Trauma in Pregnancy and Intimate Partner Violence Flashcards
When does the uterus begin to rise out of the pelvis during pregnancy?
At 12 weeks
When does the uterus reach the umbilicus during pregnancy?
-what about reaching the costal margin?
Umbilicus - at 20 weeks
Costal margin - at 34-36 weeks
What are 2 complications if amniotic fluid from the uterus enters the material intravascular space during trauma?
- Amniotic fluid embolism
2. DIC
True or false: An abrupt decrease in maternal intravrascular volume can result in a profound increase in uterine vascular resistance, reducing fetal oxygenation despite reasonably normal maternal vital signs
True!
What is physiologic anemia of pregnancy?
A small increase in RBC volume occurs resulting in a decreased hematocrit level
How much blood does a pregnant patient usually need to lose before they show signs and symptoms of hypovolemia?
1000-1500 ml of blood
***This is because pregnant patients have an increased plasma volume
What happens to the following during pregnancy:
- WBC
- fibrinogen and clotting factors
- PT and PTT
- WBC can be elevated
- fibrinogen and clotting factors are mildly elevated
- PT and PTT may be shortened but bleeding and clotting times are unchanged
When a pregnant woman is laying in the supine position, how much decrease can you see in cardiac output?
Up to 30% decrease in cardiac output due to IVC compression
-can relieve the pressure on the IVC by turning the patient to left lateral decubitus
What happens to heart rate during pregnancy?
Increase in HR by 10-15 by third trimester
What ECG changes can be seen in pregnant women?
Left axis shift
Flattened or inverted T waves in lead III and AVF
What happens to minute ventilation during pregnancy?
-what is a normal level of PaCO2 in late pregnancy?
Minute ventilation increases due to increase in tidal volume
- usually have hypocapnia in late pregnancy with PaCO2 of 30 mm
- THUS a PaCO2 of 35-40 mm Hg may indicate impending respiratory failure during pregnancy
What happens to gastric emptying during pregnancy?
Gastric emptying is slowed during pregnancy so may need early OG insertion to prevent aspiration of gastric contents
What happens to GFR and renal blood flow during pregnancy?
Increases during pregnancy
What happens to the symphysis pubis during pregnancy?
Symphysis pubic widens to 4-8 mm and the SI joint spaces increase by the 7th month of gestation
What are the clinical features of eclampsia?
May mimic head injury - seizures with hypertension, hyperreflxia, proteinuria and peripheral edema
What are 2 complications that can occur with using a lap belt alone in a pregnant trauma patient?
- Uterine rupture
2. Placental abruption
True or false: as the gravis uterus grows larger, the other viscera are relatively protected from penetrating injury
True! But the likelihood of uterine injury increases
What is the order of resuscitation for a pregnant woman?
- Resuscitate the mother first
- Then assess the fetus
- Then conduct secondary survey of mother
How do you properly provide spinal motion restriction in the supine position for a pregnant patient?
Logroll the patient to the left side by 15-30 degrees (ie. elevate the right side 4-6 inches). Support with a bolstering device
Why does it take longer for pregnant patients to develop tachycardia, hypotension and other signs of hypovolemia in blood loss?
Because of increased intravascular volume during pregnancy
- may have to lose 1000-1500 ml of blood before you start to see changes in vitals
- thus the fetus may be in distress and the placenta deprived of vital perfusion while the mother’s condition and vital signs appear stable
Why should you avoid vasopressor use in pregnancy?
Should be absolute last resort in restoring maternal blood pressure since vasopressors reduce uterine blood flow resulting in fetal hypoxia
What is the most common cause of fetal death?
-2nd most common cause of fetal death?
Most common cause of fetal death - maternal shock and maternal death
2nd most common cause of fetal death - placental abruption
What are the clinical features of placental abruption?
- Vaginal bleeding (70% of cases)
- Uterine tenderness
- Frequent uterine contractions
- Uterine tetany
- Uterine irritability (uterus contracts when touched)
What are the clinical features of uterine rupture?
Rare injury overall
- abdo tenderness
- guarding
- rigidity
- rebound tenderness
- abnormal fetal lie
- easy palpation of fetal parts because of their extrauterine location
- inability to readily palpate the uterine fundus when there is fundal rupture
- **remember that peritoneal signs are difficult to appreciate in advanced gestation because of expansion and attenuation of the abdominal wall musculature
What is placental abruption?
When the placenta detaches from the uterus
Beyond what GA should you perform continuous fetal monitoring with a tocodynamometer?
-what are the risk factors for fetal loss in trauma? (6)
Beyond 20-24 wks GA
- monitor x 6 hours at least if no risk factors for fetal loss
- monitor x 24 hours if there are risk factors for fetal loss
Risk factors for fetal loss in trauma:
- Maternal HR > 110
- Fetal HR > 160
- Injury Severity Score > 9
- Evidence of placental abruption
- Ejection during an MVC
- Motorcycle or pedestrian collisions
What happens to bicarb during pregnancy?
Generally your bicarb will be low during pregnancy to compensate for respiratory alkalosis from increased minute ventilation
What suggests ruptured chorioamniotic membranes on your secondary survey of a pregnant woman?
Presence of amniotic fluid in the vagina (evidenced by pH > 4.5)
***overall need to do a vaginal exam during the secondary survey to look for vaginal bleeding in the third trimester
True or false: CT scans can be used for pregnant trauma patients if there is significant concern for intra abdominal injury.
True! Abdo/pelvis CT scan radiation dose approaches 25 mGy and fetal radiation doses less than 50 mGy are not associated with fetal anomalies or higher risk for fetal loss
What is the indication for giving Rh immunoglobulin in pregnant trauma patients?
- what time period should the Rh immunoglobulin be administered by?
- What is the name of the test that allows you to figure out if fetal RBCs are in maternal circulation?
Administer Rh immunoglobulin to ALL injured Rh-negative mothers unless the injury is remote from the uterus (eg isolated distal extremity)
- you have 72 hours to give the immunoglobulin therapy
- *as little as 0.01 mL of Rh-positive blood will sensitize 70% of Rh-negative patients
- **test to figure out if there is fetal RBCs in maternal circulation: Kleihauer-Betke test
When is perimortem C section most likely to be successful?
Within 4-5 minutes of maternal cardiac arrest UNLESS the cause of arrest is hypovolemia due to trauma
-fetal distress can be present even when the mother has no hemodynamic abnormalities so by the time maternal hypovolemic cardiac arrest occurs, the fetus has already suffered prolonged hypoxia
True or false: Indications for peritoneal lavage are the same for pregnant vs non pregnant patients
True but the location for DPL is different for pregnant women (higher up)
What are the indications for admission for a pregnant trauma patient?
- Vaginal bleeding
- Uterine irritability
- Abdominal tenderness, pain or cramping
- Evidence of hypovolemia
- Changes in or absence of fetal heart tones
- Leakage of amniotic fluid
True or false: The fetus may be in jeopardy even with apparently minor maternal injury
True
