|SYMPOSIUM - POLYTRAUMA MANAGEMENT
|Year : 2013 | Volume
| Issue : 1 | Page : 63-69
Polytrauma during pregnancy
Sarita Agrawal1, Vinita Singh1, Prashant Kumar Nayak1, Pushpawati Thakur1, Manju Agrawal2, Asha Jain1
1 Department of Obstetrics and Gynecology, AIIMS, Raipur, Chhattisgarh, India
2 Department of Pharmacology, N S C B Medical College, Jabalpur, Madhya Pradesh, India
|Date of Web Publication||23-Sep-2013|
Department of Obstetrics and Gynecology, AIIMS, Raipur - 492 099, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Trauma during pregnancy is an important cause of nonobstetrical cause of maternal mortality & morbidity. Apart from type of injury affecting the maternal & fetal outcome there are several life threatening complications unique to pregnancy like abruption placentae, uterine rupture, amniotic fluid embolism, & direct fetal trauma which needs immediate interventions. Maternal assessment & management during pregnancy needs special consideration to physiological changes during pregnancy as well as fetal surveillance to improve the maternal & fetal outcome. All pregnant trauma patient needs multi disciplinary approach involving obstetrician, neonatologist, obstetric anaesthetist & trauma surgeons.
Keywords: Pregnancy, trauma, radiation in pregnancy
|How to cite this article:|
Agrawal S, Singh V, Nayak PK, Thakur P, Agrawal M, Jain A. Polytrauma during pregnancy. J Orthop Traumatol Rehabil 2013;6:63-9
|How to cite this URL:|
Agrawal S, Singh V, Nayak PK, Thakur P, Agrawal M, Jain A. Polytrauma during pregnancy. J Orthop Traumatol Rehabil [serial online] 2013 [cited 2019 Mar 22];6:63-9. Available from: http://www.jotr.in/text.asp?2013/6/1/63/118754
| Introduction|| |
Trauma in pregnancy poses a unique challenge to the clinician as there are two patients need to be managed simultaneously, the pregnant lady and the unborn fetus. Furthermore, pregnancy related anatomic and physiological changes needs special consideration while resuscitating the pregnant lady [Table 1]. Management of the pregnant trauma victim requires a multidisciplinary approach in order to optimize the outcomes for mother and fetus.  The treatment priorities are the same as for the non-pregnant trauma patient. The best initial treatment for the fetus is the optimum resuscitation of the mother.
|Table 1: Changes in normal pregnancy that may affect trauma management* |
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Polytrauma in pregnancy is an important non-obstetric cause of maternal death (6-7% of maternal deaths in US). 1 in 14 pregnant women experience some sort of trauma and 3-4 out of 1000 pregnant women require intensive care unit care. 
The most common etiology for trauma in pregnancy is motor vehicle accidents followed by falls, violent assaults and burn injuries. Keel et al. reported the major killers in polytrauma are head injury (66%), hemorrhagic shock (21%), sepsis and multiorgan failure (13%) and coagulopathies (dilutional and consumption).
Effects of trauma in pregnancy
The effects depend on weeks of pregnancy, severity of trauma, site of injury and intervention interval. In pregnancy, there is relatively higher incidence of abdominal but lower incidence of the chest or head injury.  Incidence of trauma increases as pregnancy progresses (8% in the first trimester, 40% in the second trimester, 52% in the third trimester). The uterus is protected within the pelvis until 12 weeks, so chances of injury are limited. At 20 weeks, the uterus and bladder is displaced upward as the uterus grows making it an intra-abdominal organ vulnerable to injury.
The gravid uterus provides protection to abdominal organs so penetrating wounds like a gunshot and stab wounds are less likely to cause bowel or vascular injury. However, upper abdominal wounds can be associated with complex bowel injuries in late pregnancy since the bowel is displaced. Maternal pelvic fractures especially late in pregnancy are associated with bladder, urethral injury, retroperitoneal bleed and direct fetal injury.
Consequences unique to pregnancy
Abruptio placentae are the most feared and most common complication of blunt abdominal trauma in pregnant lady. The incidence following major trauma is 38-66% in Minor trauma, it is 2-4%. Though most cases of abruption occurs shortly after trauma, clinical manifestation may sometimes be delayed by 24-48 h or may remain undiagnosed. The classical clinical manifestation of abruption that is maternal hypotension, tense tender abdomen and vaginal bleeding may be delayed for several hours, hence for early diagnosis one must carefully watch for fetal heart rate variation, which is usually early indicator of abruption due to resultant fetal hypoxia. The ultrasonography (USG) can detect most cases of abruption; however in 50% case even USG may miss the diagnosis. The dreaded complication of placental abruption is consumption coagulopathy.
Uterine rupture/uterine artery avulsion
This rare complication is estimated to complicate 0.6% of severe abdominal trauma. Direct trauma after 12 weeks of gestation, prior surgery (C/S or myomectomy) increases the risk. Rapid exsanguinations in the form of blood loss 60-600 ml/min are associated with almost 100% fetal mortality. 10% of maternal mortality is usually as a result of associated injuries. Clinical features include uterine pain or tenderness, non-reassuring fetal heart rate pattern, abdominal distension, peritoneal signs and vital sign changes from minimal tachycardia to hypovolemic shock.
Amniotic fluid embolism
It is a serious and fatal complication. It is an anaphylactic reaction to fetal debri rather than embolic event, deadly unpreventable obstetric emergency leading to death within minutes to about 4 h. More than 60% of those who survive develop neurological symptoms and coma. Advanced life support measures immediately only helps.
Fetomaternal hemorrhage (FMH)
Transplacental hemorrhage of fetal blood in to maternal circulation leads to maternal Rh sensitization in Rh negative mother who is carrying Rh positive fetus. The risk of FMH is 1-3% in the first trimester, 12% second trimester and 45% in the third trimester. Therefore, all Rh negative mothers who present with a history of abdominal trauma should receive a single dose, 300 microgram of Rh immunoglobulin (anti-D) within 72 h of trauma for prophylaxis. The other risks of FMH are fetal anemia, exsanguinations and fetal death and maternal sensitization to other minor antigens.
Preterm contractions are common among third trimester trauma patients (25%), but these resolve spontaneously in 90%. Even after the initial improvement, the risk for preterm birth and low birth weight is twice as high for the rest of the pregnancy. Even minor trauma can lead to preterm birth.
Direct fetal trauma
Direct fetal trauma complicates <1% of all pregnancies following trauma. In cases of penetrating injury to lower abdomen, fetus is involved in 60-90% cases. Unusual fetal consequences of trauma include limb-body wall complex, fetal subdural hemorrhage hydrocephalus or cerebral palsy. Cases of uterine rupture with fetal death and fetal spinal fracture have been reported, even with seat belts. Fetal skull fracture is most common amongst direct fetal injury, with a mortality rate of 42%. 
| Assessment and Management of Pregnant Trauma Patient|| |
Management of trauma patient need multidisciplinary approach that include involvement of trauma surgeon, emergency physician, experienced obstetrician and neonatologist with rapid assessment.  The evaluation of the traumatized pregnant patient, the approach and the interpretation of the diagnostic tests results must be accompanied by the full knowledge of all changes that take place during pregnancy [Table 1]. The best way to treat the fetus is to treat the mother. Therefore, the approach to the pregnant patient is not much different than the approach to the non-pregnant patient [ALGORITHM] [Figure 1].
Primary survey of injured pregnant patient addresses the airway/cervical spine control, breathing and circulation (ABC, volume replacement/hemorrhage control). An airway should be obtained and maintained. Breathing should be supported by supplemental oxygen provided by nasal cannula, mask or endotracheal intubation as deemed appropriate for the situation. Special considerations required while resuscitation are:
| Circulatory System|| |
Aortocaval compression - Supine hypotension
Despite 50% increase in plasma volume and cardiac out put (COP) after 20 weeks of gestation, the uterus may compress the great vessels in the supine position. This compression can cause a decrease of up to 30 mm Hg in maternal systolic blood pressure, a 30% decrease in stroke volume and a consequent decrease in uterine blood flow. Patient should be tilted 15° to the left by placing rolled towel beneath spinal board and one person may manually displace the uterus to the left [Figure 2]. Left lateral position should always be preferred if spinal immobilization is not required. This position must be maintained all times during resuscitation, transport and perioperatively.
In pregnancy increased plasma volume (hemodilution) and shunting of blood away from uterus will maintain vitals at the expense of fetus, hence the maternal shock may not manifest until blood loss exceeds 30%. Therefore, maternal circulation should be maintained with large bore intravenous catheters delivering crystalloid in the form of lactated Ringer's solution. In animal studies, improvement in fetal partial pressure of arterial oxygen is slower with crystalloids solution than with blood replacement. Therefore, blood transfusion should be initiated when significant blood loss has occurred or is suspected. It is important to recognize that significant blood loss can occur in the uterine wall or retroperitoneal space without external bleeding.
Respiratory consideration in pregnancy diaphragm rises 4 cm and chest diameter enlarges by 2 cm increasing the substernal angle by 50%. Therefore, if chest tube is placed or thoracostomies is performed it enters the space 1-2 interspaces higher than usual.
In general, pregnancy does not affect the decision to intubate, although the risk of aspiration is increased.
There is rapid falls in PaO2 during periods of apnea or airway obstruction due to 20% decrease in functional residual capacity, coupled with a 20% increase in oxygen consumption. In addition, 30% of parturients have airway closure during normal tidal ventilation in the supine position. Supplemental oxygen is always indicated because the fetus is extremely susceptible to hypoxia and oxygen reserve is a significantly diminished in pregnant women.
Be aware of the chronically compensated physiological respiratory alkalosis in pregnant patients and act accordingly (pH - 7.4-7.47).
Risk of aspiration is increased due to decrease competency of the gastroesophageal sphincter, decreased gastric tone and delayed gastric emptying.
As the uterus enlarges, it displaces abdominal viscera and intestines upward and laterally, stretching the peritoneum thus making the abdominal physical examination unreliable.
The neurological evaluation
Intracranial hemorrhage is the most common cause of death in trauma patients; however pregnancy induced hypertension can produce seizures, it may mimic a head injury. It should be suspected when hypertension is associated with hyperreflexia, proteinuria and peripheral edema.
Anesthesia in OB trauma
- Maintain good anesthesia, oxygenation, normotension, normothermia, normocarbia (PaCO 2 = 30) and LUD. Avoid ketamine >2 mg/kg (uterine hypertonus).
- There is 25-40% decrease in anesthetic requirements. This means that loss of consciousness can occur even at "sedative" doses.
- Epidural anesthesia is preferred over general anesthesia (GA) or spinal.
- Both depolarizing and non-depolarizing muscle relaxants cross placenta and can cause fetal respiratory depression. Cyclobenzaprine is the relatively safe muscle relaxant (hart).
- Defensive medicine: Probably avoid benzodiazepines and N 2 O early in gestation (little to no solid evidence for this).
Military antishock trousers, pneumatic antishock garments (PASG)
These may be used to stabilize lower extremity fractures and perhaps in hemorrhage. In pregnant patient, inflation of abdominal compartment of the PASG should be avoided as it compromises uteroplacental blood flow one must inflate only leg compartment.
Cardio-pulmonary resuscitation in pregnancy
External cardiac massage (ECM) becomes less effective as the patient approaches term due to mechanical factors. At a gestational age, 26-32 weeks, when ECM is not effective open cardiac massage (OCM) should be seriously considered before an emergency cesarian section is performed. If OCM proves to be ineffective, the fetus must be delivered immediately. Delivering the infant improve maternal cardiac filling, thereby improving success of cardio pulmonary resuscitation (CPR).
Most of the drugs commonly used are category B or C (refer to http://www.reprotox.org for drug safety in pregnancy). Safe antibiotics are ampicillin, penicillin, cephalosporin first and second generation and erythromycin. NSAIDS to be avoided for the risk of premature closure of the ductus arteriosus. Vasopressors reduce uterine blood flow. In burn siver sulfa diazine must be used sparingly for the risk of kernicterus in fetus.
As such pregnancy is not a contraindication to any surgical procedure.
Diagnostic peritoneal lavage in pregnant women may be difficult to perform.
Celiotomy - if celiotomy is indicated is performed as in non-pregnant women. Some controversies exist, but present opinion is that all gunshot injury to abdomen should undergo mandatory celiotomy. The indications for cesarian delivery during celiotomy include maternal shock and pregnancy near term, instability in a potentially viable fetus, unstable thoracolumber spine injury, mechanical limitation to CPR and maternal death.
Orthopedic injuries - the dilemma presented in a multitrauma situation at various stages of pregnancy necessitates making management modifications involving timing of surgery and delivery, use of radiation for imaging and choice of appropriate surgical procedure. However with limited use of intra and post-operative X-ray, qualified specialist with experience in acetabular and pelvic surgery, successful surgical fixation of the acetabulum and pelvic fractures in pregnancy with good fetomaternal outcome have been reported in the literature. ,
| Radiography|| |
Fetal adverse effects are unlikely if radiation dose less than 5 rads ,, or distance more than 10 cm.
- Relative risk of childhood cancer-greatest-before 8 weeks.
- Lesser than 1% of trauma patients are exposed to more than 3 rads [Table 2].
- Fetal effects of radiation depend upon gestational age at the time of exposure [Table 3].
|Table 2: Radiation exposure for the unshielded uterus in various imaging studies |
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Fetal safety and computed tomography (CT) scan:
- Radiation exposure at CT is low when the fetus is outside the field of view.
- CT of the head, neck or extremity can be safely performed at any trimester of pregnancy.
- Chest CT is a low risk procedure when the fetus is avoided from the primary beam.
- Abdominal and pelvic CT are high risk procedures consider risk and benefit.
- Spiral CT-less risk.
Preventing radiation hazards:
- Always take history of pregnancy.
- Reducing the number of exposures.
- Use Abdominal shield (scattered radiation is 24X less).
- Thermoluminescent dosimeter attached to mother to evaluate radiation exposure.
Magnetic resonance imaging (MRI) in pregnancy
In general, it should be noted that most studies evaluating MRI safety during pregnancy show no ill-effects A reduction in crown-rump length was seen in mice exposed to MRI in midgestation.  No significant risk of acoustic injury to the fetus during prenatal MRI. 
Fetal assessment [Figure 3]
After initial stabilization, other maternal injuries are evaluated and fetal heart tones are assessed by Doppler or USG. When fetal heart tones are present, gestational age is determined by clinical and USG. USG is the most accurate method of determining gestational age and abruption placentae. Determination of fetal viability is subject to institutional variation. An estimated gestational age of 24-26 weeks and an estimated fetal weight of 500 g are commonly used thresholds of viability. Only viable fetuses are monitored because no obstetric intervention will alter the outcome with a pre-viable fetus. Pelvic and rectal examinations performed to rule out vaginal bleeding, premature rupture of membrane, preterm labor. Continuous fetal and contraction monitoring with cardiotochography (CTG) remains the most widely used modality for evaluation of the fetus. Controversy exists concerning the duration of fetal monitoring following a traumatic event.
Pearlman et al.  recommends if GA >24 weeks
- Minimum 4 h CTG monitoring
- Extended to 24 h if:
- >6 contractions per hour,
- Persistent uterine tenderness,
- Non-reassuring fetal monitor strip,
- Vaginal bleeding,
- Serious maternal injury present.
Perimortem cesarean section
Perimortem cesarean section rarely is required, but is performed in the patient with a viable fetus gestational age more than 23 weeks, who has been unsuccessfully resuscitated for four minutes. Delivery within 5 min carries the best chance of fetal and maternal survival. Perimortem cesarean section can increase maternal perfusion; a few cases report maternal survival.  successful cases reported in the literature. Delivering the fetus improves maternal cardiac filling thereby improves success of CPR.
Prevention of trauma
Proper seat belt use is the most significant modifiable factor in decreasing maternal and fetal injury and mortality after motor vehicle crashes.
Prenatal care must include three-point seat belt instruction. The lap belt should be placed under the gravid abdomen, snugly over the thighs, with the shoulder harness off to the side of the uterus, between the breasts and over the midline of the clavicle. Seat belts placed directly over the uterus can cause fetal injury. Airbags should not be disabled during pregnancy.
| Conclusion|| |
- An injured pregnant woman needs Emergency Department care in the "Resuscitation bay" with close monitoring.
- Pregnant women should be positioned in 15° left lateral tilt as far as possible.
- Do not assume that all abnormal findings are related to trauma - concomitant complications specific to pregnancy may also be present (e.g., placental abruption).
- Adequate resuscitation of the mother is the most important means by which fetal resuscitation occurs.
- If, after the mother's condition is optimized, the fetal condition is still unsatisfactory, delivery should be considered if the fetus is of a viable gestational.
- If radiological assessment of trauma is necessary, or appropriate, it must be performed irrespective of the pregnancy, with shielding of the uterus, provided this does not interfere with the required radiological views.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]