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TRAUMATIZED PREGNANT
PATIENT
U. Kaswiyan
Department of Anesthesiology & Reanimation
Medical Faculty University of Padjadjaran
Hasan Sadikin General Hospital
BANDUNG
Introduction
The Committee on Trauma of The American College of
Surgeons:
trauma during pregnancy 6 7 % and leading non
obstetric cause of maternal death
fetal mortality 40 70 %
2nd trimester :
Uterus contains large amount of amniotic fluid
3rd trimester :
Uterus is thin walled,large fetal head engaging pelvis
At 36 weeks uterus reaches costal margin
Maternal Physiokogy and Anatomy vs Trauma
May complicate :
The evaluation of intravascular Volume
The assessment of Blood Loss
The diagnosis of hypovolemic shock
Maternal Physiokogy and Anatomy vs Trauma
II. Respiratory:
Diaphragma rises + 4 cm, chest diameter 2 cm
FRC , MV , TV , oxygen consumption 20 %
Supine hypotensive syndrome
- predisposerapid falls in Pa O2
- buffering capacity in the presence of acidosis
- chest tubes (thoracostomy) being misplaced
Neonatologist
(or emergency Physician if unavailable)
1. Primary and secondary surveys
2. Resucitative care
3. NICU-nursery requirements
4. Subspecialty consults
Classification of Pregnancy and Trauma
(Henderson & Mallon)
Oxygen
Position :
- Left lateral recumbent position
- Left lateral supine position with back
board
Primary Survey
1. BLS, ATLS, ACLS
Begin as you would with any other trauma patient
2. Oxygenation, Airway management
Rapid sequence induction
3. Utero-placental blood flow
position
4. Neurological deficit
GCS,ICP control, Cardiotocographic monitoring to
assess FHR and uterine activity
5. Fluid rescucitation with RL
diuresis monitoring
6. Vasopressor (?)
ephedrine
Secondary Survey
1. Anamnesis & Physical examination:
Assess and reassess uterine size, tenderness, tone
Vaginal/Pelvic exam
Blood
pH (vaginal-5 amniotic fluid-7) nitrazine paper
Sytation
Dilation of cervix
4. Radiographic studies
Obtain with the patient needs, dont hold back
Avoid repeated and unnecessary studies
0,005 to 0,1 rad safe to fetus
Single pelvis X-Ray is < 0,01 rad
Abd CT is 0,05 0,1 rad
Secondary Survey
5. Cardiotocographic Monitoring :
FHR
Rate (120 160)
Beat-to-beat variability
Baseline variability
Decelerations, esp.late
Uterine Activity
If < 1 contraction/10 min for 4 hours, risk of
complicvation drops to baseline
If greater then 20 % of placentalabruption
Premortem Cesarean Section
200 succesful cases reported in the litertaure
<26 weeks gestation survival chance is 0 %
Maternal CPR > 20 minutes fetal super unlikely
Maternal CPR <5menit, fetal survival excellent
4 minute Rule :
Maternal CPR for 4 minutes,
Infant should be delivered by the 5th
minute
Maternal Arrest to Delivery Expected Fetal Survive
5 10 minutes Good
10 15 minutes Fair
15 20minutes Poor
EARLY !!!