The Pregnant Trauma Patient

Assessment of fetal radiation exposure in pregnant women undergoing computed tomography and rotational angiography examinations for pelvic trauma

This study aimed to assess fetal radiation exposure in pregnant women undergoing computed tomography (CT) and rotational angiography (RA) examinations for the diagnosis of pelvic trauma. In addition, this study aimed to compare the dose distributions between the two examinations. Surface and average fetal doses were estimated during CT and RA examinations using a pregnant phantom model and real-time dosemeters. The pregnant model phantom was constructed using an anthropomorphic phantom, and a custom-made abdominal phantom was used to simulate pregnancy. The total average fetal dose received by pregnant women from both CT scans (plain, arterial and equilibrium phases) and a single RA examination was ~60 mGy. Because unnecessary repetition of radiographic examinations, such as CT or conventional 2D angiography can increase the radiation risk, the irradiation range should be limited, if necessary, to reduce overall radiation exposure.

Neuroanesthesia and pregnancy: Uncharted waters

An incidence of 30-40 deaths per triennium in pregnant patients is reported because of brain pathology. Over the last two decades, the obstetric cause of mortality in the pregnant patient has declined, but the trend is rising for non-obstetric cause of mortality. Pregnancy is associated with a host of anatomical and physiological alterations that complicate the conduct of anesthesia. The brain is one of the vital organs of the body, and physiological changes during pregnancy alter the anesthesia management if associated with brain pathology. Malignant brain tumors and trauma remain a leading cause of indirect maternal mortality. Review of literature revealed paucity of evidence-based neuroanesthesia management for such patients. Navigating these uncharted waters remains a challenging exercise. With the lack of guidelines, the management is based largely on few case reports or case series.

Guidelines for the Management of a Pregnant Trauma Patient

OBJECTIVE

Physical trauma affects 1 in 12 pregnant women and has a major impact on maternal mortality and morbidity and on pregnancy outcome. A multidisciplinary approach is warranted to optimize outcome for both the mother and her fetus. The aim of this document is to provide the obstetric care provider with an evidence-based systematic approach to the pregnant trauma patient.

OUTCOMES

Significant health and economic outcomes considered in comparing alternative practices.

EVIDENCE

Published literature was retrieved through searches of Medline, CINAHL, and The Cochrane Library from October 2007 to September 2013 using appropriate controlled vocabulary (e.g., pregnancy, Cesarean section, hypotension, domestic violence, shock) and key words (e.g., trauma, perimortem Cesarean, Kleihauer-Betke, supine hypotension, electrical shock). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English between January 1968 and September 2013. Searches were updated on a regular basis and incorporated in the guideline to February 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

This guideline is expected to facilitate optimal and uniform care for pregnancies complicated by trauma. Summary Statement Specific traumatic injuries At this time, there is insufficient evidence to support the practice of disabling air bags for pregnant women. (III) Recommendations Primary survey 1. Every female of reproductive age with significant injuries should be considered pregnant until proven otherwise by a definitive pregnancy test or ultrasound scan. (III-C) 2. A nasogastric tube should be inserted in a semiconscious or unconscious injured pregnant woman to prevent aspiration of acidic gastric content. (III-C) 3. Oxygen supplementation should be given to maintain maternal oxygen saturation > 95% to ensure adequate fetal oxygenation. (II-1B) 4. If needed, a thoracostomy tube should be inserted in an injured pregnant woman 1 or 2 intercostal spaces higher than usual. (III-C) 5. Two large bore (14 to 16 gauge) intravenous lines should be placed in a seriously injured pregnant woman. (III-C) 6. Because of their adverse effect on uteroplacental perfusion, vasopressors in pregnant women should be used only for intractable hypotension that is unresponsive to fluid resuscitation. (II-3B) 7. After mid-pregnancy, the gravid uterus should be moved off the inferior vena cava to increase venous return and cardiac output in the acutely injured pregnant woman. This may be achieved by manual displacement of the uterus or left lateral tilt. Care should be taken to secure the spinal cord when using left lateral tilt. (II-1B) 8. To avoid rhesus D (Rh) alloimmunization in Rh-negative mothers, O-negative blood should be transfused when needed until cross-matched blood becomes available. (I-A) 9. The abdominal portion of military anti-shock trousers should not be inflated on a pregnant woman because this may reduce placental perfusion. (II-3B) Transfer to health care facility 10. Transfer or transport to a maternity facility (triage of a labour and delivery unit) is advocated when injuries are neither life- nor limb-threatening and the fetus is viable (≥ 23 weeks), and to the emergency room when the fetus is under 23 weeks' gestational age or considered to be non-viable. When the injury is major, the patient should be transferred or transported to the trauma unit or emergency room, regardless of gestational age. (III-B) 11. When the severity of injury is undetermined or when the gestational age is uncertain, the patient should be evaluated in the trauma unit or emergency room to rule out major injuries. (III-C) Evaluation of a pregnant trauma patient in the emergency room 12. In cases of major trauma, the assessment, stabilization, and care of the pregnant women is the first priority; then, if the fetus is viable (≥ 23 weeks), fetal heart rate auscultation and fetal monitoring can be initiated and an obstetrical consultation obtained as soon as feasible. (II-3B) 13. In pregnant women with a viable fetus (≥ 23 weeks) and suspected uterine contractions, placental abruption, or traumatic uterine rupture, urgent obstetrical consultation is recommended. (II-3B) 14. In cases of vaginal bleeding at or after 23 weeks, speculum or digital vaginal examination should be deferred until placenta previa is excluded by a prior or current ultrasound scan. (III-C) Adjunctive tests for maternal assessment 15. Radiographic studies indicated for maternal evaluation including abdominal computed tomography should not be deferred or delayed due to concerns regarding fetal exposure to radiation. (II-2B) 16. Use of gadolinium-based contrast agents can be considered when maternal benefit outweighs potential fetal risks. (III-C) 17. In addition to the routine blood tests, a pregnant trauma patient should have a coagulation panel including fibrinogen. (III-C) 18. Focused abdominal sonography for trauma should be considered for detection of intraperitoneal bleeding in pregnant trauma patients. (II-3B) 19. Abdominal computed tomography may be considered as an alternative to diagnostic peritoneal lavage or open lavage when intra-abdominal bleeding is suspected. (III-C) Fetal assessment 20. All pregnant trauma patients with a viable pregnancy (≥ 23 weeks) should undergo electronic fetal monitoring for at least 4 hours. (II-3B) 21. Pregnant trauma patients (≥ 23 weeks) with adverse factors including uterine tenderness, significant abdominal pain, vaginal bleeding, sustained contractions (> 1/10 min), rupture of the membranes, atypical or abnormal fetal heart rate pattern, high risk mechanism of injury, or serum fibrinogen < 200 mg/dL should be admitted for observation for 24 hours. (III-B) 22. Anti-D immunoglobulin should be given to all rhesus D-negative pregnant trauma patients. (III-B) 23. In Rh-negative pregnant trauma patients, quantification of maternal-fetal hemorrhage by tests such as Kleihauer-Betke should be done to determine the need for additional doses of anti-D immunoglobulin. (III-B) 24. An urgent obstetrical ultrasound scan should be undertaken when the gestational age is undetermined and need for delivery is anticipated. (III-C) 25. All pregnant trauma patients with a viable pregnancy who are admitted for fetal monitoring for greater than 4 hours should have an obstetrical ultrasound prior to discharge from hospital. (III-C) 26. Fetal well-being should be carefully documented in cases involving violence, especially for legal purposes. (III-C) Obstetrical complications of trauma 27. Management of suspected placental abruption should not be delayed pending confirmation by ultrasonography as ultrasound is not a sensitive tool for its diagnosis. (II-3D) Specific traumatic injuries 28. Tetanus vaccination is safe in pregnancy and should be given when indicated. (II-3B) 29. Every woman who sustains trauma should be questioned specifically about domestic or intimate partner violence. (II-3B) 30. During prenatal visits, the caregiver should emphasize the importance of wearing seatbelts properly at all times. (II-2B) Perimortem Caesarean section 31. A Caesarean section should be performed for viable pregnancies (≥ 23 weeks) no later than 4 minutes (when possible) following maternal cardiac arrest to aid with maternal resuscitation and fetal salvage. (III-B).

Perinatal implications of motor vehicle accident trauma during pregnancy: identifying populations at risk

OBJECTIVE

The purpose of this study was to examine the association between restraint use, race, and perinatal outcome after motor vehicle accidents (MVAs) during pregnancy.

STUDY DESIGN

The Duke Trauma Registry and medical records were searched for information on pregnant women at >14 weeks' gestation who were involved in an MVA and who received care through the Emergency Department and the Obstetric Units. Between January 1994 and December 31, 2010, 126 women were identified. Variables that were collected included type of trauma, gestational age at presentation, and delivery outcomes. A prognostic study was performed that evaluated the associations between maternal demographics, details of the accident that included restraint use, and maternal treatment that was related to the accident in relationship to perinatal outcome.

RESULTS

There was no difference in the mean age or median gravidity or parity by race among pregnant women who were cared for after an MVA. There was no difference in mean age or racial distribution between women who were restrained compared with women who were unrestrained; unrestrained women were more likely to be nulliparous. Unrestrained women were more likely to require nonobstetric surgery that was related to the trauma. The overall rate of placental abruption was 6%. There were 6 intrauterine fetal deaths, 3 each in the unrestrained (25%) and restrained groups (3.5%; P = .018). Airbags deployed in 17 accidents. Among the 7 women with placenta abruption, 4 women (57%) experienced air bag deployment.

CONCLUSION

Lack of restraint use during pregnancy is associated with an increased risk of fetal death.

Management and outcomes of trauma during pregnancy

Approximately 1% to 4% of pregnant women are evaluated in emergency/delivery room because of traumatic injury, yet there are few educational strategies targeted toward prevention/management of maternal trauma. Use of illicit drugs and alcohol, domestic abuse, and depression contribute to maternal trauma; thus a high index of suspicion should be maintained when treating injured young women. Treating the mother appropriately is beneficial for both the mother and the fetus. Fetal viability should be assessed after maternal stabilization. Pregnancy-related morbidity occurs in approximately 25% of cases and may include placental abruption, uterine rupture, preterm delivery, and the need for cesarean delivery.

Successful Treatment of Peripartum Massive Pulmonary Embolism with Extracorporeal Membrane Oxygenation and Catheter-Directed Pulmonary Thrombolytic Therapy

Chronic thromboembolic pulmonary hypertension during pregnancy is uncommon but is associated with maternal mortality in excess of 35%. We report a case of decompensated thromboembolic pulmonary hypertension requiring emergency caesarean section and postpartum treatment with extracorporeal membrane oxygenation and thrombolytic therapy with urokinase. The use of extracorporeal membrane oxygenation, catheter-directed pulmonary thrombolytic therapy and other pulmonary vasodilators for management of this life-threatening disease is discussed.

Initial trauma management in advanced pregnancy

The principles enshrined in existing trauma resuscitation protocols for treating nonpregnant trauma victims should also be applied to the pregnant patient. In addition, left tilt of the pregnant patient (or the back board) and supplement oxygen are mandatory. The patient should be treated by a multidisciplinary team, preferably in a trauma center. Early intubation is recommended, but should be performed, where possible, by an experienced physician. The physician should be aware of the different physiologic and laboratory values in normal pregnancy. Fetal monitoring is important to assess both fetal and maternal welfare. Imaging examinations, where indicated, should not be delayed. Even minor maternal trauma, especially if caused by interpersonal violence, might cause fetal loss.

Laparoscopic procedures during pregnancy and the risks of anesthesia: what does an obstetrician need to know?

BACKGROUND

Nonobstetric surgery may be necessary during any stage of gestation.

METHODS

The purpose of this article is to review the current recommendations (using Medline search for the relevant publications) for the perioperative anesthetic management of pregnant women undergoing laparoscopy for indications unrelated to pregnancy.

RESULTS

The current estimates of the incidence of nonobstetric surgery in pregnancy range from 1% to 2%. Laparoscopy is the most common surgical procedure performed in the first trimester of pregnancy, whereas appendectomy is the most common procedure performed during the remainder of pregnancy.

CONCLUSIONS

In the past pregnancy was considered as an absolute contraindication to laparoscopy. However, recent years have brought an extensive experience with this technique during gestation.

The safety of anaesthetics in pregnant women

Each year, a significant number of pregnant women undergo surgery and anaesthesia for indications unrelated to pregnancy. Estimates of the incidence of non-obstetric surgery in pregnancy, which may be required at any gestational age, and for a number of indications, range from 1.0 to 2%. The diagnosis of any medical condition requiring surgery in pregnancy often raises questions about the safety of anaesthesia in these patients. This controversy is primarily attributed to the lay press speculations that surgery and anaesthesia in pregnancy may pose hazards to the mother and fetus. Despite these concerns, the safety of non-obstetric surgery and anaesthesia in pregnancy is well-documented for nearly every operative procedure. The timing and indications for surgery seem critical to the maternal and fetal outcome. Laparoscopy is the most common surgical procedure performed in the first trimester of pregnancy, whereas appendectomy is the most common procedure performed during the remainder of pregnancy.