SJWH HROB Trauma in Pregnancy
Hi, I'm Patti Shepherd, the advanced clinical specialist on high risk OB at St. Joseph's Womens' Hospital and we're going to talk today about trauma in pregnancy; caring for these patients on the high risk OB unit. Trauma in pregnancy is the leading cause of non-obstetric maternal death in the U.S.
And sometimes apparently minor injuries do have potential significant maternal and fetal morbidity and mortality and it's important to know that one in 12 women sustain significant traumatic injury during pregnancy. So how are these cases occurring? Well, a small percentage have trauma in the first trimester and about 1/3 experience it in the second trimester and almost 1/2 have trauma in the third trimester. And that makes sense; when their stomach protrudes more, their abdomen is out there more exposed. But what type of injuries are they receiving? Over 1/2 experience motor vehicle accidents and equally split 1/4 have falls and 1/4 experience assaults. Only 1% experience burns. So, maternal adaptations, well, what determines the maternal-fetal response to trauma? It depends on what the mechanism of the injury is.
Are they experiencing blunt trauma? Have they experienced a stabbing? Is it a gunshot? Are they in a motor vehicle accident? What was the gestational age at the time the trauma was recieved? What secondary complications are there? So let's look at maternal adaptations in pregnancy and how they impact the patient. And remember: I'm reviewing this only to get you in the mindset of how it impacts your patient. Most of the patients that we will be receiving have already been medically cleared and are stable, but it's important for you to just mentally review these things.
So, the cardiovascular adaptations of pregnancy. Patients' plasma volume is increased by 50%, for red blood cells your volume is up by 30% along with her heart rate and cardiac output have both also increased 10 to 15% and 30 to 50% respectively. Now, pregnancy is considered a high-flow, low resistance state so she has an increased blood volume, but there's not a lot of resistance to that blood circulating around in her body. So all of this increased blood volume could mask a significant hemorrhage because mom is going to compensate for that. Every 8 to 10 minutes that total circulating maternal blood volume is going to flow through her utero-placental bed.
But someone who is not familiar with the physiologic changes of pregnancy may not pick up quickly enough that mom is experiencing a significant hemorrhage. So any condition that decreases moms blood pressure is going to cause vasoconstriction of the uterine arteries and that's going to cause her to shunt blood to her own vital organs and make her maintain her blood pressure which peaks at the expense of her baby. This increased blood volume of pregnancy and this shunting is going to help her remain stable until this massive blood loss has occurred and once you finally see the tachycardia and the hypotension, she's had pretty extensive blood loss and you're pretty far behind, so don't wait until you're seeing tachycardia and hypotension; stay on top of her I&O and if you have a mom that you're starting to see tachycardia and hypotension on, you need to jump right on that. Because as I said before, these patients should have already been medically cleared before they get to us so they should be very stable by the time we have them. Now with maternal positioning, we all know you shouldn't really put a pregnant woman flat on her back. We should avoid that position because it decreases the veinous return and it decreases her cardiac output and you have a decrease in uterine blood flow. So we should put a wedge or a rolled blanket under her to tilt her or put her in a lateral position.
Now sometimes that's not possible; what if she has a pelvic fracture or she's in some traction and maybe we can't tilt her? Well, then your options are to manually displace the uterus. We can try to position her that way. Maybe she's going to come to us on a backboard, then we could put a rolled blanket under that to tilt the backboard to a 15 degree, just to get enough to get a little bit of a tilt on that uterus. So here's a little bit of an interlude since we've kind of got you thinking about some things that are little bit outside of what we normally think and maybe not as pleasant as we'd like to think about. Now her pulmonary system adaptations; there's already a primary normal change in the acid- base balance in pregnancy and the pregnant trauma patient is vulnerable to hypoxemia and less able to compensate if acidemia ensues.
If she's advanced in her pregnancy and ended up with a chest tube, it would be inserted between the third and fourth intercostal space, so she may already have a wound where that chest tube was inserted and maybe already removed and you would need to be looking for that. It would be in a higher than normal location than in a non-pregnant person. With her GI System, her enlarging uterus causes the cephalad displacement of intra-abdominal organs and this can lead to altered patterns of pain occurring with injury. Any abdominal tenderness, rebound, or guarding may be absent despite the presence of a significant injury. A decrease in GI motility secondary to the influence of progesterone and relaxation of smooth muscle leads to a delayed gastric emptying and a laxity of the esophageal sphincter which can make this patient vulnerable to vomiting of the abdominal contents and pulmonary aspiration. So it would be advisable that she had an NG tube early, and depending on her injuries, some of our patients may remain on our inpatient unit with an NG tube in place. Since the bladder is displaced both anterior and superiorly as the uterus grows, it also becomes an abdominal organ and is more likely to be injured during blunt trauma to the abdomen. In addition, the gravid uterus may obstruct or impede urinary outflow, so position the patient laterally when possible and remember that increased renal blood flow of pregnancy leads to an increased glomerular filtration rate and increased creatinine clearance when you're looking at their labs.
Now, psychosocial issues to consider with trauma in pregnancy. These patients may come with multiple injuries from their trauma and we need to try to get them to discuss their fears and concerns related to what they've just experienced. For most of these patients, this experience was very traumatic, unexpected, and may leave them fearful about their future.
How we help them through this time can be crucial in helping them to start to heal physically, emotionally, intellectually, and as a family. Encouraging our patients to verbalize their fears can help us provide them better care while they're here, so helping them deal with their anxiety or their alteration in bonding with their baby is going to be key in helping them to kind of get whole or get well again. Keep in mind, our patient may be dealing with some potential grief because perhaps they're relooking at the relationship that they have with their significant other particularly if this was a domestic violence injury. She may be rethinking, "Oh my gosh. I'm about to have a baby or bring a child into this relationship, and this person has caused me this harm and I don't know if I can do this now with this person or I don't know if I can bring this baby into this environment." It's also important to remember to take care of yourself when you're taking care of patients that have been through difficult situations. There's a clinical standard called, "Pregnant trauma patient, care of the." Establish the gestational age of the patient to determine the need for continuous fetal monitoring. Asses the uterus by palpating her abdomen, paying attention to any areas of tenderness, uterine tone, and any fetal activity. Mark the fundal height on her abdomen and check hourly to see if it's rising.
Assess fetal well being via the Doppler or the electronic fetal monitor. If the patient is greater than 23 weeks' gestation, she's a candidate for continuous electronic fetal monitoring for a minimum of 2 hours from the time of the injury, or as ordered by the OB provider. Determine whether the patient has leaking of the amniotic fluid. If so, what color was it, when did it occur, and is there an odor with it? Ask her whether she's having any vaginal bleeding.
Placental abruption is a common complication following blunt trauma and one of the primary reasons that we would monitor a patient on a continuous fetal monitor. As pregnancies progress, uterine musculature becomes more elastic with the placenta in a fixed location. With an acceleration-deceleration type injury like a motor vehicle accident, fall, or an assault, shearing forces are created that can cause the placenta to detach from the uterine wall. This usually occurs after 20 weeks of pregnancy.
The mother may complain of strong contractions, but not seem to be making progress in labor or she may be progressing very quickly. Tissue thrombroplastin released during an abruption can lead to plasminogen activator- mediated fibrinolysis resulting in, or exacerbating, disseminated intravascular coagulation, or DIC, and fetal mortality can approach 75% A 50% abruption is associated with fetal demise. So, your mom is going to complain of things like pain, severe contractions out of proportion to what you're are seeing in progress, she may or may not have obvious bleeding, and she may or may not complain of back pain.
Your physical exam may reveal a tender and rigid uterus or tetanic contractions; observe for any vaginal bleeding. The uterine cavity can accomodate one's entire blood volume and the bleeding can be occult and not be visible. It will lead to abdominal pain and a rigid abdomen eventually, as well as coagulopathy and hemodynamic instability. The fetus may have fetal bradycardia or tachycardia, depending on how recent the abruption is and how well they're compensating. Or prolonged deceleration associated with uterine tachysystole, or a non-reassuring fetal tracing pattern with repetitive late decelerations. Absent variability is not reassuring and tells you that your fetus is compromised, or you may see a sinusoidal baseline pattern, which is sometimes associated with an anemic fetus. Uterine rupture occurs either with rapid deceleration injuries or with direct compression injuries. It's the actual separation of the uterine wall with ruptured membranes which allows fetal parts and/or the umbilical cord into the peritoneal cavity.
This carries the potential for a massive hemorrhage and is associated with a very high rate of fetal demise. Moms will complain of a tearing sensation and then if they were contracting before their contractions will stop. When doing your assessment on the mom, palpate her abdomen to make sure it isn't rigid, checking for any rebound tenderness, areas of tenderness, or significant asymmetry to her uterine shape. If you can easily palpate fetal parts through the abdominal wall when you couldn't before, you need to be suspicious of a uterine rupture.
Signs of shock like thirst, vomiting, syncopal episodes, tachycardia, and pallor. Mom may exhibit some vaginal bleeding and absent fetal heart tones at this point and if signs of shock are present, mom requires high flow oxygen, monitoring for the mother and fetus, and emergency surgery. Unfortunately, not all pregnant trauma victims ultimately survive. It's important as OB nurses that we understand a few important things about maternal cardiac arrest and how to manage it when we have a viable fetus on board as well. You can defibrillate a pregnant patient. If she is on a fetal monitor, remove the fetal monitor belts from her abdomen. Providing high quality CPR and following the ACLS algorithms may bring your patient back.
It's important to remember to address what the cause of the arrhythmia was and to treat that in addition to treating the arrhythmia. You will need a team that can perform the ACLS protocols on your patient, as well as an OB team that can perform an emergency caesarean delivery within a short amount of time to hopefully improve both your mom and your fetus's chance of survival once the decision is made to perform the caesarean delivery. To maximize the fetus's outcome, we should start delivery within four minutes. Thank you for your time and attention today. If you have any questions, please seek me out on the unit.
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