Blunt trauma in the pregnant woman
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Blunt Trauma in the Pregnant Woman. Bill Schroeder DO Stanford Emergency Medicine. Introduction. Trauma occurs in 6-7% of pregnancies in US Leading nonobstetric cause of maternal death

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Blunt Trauma in the Pregnant Woman

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Blunt Trauma in the Pregnant Woman

Bill Schroeder DO

Stanford Emergency Medicine


Introduction

  • Trauma occurs in 6-7% of pregnancies in US

  • Leading nonobstetric cause of maternal death

  • Female drivers are more likely to be in a MVA than male drivers: 84 vs 73 drivers per 10 million miles driven

ACOG educational bulletin. Obstetric aspects of trauma management. Number 251, September 1998 (replaced Number 151,

January 1991, and Number 161, November 1991). Int J Gynecol Obstet 1999;64:87-94


Physiologic Changes in Pregnancy

Grossman NB. Blunt trauma in pregnancy. Am Fam Physician. 2004 Oct 1;70(7):1303-10.


  • Pregnant woman can lose 30% (2L) of blood volume before vital signs change

  • At 30 wks GA the uterus is large enough to compress the great vessels causing

    • up to a 30mm Hg drop in systolic BP

    • 30% drop in stroke volume

  • A series of 441 pregnant trauma victims with no detectable fetal heart tones showed no fetal survivors.

  • Grossman NB. Blunt trauma in pregnancy. Am Fam Physician. 2004 Oct 1;70(7):1303-10.

  • Morris JA Jr, et al. Infant Survival after Cesarean Section for Trauma. Ann Surg 1996;223:481-91.


Seat Belts

  • Nearly 20% of pregnant woman surveyed never or rarely used seat belts

  • 22% used them incorrectly

  • Proper placement of the lap belt is:

    • As low as possible on the pregnancy bulge across the ASIS and pubic symphysis

    • Placement on the uterus causes a 3-4x increase in force transmitted to the uterus

    • Shoulder harness should be positioned between the breasts

Pearlman MD, Phillips ME. Safety belt use during pregnancy. Obstet Gynecol 1996;88:1026-9


ACOG recommendations

  • “There is substantial evidence that seat belt use during pregnancy protects both the mother and the fetus”

  • “Airbag deployment does not appear to be associated with increase risk for either maternal or fetal injury”

    • Though based on limited data

ACOG educational bulletin. Obstetric aspects of trauma management. Number 251, September 1998 (replaced Number 151,

January 1991, and Number 161, November 1991). Int J Gynecol Obstet 1999;64:87-94


Large Population Study

  • Kady EL, et al. Trauma during Pregnancy: An ananlysis of maternal and fetal outcomes in a large population. Am J OB and GYN 2004;190:1661-8

  • Objective: to determine occurrence rates, outcomes, risk factors and timing of obstetric delivery for trauma during pregnancy

  • Design: retrospective cohort study (1991-1999)

  • Methods: Vital Statistics-Patient Discharge Database (VS/PDD)

    • Compiled from hospitals reporting to the California Office of Statewide Health Planning and Development


Results

  • Splint into two groups

    • Group 1: deliveries at the time of trauma hospitalization

    • Group 2: trauma sometime within the 9 months preceding the delivery

    • Control: all deliveries not involved in trauma

  • Fetal demise prior to 20 weeks gestation not included in this study


Results

  • 4,833,286 deliveries

  • 10,316 (0.2%) met study criteria

  • 2,494 at the time of the trauma, group I (0.52/1,000 deliveries)

  • 7,822 during the 9 months prior to trauma, group II (0.78/1,000 deliveries)


Results

  • Falls were the most common mechanism

  • MVA 2nd most common

  • MVA most common mechanism that lead to admission

  • Assault third most common mechanism and cause of admission


Results

  • Gestational age was the strongest predictor of fetal, neonatal and infant death

  • What and how severe the trauma was not as strong a predictor as gestational age

  • Highest risk at <28 weeks gestation


Results

  • Group 2 women had increased morbities compared to controls including:

    • Abruption

    • Premature delivery

    • Low birth weight

  • Trauma may cause subclinical, chronic plancenta abruptions

    • causing insufficient uterine blood supply

  • Woman involved in a trauma during pregnancy need close monitoring during labor


Study Limitations

  • Retrospective, population-based study

  • Only hospitalized patients

    • Cannot extend to minor traumas not requiring hospitalization

  • Did not include pregnancy loss prior to 20 weeks gestation


Fetal Demise

  • Rate of fetal demise after blunt trauma 3.4-38%

  • Lead causes

    • Placental abruption

    • Maternal shock

    • Maternal death

  • 1,300-3,900 pregnancies are lost due to trauma each year

  • Abruption occurs in 40-50% of pregnant woman in severe traumas compared to 1-5% in minor trauma


Why does Fetal Demise Occur?

  • Grossman NB. Blunt trauma in pregnancy. Am Fam Physician. 2004 Oct 1;70(7):1303-10.


Placental Abruption

  • Uterus consists of many elastic fibers

  • The placenta has very few elastic fibers

  • This causes an inelastic connection


Uterine Rupture

  • 0.6% of all injuries during pregnancy

  • Various degrees ranging from seosal hemorrhage to complete avulsion

  • 75% of cases involve the fundus

  • Fetal mortality approaches 100%

  • Maternal mortality 10%

    • Usually due to other injuries

Weintraub AY, Leron E, Mazor M. The Pathophysiology of Trauma in Pregnancy: A Review. J Mat-Fet and

Neo Med 2006;19(10):601-5.


Uterine Rupture


Uterine Rupture


Preterm Labor

  • Incidence following trauma is unknow

  • Estimated to be under 5%

  • Theory: caused by destabilization of lysosmal enzymes that initiate prostaglandin production

  • Consider admistering slow-released progesterone for all woman with contracts after trauma


Proposed Algorithm for Management of the Pregnant Woman after Trauma

  • Grossman NB. Blunt trauma in pregnancy. Am Fam Physician. 2004 Oct 1;70(7):1303-10.


Radiation risk to fetus

Toppenberg KS, et al. Safety of Radiographic Imaging During Pregnancy. Am Fam Physician. 1999 Apr; 59(7):1813-18


Radiation and Pregnancy

  • Risk of spontaneous abortion, major malformations, mental retardation and childhood malignancy 286 per 1,000 deliveries.

  • Exposure of 0.5 rads adds only 0.17 cases per 1,000 deliveries ( 1 in 6,000)

  • American College of Obstetricians and Gynecologist have stated that exposure to x-rays during a pregnancy is not an indication for therapeutic abortion

  • Fetus is at greatest risk at 10-17 weeks of gestation as this is key in neurodevelopment.

  • Malignancy exposure to 1-2 rad increases Leukemia from 3.6/1000 to 5/1000

  • It takes 50-100 rads to double the baseline mutation rate

Toppenberg KS, et al. Safety of Radiographic Imaging During Pregnancy. Am Fam Physician. 1999 Apr; 59(7):1813-18


Number of studies to exceed dangerous level of radiation

Toppenberg KS, et al. Safety ofRadiographic Imaging During Pregnancy. Am Fam Physician. 1999 Apr; 59(7):1813-18


References

  • Grossman NB. Blunt trauma in pregnancy. Am Fam Physician. 2004 Oct 1;70(7):1303-10.

  • Kady EL, et al. Trauma during Pregnancy: An ananlysis of maternal and fetal outcomes in a large population. Am J OB and GYN 2004;190:1661-8.

  • Morris JA Jr, et al. Infant Survival after Cesarean Section for Trauma. Ann Surg 1996;223:481-91.

  • Pearlman MD, Phillips ME. Safety belt use during pregnancy. Obstet Gynecol 1996;88:1026-9.

  • Shah KH, Simons RK, Holbrook T, Fortlage D, Winchell RJ, Hoyt DB. Trauma in pregnancy: maternal and fetal outcomes. J Trauma. 1998 Jul;45(1):83-6.

  • Toppenberg KS, et al. Safety of Radiographic Imaging During Pregnancy. Am Fam Physician. 1999 Apr; 59(7):1813-18.

  • Weintraub AY, Leron E, Mazor M. The Pathophysiology of Trauma in Pregnancy: A Review. J Mat-Fet and Neo Med 2006;19(10):601-5.

  • ACOG educational bulletin. Obstetric aspects of trauma management. Number 251, September 1998 (replaced Number 151, January 1991, and Number 161, November 1991). Int J Gynecol Obstet 1999;64:87-94


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