Ns.Fitrio Deviantony S.

Kep
Emergency department
STIKes Widyagama Husada
 Wanita 21 tahun, hamil 7 bulan dibawa ke IGD karena penurunan
kesadaran. 1 jam lalu terlibat kecelakaan lalu lintas.Nampak jelas
dari ke 2 telinganya keluar darah. Tensi saat ini 170/100 mm hg,
nadi 65/1, laju nafas 34/1 dalam.Perdarahan pervaginam +. Apa
yang anda lakukan untuk korban ini ?
Dual goals in managing pregnant trauma

Physiological changes of pregnancy

Response to hypovolemia

Types of injuries most commonly associated

Initial assessment and management

Trauma prevention in pregnancy

 32,810 pregnant women sustain injuries in motor vehicle crashes /
year in the U.S., a rate of 9 per 1000 live births.1
Motor vehicle collisions, 70% of acute injuries. This is followed by
falls and direct assault .
 Hypervolemia begins at week 10 of gestation and peaks at about a
45% increase from baseline at week 28.
Red cell mass increases to a lesser extent physiologic anemia of
pregnancy.
 Cardiac output is increased by 1.0 to 1.5 L/min at week 10 of
pregnancy and remains elevated until the end of pregnancy.
Heart rate increased by 10 to 20 beats/min in the second trimester,
accompanied by decreases in systolic and diastolic blood pressures
of 10 to 15 mm Hg.
A pregnant patient may lose 30% to 35% of circulating blood volume
before manifesting hypotension or clinical signs of shock.
Vasoconstriction and tachycardia
Reduction of uterine blood flow by 2030%
Fetal heart rate and blood flow decreases
Fetus becomes hypoxemic
 After week 12 of gestation, the uterus becomes an intra-abdominal
organ susceptible to direct injuries.
The gravid uterus also causes passive stretching of the abdominal
wall and peritoneum as it enlarges and may lead to diminished
sensitivity to injury and irritation from intraperitoneal blood.
 At or about weeks 18 to 20 of gestation, the expanding mass of the
gravid uterus may give rise to the "supine hypotension syndrome,"
venous return and cardiac output are diminished by compression
of the maternal inferior vena cava in the supine position Placement
of IV lines in the femoral region and lower extremity should be
avoided
 Diaphragm elevates by as much as 4 cm, and tidal volume increases
by 40% as residual volume 25% and Functional residual capacity .
impair the ability of a pregnant trauma patient to compensate for
respiratory compromise.
 There is delayed gastric emptying during pregnancy.
gastroesophageal reflux and the potential for aspiration .
The liver is typically unaffected by pregnancy, and the most common
cause of abdominal hemorrhage remains splenic injury.
 Tilt or rotate backboard 2030o to patients left
Elevate right hip 46 inches with towel
Manually displace uterus to left
 Attend to maternal airway, breathing, and
circulation as a priority for both mother and
fetus.
Maintain patient in the left lateral decubitus
position.
Blood typing and Rh status in laboratory
studies.
Attempt to establish fetal age.
Looking for any peritoneal signs such as
guarding, rebound, distension, rigidity.
 Determine if Rh0 (D) immunoglobulin
administration is indicated.
Perform imaging as for non pregnant
patients.
Initiate fetal monitoring as soon as
possible and continue for at least 46 h
even if patient is apparently uninjured.
Screen for potential intimate partner
violence.
 Complete blood count
Blood typing, and Rh status
Coagulation profiles with levels of fibrin degradation products and
fibrinogen
 At week 12 pubic symphysis,
At week 20 level of the umbilicus.
The uterus then expands approximately 1 cm beyond the umbilicus
per additional week of gestation.
Assessing fetal age will help determine fetal viability.
 Fluid in the vagina with a pH of 7 is suggestive of amniotic fluid,
whereas fluid with a pH of 5 is consistent with vaginal secretions.
A branchlike pattern, or "ferning," seen upon drying of vaginal fluid
on a microscope slide.
 uterine tenderness
uterine contractions
vaginal bleeding
direct or indirect maternal abdominal trauma.
if the mother is Rh negative and the fetus is Rh positive, as little
as 0.1 microliter of fetal blood can sensitize the mother6 and
endanger this pregnancy and subsequent ones.
 The Apt test is a qualitative determination of the presence of fetal
hemoglobin in maternal blood.
The Kleihauer-Betke test applies acid elution to an aliquot of
maternal blood, and then maternal and fetal red blood cells are
counted under the microscope.
 Should be given to all Rh-negative pregnant women with abdominal
trauma within 72 hours ,7 except ;
(1) prior maternal sensitization
(2) a known Rh-negative fetus
(3) a known Rh-negative father
50 micrograms IM for gestation of 12 weeks and 300 micrograms IM for
gestation of 13 weeks, or 300 micrograms IM for all gestational ages.
50-microgram dose is effective for up to 5 microliters of fetomaternal
hemorrhage.
 Tetanus Prophylaxis.
Diagnostic Imaging Adverse fetal effects due to radiation
exposure are negligible for doses of <5 rad, and this is the
accepted cumulative dose limit during pregnancy. Radiograph
after 20 weeks gestation are safe ( Rosen and Barkin 1998).
Abruption can occur after 48 hours after injury (ENA 2007). No vaginal
bleeding if the abruption is partial (ATLS 2008).
Treated same as for other victims
Defibrillation settings are same
Drug dosages are same
Fluid volume needed increases
4 liters normal saline rapid infusion during transport

If mother unsalvageable:
Continue CPR
Notify hospital of possible cesarean section
10% experience abuse during pregnancy

Proximal and midline injuries

Face and neck most common
Low birth weight
Abused by spouse or boyfriend: 7085% (U.S.)
Proper seat-belt use

Report domestic violence

Counseling for domestic violence

Patient education
Multiple changes associated with pregnancy
Physiological, anatomical, emotional
Thank You
Matur Nuwun