Blog

Laura Joyce 12th January 2016

Trauma in Pregnancy

TAKE HOME MESSAGES

There are TWO patients. Mum is priority - fetal survival depends on maternal well-being
Every pregnant woman over 18/40 is named Mrs Tilt - LEFT LATERAL POSITION avoids IVC compression
Phone a friend - early: call O+G, plus birthing suite for midwife+CTG machine


pregnancytrauma

Trauma is the most common cause of maternal death - this includes motor vehicle accidents, along with suicide and homicide. The pregnant trauma patient presents a unique challenge because care must be provided for two patients — the mother and the fetus. Anatomic and physiologic changes in pregnancy can mask or mimic injury, making diagnosis of trauma-related problems difficult.

Care of pregnant trauma patients with severe injuries often requires a multidisciplinary approach involving the ED team, obstetrician, neonatologist and midwives.
Never be scared to phone a friend!


Assessment of the Pregnant Trauma Patient

Airway

Issues
  • Difficult airway
  • Oedematous airways tissues
  • Large boobs in the way
  • Increased aspiration risk
Management
  • May need 0.5 - 1 size smaller ETT
  • Short handled laryngoscope, ramping
  • RSI, consider cricoid (if you believe in it), NGT

Breathing

Issues
  • May be dyspnoeic lying flat
  • Decreased ability for respiratory compensation (increased tidal volume/decreased residual capacity)
  • Ventilation can be difficult (increased abdominal pressure)
  • Diaphragm elevated
Management
  • Positioning - ramped
  • Apply high flow O2
  • Consider two person technique for BVM
  • Insert ICC higher: 3rd or 4th IC space

Circulation

Issues
  • Supine position can compress IVC
  • Relative hypervolaemia (can lose 35% blood volume before becoming tachycardic/hypotensive)
  • Relative anaemia/tachycardia/hypotension
  • Increased cardiac output
  • Fetal HR is a 'C' assessment - use doppler/USS or CTG (Fetal shock can precede signs of maternal shock)

These all mean less reserve in case of major haemorrhage all mean less reserve in case of major haemorrhage

Management
  • Left lateral tilt or manual uterine displacement
  • Large bore iv access + crossmatch
  • May need more fluid/blood than usual
  • Early signs of shock may be subtle: look closely
  • CTG more predictive than USS for abruption

Abdo/Fetus

Issues
  • Fundus at umbilicus = 20/40
  • Abdo pain/tenderness can indicate placental abruption or ruptured uterus
  • Look for PV blood loss (but leave the PV exam to the obstetric team)
Management
  • Phone a friend. Now.