Outline the special considerations involved in the care of a pregnant patient involved in multi-trauma.

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College Answer

a High flow 02 to avoid maternal and fetal distress

b.  Reduced respiratory reserve

c.  Matemal compensation for blood loss is at ilie expense of uteroplacental flow

d.  Avoid aortocaval compression

e.  Transfusion should be Rh compatible

f   All Rh negative mothers to receive lg because of the immunological risk of minor fetomatemal hemorrhage

g.  Minimal exposure to radiation

h.  U/S may be preferable

i.    Retroperitoneal hemorrhage, placental abruption, fetal distress may occur

j.     Premature labour may be precipitated

k.  Need for regular cardiotocograph.

I.     ·Pelvic binders may be unsuitable

m. Physiological anemia of pregnancy

Discussion

The management of the pregnant poly-trauma patient is discussed elsewhere.

This is one of those questions which could fit equally well into the "pregnancy and obstetrics" category.

In summary:

  • Airway issues
    • The airway is more difficult to control.
    • There is an increased risk of aspiration due to decreased gastric emptying and weakened lower oesophageal sphincter.
  • Respiratory issues
    • The respiratory function is impaired by decreased FRC;
    • One needs to insert their chest drains higher, so as to avoid the pushed-up diaphragms
    • When setting up the ventilator, one needs to keep in mind that the PaCO2 is supposed to be 30mmHg in late pregnancy.
  • Circulatory issues
    • The total blood volume has expanded, the cardiac output is high, and thus signs of shock will develop late.
    • Vena cava compression means the patient needs to be positioned at a 30° tilt
  • Neonatal and foetal welfare
    • Pelvic binders are inappropriate
    • Pelvic fractures may threaten the near-term foetus
    • Placental abruption may result in massive haemorrhage and needs to be excluded early in the primary survey
    • Foetal heart rate monitoring is essential
    • Early transfer to an O&G-equipped hospital is essential
    • Retroperitoneal haemorrhage from dilated pelvic veins can be difficult to assess without ultrasound
    • A vaginal examination needs to be performed, looking for amniotic fluid (a pH of 7.0-7.5 will confirm this - the normal vaginal pH is much lower than this)
  • Transfusion and general haematology issues
    • Rhesus-negative mothers need to receive IV immunoglobulin at least within 48 hours of the trauma
    • Transfusion needs to be Rh compatible
    • The pregnant trauma patient is in an even more hypercoagulable state than the normal trauma patient, and thus requires special attention to DVT prophylaxis
  • Drug choices
    • Antibiotic choices are limited; tetracyclines and fluoroquinolones are to be avoided
    • If urgent caesarian delivery is planned, intubation drugs wil affect the foetus; thus there is need for NICU involvement for ventilation

Issues to consider in investigations and the secondary survey

  • The usual barrage of blood tests remains unchanged.
  • FBC, EUC, CMP LFT coags and crossmatch get sent away just as they would in any trauma patient, but the savvy candidate will mention the need for Rh blood grouping to prevent Rh isoimmunisation (where the mother is Rh negative and the foetus is Rh positive). An administration of anti-Rh IVIG can mop up any Rh-positive foetal erythrocytes which might have haemorrhaged into the maternal circulation, preventing the mother from developing her own anti-Rh antibodies (and thus preventing the haemolytic disease of the newborn).
  • An abdominal ultrasound (FAST) is still performed, with additional focus on the uterus; uterine rupture or placental abruption need to be detected early.
  • Foetal welfare can be monitored by CTG, and the O&G specialist should be invited to perfrom their own focused ultrasound to investigate the pregnancy.
  • Though radiation exposure is undesirable, it is tolerated (particularly in late term pregnancy) because organogenesis has already taken place, and because the risk from ionising radiation exposure is minute in comparison to the risk of missed injuries and haemorrhage.

References

References

 

Oh's Intensive Care manual: Chapter 64   (pp. 684) General  obstetric  emergencies by Winnie  TP  Wan  and  Tony  Gin

 

Soar, Jasmeet, et al. "European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution." Resuscitation 81.10 (2010): 1400-1433.

 

Mattox, Kenneth L., and Laura Goetzl. "Trauma in pregnancy." Critical care medicine 33.10 (2005): S385-S389.

 

DROST, THOMAS F., et al. "Major trauma in pregnant women: maternal/fetal outcome." Journal of Trauma-Injury, Infection, and Critical Care 30.5 (1990): 574-578.