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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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