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Awad KG, Nahmias J, Aryan N, Lucas AN, Fierro N, Dhillon NK, Ley EJ, Smith J, Burruss S, Dahan A, Johnson A, Ganske W, Biffl WL, Bayat D, Castelo M, Wintz D, Schaffer KB, Zheng DJ, Tillou A, Coimbra R, Tuli R, Santorelli JE, Emigh B, Schellenberg M, Inaba K, Duncan TK, Diaz G, Tay-Lasso E, Zezoff DC, Grigorian A. Outcomes of severely injured pregnant trauma patients: a multicenter analysis. Updates Surg 2024:10.1007/s13304-024-01817-3. [PMID: 38554224 DOI: 10.1007/s13304-024-01817-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/04/2024] [Indexed: 04/01/2024]
Abstract
Nearly 10% of pregnant women suffer traumatic injury. Clinical outcomes for pregnant trauma patients (PTPs) with severe injuries have not been well studied. We sought to describe outcomes for PTPs presenting with severe injuries, hypothesizing that PTPs with severe injuries will have higher rates of complications and mortality compared to less injured PTPs. A post-hoc analysis of a multi-institutional retrospective study at 12 Level-I/II trauma centers was performed. Patients were stratified into severely injured (injury severity score [ISS] > 15) and not severely injured (ISS < 15) and compared with bivariate analyses. From 950 patients, 32 (3.4%) had severe injuries. Compared to non-severely injured PTPs, severely injured PTPs were of similar maternal age but had younger gestational age (21 vs 26 weeks, p = 0.009). Penetrating trauma was more common in the severely injured cohort (15.6% vs 1.4%, p < 0.001). The severely injured cohort more often underwent an operation (68.8% vs 3.8%, p < 0.001), including a hysterectomy (6.3% vs 0.3%, p < 0.001). The severely injured group had higher rates of complications (34.4% vs 0.9%, p < 0.001), mortality (15.6% vs 0.1%, p < 0.001), a higher rate of fetal delivery (37.5% vs. 6.0%, p < 0.001) and resuscitative hysterotomy (9.4% vs. 0%, p < 0.001). Only approximately 3% of PTPs were severely injured. However, severely injured PTPs had a nearly 40% rate of fetal delivery as well as increased complications and mortality. This included a resuscitative hysterotomy rate of nearly 10%. Significant vigilance must remain when caring for this population.
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Affiliation(s)
- Kyrillos G Awad
- Department of Surgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Jeffry Nahmias
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Negaar Aryan
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Alexa N Lucas
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Nicole Fierro
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Navpreet K Dhillon
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric J Ley
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jennifer Smith
- Division of Trauma and Critical Care, Harbor-UCLA Hospital, Torrance, CA, USA
| | - Sigrid Burruss
- Division of Trauma and Critical Care, Harbor-UCLA Hospital, Torrance, CA, USA
| | - Alden Dahan
- Department of Trauma, Acute Care Surgery, Surgical Critical Care, Loma Linda Medical Center, Loma Linda, CA, USA
| | - Arianne Johnson
- Cottage Health Research Institute, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA
| | - William Ganske
- Cottage Health Research Institute, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA
| | - Walter L Biffl
- Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA, USA
| | - Dunya Bayat
- Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA, USA
| | - Matthew Castelo
- Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA, USA
| | - Diane Wintz
- Department of Surgery, Sharp Memorial Hospital, San Diego, CA, USA
| | | | - Dennis J Zheng
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Areti Tillou
- Riverside University Health System Medical Center, Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, Moreno Valley, CA, USA
| | - Raul Coimbra
- Riverside University Health System Medical Center, Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, Moreno Valley, CA, USA
| | - Rahul Tuli
- Riverside University Health System Medical Center, Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, Moreno Valley, CA, USA
| | - Jarrett E Santorelli
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego School of Medicine, University of California, San Diego, CA, USA
| | - Brent Emigh
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Morgan Schellenberg
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Kenji Inaba
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Thomas K Duncan
- Department of Trauma, Ventura County Medical Center, Ventura, CA, USA
| | - Graal Diaz
- Department of Trauma, Ventura County Medical Center, Ventura, CA, USA
| | - Erika Tay-Lasso
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Danielle C Zezoff
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Areg Grigorian
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA.
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Lopez CE, Salloum J, Varon AJ, Toledo P, Dudaryk R. The Management of Pregnant Trauma Patients: A Narrative Review. Anesth Analg 2023; 136:830-840. [PMID: 37058718 DOI: 10.1213/ane.0000000000006363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
Trauma is the leading nonobstetric cause of maternal death and affects 1 in 12 pregnancies in the United States. Adhering to the fundamentals of the advanced trauma life support (ATLS) framework is the most important component of care in this patient population. Understanding the significant physiologic changes of pregnancy, especially with regard to the respiratory, cardiovascular, and hematologic systems, will aid in airway, breathing, and circulation components of resuscitation. In addition to trauma resuscitation, pregnant patients should undergo left uterine displacement, insertion of 2 large bore intravenous lines placed above the level of the diaphragm, careful airway management factoring in physiologic changes of pregnancy, and resuscitation with a balanced ratio of blood products. Early notification of obstetric providers, initiation of secondary assessment for obstetric complications, and fetal assessment should be undertaken as soon as possible but without interference to maternal trauma assessment and management. In general, viable fetuses are monitored by continuous fetal heart rate for at least 4 hours or more if abnormalities are detected. Moreover, fetal distress may be an early sign of maternal deterioration. When indicated, imaging studies should not be limited out of fear for fetal radiation exposure. Resuscitative hysterotomy should be considered in patients approaching 22 to 24 weeks of gestation, who arrive in cardiac arrest or present with profound hemodynamic instability due to hypovolemic shock.
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Affiliation(s)
- Carmen E Lopez
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Joe Salloum
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Albert J Varon
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
| | - Paloma Toledo
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
| | - Roman Dudaryk
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
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Al Fauzi A, Apriawan T, Ranuh IGMAR, Christi AY, Bajamal AH, Turchan A, Agus Subagio E, Suroto NS, Santoso B, Dachlan EG, Utomo B, Kasper EM. Traumatic brain injury in pregnancy: A systematic review of epidemiology, management, and outcome. J Clin Neurosci 2023; 107:106-117. [PMID: 36527810 DOI: 10.1016/j.jocn.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/07/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) during pregnancy is an extremely rare condition in our neurosurgical emergency practices. Studies on the epidemiology and management of TBI in pregnancy are limited to case reports or serial case reports. There is no specific guidelines of management of TBI in pregnancy yet. METHODS The authors performed a structured search of all published articles on TBI in pregnancy from 1990 to 2020. We restricted search for papers in English and Bahasa. RESULTS The literature search yielded 22 articles with total 43 patients. We distinguished C-section based on its timing according to the neurosurgical treatment into primary (simultaneous or prior to neurosurgery) and secondary group (delayed C-section). The mean GOS value in primary C-section is better compared to secondary C-section in severe TBI group (3.57 ± 1.47 vs 3.0 ± 1.27, respectively) consistently in the moderate TBI group (4.33 ± 1.11 vs 3.62 ± 1.47, respectively). The fetal death rate in primary C-section is lower compared to secondary C-section in severe TBI group (14.2 % vs 33.3 %, respectively), contrary, in moderate TBI group (16.7 % vs 12.5 %, respectively). CONCLUSIONS Care of pregnant patients with TBI often requires multidisciplinary approach to optimize treatment strategy on a case-by-case basis in light of prior experience across different center. We propose management guideline for head injury in pregnancy.
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Affiliation(s)
- Asra Al Fauzi
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia.
| | - Tedy Apriawan
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - I G M Aswin R Ranuh
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Ayu Yoniko Christi
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Abdul Hafid Bajamal
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Agus Turchan
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Eko Agus Subagio
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Nur Setiawan Suroto
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Budi Santoso
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Erry Gumilar Dachlan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Budi Utomo
- Department of Public Health and Preventive Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Ekkehard M Kasper
- Department of Neurosurgery, St. Elizabeth's Medical Center, Boston, Massachusetts, USA
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Factor S, Barriga J, Halperin D, Krespi R, Ben-Tov T. Displaced femoral neck fracture in a pregnant patient diagnosed with transient osteoporosis of the hip. SICOT J 2022; 8:44. [PMID: 36426960 PMCID: PMC9879124 DOI: 10.1051/sicotj/2022045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 11/06/2022] [Indexed: 11/27/2022] Open
Abstract
Transient osteoporosis of pregnancy (TOP) is a self-limiting pathology with unspecified etiology. It is typically found in women in late pregnancy or early postpartum. A femoral neck fracture is an infrequent complication. Herein, we describe a TOP case in a 38-year-old female who suffered a displaced sub-capital femoral neck fracture without obvious trauma at 28 weeks of gestation. The patient underwent operative treatment using closed reduction and internal fixation (CRIF), using cannulated screws, with no intraoperative complications. The postoperative radiograph revealed a collapse and further displacement of the femoral neck. A decision was made to postpone a definitive treatment to a postpartum date. The patient underwent a cesarean section at 38-week of gestation with no complications. At her latest follow-up, 24 months postoperatively, the patient was asymptomatic. Pelvic and hip radiographs demonstrated consolidation of the fracture. Level of evidence: IV.
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De Vito M, Capannolo G, Alameddine S, Fiorito R, Lena A, Patrizi L, D' Antonio F, Rizzo G. Trauma in pregnancy clinical practice guidelines: systematic review. J Matern Fetal Neonatal Med 2022; 35:9948-9955. [PMID: 35703623 DOI: 10.1080/14767058.2022.2078190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To objectively evaluate the methodological quality and clinical heterogeneity robustness of the published clinical practice guidelines (CPGs) on the management of trauma in pregnancy. MATERIALS AND METHODS Pubmed, Google Scholar, UpToDate, and Scopus Database were searched. The risk of bias and quality assessment of the included CPGs were performed using "The Appraisal Of Guidelines for Research and Evaluation (AGREE II)" tool. The following points relating to the management of trauma during pregnancy were addressed: quality of evidence assessment, classification of recommendations, main causes of trauma in pregnancy, importance of correct use of seat belts, ultrasound scans and/or pregnancy test in every female of reproductive age, description of physiological changes in pregnancy, classification in primary and secondary survey, primary survey based on ABCD Approach, fetus viable based on the weeks, radiographic studies for maternal evaluation, duration of fetal monitoring, use of anti-D immunoglobulin in rhesus-D-negative pregnant trauma patients, description of dose of RhD-Ig, the way to define gestational age if it was undetermined, descriptions of obstetrical complications, use of tetanus vaccination, and timing to perimortem cesarean section (CS). RESULTS Six CPGs were included. Quality of evidence assessment was described in 16.7% of CPGs (1/6), while it was not reported in 83.3% (5/6). Classification of recommendations was reported in 50% (3/3) of the CPGs. Motor vehicle crash was reported as the main cause of trauma in pregnancy in all the CPGs included in the present review, despite that the importance of a correct use of seat belts was described only in the 50% (3/6). Definition of fetal viability was also different among the included CPGs; in 50% (3/6) defined a fetus viable when it from 23 weeks, 33.3% (2/6) from 24 weeks, and 16.7% (1/6) from 20 weeks of gestation. Regarding the type of fetal monitoring, 33.3% (2/6) CPGs recommended CTG assessment at least every 4 h, 16.7% (1/6) at least every 6 h, 33.3% for 24 h if there are not reassuring signs and 16.7% (1/6) did not specify the duration of monitoring. Recommendations about the use of anti-D-immunoglobulin in rhesus-D-negative pregnant were also heterogeneous: 50% (3/6) of the CPGs suggested administration in all rhesus-D-negative pregnant women, 16.7% (1/6) only according to gestational age at trauma or in case of significant abdominal trauma, and 16.7% (1/6) only in case of positive Kleihauer test while 16.7% (1/6) did not specify it. Administration of tetanus vaccination was suggested in in 33.3% (2/6) of CPGs. Finally, there were different descriptions of timing to perimortem CS: 33.3% (2/6) of CPGs claims to do CS no later than 4 min, 50% (3/6) no later than 5 min, and 16.7% (1/6) does not describe timing for CS. The AGREE II standardized domain scores for the first overall assessment (OA1) had a mean of 69%. Only three CPGs scored more than 60% and revealed a consensus agreement between the reviewers on recommending the use of these CPGs. CONCLUSION There is clinical heterogeneity in some of the most relevant aspects of the management of pregnant women with trauma. The findings from this systematic review highlight the need for up to date and shared guidelines promoted by the main body societies in order make management of pregnant women with trauma homogenous.
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Affiliation(s)
- Marika De Vito
- Department of Obstetrics and Gynecology Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Roma, Italy
| | - Giulia Capannolo
- Department of Obstetrics and Gynecology Chieti, Università di Chieti, Chieti, Italy
| | - Sara Alameddine
- Department of Obstetrics and Gynecology Chieti, Università di Chieti, Chieti, Italy
| | - Roberto Fiorito
- Department of Surgery Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Roma, Italy
| | - Alessandro Lena
- Department of Obstetrics and Gynecology Ospedale San Paolo Civitavecchia, Roma, Italy
| | - Lodovico Patrizi
- Department of Obstetrics and Gynecology Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Roma, Italy
| | - Francesco D' Antonio
- Department of Obstetrics and Gynecology Chieti, Università di Chieti, Chieti, Italy
| | - Giuseppe Rizzo
- Department of Obstetrics and Gynecology Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Roma, Italy
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Leenellett E, Rieves A. Occult Abdominal Trauma. Emerg Med Clin North Am 2021; 39:795-806. [PMID: 34600638 DOI: 10.1016/j.emc.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Occult abdominal injuries are common and can be associated with increased risk of morbidity and mortality. Patients with a delayed presentation to care or who are multiply injured are at increased risk of this type of injury, and a high index of suspicion must be maintained. A careful combination of history, physical examination, laboratory, and imaging can be quite helpful in mitigating the risk of a missed occult abdominal injury.
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Affiliation(s)
- Elizabeth Leenellett
- Department of Emergency Medicine, University of Cincinnati, 231 Albert Sabin Way, Room 1505, Cincinnati, OH 45267-0769, USA.
| | - Adam Rieves
- Department of Emergency Medicine, Washington University in Saint Louis, 660 South Euclid Avenue, BC 8072, Saint Louis, MO 63110, USA
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Abstract
One of the most common causes of obstetric morbidity and mortality is trauma in pregnancy. Several maternal physiological changes during pregnancy have a significant impact on the mechanism, presentation, and management of trauma in this population. It is crucial for health providers dealing with trauma to know and understand these differences between pregnant and nonpregnant patients. The obstetric trauma patient requires a multidisciplinary approach, including obstetrics, maternal fetal medicine, anesthesiology, surgery, and intensive care teams. The aim of this article is to review the most updated information on trauma during pregnancy.
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Hrvatin I, Rugelj D. Risk factors for accidental falls during pregnancy - a systematic literature review. J Matern Fetal Neonatal Med 2021; 35:7015-7024. [PMID: 34139937 DOI: 10.1080/14767058.2021.1935849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Falls during pregnancy occur in 25-27% of women and can cause serious harm to both the mother and the fetus. The objective of this systematic review was to identify intrinsic and extrinsic risk factors for falls during pregnancy by reviewing original studies and addressing possible forms of prevention. METHODS We searched PubMed, Cochrane library, and Web of Science databases for studies assessing risk factors for falling after a fall has occurred or by using posturographic assessment. RESULTS Fourteen studies were included in the review. The identified extrinsic risk factors include slippery floors, cluttered areas, uneven ground, inappropriate shoes, hurrying, walking on stairs, carrying additional loads, poor lighting or obstructed view, sedentary lifestyle and working in physically demanding jobs. The identified intrinsic factors include age less than 30, height more than 160 cm, advanced pregnancy, unintended pregnancy, multiparity, hyperemesis gravidarum, low back pain, gestational diabetes, increase in abdominal circumference, lower ankle stiffness and joint laxity. Physical activity, maternity support belts, and education are possible strategies for fall prevention. CONCLUSION Our systematic review identified 13 intrinsic and 11 extrinsic risk factors for falling during pregnancy. With the knowledge of risk factors and the optimal prevention strategy, healthcare providers could incorporate this information in the treatment of pregnant women and reduce the risk of falling.
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Affiliation(s)
- Ivana Hrvatin
- Faculty of Health Sciences, Biomechanical Laboratory, University of Ljubljana, Ljubljana, Slovenia
| | - Darja Rugelj
- Faculty of Health Sciences, Biomechanical Laboratory, University of Ljubljana, Ljubljana, Slovenia
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Kumar S, Gupta A, Sagar S, Bagaria D, Kumar A, Choudhary N, Kumar V, Ghoshal S, Alam J, Agarwal H, Gammangatti S, Kumar A, Soni KD, Agarwal R, Gunjaganvi M, Joshi M, Saurabh G, Banerjee N, Kumar A, Rattan A, Bakhshi GD, Jain S, Shah S, Sharma P, Kalangutkar A, Chatterjee S, Sharma N, Noronha W, Mohan LN, Singh V, Gupta R, Misra S, Jain A, Dharap S, Mohan R, Priyadarshini P, Tandon M, Mishra B, Jain V, Singhal M, Meena YK, Sharma B, Garg PK, Dhagat P, Kumar S, Kumar S, Misra MC. Management of Blunt Solid Organ Injuries: the Indian Society for Trauma and Acute Care (ISTAC) Consensus Guidelines. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02820-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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10
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Implementation of a multidisciplinary perinatal emergency response team improves time to definitive obstetrical evaluation and fetal assessment. J Trauma Acute Care Surg 2020; 88:615-618. [PMID: 32044870 DOI: 10.1097/ta.0000000000002615] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Trauma is the leading cause of nonobstetric death during pregnancy and is associated with an increased risk of maternal and fetal mortality. In an effort to improve the delivery of care to pregnant trauma patients, we developed an institutional multidisciplinary quality initiative designed to improve response times of nontrauma specialists and ensure immediate availability of resources. We hypothesized that implementation of a perinatal emergency response team (PERT) would improve time to patient and fetal evaluation and monitoring by the obstetrics (OB) team and improve both maternal and fetal outcomes. METHODS We performed a 6-year (2012-2018) retrospective cohort analysis of consecutive pregnant trauma patients presenting to our university-affiliated, level I trauma center. Patients in the pre-PERT cohort (before April 2015) were compared with a post-PERT cohort. Variables analyzed included patient demographics, mechanism of injury, Injury Severity Score, and level of trauma activation. The main outcome measure was time to OB evaluation. Secondary outcomes included time to cardiotocometry, and mortality. RESULTS Of 92 pregnant trauma patients, there were 50 patients (54.3%) in the pre-PERT cohort and 42 (45.7%) in the post-PERT group. Blunt injuries predominated (98.9%), with the most common mechanism being motor vehicle collisions (76.1%), followed by assaults (13%) and falls (6.5%). The mean time to obstetrical evaluation was 44 minutes in the pre-PERT cohort compared with 14 minutes in the post-PERT cohort (p = 0.001). There was a significant decrease in level I (highest acuity) trauma activations pre-PERT and post-PERT (46% vs. 21%, p = 0.01), and the time to cardiotocography was significantly decreased post-PERT implementation (72 vs. .37 min, p = 0.01) CONCLUSION: Implementation of a multidisciplinary PERT improves time to evaluation by the OB team and time to cardiotocometry in the pregnant trauma patient. LEVEL OF EVIDENCE Retrospective review, level IV.
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Maxwell BG, Greenlaw A, Smith WJ, Barbosa RR, Ropp KM, Lundeberg MR. Pregnant trauma patients may be at increased risk of mortality compared to nonpregnant women of reproductive age: trends and outcomes over 10 years at a level I trauma center. ACTA ACUST UNITED AC 2020; 16:1745506520933021. [PMID: 32578516 PMCID: PMC7315661 DOI: 10.1177/1745506520933021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background: Pregnancy has been identified as a risk factor for poor outcomes after traumatic injury, but prior outcome analyses are conflicting and dated. We sought to examine outcomes in a contemporary cohort. Methods: Retrospective cohort analysis at a level I trauma center’s institutional registry from 2009 to 2018, with comparison to population-level demographic trends in women of reproductive age and pregnancy prevalence. Unadjusted cohorts of pregnant versus nonpregnant trauma patients were compared. Pregnant patients then were matched on age, mechanism of injury, year, and injury severity score with nonpregnant controls for adjusted analysis with a primary outcome of maternal mortality. Results: Despite declining birth and pregnancy rates in the population, pregnant women comprised a stable 5.3% of female trauma patients of reproductive age without decline over the study period (p = 0.53). Compared with nonpregnant women, pregnant trauma patients had a lower injury severity score (1 [1–5] vs 5 [1–10] p < 0.0001) and a shorter length of stay (1 [1–2] vs 1 [1–4] p = 0.04), were less likely to have CT imaging (48.8% vs 67.4%, p < 0.0001) and more likely to be admitted (89.3% vs 79.2%, p = 0.003). Positive toxicology screens were less prevalent in pregnant women, but only for ethanol (5.4% vs 31.4%, p < 0.0001); there was no difference in rates of cannabis, opiates, or cocaine. After matching to adjust for age, year, mechanism of injury, and injury severity score, mortality occurred significantly more frequently in the pregnant cohort (2.1% vs 0.2%, OR = 13.5 [1.39–130.9], p = 0.02). Conclusion: Pregnant trauma patients have not declined in our population despite population-level declines in pregnancy. After adjusting for lower injury severity, pregnant women were at substantially greater risk of mortality. This supports ongoing concern for pregnant trauma patients as a vulnerable population. Further efforts should optimize systems of care to maximize the chances of rescue for both mother and fetus.
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Affiliation(s)
- Bryan G Maxwell
- Department of Anesthesiology, Legacy Emanuel Medical Center, Portland, OR, USA
| | - Andrea Greenlaw
- Department of Trauma Services, Legacy Emanuel Medical Center, Portland, OR, USA
| | - Wendy J Smith
- Department of Obstetrics, Legacy Emanuel Medical Center, Portland, OR, USA
| | - Ronald R Barbosa
- Department of Surgery; Legacy Emanuel Medical Center, Portland, OR, USA
| | - Kate M Ropp
- Department of Anesthesiology, Legacy Emanuel Medical Center, Portland, OR, USA
| | - Megan R Lundeberg
- Department of Surgery; Legacy Emanuel Medical Center, Portland, OR, USA
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McCracken B. Maternal Fetal Trauma: When One Patient Becomes Two: A Case Study. JOURNAL OF ACUTE CARE SURGERY 2020. [DOI: 10.17479/jacs.2020.10.1.25] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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13
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Greco PS, Day LJ, Pearlman MD. Guidance for Evaluation and Management of Blunt Abdominal Trauma in Pregnancy. Obstet Gynecol 2019; 134:1343-1357. [PMID: 31764749 DOI: 10.1097/aog.0000000000003585] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Blunt abdominal trauma is the leading type of traumatic injury in pregnancy, with motor vehicle crashes, falls, and assault being the most common etiologies. Several adverse outcomes can occur in pregnancy, including placental abruption, preterm labor and preterm delivery, uterine rupture, and pelvic fracture. Understanding and integration of key anatomic and physiologic changes in pregnancy are key when evaluating a pregnant trauma patient. Pregnant women should be managed in a medical center with the ability to provide adequate care to both trauma patients-the pregnant woman and fetus. Multiple clinical providers are usually involved in the care of pregnant trauma patients, but obstetric providers should play a central role in the evaluation and management of a pregnant trauma patient given their unique training, knowledge, and clinical skills. An algorithm for management of trauma in pregnancy should be used at all sites caring for pregnant women. An alignment of policies within each system optimizes appropriate triage, integration of care, management, and monitoring of pregnant trauma patients and their fetuses. Ensuring effective protocols for prehospital and hospital treatment, as well as thorough training of involved health care providers, is essential in ensuring that optimal care is provided.
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Affiliation(s)
- Patricia S Greco
- University of Michigan Department of Obstetrics and Gynecology, Ann Arbor, Michigan
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van der Knoop BJ, Oostrom KJ, Zonnenberg IA, van Weissenbruch MM, Vermeulen RJ, de Vries JIP. Neurobehavioural outcome in 6-18 year old children after trauma in pregnancy: Case-control study. Eur J Paediatr Neurol 2018; 22:845-853. [PMID: 29735386 DOI: 10.1016/j.ejpn.2018.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 02/20/2018] [Accepted: 04/04/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Maternal trauma complicates pregnancy in approximately 7%. Long-term development of children exposed to maternal trauma is unknown. AIM To determine neurobehavioural outcome of children (6-18 years) born after maternal trauma in pregnancy compared to a matched control group. STUDY DESIGN Case-control study performed at a tertiary medical centre. SUBJECTS All consecutive children born after maternal hospitalization for trauma during pregnancy between 1995 and 2005. Controls were children born at the same hospital and period after an uneventful pregnancy. OUTCOME MEASURES Trauma type and severity (Injury Severity Score, ≥9: severe); information from medical files at admission (cases). All mothers filled out two questionnaires about the infant; 1. concerning health, motor development and educational level, 2. concerning behavioural development through the validated Dutch version of the Child Behavior Checklist (CBCL). RESULTS Questionnaires were returned by 34 cases and 28 controls. The traumas concerned mainly motor vehicle accidents and falls, and 3/34 had severe injuries. No differences in health, motor development, educational level and CBCL was found between the cases and controls, except for more hospitalization in the cases (p = 0.009). CONCLUSION Long-term follow-up of a limited population of children 6-18 years after exposure of mainly non-severe trauma before birth is similar to a control population except for unexplained more hospitalization in the cases.
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Affiliation(s)
- B J van der Knoop
- Department of Obstetrics and Gynaecology, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands; Neuroscience Campus, VU University, Amsterdam, The Netherlands.
| | - K J Oostrom
- Dept of Pediatric Psychology, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
| | - I A Zonnenberg
- Department of Neonatology, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
| | - M M van Weissenbruch
- Department of Neonatology, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
| | - R J Vermeulen
- Department of Child Neurology, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
| | - J I P de Vries
- Department of Obstetrics and Gynaecology, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands; Research Institute MOVE, Amsterdam, The Netherlands.
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Lebrun B, Jacquemyn Y. Usefulness of maternal fetal red blood cell count in rhesus-positive pregnant women. Horm Mol Biol Clin Investig 2018; 35:/j/hmbci.ahead-of-print/hmbci-2018-0028/hmbci-2018-0028.xml. [PMID: 30059348 DOI: 10.1515/hmbci-2018-0028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 06/19/2018] [Indexed: 11/15/2022]
Abstract
Background Fetal red blood cells (FRBC) in maternal blood are counted in rhesus-negative women to determine the amount of anti-D immunoglobulin to be administered in the case of a rhesus-positive fetus. In rhesus-positive pregnant women this is done in not always very well-defined indications including trauma, miscarriage, fetal death and diminished fetal movements. The aim of this study is to determine if the detection of FRBC is useful in rhesus-positive pregnant woman. This was done by assessing maternal and fetal characteristics that are more likely to give a positive test. Materials and methods This was a retrospective cohort study. Results A total of 169 FRBC tests were performed in 161 rhesus-positive pregnant women. FRBC were found in 45 (26.6%) of the women. Three patients experienced a miscarriage although their FRBC tests were negative (p = 0.295). Of the seven patients who experienced unexpected stillbirths, three tested positive. The deaths were not less likely to occur if the results had been negative (p = 0.631). There was a statistically significant difference between the different types of trauma indications (p = 0.025): the test was more likely positive if there had been a fall on the ground or staircase or blunt trauma (p = 0.041, 0.026 and 0.018, respectively). FRBC were not more frequently present in the absence of fetal movements (n = 16, p = 0.693). Conclusion FRBC in maternal blood were more likely positive in the case of a fall on the ground, or from a staircase. However, a positive test does not necessarily imply fetal pathology and, therefore, does not contribute to clinical management.
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Affiliation(s)
- Benjamin Lebrun
- UZA Antwerp University Hospital, Department of Gynecology and Obstetrics, Wilrijkstraat 10 2650 Edegem, Belgium
| | - Yves Jacquemyn
- UZA Antwerp University Hospital, Departement of Gynecology and Obstetrics, Edegem, Belgium
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16
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Caspers CG. Care of Traumatic Conditions in an Observation Unit. Emerg Med Clin North Am 2017; 35:673-683. [PMID: 28711130 DOI: 10.1016/j.emc.2017.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Patients presenting to the emergency department with certain traumatic conditions can be managed in observation units. The evidence base supporting the use of observation units to manage injured patients is smaller than the evidence base supporting the management of medical conditions in observation units. The conditions that are eligible for management in an observation unit are not limited to those described in this article, and investigators should continue to identify types of conditions that may benefit from this type of health care delivery.
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Affiliation(s)
- Christopher G Caspers
- Ronald O. Perelman Department of Emergency Medicine, New York University Langone Medical Center, 560 First Avenue, New York, NY 10016, USA.
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17
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Abstract
Fracture management in pregnant patients is challenging. Anatomic and physiologic changes in pregnancy increase the complexity of treatment. Maternal trauma increases the risk of fetal loss, preterm birth, placental abruption, cesarean delivery, and maternal death. Initial resuscitation and treatment in a facility equipped to handle the orthopaedic injury and preterm births are paramount. Pelvic and acetabular injuries are potentially life threatening. The benefits and risks of surgical treatment must be carefully considered. The risks posed by anesthetic agents, antibiotic agents, anticoagulant agents, and radiation exposure must be understood. Positioning of the patient can affect the viability of the fetus. If surgery is necessary, the left lateral decubitus position decreases fetal hypotension. A specialized team including an obstetrician, perinatologist, orthopaedic surgeon, general trauma surgeon, critical care specialist, emergency medicine specialist, anesthesiologist, radiologist, and nurse must collaborate to improve maternal and fetal outcomes.
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van der Knoop BJ, Zonnenberg I.A, Otten VM, van Weissenbruch MM, de Vries JIP. Trauma in pregnancy, obstetrical outcome in a tertiary centre in the Netherlands. J Matern Fetal Neonatal Med 2017; 31:339-346. [DOI: 10.1080/14767058.2017.1285891] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- B. J. van der Knoop
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam, The Netherlands
| | - I .A. Zonnenberg
- Department of Neonatology, VU University Medical Center, Amsterdam, The Netherlands
| | - V. M. Otten
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam, The Netherlands
| | | | - J. I. P. de Vries
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam, The Netherlands
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Bozkurt C, Sarikaya B. A Surgical Opinion in a 36-Week Pregnant with Tibia Fracture: Intramedullary Nailing. Case Rep Orthop 2016; 2016:1454835. [PMID: 28070433 PMCID: PMC5187484 DOI: 10.1155/2016/1454835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 11/04/2016] [Accepted: 11/27/2016] [Indexed: 12/02/2022] Open
Abstract
The operative treatment of tibial fractures in late pregnancy is a controversial issue that is rarely discussed in the literature. Here we present a case of a tibial diaphyseal fracture in a woman that was 36 weeks pregnant, which was treated with intramedullary nails under noninvasive foetal monitoring with cardiotocography. The patient underwent a successful surgery, and no harm or adverse events to either the mother or the foetus were reported during or after the procedure. Following surgery, the mother had a comfortable pregnancy and a normal spontaneous vaginal delivery with a healthy newborn.
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Affiliation(s)
- Celal Bozkurt
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Harran University, Sanliurfa, Turkey
| | - Baran Sarikaya
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Harran University, Sanliurfa, Turkey
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Luo F, Hu Y, Zhao W, Zuo Z, Yu Q, Liu Z, Lin J, Feng Y, Li B, Wu L, Xu L. Maternal Exposure of Rats to Isoflurane during Late Pregnancy Impairs Spatial Learning and Memory in the Offspring by Up-Regulating the Expression of Histone Deacetylase 2. PLoS One 2016; 11:e0160826. [PMID: 27536989 PMCID: PMC4990207 DOI: 10.1371/journal.pone.0160826] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 06/06/2016] [Indexed: 12/26/2022] Open
Abstract
Increasing evidence indicates that most general anesthetics can harm developing neurons and induce cognitive dysfunction in a dose- and time-dependent manner. Histone deacetylase 2 (HDAC2) has been implicated in synaptic plasticity and learning and memory. Our previous results showed that maternal exposure to general anesthetics during late pregnancy impaired the offspring's learning and memory, but the role of HDAC2 in it is not known yet. In the present study, pregnant rats were exposed to 1.5% isoflurane in 100% oxygen for 2, 4 or 8 hours or to 100% oxygen only for 8 hours on gestation day 18 (E18). The offspring born to each rat were randomly subdivided into 2 subgroups. Thirty days after birth, the Morris water maze (MWM) was used to assess learning and memory in the offspring. Two hours before each MWM trial, an HDAC inhibitor (SAHA) was given to the offspring in one subgroup, whereas a control solvent was given to those in the other subgroup. The results showed that maternal exposure to isoflurane impaired learning and memory of the offspring, impaired the structure of the hippocampus, increased HDAC2 mRNA and downregulated cyclic adenosine monophosphate (cAMP) response element binding protein (CREB) mRNA, N-methyl-D-aspartate receptor 2 subunit B (NR2B) mRNA and NR2B protein in the hippocampus. These changes were proportional to the duration of the maternal exposure to isoflurane and were reversed by SAHA. These results suggest that exposure to isoflurane during late pregnancy can damage the learning and memory of the offspring rats via the HDAC2-CREB -NR2B pathway. This effect can be reversed by HDAC2 inhibition.
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Affiliation(s)
- Foquan Luo
- Department of Anesthesiology, the First Affiliated Hospital, Nanchang University, Nanchang 33006, China
- * E-mail:
| | - Yan Hu
- Department of Anesthesiology, the First Affiliated Hospital, Nanchang University, Nanchang 33006, China
- Department of Anesthesiology, Jiangxi Province Traditional Chinese Medicine Hospital, Nanchang 33006, China
| | - Weilu Zhao
- Department of Anesthesiology, the First Affiliated Hospital, Nanchang University, Nanchang 33006, China
| | - Zhiyi Zuo
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, 22908, United States of America
| | - Qi Yu
- Department of Anesthesiology, the First Affiliated Hospital, Nanchang University, Nanchang 33006, China
| | - Zhiyi Liu
- Department of Anesthesiology, the First Affiliated Hospital, Nanchang University, Nanchang 33006, China
| | - Jiamei Lin
- Department of Anesthesiology, the First Affiliated Hospital, Nanchang University, Nanchang 33006, China
| | - Yunlin Feng
- Department of Anesthesiology, the First Affiliated Hospital, Nanchang University, Nanchang 33006, China
| | - Binda Li
- Department of Anesthesiology, Jiangxi Province Tumor Hospital, Nanchang 330006, China
| | - Liuqin Wu
- Department of Anesthesiology, Jiangxi Province Tumor Hospital, Nanchang 330006, China
| | - Lin Xu
- Department of Anesthesiology, the First Affiliated Hospital, Nanchang University, Nanchang 33006, China
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Zhong L, Luo F, Zhao W, Feng Y, Wu L, Lin J, Liu T, Wang S, You X, Zhang W. Propofol exposure during late stages of pregnancy impairs learning and memory in rat offspring via the BDNF-TrkB signalling pathway. J Cell Mol Med 2016; 20:1920-31. [PMID: 27297627 PMCID: PMC5020635 DOI: 10.1111/jcmm.12884] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 04/09/2016] [Indexed: 12/20/2022] Open
Abstract
The brain‐derived neurotrophic factor (BDNF)‐tyrosine kinase B (TrkB) (BDNF‐TrkB) signalling pathway plays a crucial role in regulating learning and memory. Synaptophysin provides the structural basis for synaptic plasticity and depends on BDNF processing and subsequent TrkB signalling. Our previous studies demonstrated that maternal exposure to propofol during late stages of pregnancy impaired learning and memory in rat offspring. The purpose of this study is to investigate whether the BDNF‐TrkB signalling pathway is involved in propofol‐induced learning and memory impairments. Propofol was intravenously infused into pregnant rats for 4 hrs on gestational day 18 (E18). Thirty days after birth, learning and memory of offspring was assessed by the Morris water maze (MWM) test. After the MWM test, BDNF and TrkB transcript and protein levels were measured in rat offspring hippocampus tissues using real‐time PCR (RT‐PCR) and immunohistochemistry (IHC), respectively. The levels of phosphorylated‐TrkB (phospho‐TrkB) and synaptophysin were measured by western blot. It was discovered that maternal exposure to propofol on day E18 impaired spatial learning and memory of rat offspring, decreased mRNA and protein levels of BDNF and TrkB, and decreased the levels of both phospho‐TrkB and synaptophysin in the hippocampus. Furthermore, the TrkB agonist 7,8‐dihydroxyflavone (7,8‐DHF) reversed all of the observed changes. Treatment with 7,8‐DHF had no significant effects on the offspring that were not exposed to propofol. The results herein indicate that maternal exposure to propofol during the late stages of pregnancy impairs spatial learning and memory of offspring by disturbing the BDNF‐TrkB signalling pathway. The TrkB agonist 7,8‐DHF might be a potential therapy for learning and memory impairments induced by maternal propofol exposure.
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Affiliation(s)
- Liang Zhong
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China
| | - Foquan Luo
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China.
| | - Weilu Zhao
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China
| | - Yunlin Feng
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China
| | - Liuqin Wu
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China
| | - Jiamei Lin
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China
| | - Tianyin Liu
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China
| | - Shengqiang Wang
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China
| | - Xuexue You
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China
| | - Wei Zhang
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China
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23
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Moon TS, Sappenfield J. Anesthetic Management and Challenges in the Pregnant Patient. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-015-0132-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Ciavattini A, Mancioli F, Paci E, Politano R. Management of pathological femoral fracture secondary to breast cancer in pregnancy: A case report. Oncol Lett 2016; 11:439-441. [PMID: 26870230 DOI: 10.3892/ol.2015.3900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 05/01/2015] [Indexed: 11/05/2022] Open
Abstract
Bone metastasis resulting from breast cancer in pregnancy is rare. In the literature there are few reports regarding osteolytic lesions in pregnancy and no data on the treatment of such femoral fractures. The present study reports a case of a 29-week primigravida presenting with severe lumbosciatica in the left side, refractory to medical therapy. During neurosurgical examination a spontaneous pathological fracture of the left femur occurred. Damage control orthopedic principals were applied and a biopsy specimen from the femoral lesion was obtained, providing a diagnosis of metastases from breast adenocarcinoma. Cesarean section was performed at 32 gestational weeks. Following delivery, an internal fixator was placed in the left femur for definitive treatment of the fracture and staging of cancer was conducted. Subsequently, adjuvant treatment comprising left mastectomy and percutaneous radiofrequency thermoablation of the sacroiliac lesion were performed. A follow-up one-year following percutaneous radiofrequency thermoablation of the sacroiliac lesion detected no metastatic bone pain, and identified a stable sacroiliac lesion.
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Affiliation(s)
- Andrea Ciavattini
- Women's Health Sciences Department, Polytechnic University of Marche, Ancona 60100, Italy
| | - Francesca Mancioli
- Women's Health Sciences Department, Polytechnic University of Marche, Ancona 60100, Italy
| | - Enrico Paci
- Department of Interventional Radiology, Umberto I Hospital, Polytechnic University of Marche, Ancona 60100, Italy
| | - Rocco Politano
- Department of Orthopedics, Polytechnic University of Marche, Ancona 60100, Italy
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Faulconer ER, Irani S, Dufty N, Bowley D. Obstetric complications on deployed operations: a guide for the military surgeon. J ROY ARMY MED CORPS 2015; 162:326-329. [PMID: 26530216 DOI: 10.1136/jramc-2015-000426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 09/22/2015] [Indexed: 11/04/2022]
Abstract
Modern military general surgeons tend to train and then practice in 'conventional' surgical specialties in their home nation; however, the reality of deployed surgical practice, either in a combat zone or on a humanitarian mission, is that they are likely to have to manage patients with a broad range of ages, conditions and pathologies. Obstetric complications of war injury include injury to the uterus and fetus as well as the mother and both placental abruption and uterine rupture are complications that military surgeons may have little experience of recognising and managing. On humanitarian deployments, fetomaternal complications are a common reason for surgical intervention. We report a recent patient's story to highlight the obstetric training needs of military surgeons.
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Affiliation(s)
- Edwin R Faulconer
- Royal Shrewsbury Hospital, Shrewsbury, UK Army Medical Directorate, Former Army Staff College, Camberley, Surrey, UK
| | - S Irani
- Heart of England NHS Foundation Trust, Bordesley Green, Birmingham, UK
| | - N Dufty
- Heart of England NHS Foundation Trust, Bordesley Green, Birmingham, UK Royal Centre for Defence Medicine, Birmingham, UK
| | - D Bowley
- Heart of England NHS Foundation Trust, Bordesley Green, Birmingham, UK Royal Centre for Defence Medicine, Birmingham, UK
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Matthews LJ, McConda DB, Lalli TAJ, Daffner SD. Orthostetrics: Management of Orthopedic Conditions in the Pregnant Patient. Orthopedics 2015; 38:e874-80. [PMID: 26488781 DOI: 10.3928/01477447-20151002-53] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 02/04/2015] [Indexed: 02/03/2023]
Abstract
Managing orthopedic conditions in pregnant patients leads to challenges that must be carefully considered so that the safety of both the mother and the fetus is maintained. Both perioperative and intraoperative considerations must be made based on physiologic changes during pregnancy, risks of radiation, and recommendations for monitoring. Operative timing, imaging, and medication selection are also factors that may vary based on trimester and clinical scenario. Pregnancy introduces unique parameters that can result in undesirable outcomes for both mother and fetus if not handled appropriately. Ultimately, pregnant patients offer a distinct challenge to the orthopedic surgeon in that the well-being of 2 patients must be considered in all aspects of care. In addition, not only does pregnancy affect the management of orthopedic conditions but the pregnant state also causes physiologic changes that may actually induce various pathologies. These pregnancy-related orthopedic conditions can interfere with an otherwise healthy pregnancy and should be recognized as possible complications. Although the management of orthopedic conditions in pregnancy is often conservative, pregnancy does not necessarily preclude safely treating pathologies operatively. When surgery is considered, regional anesthesia provides less overall drug exposure to the fetus and less variability in fetal heart rate. Intraoperative fluoroscopy can be used when appropriate, with 360° fetal shielding if possible. Lateral decubitus positioning is ideal to prevent hypotension associated with compression of the inferior vena cava.
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van der Knoop BJ, van Schie PEM, Vermeulen RJ, Pistorius LR, van Weissenbruch MM, de Vries JIP. Effect of (minor or major) maternal trauma on fetal motility: A prospective study. Early Hum Dev 2015; 91:511-7. [PMID: 26132633 DOI: 10.1016/j.earlhumdev.2015.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/05/2015] [Accepted: 06/09/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Fetal motility represents the spontaneous activity of the central nervous system and as such can be used to evaluate its functional integrity. Maternal mechanical trauma in pregnancy is a risk factor for hypoxic ischemic brain injury and can potentially affect the CNS and fetal motility. AIM To study motility in fetuses after maternal trauma. STUDY DESIGN Prospective study; 1-h sonographic observations at 2-8h (T1), 24-72h (T2) and >72h (T3) after trauma. SUBJECTS Fetuses exposed to trauma after 20weeks gestational age. OUTCOME MEASURES Motor aspects; differentiation into specific movement patterns, quality and quantity of general movements were compared to a normal population. Obstetrical outcome; neurological outcome at term and 1year of age. RESULTS Sixteen fetuses were examined between 2012 and 2014. Median gestational age at time of trauma was 25+6 (range 20-38) weeks. Most traumas were traffic accidents or falls, injuries were mainly minor. Motility assessment showed abnormal differentiation in 2/16; 2/14 and 0/16; abnormal quality in 2/16; 3/14 and 6/16; and abnormal quantity in 6/16, 9/14 and 9/16 at T1, T2 and T3 respectively. Preterm delivery occurred once. Neurological development was normal in 13/14 infants at term and 14/14 at one year. CONCLUSIONS This study shows that maternal trauma affected fetal motility in the majority of the fetuses. The changes in motility support the concern that even minor mechanical trauma may have influence on the functional integrity of the central nervous system, although no neurological sequelae were present at 1year.
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Affiliation(s)
- Bloeme J van der Knoop
- Department of Obstetrics and Gynaecology, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.
| | - Petra E M van Schie
- Department of Rehabilitation Medicine and Physical Therapy, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.
| | - Roland J Vermeulen
- Department of Child Neurology, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.
| | - Lourens R Pistorius
- Department of Obstetrics and Gynaecology, University Medical Center, Utrecht, Utrecht, The Netherlands.
| | - Mirjam M van Weissenbruch
- Department of Neonatology, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.
| | - Johanna I P de Vries
- Department of Obstetrics and Gynaecology, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands; Research Institute MOVE, VU University, Amsterdam, The Netherlands.
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28
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Tawfik MM, Badran BA, Eisa AA, Barakat RI. Simultaneous cesarean delivery and craniotomy in a term pregnant patient with traumatic brain injury. Saudi J Anaesth 2015; 9:207-10. [PMID: 25829914 PMCID: PMC4374231 DOI: 10.4103/1658-354x.152890] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The management of pregnant patients with traumatic brain injury is challenging. A multidisciplinary team approach is mandatory, and management should be individualized according to the type and extent of injury, maternal status, gestational age, and fetal status. We report a 27-year-old term primigravida presenting after head injury with Glasgow coma scale score 11 and anisocoria. Depressed temporal bone fracture and acute epidural hematoma were diagnosed, necessitating an urgent neurosurgery. Her fetus was viable with no signs of distress and no detected placental abnormalities. Cesarean delivery was performed followed by craniotomy in the same setting under general anesthesia with good outcome of the patient and her baby.
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Affiliation(s)
- Mohamed Mohamed Tawfik
- Department of Anesthesia and Surgical Intensive Care, Mansoura University Hospitals, Mansoura, Daqahlia, Egypt
| | - Basma Abed Badran
- Department of Anesthesia and Surgical Intensive Care, Mansoura University Hospitals, Mansoura, Daqahlia, Egypt
| | - Ahmed Amin Eisa
- Department of Anesthesia and Surgical Intensive Care, Mansoura University Hospitals, Mansoura, Daqahlia, Egypt
| | - Rafik Ibrahim Barakat
- Department of Obstetrics and Gynecology, Mansoura University Hospitals, Mansoura, Daqahlia, Egypt
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29
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Martiny F, Jelinek E, Fleisch M, Flohé S. Versorgung verletzter schwangerer Patientinnen. Notf Rett Med 2014. [DOI: 10.1007/s10049-014-1877-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Hartzell TL, Kuo P, Eberlin KR, Winograd JM, Day CS. The overutilization of resources in patients with acute upper extremity trauma and infection. J Hand Surg Am 2013; 38:766-73. [PMID: 23395105 DOI: 10.1016/j.jhsa.2012.12.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 12/12/2012] [Accepted: 12/12/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare patients with acute upper extremity injuries and infections presenting initially to the emergency department with patients transferred from outside institutions, and to evaluate triage guidelines for the appropriate transfer of these patients. METHODS We reviewed the records of 1,172 consecutive patients with acute upper extremity injuries or infections presenting to 2 level 1 trauma centers over 3-month periods. We analyzed demographics, transfer details, injury characteristics, intervention received, follow-up, and complications. Triage guidelines were established by a board of academic upper extremity and emergency physicians and retrospectively applied to patient data. RESULTS Of 1,172 patients, 155 (13%) arrived via transfer from outside facilities. Transferred patients had more complex injuries by our guidelines, but many did not require level 1 emergent care. The receiving emergency department discharged 26% of the transferred patients without upper extremity specialist evaluation, and 24% of the transferred patients received no procedural intervention at any point. Only 10% went to the operating room emergently. Implementing our guidelines for appropriate triage, we found that 53% of transfers did not require emergent transfer to a level 1 facility. These nonemergent transfers spent an average of 15.2 hours from the time of initial evaluation at the outside facility to discharge from the level 1 emergency department, compared with 3.1 hours in patients who arrived primarily. Retrospectively, our triage guidelines had a 2% undertriage rate and a 3% overtriage rate. CONCLUSIONS Over half of the patients transferred with upper extremity injuries and infections for specialized evaluation may be transferred unnecessarily. Guidelines for the care and transfer of patients with acute upper extremity injuries or infections may lead to better use of resources. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic III.
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The ability of computed tomography to diagnose placental abruption in the trauma patient. J Trauma Acute Care Surg 2013; 74:236-41. [PMID: 23271100 DOI: 10.1097/ta.0b013e318278937b] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fetal demise following trauma remains a devastating complication largely owing to placental injury and abruption. Our objective was to determine if abdominopelvic computed tomographic (CT) imaging can assess for placental abruption (PA) when obtained to exclude associated maternal injuries. METHODS Retrospective review of pregnant trauma patients of 20-week gestation or longer presenting to a trauma center during a 7-year period who underwent CT imaging as part of their initial evaluation. Radiographic images were reviewed by a radiologist for evidence of PA and classified based on percentage of visualized placental enhancement. Blinded to CT results, charts were reviewed by an obstetrician for clinical evidence of PA and classified as strongly positive, possibly positive, or no evidence. RESULTS A total of 176 patients met inclusion criteria. CT imaging revealed evidence of PA in 61 patients (35%). As the percentage of placental enhancement decreased, patients were more likely to have strong clinical manifestations of PA, reaching statistical significance when enhancement was less than 50%. CT imaging evidence of PA was apparent in all patients who required delivery for nonassuring fetal heart tones. CONCLUSION CT imaging evaluation of the placenta can accurately identify PA and therefore can help stratify patients at risk for fetal complications. The likelihood of requiring delivery increased as placental enhancement declined to less than 25%. LEVEL OF EVIDENCE Diagnostic study, level III.
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Karadaş S, Gönüllü H, Öncü MR, Kurdoğlu Z, Canbaz Y. Pregnancy and trauma: analysis of 139 cases. J Turk Ger Gynecol Assoc 2012; 13:118-22. [PMID: 24592020 PMCID: PMC3939133 DOI: 10.5152/jtgga.2012.13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 04/23/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The aim of this study was to examine the diagnoses and treatment methods and demographical and clinical characteristics of pregnant women who were exposed to trauma and in additon, review of the literature was carried out in this regard. MATERIAL AND METHODS One hundred thirty-nine pregnant women who presented at the Yüzüncü Yıl University between January 2006 and September 2009 with local or general body trauma complaints were analysed retrospectively. RESULTS The average age of the cases was 26.72±6.29 years and the age group ranging from 21-34 composed the majority. When they were studied according to their etiologies, falls during daily activities formed 43.9%. When they were analyzed in terms of their gestational weeks, 64.46% were in the 3(rd) trimester. Pregnant cases with trauma resulted in maternal (3 cases) and fetal (9 cases) loss. It was found that 19 cases who had imaging techniques involving radiation and whose gestation was continuing had a problem-free gestation period and healthy children. CONCLUSION It is mandatory to evaluate both mother and fetus together when trauma exposure is in question, the general well-being of the fetus should be provided and the mother should be informed about the presence of advanced trauma life support.
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Affiliation(s)
- Sevdegül Karadaş
- Department of Emergency Medicine, Faculty of Medicine, Yüzüncü Yıl University, Van, Turkey
| | - Hayriye Gönüllü
- Department of Emergency Medicine, Faculty of Medicine, Yüzüncü Yıl University, Van, Turkey
| | - Mehmet Reşit Öncü
- Clinic of Emergency Service, Van Training and Research Hospital, Van, Turkey
| | - Zehra Kurdoğlu
- Department of Gynecology and Obstetrics, Faculty of Medicine, Yüzüncü Yıl University, Van, Turkey
| | - Yasin Canbaz
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Yüzüncü Yıl University, Van, Turkey
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Singh PK, Shrivastva D, Paddalwar S, Shetty N, Raut V, Patnaik S, Yadav A. Management of maternofetal emergency in shock with fracture of femur. J Surg Tech Case Rep 2011; 3:52-5. [PMID: 22022657 PMCID: PMC3192515 DOI: 10.4103/2006-8808.78477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Trauma is the leading nonobstetric cause of maternal death. The worst complication can be fetal compromise that threatens premature labor or even fetal death. We are reporting a case of a 30-year-old primi, short stature woman who had fracture femur with hypovolaemic shock. Managing such trauma complicated by shock in a pregnant patient needs multidisciplinary approach. Clinician team evaluating and coordinating the care of pregnant trauma patient should understand the pathophysiological changes in pregnancy with trauma to manage hypovolaemic shock, related complications, treatment of fracture, and radiation exposure to the fetus. The use of imaging studies, invasive hemodynamics and surgery, if necessary, should be individualized. A clear understanding of fetal viability, physiological changes of pregnancy, and pathophysiology of shock, is mandatory for optimal, maternal functional, and obstetrical outcome.
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