TRAUMA IN

PREGNANCY

TRAUMA IN
PREGNANCY

OVERVIEW

Anatomy and physiology

Pathophysiology
Evaluation and management

TRAUMA IN
PREGNANCY

THE PREGNANT
TRAUMA PATIENT
Two patients with separate needs
Mother
Fetus

Twin goals of management

Support mother
Identify needs of the fetus
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TRAUMA IN
PREGNANCY

PHYSIOLOGIC CHANGES
OF PREGNANCY
Changes related to gestational
age
Major shift of circulatory system
to provide blood flow to uterus
Mother at more risk
Increased risk of injury
Less able to compensate for shock
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TRAUMA IN
PREGNANCY

CARDIOPULMONAR
Y CHANGES
Increased cardiac output by
2030%
Pulse increases by 10-15
beats/minute
BP decreases by 10-15mmHg
Increased resting respiratory rate
Elevation of diaphragm by uterus
decreases thoracic volume
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TRAUMA IN
PREGNANCY

SYSTEMIC BLOOD
VOLUME

Increased plasma volume

Increased red cell volume
Blood volume increases 45-50%
Anemia of Pregnancy
Rise in plasma volume is greater than
the rise in red cell volume
Results in a relative anemia

TRAUMA IN
PREGNANCY

ABDOMEN
Delayed gastric emptying
Increased risk of vomiting and
aspiration

Uterus becomes the largest

abdominal organ
More likely to be injured from either
blunt or penetrating trauma
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TRAUMA IN
PREGNANCY

URINARY SYSTEM
CHANGES
Bladder is displaced upward and
forward by enlarging uterus
Increased risk of bladder injury
from blunt or penetrating trauma

TRAUMA IN
PREGNANCY

CHANGES IN THE
UTERUS
Uterine blood flow increases
Nonpregnant = 2% cardiac output
Pregnant = 20% cardiac output

Uterine vessels constrict in

response to catecholamine release
in early shock
20-30% decrease in uterine blood flow
Risk fetal hypoxia and death
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TRAUMA IN
PREGNANCY

CAUSES OF
TRAUMATIC FETAL
DEATH
#1 - Maternal death
#2 - Maternal shock
#3 - Abruptio placenta

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TRAUMA IN
PREGNANCY

FETAL
DEVELOPMENT

11

TRAUMA IN
PREGNANCY

SUPINE
HYPOTENSION
SYNDROME
The enlarging uterus can
compress the inferior vena cava
when the mother is in the supine
position
Reduces venous return and cardiac
output by up to 30%
More likely after the 20th week of
pregnancy
12

TRAUMA IN
PREGNANCY

COMPRESSION OF
THE VENA CAVA CAN
CAUSE
Maternal
hypotension
Syncope
Fetal bradycardia

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TRAUMA IN
PREGNANCY

PACKAGING OF PREGNANT
TRAUMA PATIENTS
Full spinal immobilization
Tilt backboard 20-30 degrees to the
left
May manually displace the uterus to
the left but not as effective
Short backboards and similar
devices not useful because of
difficulty attaching straps
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TRAUMA IN
PREGNANCY

ASSESSMENT
Assessment sequence same as for
nonpregnant patients
BTLS Primary Survey
Initial Assessment
Rapid Trauma Survey or Focused Exam

Detailed Exam
Ongoing Exam

Priorities same as for nonpregnant

patients
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TRAUMA IN
PREGNANCY

DO NOT CONFUSE
NORMAL VITAL
SIGNS IN
PREGNANCY FOR
SIGNS OF SHOCK
Pulse is 10-15 beats/min. faster
BP is 10-15mmHg lower

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TRAUMA IN
PREGNANCY

SHOCK IN
PREGNANCY
Can lose 30% of blood volume
before having significant change
in BP
Can have significant occult
intrauterine or abdominal bleeding
Uterus is very vascular
May not have abdominal tenderness
early even with significant bleeding
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TRAUMA IN
PREGNANCY

MANAGEMENT
100% oxygen
Very important
You are treating the fetus also

Transport with full spinal

packaging
Tilt backboard to the left

Treat specific injuries

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TRAUMA IN
PREGNANCY

MANAGEMENT OF
SHOCK
IV access
Two large bore IVs of NS or RL

May require larger volume of

fluids for resuscitation
Blood should be given early

If PASG is indicated, inflate leg

compartments only
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TRAUMA IN
PREGNANCY

MATERNAL
CARDIAC ARREST
Manage same as the nonpregnant
patient
Perform CPR
Notify hospital to be prepared for
possible emergency c-section

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TRAUMA IN
PREGNANCY

SUMMARY

TRAUMA IN
PREGNANCY

Treating two patients

Physiologic changes increase the risk
of injury and shock
Treat shock early
Prevent and treat hypoxia
Prevent supine hypotension syndrome
Frequent reassessment
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QUESTIONS?

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TRAUMA IN
PREGNANCY