Clinical: Trauma In Pregnancy. Flashcards
Where does trauma rank in the leading causes of mortality in pregnancy ?
1!!
It is the leading cause of mortality in pregnancy
What percentage of fatalities in pregnancy are due to Trauma ?
46.3%
Which trimester is associated with more injuries than the other ?
3rd
Most fetal losses are due to which kind of injuries ?
Minor ! (occur more often)
Life threatening trauma is associated with what risk of fetal loss ?
40-50%
What are the two main categories of trauma ?
Blunt
Penetrating
What makes up the majority of blunt traumas seen in pregnancy ?
Motor Vehicle Accidents (70%)
What type of blunt trauma occurs 2nd most often and increases after 20 weeks of gestation ?
Falls
3rd most common blunt trauma seen in pregnancy ?
Domestic Violence
What factor leads to MVA’s having a higher risk of blunt injury ?
Absence or incorrectly wearing a seatbelt
In MVA’s, what is the most common cause of maternal death ? Fetal ?
Head Injury Maternal Shock (80% of fetal death associated with MVA's)
Is direct fetal trauma a common cause of death in pregnancy ?
No (1%)
What can occur in a MVA due to quick deceleration ?
Placental Abbruption (occurs in 30-60% of fetal mortality, 2nd only to maternal shock)
Occurs mainly with MAJOR TRAUMa (only seen in 5% of minor traumas)
How does placental abruption occur ?
Shearing of the inelastic placenta from the elastic myometrium.
Is vaginal bleeding always associated with Placental Abruption ?
No
Often the a complete abruption will lead to concealed bleeding between the myometrium and placenta
If there is bleeding due to abruption what color is it ?
Very dark !
Firm Abdomen, Hypertonicity and Constant Abdominal pain are all signs of ..
placental abruption
What hormone is responsible for ligamentous laxity especially at the hips and may be a cause for increased falls post 20 weeks ?
Relaxin
What is the most common way that women are physically abuse during pregnancy ?
Being kicked or punched.
What is the most common cause of penetrating trauma ?
Gunshot wounds
Which is more lethal to the fetus, gunshots or stab wounds ?
Stab wounds are often more lethal tp the fetus because they are more direct , where bullets can change course in the body a knife stays on a constant course
During the first 12 weeks of pregnancy, what protects the fetus ?
The bony pelvis
At 20 weeks, the uterus is roughly at which level in the body ?
The umbilicus
The maternal blood volume usually goes up by 45% during pregnancy. During which trimester is the increase more pronounced ?
The First ! Rapid expansion of blood volume.
In the first 12 weeks blood from goes from 60ml/min to 600 ml/min in the uterus (10x)
What causes physiologic anemia ?
Expnasion of plasma volume with relatively lower expansion of RBC productions
Are the symptoms of blood loss more pronounced in pregnancy or in the typical adult ?
The typical adult. In pregnancy you may lose up to 30-50% of blood before typical signs of blood loss are seen
What should you give to all Rh - mothers in the cause of blunt or penetrating wounds ?
Rhogam
What leads to venous congestion in the lower extremities at around 20 weeks of pregnancy ?
The uterus pressing on the IVC (and Aorta) in supine.
(lowers cardiac output and systolic BP)`
What occurs to blood pressure in the first trimester ?
It DECREASES (returns to normal by the third)
How much does cardiac output increase by week 10
around 1-1.5L/ min ( up to 6L/min total )
How much does tidal volume increase in pregnancy ?
40% (this will reduce functional residual capacity by about 20%)
What increased the risk of pneumothorax due to chest tube placement in a pregnant patient ?
The displacement of the diaphragm 4cm superiorly
Where should chest tubes be placed on a pregnant patient ?
1-2 segments higher than the normal 5th intercostal space
During pregnancy the small bowel and stomach are displaced superiorly. This can lead to delays and gastric emptying. Which complication is associated with this abnormality of pregnancy ?
ASPIRATION !
Are the liver and spleen affected during pregnancy ?
Apparently not
What is the most common cause of intrabdominal bleeding ? (Both pregnant and non pregnant)
Splenic injury
What should you worry about first: mother or fetus ?
Mother first (fetal survival is dependent on maternal survival)
Of course is mother is in code and baby is post 24 weeks gestation you may want to look into getting that little nubbin out of there.
Along with giving oxygen, how many IV’s should you start in a pregnant patient ?
2 ( he enjoys bringing up being prepared. Two IV access points allow for more flexibility)
What is the replacement schedule for Lactated Ringers or Normal saline (fluids) in a pregnant trauma patient ?
3:1 for first 30 mins
What should you avoid giving until fluids are replaced ?
Vasopressors
what position should pregnant trauma patients be in if at all possible ?
Left lateral tilt (takes pressure off of IVC and Aorta)
What are possible ways to determine fetal age ?
FDLNMP, Ultrasound, Fundus height (really more useful if funds is above the umbilicus)
how long do you monitor the fetus for minor trauma ? Major ?
4-6 hrs
24 hrs
In the first trimester, what is the ‘all or none’ postulate for radiation ?
either radiation will terminate the pregnancy or there will be no problems at all
What level of radiation should you try to stay under for all pregnancies ?
5-10 Rads
Above 10 rads and you can safely assume the pregnancy should be terminated.
Can you cardiovert a pregnant patient ?
yes ( up to 300 J will not harm the patient)
Can you use CT in pregnancy ?
Yes, as long as the rads are lower than 5-10 rads.
CT can be used to assess placental abruption. What was a positive interpretation on CT ?
Retroplacental hematoma (bleeding between placenta and myometrium
What is the dosing regimen for Rhogam ?
300ug for every 15-30cc’s of fetal blood
What is the cutoff line for gestation time and viability of fetus for c-section ?
24 weeks (less than this and fetal lungs are not well enough developed to survive)
If mother is in shock and baby is at 32 weeks, what must you do ?
Deliver via c-section.
this will help improve maternal cardiac filling.
By how much does maternal HR increase by in the second trimester ?
20 BPM
