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ATLS > Trauma in Pregnancy and Intimate Partner Violence > Flashcards

Trauma in Pregnancy and Intimate Partner Violence Flashcards

1
Q

When does the uterus begin to rise out of the pelvis during pregnancy?

A

At 12 weeks

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2
Q

When does the uterus reach the umbilicus during pregnancy?

-what about reaching the costal margin?

A

Umbilicus - at 20 weeks

Costal margin - at 34-36 weeks

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3
Q

What are 2 complications if amniotic fluid from the uterus enters the material intravascular space during trauma?

A
  1. Amniotic fluid embolism

2. DIC

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4
Q

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

A

True!

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5
Q

What is physiologic anemia of pregnancy?

A

A small increase in RBC volume occurs resulting in a decreased hematocrit level

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6
Q

How much blood does a pregnant patient usually need to lose before they show signs and symptoms of hypovolemia?

A

1000-1500 ml of blood

***This is because pregnant patients have an increased plasma volume

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7
Q

What happens to the following during pregnancy:

  • WBC
  • fibrinogen and clotting factors
  • PT and PTT
A
  • WBC can be elevated
  • fibrinogen and clotting factors are mildly elevated
  • PT and PTT may be shortened but bleeding and clotting times are unchanged
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8
Q

When a pregnant woman is laying in the supine position, how much decrease can you see in cardiac output?

A

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

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9
Q

What happens to heart rate during pregnancy?

A

Increase in HR by 10-15 by third trimester

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10
Q

What ECG changes can be seen in pregnant women?

A

Left axis shift

Flattened or inverted T waves in lead III and AVF

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11
Q

What happens to minute ventilation during pregnancy?

-what is a normal level of PaCO2 in late pregnancy?

A

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
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12
Q

What happens to gastric emptying during pregnancy?

A

Gastric emptying is slowed during pregnancy so may need early OG insertion to prevent aspiration of gastric contents

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13
Q

What happens to GFR and renal blood flow during pregnancy?

A

Increases during pregnancy

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14
Q

What happens to the symphysis pubis during pregnancy?

A

Symphysis pubic widens to 4-8 mm and the SI joint spaces increase by the 7th month of gestation

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15
Q

What are the clinical features of eclampsia?

A

May mimic head injury - seizures with hypertension, hyperreflxia, proteinuria and peripheral edema

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16
Q

What are 2 complications that can occur with using a lap belt alone in a pregnant trauma patient?

A
  1. Uterine rupture

2. Placental abruption

17
Q

True or false: as the gravis uterus grows larger, the other viscera are relatively protected from penetrating injury

A

True! But the likelihood of uterine injury increases

18
Q

What is the order of resuscitation for a pregnant woman?

A
  1. Resuscitate the mother first
  2. Then assess the fetus
  3. Then conduct secondary survey of mother
19
Q

How do you properly provide spinal motion restriction in the supine position for a pregnant patient?

A

Logroll the patient to the left side by 15-30 degrees (ie. elevate the right side 4-6 inches). Support with a bolstering device

20
Q

Why does it take longer for pregnant patients to develop tachycardia, hypotension and other signs of hypovolemia in blood loss?

A

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
21
Q

Why should you avoid vasopressor use in pregnancy?

A

Should be absolute last resort in restoring maternal blood pressure since vasopressors reduce uterine blood flow resulting in fetal hypoxia

22
Q

What is the most common cause of fetal death?

-2nd most common cause of fetal death?

A

Most common cause of fetal death - maternal shock and maternal death
2nd most common cause of fetal death - placental abruption

23
Q

What are the clinical features of placental abruption?

A
  1. Vaginal bleeding (70% of cases)
  2. Uterine tenderness
  3. Frequent uterine contractions
  4. Uterine tetany
  5. Uterine irritability (uterus contracts when touched)
24
Q

What are the clinical features of uterine rupture?

A

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
25
Q

What is placental abruption?

A

When the placenta detaches from the uterus

26
Q

Beyond what GA should you perform continuous fetal monitoring with a tocodynamometer?
-what are the risk factors for fetal loss in trauma? (6)

A

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:

  1. Maternal HR > 110
  2. Fetal HR > 160
  3. Injury Severity Score > 9
  4. Evidence of placental abruption
  5. Ejection during an MVC
  6. Motorcycle or pedestrian collisions
27
Q

What happens to bicarb during pregnancy?

A

Generally your bicarb will be low during pregnancy to compensate for respiratory alkalosis from increased minute ventilation

28
Q

What suggests ruptured chorioamniotic membranes on your secondary survey of a pregnant woman?

A

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

29
Q

True or false: CT scans can be used for pregnant trauma patients if there is significant concern for intra abdominal injury.

A

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

30
Q

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?
A

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
31
Q

When is perimortem C section most likely to be successful?

A

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

32
Q

True or false: Indications for peritoneal lavage are the same for pregnant vs non pregnant patients

A

True but the location for DPL is different for pregnant women (higher up)

33
Q

What are the indications for admission for a pregnant trauma patient?

A
  1. Vaginal bleeding
  2. Uterine irritability
  3. Abdominal tenderness, pain or cramping
  4. Evidence of hypovolemia
  5. Changes in or absence of fetal heart tones
  6. Leakage of amniotic fluid
34
Q

True or false: The fetus may be in jeopardy even with apparently minor maternal injury

A

True

ATLS (13 decks)

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