Case 1: Pregnant women and Trauma

Question 1

Pregnant women brought to trauma bay - how is management changed by the fact that she is pregnant?

Answer 1

1) Ensure left uterine displacement, maintain inline neck stabilization 2) recognize increased risk of difficult airway management d/t physiologic changes of pregnancy - aspiration, engorged oropharyngeal soft tissue, increased risk of thromboembolic events. 3) Include monitoring of fetal heart rate and contractions 4) evaluate patient for ruptured membranes, uterine rupture, placental abruption 5) prepare for necessity of urgent/emergent delivery of the baby.

Question 2

Would you recommend CT scan?

Answer 2

Assuming the mother were stable w/ IV access and she could tolerate interruption of resuscitation, I would proceed to CT recognizing the benefits of obtaining appropriate imaging would likely outweigh the minimal risk of radiation induced teratogenesis

Question 3

She has significant pain, facial trauma, rib fractures - what would you do about her pain?

Answer 3

Recognizing that pain could lead to pulm splinting and reduced uteroplacental blood flow, i would attempt to control her pain utilizing intercostal nerve blocks for rib fracture and the titration of narcotics. Finally, considering the affects of NSAIDs on platelet function and fetal ductus arteriosus, I would avoid using these drugs for this pregnant patient who is at increased risk of coagulopathy and occult bleed.

Question 4

The patient is being transferred to the obstetric suite for urgent C section, would you encourage her to hyperventilate during transport?

Answer 4

I would not reccommend hyperventilation unless i thought her ICP was elevated enough to place her at risk for brain stem herniation. While hyperventilation to CO2 25 - 30 may be helpful in reducing ICP, it can also exacerbate cerebral ischemia by inducing cerebral vasoconstriction. Moreover hyperventilation can also lead to reduced maternal cardiac output, decreased blood pressure, and increased uteroplacental vasoconstriction – all of which may result in compromised uteroplacental blood flow placing the baby at increased risk.

Question 5

Exam reveals HTN, proteinuria, low platelets in pregnant patient following trauma- would you consider giving magnesium?

Answer 5

I would consider giving magnesium because while these findings may result from trauma, they may also be do to pre-eclampsia placing patient at risk for eclampsia and seizure. Avoiding seizure may be important for this patient who already at risk for cerebral ischemia 2/2 elevated ICP, anemia, and hypovolemia. However, I would keep in mind the administration of magnesium could lead to potentially deleterious cardiac affects (hypotension, bradycardia, heart block, cardiac arrest). I would ensure patient monitored closely

Question 6

Can you explain the difference between spina bifida occulta and spina bifida cystica?

Answer 6

• Spina bifida occulta: condition where there is abnormal or incomplete formation of the midline structures over the back w/o herniation of meninges or neural elements.
  
  • ​usually affects single vertebra, remains asymptomatic, does not involve underlying spinal anomalies.
  • ​Rarely abnormality is more extensive w/ cutaneous manifestation over site of defect (tuft of hair, dimple, hyperpigmentation), involves underlying spinal corn abnormalities. ie. tethered cord, Neuro deficits
  • Scoliosis
• Spina bifida cystica: condition where failed fusion of the nueral arch associated w/ herniation of meninges.
  
  • Meningocele is rarest form of spina bifida cystica, usually asymptomatic and associated w/ normal spinal cord.
  • Myelomeningocele, however, associated w/ tethered cord, hydrocephalus, scoliosis, and neuro deficits of lower limb.