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					       TRAUMA AND SURGERY
       IN THE PREGANANT PATIENT

PRINCIPLES OF SURGERY-2011
NICHOLAS LEYLAND,BASc,MD,MHCM,FRCSC
PROFESSOR AND CHAIR,
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY,
FACULTY OF HEALTH SCIENCES,
MICHAEL G. DEGROOTE SCHOOL OF MEDICINE,
McMASTER UNIVERSITY
 SURGERY IN THE PREGNANT
         PATIENT
         Learning objectives:
      1)TRAUMA IN PREGNANCY
2)THE ACUTE ABDOMEN IN PREGNANCY
   3)NEUROVASCULAR EMERGENCIES
               4)CASES
         5) UPDATE LEYLAND
“THERAPEUTIC PARALYSIS”
  TRAUMA IN PREGNANCY Incidence:
• Trauma occurs in 6-7% of pregnancies
• 4.6-8.3% of Traumas are complicated by pregnancy


  Maternal mortality rate              Fetal mortality rate
  • 3.5%                               • 1% in minor trauma
     – Mortality rate is similar for   • 15% in major trauma
       non-pregnant women
                                       • Overall fetal death rate
                                          from trauma = 1/30000
                                          pregnancies
           TRAUMA IN PREGNANCY:
           MATERNAL PHYSIOLOGY
             Surgical Implications:

• Cardiovascular Changes; CO ^ 50%,Blood Vol^ 50%
• Maternal rbc ^ 30% ‘Dilutional Anaemia’
• WBC ^ 12000, Labour 20,000
• GI: Appendix (localization), Progesterone Decreased
  motility,^ alk phosphatase, no change in Transaminases
• Respiratory Changes: e.g. Decreased pCO2
         General Management Principles
             Maternal Assessment


• Primary Survey
   – ABCs…Fetus
• Lateral Tilt
   – Supine position can  cardiac output by 30%
   – 15° tilt is appropriate
   – Can decrease effect of CPR
          General Management Principles
                Fetal Assessment
• Ultrasound
    –   GA
    –   Placentation/Abruption
    –   Fetal viability
    –   Extent of fetal trauma/demise
    –   BPP?
•   Celestone as indicated
•   Initiate FHM after patient is stabilized
•   Consider Tocolysis as indicated
•   Vaginal exam to rule out PPROM
      General Management Principles
          Maternal Assessment
• Rhogam:
  – Administer within 72 hrs
  – 10-30% of trauma have evidence of admixture
  – Betke-Kleihaurer test to determine quantity of
    hemorrhages
  – 90% of hemorrhages are < 30 cc
     • Anterior placed placentas have higher risk
      General Management Principles
          Maternal Assessment
• Exploratory Laparotomy
  – usually necessary in penetrating trauma
  – C/S may be required to attain adequate surgical exposure
• Tetanus
  – As usual
       Imaging & Radiation
Harmful effects:
1. Cell death and teratogenesis
   –   High doses of radiation before implantation is likely
       lethal
   –   In humans, high dose  growth restriction,
       microcephaly, mental retardation
   –   Effects are greatest at 8-15 wks gestation
   –   No proven effects before 8 wks or after 25 wks
   –   Risk are not increased until radiation exposure = 5
       rad
       Imaging & Radiation

Fetal Radiation Exposure in typical trauma

                               Fetal Exposure
           CXR (2 views)       0.02-0.07   mrad
           Abdo XR (3 views)   100         mrad
           CT Head/Chest       <1          rad
           CT Abdo             3.5         rad
           Total               4.8         rad

        ACOG guidelines suggest that imaging is
           safe when exposure is ≤ 5 rad
                   Blunt Trauma
• MVAs and abuse most common
• Fetal death can follow direct blunt trauma or
  maternal death
   – Specifically head trauma and ejection from vehicle
• Abdominal contents shifted in pregnancy
   – Retroperitoneal & splenic injury more frequent
   – GI injuries less frequent
   Blunt Trauma - Consequences
• Placental Abruption
   –   In up to 40% of severe blunt trauma
   –   In up to 3% of minor blunt trauma
   –   CTXs q10min = 20% risk of abruption
   –   Abruption confers 50% fetal mortality
• Uterine rupture
   – Increases with force and gestation
   – Fetal death frequent here, but maternal death 10%
• Pelvic Fracture
   – Consider fetal skull fracture
   – MAST trousers contraindicated
   – If stable vaginal delivery still feasible
• Pre-Term Labour …
              Blunt Trauma – Pre Term Labour
Can PTL be predicted after blunt abdominal trauma?
• 85 patients over 3 yrs with non-catastrophic trauma
Findings
• Preterm Labour in 13 (15%)
• Presence of Abdo pain or CTXs do not predict PTL
• Domestic abuse victims were more likely to have
  repeated trauma




 (Pak 1998)
                         MVAs
Frequency
• In USA, 2% of all live births have
   been exposed to a reported MVA
Seatbelts
• Up to 25% of pregnant drivers
   are unrestrained.
• Seatbelts positioned improperly
   cause a 3-4 fold increase in
   energy transmission through the
   uterus
                              MVAs




Pregnant occupant in a 35 km/hr crash at peak uterine strain.
• a) An unbelted pregnant occupant contacting the steering wheel
     • results in large deformation of the uterus.
• b) A matched belted occupant simulation
     •steering wheel contact is minimal
     •considerable neck flexion, which could lead to maternal injury.
• c) Airbag deployment combined with a three-point belt and airbag
                       MVAs
Airbags
• No large scale data of airbags in pregnancy
• Pregnancy is not an indication for deactivation of
   airbags
Pregnant Crash Test Dummy:
                 Penetrating Trauma

• Uterus may serve to protect maternal organs
   – Visceral injury from penetrating trauma in pregnancy =
     38% vs 90%
   – Of GSWs to abdomen, death in pregnancy is 1/3 rate of
     non-pregnant
   – Fetal death rate: 71% of GSWs, 42% stabs
• Penetrating trauma is generally an indication for
  exploratory laparotomy
• Half the women had perinatal deaths due to
  either maternal shock, uteroplacental injury, or
  direct fetal injury.
         A Unified Approach
Is there a need for a standardized protocol for
obstetrical patients who experience trauma?
    The low incidence of trauma during pregnancy leaves
    trauma teams at risk of ignoring steps that may prevent
    adverse outcomes. An organized approach of stabilizing
    the injured gravida and then initiating ultrasound and
    EFM in pregnancies beyond 24 wks will ensure the best
    outcome for the mother and her unborn child. It is now a
    requirement in Australia for a level 1 trauma centre to
    have a protocol detailing the management of pregnant
    patients after trauma.
          A Unified Approach
Issues to consider
• Delayed monitoring during primary survey and imaging
   – Average time to clear c-spine estimated at 36 minutes
• Access to FHR monitor in ER may not be available
   – Estimated that 15% of ERs in USA have this
• Other activities in resuscitation room may preclude
  continuous access to FH, or hinder ability to hear it
• Patients transferred to labour floor for ongoing monitoring
  may not receive optimal management of non-obstetrical
  issues
   – Eg. Soft tissue injury, Physiotherapy, occupational therapy, etc.
             TRAUMA IN PREGNANCY-
                  Key Points:
• Trauma occurs in 6-7% of pregnancies
• Physiologic changes of pregnancy may confuse the picture
• ABCs should not be abandoned in managing a pregnant
  trauma patient
• Consider Rhogam, Celestone, PPROM, and initial FH
  monitoring
• Education regarding proper use of seatbelts in pregnancy is
  paramount
• Consideration of a standardized trauma protocol or record for
  obstetrical use may be warranted.
      TRAUMA IN PREGNANCY-
           Key Points:
• Investigations ….LEYLAND’S AXIOM… “IF AN
  INVESTIGATION IS INDICATED DO IT”
• Fetal viability….24 weeks
• Fetal monitoring….OBS/PERINATOLOGY
• Transfer to regional center ONLY after
  maternal stabilization
TRAUMA IN PREGNANCY:
    Head Trauma


• Dead Mother = Dead Fetus
   CARDIOPULMONARY RESUSCITATION


• There are special considerations for
  cardiopulmonary resuscitation (CPR)
  conducted in the second half of pregnancy.
• uterine displacement is paramount to
  accompany other resuscitative efforts
          G.I. DISEASE IN PREGNANCY:
                  APPENDICITIS
•   Abdominal pain, nausea,vomiting
•   Anorexia*
•   Localization of the pain and tenderness
•   Ultrasound?
•   Laparoscopy?…Negative Laparotomy Rate
•   Fetal Mortality and Maternal Morbidity rates
    are directly correlated to the delay in
    diagnosis and treatment******
    OB/GYNE CONDITIONS MIMICKING
            APPENDICITIS:
•   PRETERM LABOUR
•   PLACENTAL ABRUPTION
•   DEGENERATION OF FIBROIDS
•   ADNEXAL EVENTS
•   ROUND LIGAMENT PAIN
•   ECTOPIC PREGNANCY
•   CHORIOAMNIONITIS
 CHOLECYSTITIS IN PREGNANCY:

• SIGNS AND SYMPTOMS =
• DDx:
  MI
  ACUTE FATTY LIVER OF PREGNANCY
  APPENDICITIS
  SEVERE PREECLAMPSIA/HELLP
  PUD
  PANCREATITIS
 CHOLECYSTITIS IN PREGNANCY:

• DIAGNOSIS…U/S
• TREATMENT…MEDICAL.1ST AND 3D TM
             …SURGICAL.2ND TM
…FAILURE OF MEDICAL OR RECURRENT ATTACKS
• LAPAROSCOPY?
         G.I. DISEASE IN PREGNANCY:
             BOWEL OBSTRUCTION
• Morbidity and Mortality related to the delay
    in diagnosis*
•   Previous Surgery and Adhesions--3d TM
•   Volvulus, Hernia, Intussusception
•   Signs and Symptoms =
•   Diagnosis Serial Assessments and Serial AXRs
•   Management?
    PANCREATITIS IN PREGNACY


•   PRESENTATION
•   INVESTIGATIONS
•   MANAGEMENT
•   FETAL CONSIDERATIONS?
NEUROVASCULAR EMERGENCIES IN
        PREGNANCY:


• AVMs, ANEURYSMS
• SURGICAL MANAGEMENT: TREATMENT AT
  THE TIME OF PRESENTATION(ANEURYSM)
  AVM LESS CLEAR
• SUPERIOR SAGITAL SINUS THROMBOSIS
                CASE 1
• 29 YR OLD @ 34 WEEKS GESTATION
  N/V X 8 HOURS, ANOREXIA (NEW ONSET)
• PX… AFEBRILE, TENDER MID- ABDOMEN
  RIGHT WITH REBOUND
• UTERUS NON TENDER BUT CAUSES
  TENDERNESS ON RIGHT WITH PALPATION
  FROM THE LEFT
              CASE 1

•   INVESTIGATIONS?
•   DDx?
•   FETAL CONSIDERATIONS?
•   MANAGEMENT
               CASE 2
• “THE MOOSE STORY”
                 CASE 2

•   “THE MOOSE STORY”
•   NOW IN THE NEUROSURGICAL ICU
•   CONSULTS OBS RE CT, ANGIOGRAPHY
•   CONSIDERATION OF TERMINATION?
              CASE 2

• “THE MOOSE STORY”
• THE HAPPY ENDING……….
                CASE 3
• 30 YR OLD WOMAN AT 24 WEEKS GESTATION
  MVA HIT FROM BEHIND
• HAD SEAT BELT ON, NO HEAD INJURY
• O/E VSS, BRUISED AND TENDER ABDOMEN
• FETAL HEART TONES HEARD
• WHAT ARE THE ISSUES HERE?
                 CASE 3
• MATERNAL CONSIDERATIONS FIRST!
• FETUS SECONDARY
• MONITORING IF FETUS VIABLE
• FETAL MATERNAL TRANSFUSION
BETKE-KLEIHAUER
• SURGICAL DELIVERY IF FETAL DISTRESS AND
  MOTHER IS STABLE
    SURGERY IN THE PREGNANT
            PATIENT
• AVOID “THERAPEUTIC PARALYSIS”
• IF AN INVESTIGATION IS INDICATED FOR
  DIAGNOSIS ---DO IT!
• NEVER COMPROMIZE THE MATERNAL CARE
  FOR THE SAKE OF THE FETUS!
• THERE ARE VERY FEW DRUGS OR
  INVESTIGATIVE TESTS WHICH CAUSE
  SERIOUS FETAL DAMAGE
 SURGERY IN THE PREGNANT
         PATIENT
         Learning objectives:
      1)TRAUMA IN PREGNANCY
2)THE ACUTE ABDOMEN IN PREGNANCY
   3)NEUROVASCULAR EMERGENCIES
               4)CASES

             THANKS!

				
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