trauma in pregnancy 19-1

Chapter
XIX
TRAUMA IN
PREGNANCY
trauma in pregnancy 19-2
Overview
Anatomy and physiology
Pathophysiology
Evaluation and management
trauma in pregnancy 19-3
The Pregnant Trauma
Patient
Two patients with separate
needs
Mother
Fetus
Twin goals of management
Support mother
Identify needs of the fetus
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Physiologic Changes
of Pregnancy
Changes related to gestational age
Major shift of circulatory system
to provide blood flow to uterus
Mother at more risk
Increased risk of injury
Less able to compensate for shock
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Cardiopulmonary
Changes
Cardiac output increases by 20-30%.
Pulse increases by 10-15 beats/minute.
BP decreases by 10-15mmHg.
Increased resting respiratory rate.
Elevation of diaphragm by uterus
decreases thoracic volume.

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Systemic Blood
Volume
Increased plasma volume.
Increased red cell volume.
Blood volume increases 45-50%.
Anemia of pregnancy
Rise in plasma volume is greater than the
rise in red cell volume.
Results in a relative anemia.
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Abdomen
Delayed gastric emptying.
Increased risk of vomiting and
aspiration
Uterus becomes the largest
abdominal organ.
More likely to be injured from
either blunt or penetrating trauma
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Urinary System
Changes
Bladder is displaced upward
and forward by enlarging
uterus.
Increased risk of bladder injury
from blunt or penetrating
trauma.
trauma in pregnancy 19-9
Changes in the Uterus
Uterine blood flow increases.
Nonpregnant = 2% cardiac output
Pregnant = 20% cardiac output
Uterine vessels constrict in
response to catecholamine
release in early shock.
20-30% decrease in uterine blood
flow
Risk fetal hypoxia and death
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Causes of Traumatic
Fetal Death
#1 - Maternal death
#2 - Maternal shock
#3 - Abruptio placenta

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Fetal Development
trauma in pregnancy 19-12
Supine Hypotension
Syndrome
The enlarging uterus can
compress the inferior vena
cava when the mother is in the
supine position.
Reduces venous return and cardiac
output by up to 30%
More likely after the 20th week of
pregnancy

trauma in pregnancy 19-13
Compression of the
vena cava can cause:
Maternal
hypotension
Syncope
Fetal
bradycardia
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Packaging of Pregnant
Trauma Patients
Spinal motion restriction.
Tilt backboard 20-30 degrees to
the left.
May manually displace the uterus
to the left but not as effective.
Short backboards and similar
devices are not useful because of
difficulty attaching straps.
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Packaging of Pregnant
Trauma Patients
The vacuum
backboard is the
most secure (and
comfortable)
device to restrict
spinal movement
in the pregnant
patient.
trauma in pregnancy 19-16
Assessment
Assessment sequence same as for
nonpregnant patients
BTLS Primary Survey
Initial Assessment
Rapid Trauma Survey or Focused Exam
Ongoing Exam
Use Doppler (if available) to monitor fetal
heart tones
Detailed Exam
Priorities same as for nonpregnant
patients
trauma in pregnancy 19-17
Do not confuse normal
vital signs in pregnancy
for signs of shock.
Pulse is 10-15 beats/min faster.
BP is 10-15mmHg lower.
trauma in pregnancy 19-18
Shock in Pregnancy
Can lose 30% of blood volume
before having significant change
in BP.
Can have significant occult
intrauterine or abdominal
bleeding.
Uterus is very vascular.
May not have abdominal tenderness early
even with significant bleeding.
trauma in pregnancy 19-19
Management
100% oxygen.
Very important.
You are treating the fetus also.
Transport with full spinal
packaging.
Tilt backboard to the left if uterus is to the
umbilicus.
Secure backboard so it does not flip over
onto the floor.
Treat specific injuries.
trauma in pregnancy 19-20
Management of Shock
IV access:
Two large bore IVs of NS or RL.
May require larger volume of
fluids for resuscitation.
Blood should be given early.
If PASG is indicated, inflate
leg compartments only.
trauma in pregnancy 19-21
Maternal Cardiac Arrest
Manage same as the
nonpregnant patient.
Perform CPR.
Notify hospital to be prepared
for possible emergency c-
section.
trauma in pregnancy 19-22
Summary
Treating two patients.
Physiologic changes increase
the risk of injury and shock.
Treat shock early.
Prevent and treat hypoxia.
Prevent supine hypotension
syndrome.
Frequent reassessment.

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Questions?