual manner of presentation. Many elective and urgent operations can be performed during pregnancy with minimal risk to the mother and fetus. The mother's condition should always take priority because her proper treatment usually benefits the fetus as well.

Trauma in pregnancy

Over the past 60 years, trauma has become the leading cause of morbidity and mortality in the pregnant patient. The emotional and physiological challenges of treating two patients simultaneously adds to an already stressful situation. Resuscitation of the pregnant trauma patient is discussed from the prehospital setting to disposition. Also discussed are non-invasive monitoring tools, such as tocodynanomometry and ultrasonography.

Nonobstetric emergencies in pregnancy: trauma and surgical conditions

Nonobstetric surgical emergencies may be difficult to recognize in pregnant patients whose normal physiologic state is altered by pregnancy. Early suspicion and serial examination in pregnancy may result in appropriate interventions for appendicitis, cholecystitis, pancreatitis, and bowel obstruction. Treatment in pregnant patients who experience trauma must be systematic so that situations at risk for maternal and fetal loss can be recognized.

Obstetric and gynecologic emergencies

This article reviews the pearls and pitfalls of obstetric and gynecologic emergencies occurring in women presenting to the emergency department. Some pitfalls include failure to screen for ectopic pregnancy, tachycardia as an unreliable indicator of a ruptured ectopic pregnancy, and the use of serum hCG as a testing procedure during pregnancy. Updates include serologic markers of ectopic pregnancy, ultrasonography in the emergency department, methotrexate treatment of ectopic pregnancy, traumatic placental separation, and fetomaternal hemorrhage.

Infant survival after cesarean section for trauma

HYPOTHESIS

Emergency cesarean sections in trauma patients are not justified and should be abandoned.

SETTING AND DESIGN

A multi-institutional, retrospective cohort study was conducted of level 1 trauma centers.

METHODS

Trauma admissions from nine level 1 trauma centers from January 1986 through December 1994 were reviewed. Pregnant women who underwent emergency cesarean sections were identified. Demographic and clinical data were obtained on all patients undergoing a cesarean section. Fetal distress was defined by bradycardia, deceleration, or lack of fetal heart tones (FHTs). Maternal distress was defined by shock (systolic blood pressure < 90) or acute decompensation. Statistical analyses were performed.

RESULTS

Of the 114,952 consecutive trauma admissions, more than 441 pregnant women required 32 emergency cesarean sections. All were performed for fetal distress, maternal distress, or both. Overall, 15 (45%) of the fetuses and 23 (72%) of the mothers survived. Of 33 fetuses delivered, 13 had no FHTs and none survived. Twenty infants (potential survivors) had FHTs and an estimated gestational age (EGA) of greater than or equal to 26 weeks, and 75% survived. Infant survival was independent of maternal distress or maternal Injury Severity Score. The five infant deaths in the group of potential survivors resulted from delayed recognition of fetal distress, and 60% of these deaths were in mothers with mild to moderate injuries (Injury Severity Score < 16).

CONCLUSIONS

In pregnant trauma patients, infant viability is defined by the presence of FHTs, estimated gestational age greater than or equal to 26 weeks. In viable infants, survival after emergency cesarean section is acceptable (75%). Infant survival is independent of maternal distress or Injury Severity Score. Sixty percent of infant deaths resulted from delay in recognition of fetal distress and cesarean section. These were potentially preventable. Given the definition of fetal viability, our initial hypothesis is invalid.

Objectives to direct the training of emergency medicine residents on off-service rotations: traumatology, Part 3

This is the thirty-second article in a continuing series of objectives to direct emergency medicine resident experiences on off-service rotations. Instruction during rotations in traumatology may be conducted at the bedside in difficult and demanding clinical settings. Yet, residents must not only obtain an essential fund of knowledge, but also become comfortable with a variety of life-saving and diagnostic procedures. It is essential for residents to have specific goals and objectives to guide their acquisition of knowledge and skills required to manage major trauma effectively.