Pregnant patient with major trauma

Question 1

What is the most common cause of non-obstetric death in pregnant women?

Answer 1

trauma

Question 2

What does survival of the fetus following trauma depend on?

Answer 2

effective resuscitation of the mother

Question 3

How can the gestational age be estimated in a trauma situation?

Answer 3

• just out of pelvis = 12 weeks
• to the umbilicus = 20-22 weeks
• up to the costal margin = 34-36 weeks

Question 4

What are 2 changes in airway management in pregnancy?

Answer 4

1. Increased risk of airway obstruction in the supine position and difficulty intubating from increased soft tissue
2. High risk of aspiration due to reduced gastrointestinal motility and competence of the oesophageal sphincter (relaxation due to progesterone)

Question 5

What are 3 differences in the management of breathing in trauma in pregnancy?

Answer 5

1. Increased oxygen consumption in pregnancy - give high flow oxygen early
2. Rise in tidal volume by 40% and physiological hyperventilation giving a normal PaCO₂ of around 4 kPa (normally 4.7-6) - interpret ABG accordingly
3. Diaphragm rises up to 4cm as uterus enlarges, so ensure any thoracostomies are performed high for chest drain insertion

Question 6

What are 4 differences in circulation management in pregnant trauma patients?

Answer 6

1. In the supine position, the uterus will compress the vena cava and cause hypotension
2. Blood volume increases by up to 40%.
3. the uterine circulation has no autoregulation
4. uterus displaces abdominal organs making physical examination of abdomen unreliable

Question 7

What should be done during initial assessment of a pregnant trauma patient due to the uterus compressing the vena cava, causing hypotension?

Answer 7

tilt the patient ot he left side, or manually displace the uterus to the left, rather than lying in the supine position

Question 8

How should you change your assessment of circulation in a pregnant patient due to the increase in blood volume by 40%?

Answer 8

be aware major haemorrhage of >1.5L can occur without signs of hypovolaemic shock, so consider fluids or blood earlier

Question 9

What should change in the assessment of circulation in a pregnant trauma patient due to the fact uterine circulation has no autoregulation?

Answer 9

avoid hypotension, because blood flow to the uterus will be directly proportional to maternal blood pressure, and any vasoconstriction in shock will compromise the fetus

Question 10

What are 4 additional differences to be aware of when assessing a trauma patient who is pregnant?

Answer 10

1. Prescribing in pregnancy - consult BNF
2. Radiation exposure
3. Rhesus group - transplacental haemorrhage
4. Domestic violence - risk greater when pregnant

Question 11

What are 3 examples of drugs to avoid to avoid in pregnancy?

Answer 11

1. Opiates cause respiratory depression in neonates
2. NSAIDs contraindicated in third trimester
3. Pregnant women require lower doses of anaesthetic drugs

Question 12

What are 3 things that excessive radiation exposure can put the fetus at risk of in pregnant trauma patients?

Answer 12

1. Teratogenesis
2. Growth retardation
3. Childhood cancer

Question 13

What should be the approach to performing x-rays in pregnant women with traumatic injury?

Answer 13

• x-rays on severely injured pregnant women should not be withheld in life-threatening circumstances
• where possible, use lowest exposure e.g. US rather than CT, and use abdo lead aprons during x-rays
• seek senior help to weight up the risks and benefits, and liaise with the consultant radiologist on-call

Question 14

At what point in pregnancy is the risk of excessive radiation exposure to the fetus highest?

Answer 14

first trimester

Question 15

What can trauma lead to that concerns rhesus group in pregnancy?

Answer 15

trauma can cause transplacental haemorrhage of fetal blood into the maternal circulation

rhesus negative woman would form antibodies to any fetal rhesus positive blood cells passing into circulation - can lead to fatal haemolytic disease of newborn

Question 16

What should be done following any antibody sensitising traumatic episode in pregnancy? 4 stages

Answer 16

1. check the rhesus blood group of the mother
2. perform a Kleihauer test, which will detect fetal red blood cells in the maternal circulation
3. if woman rhesus negative, give anti-D immunoglobulin within 72h
   
   • 250 units for <20 weeks
   • 500 units for >20 weeks gestation
4. seek advice from obs and gynae

Question 17

Within what time frame must anti-D immunoglobulin be given in rhesus-negative women who have had a sensitising event?

Answer 17

within 72h

Question 18

What dose of anti-D immunoglobulin must be given to a rhesus negative pregnant woman following a sensitising event?

Answer 18

250 units if <20 weeks gestation

500 units if >20 weeks gestation

Question 19

What are 6 things that should make you think of domestic violence in pregnancy, in a patient presenting with trauma?

Answer 19

1. Explanation of mechanism of injury not consistent with clinical findings
2. Delayed presentation
3. Partner insists on staying with patient for whole consultation and answers questions for them
4. Injuries to breasts, abdomen, or genitals
5. Repeated attendances to emergency department
6. Poor eye contact and self-blame by patient

Question 20

How should you manage a patient presenting with domestic violence?

Answer 20

offer the patient support, give them information regarding local domestic violence organisations and encourage them to report to the police

Question 21

When should you call for the obs and gynae reg/consultant when a trauma patient comes to the ED?

Answer 21

as soon as receive trauma alert or patient arrives in department

Question 22

How should a patient be positioned following trauma in pregnancy, if there is a visible ‘bump’?

Answer 22

• left lateral position
• patient strapped fully on a spinal board: tilt with blankets under the right side of the board
• patient on trolley: displace uterus manually to the left with two hands. once any life-threatening injuries and spine have been cleared, can be rolled onto left side or tilted to left with wedge under right hip

Question 23

What are 4 things to ask about in the history to assess the fetus in a pregnant trauma patient?

Answer 23

1. obstetric history, any previuos preterm labours or abruptions
2. last menstrual period and expected date of delivery
3. any abdominal pain, contractions, PV loss of blood, or clear fluid
4. any fetal movements

Question 24

What are 6 aspects of the obstetric examination in a pregnant trauma patient?

Answer 24

1. measure fundal height to predict gestational age
2. look for uterine tenderness or rigidity, easily palpable fetal parts, external inspection for PV bleeding or amniotic fluid loss
3. do not perform a PV examination
4. doppler USS for fetal heart rate
5. look for pregnancy record ‘green book’ which mother normally carries with her at all times
6. ask obs and gynae to assess patient early - abdomen, PV, CTG etc.

Question 25

What are 6 types of specific traumatic injuries that may occur in pregnancy?

Answer 25

1. Blunt injury
2. Placental abruption
3. Uterine rupture
4. Penetrating injury
5. Uterine penetration
6. Cardiac arrest in pregnancy

Question 26

Which structures protect the fetus from blunt injury?

Answer 26

bony pelvis, uterine wall and amniotic fluid

Question 27

What are 3 types of blunt injry which could cause uterine rupture or placental abruption?

Answer 27

1. Direct impact to the abdomen
2. Compression by seatbelt in RTA
3. Deceleration shearing forces

Question 28

What are 5 signs of placental abruption?

Answer 28

1. PV bleeding
2. uterine tenderness and rigidity (woody)
3. Contractions
4. Larger fundal height than expected for dates
5. Hypovolaemic shock

Question 29

What is the usual treatment of placental abruption?

Answer 29

emergency caesarean section

Question 30

What are 5 symptoms and signs of uterine rupture?

Answer 30

1. PV bleeding
2. Abdominal tendernes
3. Loss of fetal movements
4. Palpable extra-uterine fetal parts
5. Hypovolaemic shock

Question 31

What are the options for treatment of uterine rupture?

Answer 31

emergency laparotomy, Caesarean section ± hysterectomy

Question 32

How does penetrating injury relate to the size of the uterus?

Answer 32

a larger uterus protects the abdominal viscera from penetrating injury but means a poor prognosis for the fetus if the uterus is penetrated

Question 33

What are 4 signs/symptoms of uterine penetration injury?

Answer 33

1. Penetrating wound to abdomen
2. Loss of fetal movements
3. Loss of fetal heart sounds
4. Bradycardia

Question 34

What is the treatment of uterine penetration?

Answer 34

emergency laparotomy, Caesarean section

Question 35

What should be done if cardiac arrest occurs in pregnancy?

Answer 35

perimortem caesarean section should be performed within 5 minutes of cardiac arrest if the uterine fundus is above the umbilicus or known gestation >24 weeks

call for obstetric and paediatric support immediately

Question 36

Within what time frame should C-section be performed following maternal cardiac arrest, if indicated?

Answer 36

within 5 min