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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

Blunt Trauma in the Pregnant Woman

Bill Schroeder DO

Stanford Emergency Medicine


Introduction
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
Physiologic Changes in Pregnancy

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


Blunt trauma in the pregnant woman

  • 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
Seat Belts vital signs change

  • 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
ACOG recommendations vital signs change

  • “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
Large Population Study vital signs change

  • 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
Results vital signs change

  • 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


Results1
Results vital signs change

  • 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)


Results2
Results vital signs change

  • 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


Results3
Results vital signs change

  • 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


Results4
Results vital signs change

  • 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
Study Limitations vital signs change

  • 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
Fetal Demise vital signs change

  • 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
Why does Fetal Demise Occur? vital signs change

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


Placental abruption
Placental Abruption vital signs change

  • Uterus consists of many elastic fibers

  • The placenta has very few elastic fibers

  • This causes an inelastic connection


Uterine rupture
Uterine Rupture vital signs change

  • 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 rupture1
Uterine Rupture vital signs change


Uterine rupture2
Uterine Rupture vital signs change


Preterm labor
Preterm Labor vital signs change

  • 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
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
Radiation risk to fetus after Trauma

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


Radiation and pregnancy
Radiation and Pregnancy after Trauma

  • 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
Number of studies to exceed dangerous level of radiation after Trauma

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


References
References after Trauma

  • 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