Trauma and Pregnancy

Douglas J.E. Schuerer M.D.

Associate Professor of Surgery
Director of Trauma BJH
October 4, 2014.
Is Mom Injured?
Patient VH
25 yo F, 8 months pregnant, front-seat
restrained passenger in head-on MVC with
heavy damage. Transported via ARCH to ED.
+LOC, c/o neck, back and abdominal pain.





LLD position, 2 L crystalloid complete at 21:32
Fetal heart rates (twins) in 140s.
History and Exam
History
TL spinal fusion for scoliosis, C-section

Exam
Alert and oriented x 3
+C-spine TTP w/ collar in place
Right clavicle TTP
Diffuse abdominal TTP with intermittent
firmness, no seat belt sign.
No vaginal bleeding or fluid leakage.
FAST
Performed in left lateral decubitus and
supine positions, no free fluid seen
except ?trace fluid in the pelvis. +fetal
heart motion in both fetuses.

Performed by resident physician and
ED attending.
Labs and Imaging
Labs
H/H 10.6/32.4. INR 1.08. Cr 0.62

Imaging
CXR clear
Displaced R clavicle fracture
C-spine XR limited but negative
Assessment
Pt initially hypotensive but responded to IVF.
Abdominal pain increased and evolved from
intermittent (and corresponding to
contractions) to constant during evaluation in
ED.
Given increasing abdominal pain and firm
uterus, concern for evolving placental
abruption.
Pt admitted to labor and delivery for fetal
monitoring and evaluation, with plan for full
trauma evaluation once stabilized from OB
standpoint.
Hospital Course
Fetal heart tracings: Initially reassuring, then
with frequent decelerations and change in
variability from moderate to minimal.
Given change in tracings and increasing
abdominal pain with more frequent contractions,
taken to OR for suspected placental abruption.
Trauma and Pregnancy
ABCs of Trauma
Primary and Secondary Survey
Special Topics
Fetal Monitoring
Minor Trauma
Radiation / FAST
Abruption
Surgery/ Splenic Artery Aneurysm/ Other
How to make improvements?
Trauma in Pregnancy
Trauma complicates 1 in 12 pregnancies
MVC 55%
Falls 22%
Assaults 22%
Burns 1%
Patient stratification
Women unaware they are pregnant
Women < 26wks gestation
Women > 26wks gestation
Maternal peri-mortem state
Anatomic Changes
Uterine size
12wks uterus becomes intra-abdominal organ
20wks vertex of uterus palpable at umbilicus
36wks uterus reaches the costal margin
In late pregnancy, majority of GI tract may be found
above inferior costal margins
Diaphragm elevated 4cm
Mediastinum may appear enlarged on radiographs
Descent in late pregnancy make fetus susceptible to
head injury with maternal pelvic trauma


How are pregnant patients leveled?



Pregnancy as Criteria?
Single institution study of Level II trauma patients
57 had only pregnancy as criteria for Level II
28 also had physiologic criteria
The pregnancy only patients had a significantly
lower incidence of c-section 2 vs. 5.
Authors conclude that pregnancy itself may not be
a necessary criteria.
Other would argue that the resources needed for
these patients may still be greater.
Aufforth et al. Am Jour Surg 2010
Primary Survey
ABCs
A- Airway with cervical spine control
B- Breathing
C- Circulation
D- Disability or neuro status
E- Exposure (undress)
Airway
Can patient talk, are they hoarse or
breathless or not awake?
Are they agitated (could be hypoxia)
Is there blood in the airway?
Intubation
Breathing and Ventilation
Deliver oxygen, facemask or nasal cannulae
if not intubated.
Follow pulse-ox.
Check ABG if unsure (vasoconstriction or
CO poisoning e.g.)
Inspection, palpation, auscultation.
Make sure chest is rising and falling.

Breathing and Ventilation
Decreased breath sounds?
Pneumothorax (tension), hemothorax.
Paradoxical chest movement?
Flail chest
Sucking sound?
Open pneumothorax


Circulation with Hemorrhage
Control
2 large bore IVs
Short and wide is better (no triple lumen
CVPs)
Cover wounds and hold pressure
Assess pulses
Check blood pressure
Roll patient to the left
Is the patient in shock?
Circulation
2 liters crystalloid
Then use blood.

Tailor based on hemodynamic response.

Disability: Neuro Status
Determine level of consciousness and
pupillary size and reaction.
A Alert
V Responds to verbal stimuli
P Responds to painful stimuli
U Unresponsive
Neuro Status
Glasgow Coma Scale
GCS 15 points
Eye opening 1- 4 points
Verbal Response 1- 5 points
Motor Response 1- 6 points
GCS < 8 should be intubated.
Other outcomes/ treatments based on GCS.
Exposure
Remove clothes especially wet/cold items.
Examine for all injuries.
Keep patient warm.

Dont be distracted
Secondary Survey
A Allergies
M Medications
P Past illness and operations
L Last meal
E Events/ Environment related to the injury

Secondary Survey
Head
Neck
Chest
Abdomen
Musculoskeletal
Neurologic
Special Considerations
Primary focus remains maternal assessment and
resuscitation using ATLS protocols
Early gastric decompression
Supplemental oxygen for all pregnant patients
If thoracostomy tube drainage required, place 1-2
interspaces higher than usual
Avoid supine hypertension left lateral decubitus
positioning, manual uterine displacement to left, or
15 backboard tilt
Avoid vasopressors unless absolutely indicated
Tetanus vaccination is safe in pregnancy


Special Considerations
HCT
BP
HR
Blood Volume
Functional Residual Capacity
Primary Survey of Fetus in Secondary
Survey
ED C-Section
Ideally by most experienced physician (OB, Trauma, EP)
Midline Vertical epigastrium to symphysis pubis

Quick Facts
1) No infant survives if there is no fetal heart tone before emergency
cesarean section commences.
2) If fetal heart tones are present and the gestational age is 26 weeks or
more, then infant survival is 75%
3) Sixty percent of fetal deaths result from underuse of
cardiotocographic monitoring and delayed recognition of fetal
distress
4) 70% of children who survive perimortem cesarean sections are
delivered in less than 5 minutes of emergency department arrival




Fetal Monitoring
Performed once maternal life-threatening injuries
identified and treated
Fetal heart tones discernable with Doppler by 10
th

wk gestation
Assess uterine size, contractions, vaginal
lacerations or bleeding, amniotic fluid leak (pH =
7, ferning)
Continuous monitoring in all pregnancies of > 20
wks gestation. Premature labor in 25% of trauma
cases after 22-24 wks. Duration of monitoring
remains controversial.
Duration of Fetal Monitoring
Initiate for a minimum of 4hrs and during any
operation
At end of 4hr period, may discontinue electronic
monitoring if contractions less frequent than
q15min and no signs of placental abruption
Perlman et al, N Engl J Med, 323, 1990.
Continue monitoring 24hrs for injuries related to
motorcycle accidents, ejected MVC, ped vs MVC,
and patients with maternal tachycardia or
abnormal fetal heart rate Curet et al, J Trauma, 49, 2000.

Is all that really needed?
Minor Trauma
Cahill et al.
Evaluated 317 patients with minor trauma
(ISS=0)
9 had positive KB test
1 of 256 with delivery information had
abruption
Abruption and pregnancy mortality could not
be predicted
Cahill et al. Am Jour Ob Gyn 2008
Minor Trauma
No patients had nonreassuring fetal
parameters
14% had > 5 contractions per hour
Prediction index did not help predict who
would abrupt.
Suggest no need for intensive workup for
minor trauma.
Radiation

A Typical Case
22 y/o WF trauma packaged on NRB just moved
over to bed
Flight reports VSS
13wks preg restrained front seat passenger
head on by drunk driver, driver of pts car
deceased (her fianc)
no LOC, +prolonged extrication but pt compartment
relatively preserved
traction splint to left leg for closed thigh deformity,
+jaw pain/HA/thigh/abd pain
Primary Survey
C-collar in place, reports name clearly, left jaw pain when
asked to open mouth, +dried blood in OP (teeth/mucosa intact)
with active slow ooze from bilat nares, +raccoon eyes, no
gross midface instability but painful with frontal incisor
manipulation--- 100% on NRB
CTA bilat, no flail, trach midline
+radial, no muffled heart sounds, no active extremity
hemorrhage, 151/96 99, 2-18ga bilat AC (rcd 500ml NS)
GCS 15 PERRL, moves all 4 (moves toes left foot)
97.4, left leg in traction with closed thigh deformity/TTP, able
to move toes and intact palpable left DP but faint vs. right
warm blankets placed
Secondary Survey
VSS, HR <100
HEENT- raccoon eyes and left maxilla abrasion, left lat scleral subconj
hemorrhage, EOMI w/o entrapment, VA 20/20 OU, neg CD with stain,
TMs clear, epistaxis stopped with neosynephrine, no septal hematoma,
+left lat jaw TTP
Neck- c-collar
Lungs- unchanged
CV- unchanged
Abdomen- +seat belt abrasion to RLQ/hip with +mid TTP w/o rebound
Back- no TTP
Pelvis- no gross blood by ext inspection, no pelvic instability, no perineal
bruising
Rectal- nl tone, no gross blood
Extremities- abrasion to left elbow, no bony TTP, left thigh per primary
(no knee/tib-fib/ankle/foot TTP)
East Guidelines
Level I
There are no level I standards.

Recommendations
Level II
a. All pregnant women >20-week gestation who
suffer trauma should have cardiotocographic
monitoring for a minimum of 6 hours. Monitoring
should be continued and further evaluation should
be carried out if uterine contractions, a
nonreassuring fetal heart rate pattern, vaginal
bleeding, significant uterine tenderness or
irritability, serious maternal injury, or rupture of
the amniotic membranes is present.

Recommendations

Level II
b. Kleihauer-Betke analysis should be
performed in all pregnant patients >12
week-gestation.

Recommendations
c. Concern about possible effects of high-
dose ionizing radiation exposure should not
prevent medically indicated maternal
diagnostic X-ray procedures from being
performed. During pregnancy, other
imaging procedures not associated with
ionizing radiation should be considered
instead of X-rays when possible.
Recommendations
d. Exposure to <5 rad has not been
associated with an increase in fetal
anomalies or pregnancy loss and is herein
deemed to be safe at any point during the
entirety of gestation.
Recommendations
e. Ultrasonography and magnetic resonance
imaging are not associated with known
adverse fetal effects. However, until more
information is available, magnetic
resonance imaging is not recommended for
use in the first trimester.
Recommendations
f. Consultation with a radiologist should be
considered for purposes of calculating
estimated fetal dose when multiple
diagnostic X-rays are performed.
g. Perimortem cesarean section should be
considered in any moribund pregnant
woman of 24-week gestation.
Recommendations
h. Delivery in perimortem cesarean sections
must occur within 20 minutes of maternal
death but should ideally start within 4
minutes of the maternal arrest. Fetal
neurologic outcome is related to delivery
time after maternal death.

Recommendations
i. Consider keeping the pregnant patient
tilted left side down 15 degrees to keep the
pregnant uterus off the vena cava and
prevent supine hypotension syndrome.
j. Obstetric consult should be considered in
all cases of injury in pregnant patients.

CT or not to CT?
Decisions
Standard care IV/O2/Monitor/Analgesics
Toco if viable (>24wks)
CT Head/neck
CXR & pelvis
FAST & Pelvic US

Panscan

OR
+
CT for Pregnant Trauma Patients
ATLS?
1) Support the mom and you support the
baby
2) Less likely to have uterine/fetal trauma if 1
st

trimester d/t still in pelvis
3) 2
nd
/3
rd
Trimester increase risk to fetus with
maternal abdominal organ protection
Radiation Dosing
Dose (rad or Gy)
Strength Quality Factor of ionizing
radiation (i.e. photons/beta QF=1 vs. alpha
QF= 20)
Final Product/Tissue Damage= One Sv
=100 rem
1 mGy = 100 mrad
100 mGy= 10 Rads
November 2007. RadioGraphics, 27, 1705-1722.
Estimated mean fetal
absorbed dose
Whats acceptable for my children?
(Brigham Website)
Latent leukemia and cancers manifest years after the
exposure
The fetus mimics child radiocarcinogenic effects which run
2 to 3 times higher than the adult risk
A study of prenatal and childhood cancer studies showed a
relative risk (RR) of 1.4 (40% increase above the normal
incidence) following a fetal dose of ~ 10 mGy (1 Rad).
The normal incidence of childhood cancer is ~ 0.2-0.3 %,
so a 10 mGy (1 Rad) fetal dose would increase this
incidence to ~0.35%.
A fetal dose of 10-20 mGy (1-2 Rads) raises the incidence
of childhood leukemia to 5/10,000 from a baseline rate of
3.6/10,000.
Early Radiation Effects
Gestational Age <100mGy (10 Rads) >100mGy (10 Rads)
<2 wks I III

3-8 wks I III
8-15 I
III
>15 wks I II
I = negligible risk
II= potential association with adverse birth outcome,
especially with other
teratogenic risk factors
III= highest risk
At 0-2 weeks post-conception, doses 100 mGy have an "all or none effect"
potentially causing embryologic demise, surviving fetus will progress to term
without associated effects
At 3-8 weeks post-conception, doses 100 mGy have potential for organ malformation
100 mGy threshold dose for mental effects

United Nations Scientific Committee on the Effects of Atomic Radiation. Sources and Effects of Ionizing
Radiation. New York, NY: United Nations; 1977
Future?
Next generation scanners
May decrease the radiation exposure
128 slice double helix scanners can scan entire
patient in 2 seconds
What about FAST?
Focused Abdominal Sonography for
Trauma
Four views (Each flank, cardiac, pelvis) to
evaluate for fluid in the abdomen
Does not evaluate what is bleeding, just
evaluates for fluid
FAST in Pregnancy
(Rosens 6
th
Ed)
Sensitivity Specificity +LR -LR
Intra-abdominal
injury
88 99 88 0.12
Free fluid 83 98 42 0.17
False neg usually d/t bowel perforation or
liver/spleen lacs w/o FF

FAST
Use of FAST in pregnancy

2001
FAST
Use of FAST in pregnancy

FAST
Use of FAST in pregnancy

FAST
Use of FAST in pregnancy

Retrospective study at a Level 1 trauma center, evaluating all
female pts 10-50 years of age, who sustained blunt abdominal
trauma and underwent FAST. 1995-2002, n= 2319.
Non-pregnant pts
N=1804
90.6% no FF
3.7% (n=67) had
injuries

Pregnant pts
N=299
91% no FF
3% (n=9) had injuries
Bowel injury (1)
Abruption (2)
Liver lac w/
abruption (1)
Splenic lac (1)
Abruption with
emergent C-sxn (4)
FAST
Likely of benefit
Must be used as a serial test
Cannot make definitive decisions on the
status of the abdomen based on 1
evaluation.
Relatively easy to perform
Placental Abruption
Second most common cause of fetal death in
trauma
Clinical Diagnosis
Occurs in ~5% (or less) of minor & ~50% major
injuries
Fetal mortality can be > 60%
Symptoms are similar to any trauma with
abdominal pain.
Ultrasound can miss up to 50%
CT for Abruption
Wei et al Emerg Radiol, 2009
44 trauma and 22 non-trauma CTs with
contrast evaluated
All 7 placental abruptions were identified
by senior reviewers, but not by initial reads
Concluded that with training CT with
contrast can be a good evaluation tool.

CT for Abruption
Manriquez et al. Am J OB Gyn, 2010
Reviewed 61 pregnant patients with
abdominal trauma and CT with contrast
Images reviewed by trained radiologist
Abruption defined as delivery within 36
hours with symptoms of abruption
Confirmed by placental abruption
Identified 6 of 7 abruptions.


CT for Abruption
Manriquez et al. Am J OB Gyn, 2010
Claim sens of 86% and spec of 98%, but
there is no true evaluation of false
negatives.

My thought Improving CTs obtained for
trauma reasons maybe more helpful than
US for abruption.

Surgery
Keep right side bumped up or rotate table to
the left
If non-abdominal operation, can perform
continuous monitoring in the OR
Always plan on possibility of urgent
section.
If known or suspected trauma injuries use
vertical incision.
Potential Surgical Catastrophes
Splenic Artery Aneurysms
Usually presents as sudden unexpected shock or
death
of all cases in pregnant women, most commonly
3
rd
trimester or labor
If found prior to rupture, treat with splenectomy
and arterial resection, aneurysm exclusion, or
angiographic embolization

I have removed two spleens in the OB suite for this
indication due to bleeding at the time of stat
section.
Uterine Rupture
Rare
Most common if previous c-section
Usually result of direct abdominal trauma in
2
nd
or 3
rd
trimester
Maternal mortality ~10%
Fetal mortality ~100%
Back to our Case
Hemoperitoneum after Pfannenstiel incision
Packs placed in RUQ by OB
Midline incision performed by Unit III
Large amount of blood and clot in LUQ
Grade 2 splenic laceration (2-3 cm), active bleeding from
splenic hilum, splenectomy performed with oversewing
of short gastric vessel
No liver deformity palpated
LUQ packed, temporary abdominal closure
EBL 3.5 L, received 4 u pRBC, 1uFFP, 1L coll, 2L cryst
Fetal demise x 1, one neonate critical
Postop Course
CT Imaging:
C-spine negative
Grade 2 liver laceration
Nondisplaced right rib fractures
Small right PTX and pulmonary contusion
Taken back POD 1 for abdominal
exploration and closure. Minor oozing
from tail of pancreas controlled with suture
ligation and cautery. Drain left in splenic
bed.
Postop Course
C-spine cleared
Non-operative management for clavicle
fracture.
Postoperative ileus
Tolerating diet by POD 8.
Drain output serous, fluid amylase 88
Discharged to home POD 9.
Seen in follow-up 2 weeks postop, doing
well, drain removed.
Discussion
Patients with significant abdominal pain
CANNOT have their c-spine cleared.
Involve trauma anesthesia attending if
needed.
Consider doing any such case in the OR
instead of the OB floor.
Perhaps surgery resident can do follow up
FASTs.
Biggest issue is with communication.
Summary
Always remember that the fetus cannot live
if the mom has expired.
FAST is a useful adjunct in the initial
resuscitation, but is not the end word on
abdominal injuries.
Team communication critical for all trauma
patients, especially when there are two (or
more) patients.
Thank You