9/1/2009. Lemons 2001

(1)

TRAUMA IN PREGNANCY

Fifth leading cause of Fifth leading cause of death worldwide death worldwide

Death rate of women from Death rate of women from unintentional injury is unintentional injury is 24/100 000 24/100 000 24/100,000 24/100,000

Most frequent form is Most frequent form is motor vehicle accidents motor vehicle accidents

US 1.6 deaths per 10US 1.6 deaths per 1066

miles miles

Accidents: women 143, Accidents: women 143, men 95 / 10

men 95 / 1077_{miles driven}_{miles driven}

TRAUMA IN PREGNANCY

INCIDENCE 1:12 INCIDENCE 1:12 LIFE THREATENING LIFE THREATENING 33--4:10004:1000 MATERNAL DEATH RATE MATERNAL DEATH RATE 1.9/100,00 LIVE BIRTHS 1.9/100,00 LIVE BIRTHS MVA’S, FALLS, ASSAULTS MVA’S, FALLS, ASSAULTS ABUSE AND BATTERY 1:10 ABUSE AND BATTERY 1:10

TRAUMA IN PREGNANCY

Fetal Mortality

1300 to 3900 pregnancies in U.S. per year 1300 to 3900 pregnancies in U.S. per year are lost due to trauma

are lost due to trauma

Life threatening maternal trauma 40% Life threatening maternal trauma 40%--50% fetal loss rate

50% fetal loss rate

Minor Maternal trauma 1%

Minor Maternal trauma 1% -- 5% fetal loss 5% fetal loss rate

rate

More than 50% of fetal losses occur with More than 50% of fetal losses occur with minor or insignificant maternal trauma minor or insignificant maternal trauma

(2)

Etiology of Severe Trauma in

Pregnancy

Motor Vehicle Accidents

Motor Vehicle Accidents 63.9%63.9% Falls Falls 19.2%19.2% Penetrating wounds Penetrating wounds 10.0%10.0% Penetrating wounds Penetrating wounds 10.0%10.0% Blunt Trauma Blunt Trauma 5.8%5.8% Burns Burns 1.0%1.0% Maternal Mortality Maternal Mortality 1.9%1.9% Fetal Mortality Fetal Mortality 10.0%10.0%

Gestational Age Specific

Survival Rates

not specifically trauma related not specifically trauma related

Gestational age in week

Gestational age in week Survival rate in %Survival rate in % 22 22 0.0 %0.0 % 21%21% 24 24 9.9 %9.9 % 50%50% 26 26 54 7%54 7% 80%80% Cooper, RL 1993 Cooper, RL 1993 26 26 54.7%54.7% 80%80% 28 28 77.4%77.4% 92%92% 30 30 90.6%90.6% 97%97% 32 32 96.5%96.5% 93%93% 34 34 98.7%98.7% 36 36 99.5%99.5% Lemons 2001

Intentional Injury MS 1995

MVA 43.4%

MVA 43.4% Fall 25.1% Blunt assault Fall 25.1% Blunt assault 25.1%

25.1% Shooting 3 9%

Shooting 3 9% Stabbing 2 5%Stabbing 2 5% Shooting 3.9%

Shooting 3.9% Stabbing 2.5% Stabbing 2.5% Intentional injury 31.5% Intentional injury 31.5%

5 of 8 fetal losses were without obvious signs 5 of 8 fetal losses were without obvious signs

of trauma externally of trauma externally

Think interpersonal violence and abuse with Think interpersonal violence and abuse with

defensive bruising and facial and neck defensive bruising and facial and neck injuries injuries

Critical

Physiologic

changes of

Pregnancy

affect

assessment

of the injured

gravida

(3)

PHYSIOLOGICAL CHANGES OF

PREGNANCY AS THEY RELATE TO

TRAUMA

PARAMETER

PARAMETER CHANGECHANGE IMPLICATIONIMPLICATION Maternal blood volume

Maternal blood volume Attenuated initial Attenuated initial response to

response to hemorrhage hemorrhage Cardiac Output

Cardiac Output Increased metabolic Increased metabolic demands

demands Uterine enlargement

Uterine enlargement Propensity for supine Propensity for supine hypotension hypotension from aorto

from aorto--caval caval compression compression

PHYSIOLOGICAL CHANGES OF

PREGNANCY AS THEY RELATE TO

TRAUMA

PARAMETER

PARAMETER CHANGECHANGE IMPLICATIONIMPLICATION Functional Residual volume

Functional Residual volume Hypoxemia Hypoxemia from atelectasis from atelectasis is more likely is more likely is more likely is more likely Gastrointestinal motility

Gastrointestinal motility Greater risk of Greater risk of aspiration aspiration

Minute ventilation

Minute ventilation Compensated Compensated respiratory alkalosis, respiratory alkalosis,

diminished diminished buffering

buffering capacitycapacity

Caveats in the Management of

the traumatized gravida and her

Fetus

The greater the severity of maternal trauma, The greater the severity of maternal trauma, the more likely a significant fetal insult will the more likely a significant fetal insult will occur

occur occur occur

Retroperitoneal hemorrhage occurs more Retroperitoneal hemorrhage occurs more frequently with gestational trauma than in frequently with gestational trauma than in the presence of a nongravid uterus the presence of a nongravid uterus Bowel injuries are less frequent in Bowel injuries are less frequent in gestational trauma

gestational trauma

ABG Differences

Gravid

Gravid NonNon--GravidGravid pCO2 pCO2 2727--3232 3939--4040 O2 O2 100100 108108 9595 100100 pO2 pO2 100100--108108 9595--100100 pH pH 7.407.40--7.457.45 7.407.40 Bicarbonate Bicarbonate 18 18 -- 21 21 24 24 -- 2929 For best fetal outcome, pO2 should be kept at For best fetal outcome, pO2 should be kept at

greater than 60 mm Hg greater than 60 mm Hg

(4)

Fetus

Pelvic fractures correlate with an increased Pelvic fractures correlate with an increased

frequency of placental abruption, frequency of placental abruption, qq yy pp pp retroplacental hemorrhage, urinary tract retroplacental hemorrhage, urinary tract injuries, uterine rupture, and fetal head injuries, uterine rupture, and fetal head injuries

injuries

Pneumatic shock garments may compromise Pneumatic shock garments may compromise

UBF UBF

Maternal blood loss is often underestimated Maternal blood loss is often underestimated

Caveats in the Management of

Fetus

Minor injuries can lead to placental Minor injuries can lead to placental abruption, fetal

abruption, fetal--maternal hemorrhage andmaternal hemorrhage and abruption, fetal

abruption, fetal maternal hemorrhage and maternal hemorrhage and premature birth

premature birth

Abdominal complaints and abnormal Abdominal complaints and abnormal findings may not present initially and findings may not present initially and diagnostic tests are not as definitive as in diagnostic tests are not as definitive as in the nonpregnant patient

the nonpregnant patient

Caveats in the Management of

Fetus

Maternal blood loss is often underestimated Maternal blood loss is often underestimated Splenic rupture is the most common cause Splenic rupture is the most common cause Splenic rupture is the most common cause Splenic rupture is the most common cause

of intraperitoneal hemorrhage in of intraperitoneal hemorrhage in pregnancy trauma

pregnancy trauma

Rib fractures are associated with splenic Rib fractures are associated with splenic and hepatic injury more so in pregnancy and hepatic injury more so in pregnancy trauma

trauma

Caveats in the Management of

Fetus

Tocolytic therapy must be used with Tocolytic therapy must be used with

discretion and sensitivity for side effects as discretion and sensitivity for side effects as yy well as potential hazards

well as potential hazards

Pregnancy should not be the rationale for Pregnancy should not be the rationale for

compromise modification of the evaluation compromise modification of the evaluation and treatment plan for the gravid trauma and treatment plan for the gravid trauma victim

(5)

Caveats in the Management of

Fetus

Vaginal bleeding and uterine contractions Vaginal bleeding and uterine contractions are cardinal signs of placental abruption are cardinal signs of placental abruption Diagnostic tests ( Radiography) and therapy Diagnostic tests ( Radiography) and therapy should be directed primarily at the care of should be directed primarily at the care of the mother and should not be delayed or the mother and should not be delayed or compromised because of the pregnancy compromised because of the pregnancy

Caveats in the Management of

Fetus

The Radiation Safety Officer ( physicist) for The Radiation Safety Officer ( physicist) for

the diagnostic radiology center should the diagnostic radiology center should keep records on dosimetry which allow for keep records on dosimetry which allow for later calculations on fetal exposure.

later calculations on fetal exposure. Ionizing radiation should be kept to the Ionizing radiation should be kept to the

minimum in those situations when MRI or minimum in those situations when MRI or ultrasound will be just as helpful

ultrasound will be just as helpful

CARDIAC ARREST

CPR is not particularly efficient in aiding CPR is not particularly efficient in aiding cardiac output or organ perfusion cardiac output or organ perfusion

Combined with aortocaval compression in Combined with aortocaval compression in pp late pregnancy it is very inefficient

late pregnancy it is very inefficient

Lateral tilt diminishes the compressive force Lateral tilt diminishes the compressive force of closed chest massage ( early use of open of closed chest massage ( early use of open massage?)

massage?)

Bedside C/S within 5 minutes of Bedside C/S within 5 minutes of unsuccessful CPR

unsuccessful CPR

ADDITIONAL FACTS REGARDING

TRAUMA IN PREGNANCY

In nonIn non--catastrophic injury there is a 9% catastrophic injury there is a 9%

incidence of pregnancy related complications incidence of pregnancy related complications

Maintenance of maternal physiologicMaintenance of maternal physiologicMaintenance of maternal physiologic Maintenance of maternal physiologic equilibrium is the best assurance of fetal equilibrium is the best assurance of fetal well

well--beingbeing

Head injuries and hemorrhagic shock are Head injuries and hemorrhagic shock are implicated in 85% of cases of maternal death implicated in 85% of cases of maternal death

In lifeIn life--threatening maternal injury, fetal loss threatening maternal injury, fetal loss rate may be as high as 41%

(6)

LABORATORY EVALUATION OF THE

OBSTETRIC TRAUMA VICTIM

COAGULATION PROFILE COAGULATION PROFILE HEPATITIS SCREEN HEPATITIS SCREEN HIV SCREEN HIV SCREEN

ARTERIAL BLOOD GASES AS NEEDED ARTERIAL BLOOD GASES AS NEEDED ARTERIAL BLOOD GASES, AS NEEDED ARTERIAL BLOOD GASES, AS NEEDED SONOGRAPHY FOR FETAL AGE, ACTIVITY SONOGRAPHY FOR FETAL AGE, ACTIVITY ( BPP), PLACENTAL LOCATION ( BPP), PLACENTAL LOCATION ( subject to a two weeks error in EGA) ( subject to a two weeks error in EGA) TOXICOLOGY SCREEN FOR SUBSTANCE TOXICOLOGY SCREEN FOR SUBSTANCE

ABUSE AND ALCOHOL ABUSE AND ALCOHOL

TRAUMA SPECIFIC RADIOGRAPHIC STUDIES TRAUMA SPECIFIC RADIOGRAPHIC STUDIES

FETAL DEATH OCCURRING

WITH MATERNAL TRAUMA

Direct Utero

Direct Utero--Placental Fetal Injury 100%Placental Fetal Injury 100% Maternal Shock Maternal Shock 67%67% Maternal Shock Maternal Shock 67%67% Pelvic Fracture Pelvic Fracture 57%57%

Severe Head Injury

Severe Head Injury 56%56%

Maternal Hypoxia

Maternal Hypoxia 33%33%

Maternal Death

Maternal Death 67%67%

FETAL INJURY AND

MATERNAL TRAUMA

Uncommon in first trimester without maternal Uncommon in first trimester without maternal

pelvic fracture or shock pelvic fracture or shock Most common direct fetal injuries are: Most common direct fetal injuries are:

Intracranial hemorrhage and skull Intracranial hemorrhage and skull Intracranial hemorrhage and skull Intracranial hemorrhage and skull

fractures fractures

Care must be taken in administration of Care must be taken in administration of

medications to the injured mother medications to the injured mother Legal consequences of maternal trauma to Legal consequences of maternal trauma to

fetal outcome fetal outcome

Postmortem cesarean Section Postmortem cesarean Section

BLUNT TRAUMA

Motor vehicle accidentsMotor vehicle accidents

FallsFalls

Aggravated AssaultsAggravated Assaults

Blast injuryBlast injury

Crush injury Crush injury

In pregnancy increased frequency of In pregnancy increased frequency of spleen rupture and retroperitoneal spleen rupture and retroperitoneal hemorrhage; decreased frequency of hemorrhage; decreased frequency of bowel injury

(7)

BLUNT TRAUMA

MANAGEMENT IN OB

Treatment priorities to the injured motherTreatment priorities to the injured mother

Important aspect in initial management is Important aspect in initial management is deflection of the large uterus away from the deflection of the large uterus away from the great vessels to diminish their effect on great vessels to diminish their effect on decreased cardiac output

decreased cardiac outputpp

Low maternal HCOLow maternal HCO₃₃associated with fetal associated with fetal death

death

Aggressive approach to exploratory celiotomy, Aggressive approach to exploratory celiotomy, blunted clinical response to irritation of

blunted clinical response to irritation of peritoneal lavage.

peritoneal lavage.

Laparotomy itself is NOT an indication for Laparotomy itself is NOT an indication for Cesarean Cesarean

BLUNT TRAUMA

MANAGEMENT IN OB

Consider Cesarean if the large uterus Consider Cesarean if the large uterus

hinders adequate treatment or evaluation of hinders adequate treatment or evaluation of intra

intra--abdominal injuriesabdominal injuries

Whereas exploration is mandatory for Whereas exploration is mandatory for pp yy abdominal gunshot, some advocates use abdominal gunshot, some advocates use close observation for stab wounds

close observation for stab wounds

Ensure tetanus immunization (TIG 250 Units Ensure tetanus immunization (TIG 250 Units IV)

IV)

For contaminated wounds give TetanusFor contaminated wounds give Tetanus--diptheria toxoid 0.5 mL ( if series was > 5 diptheria toxoid 0.5 mL ( if series was > 5 yrs ago)

yrs ago)

GENERAL COMMENTS ON

TRAUMA MANAGEMENT IN THE

OB PATIENT

Pressors/inotropes may reduce Pressors/inotropes may reduce

uteroplacental blood flow; however, their uteroplacental blood flow; however, their use may be necessary to save the mother’s use may be necessary to save the mother’s yy yy life

life

The sensitivity of ultrasound evaluation in The sensitivity of ultrasound evaluation in trauma is equivalent in the gravid and non trauma is equivalent in the gravid and non--gravid abdomen

gravid abdomen

Maximum recommended radiation dose of Maximum recommended radiation dose of 0.5 cGy but 5

0.5 cGy but 5--15 cGy is low risk15 cGy is low risk

GENERAL COMMENTS ON

TRAUMA MANAGEMENT IN THE

OB PATIENT

CT generally exposes the fetus to 3.5 cGy, CT generally exposes the fetus to 3.5 cGy, above 20 cGy adverse effects have been above 20 cGy adverse effects have been seen

seen

Intraoperative fetal heart rate monitoring Intraoperative fetal heart rate monitoring can be performed with a transducer can be performed with a transducer wrapped in a sterile bag, if this becomes a wrapped in a sterile bag, if this becomes a concern

concern

Decision for Cesarean within four minutes Decision for Cesarean within four minutes of cardiorespiratory arrest for fetal survival of cardiorespiratory arrest for fetal survival

(8)

MOTOR VEHICLE ACCIDENTS

Most common cause of fetal death is Most common cause of fetal death is

maternal death maternal death

Maternal hypoxemia has adverse Maternal hypoxemia has adverse consequences for the fetus even when consequences for the fetus even when

maternal condition is stable maternal condition is stable

Severe maternal head injury has a high fetal Severe maternal head injury has a high fetal

loss rate ( 56%) loss rate ( 56%)

MOTOR VEHICLE ACCIDENTS

Abruptio placenta is caused by shearing Abruptio placenta is caused by shearing

forces at abrupt stops forces at abrupt stops

( neither physical signs nor severity of injury can rule ( neither physical signs nor severity of injury can rule

out adverse outcome)

out adverse outcome) -- 48 hours48 hours Skull Fractures and internal bleeds lead to Skull Fractures and internal bleeds lead to

stillbirth stillbirth stillbirth stillbirth

PRETERM LABOR: tocolytic therapy in PRETERM LABOR: tocolytic therapy in

question question

Intraperitoneal Hemorrhage: Intraperitoneal Hemorrhage:

Diagnostic tests are obscured by late pregnancy ( Diagnostic tests are obscured by late pregnancy (

such as diagnostic peritoneal lavage) such as diagnostic peritoneal lavage)

THE SEAT BELT

Unbelted women are 4 X more likely to have Unbelted women are 4 X more likely to have a fetal demise and 2.5 X more likely to give a fetal demise and 2.5 X more likely to give birth within 2 days of the injury compared to birth within 2 days of the injury compared to belted pregnant women

belted pregnant women

Correct placement is to wear the lap portion Correct placement is to wear the lap portion of the belt across the pelvis, below the of the belt across the pelvis, below the pregnant abdomen, with the shoulder pregnant abdomen, with the shoulder harness placed over the midpoint of the harness placed over the midpoint of the clavicle, between the breasts to the side of clavicle, between the breasts to the side of the gravid abdomen. Instruction by health the gravid abdomen. Instruction by health care workers increases compliance by care workers increases compliance by patients 83% vs. 65%

patients 83% vs. 65%

THE USE OF AUTOMOBILE

RESTRAINTS AND PREGNANCY

OUTCOME

OUTCOME NO RESTRAINTNO RESTRAINT RESTRAINT RESTRAINT USE USE Maternal Death Maternal Death 33%33% 5%5% Fetal Death Fetal Death 47%47% 11%11%

Deployment of airbags have not been widely Deployment of airbags have not been widely studied in pregnancy but preliminary results studied in pregnancy but preliminary results are promising

(9)

THE USE OF AUTOMOBILE

RESTRAINTS AND PREGNANCY

Deployment of airbags have not been widely Deployment of airbags have not been widely

studied in pregnancy but preliminary studied in pregnancy but preliminary results are promising. ( ongoing study in results are promising. ( ongoing study in pp g (g ( gg gg yy Wisconsin)

Wisconsin)

It is recommended that there be 10 inches It is recommended that there be 10 inches

between the pregnant woman and the between the pregnant woman and the airbag before deployment for least airbag before deployment for least complications and maximum effect complications and maximum effect There is no data on side impact bags There is no data on side impact bags

THE IMPACT SEQUENCE

IMPACT all IMPACT all

increase increase

UPPER BODY UPPER BODY EXTENSION only EXTENSION only belt tension belt tension increases increases increases increases JACKNIFE JACKNIFE ABDOMINAL ABDOMINAL COMPRESSION COMPRESSION uterine pressure uterine pressure increases increases

REBOUND all REBOUND all return to normal

return to normal ACCELERATIONPRESSURE BELT TENSIONUTERINE

IMPACT AND ABRUPTION

Illustration of the

Illustration of the gravida hitting the gravida hitting the steering wheel with steering wheel with gg deformation of the deformation of the uterus and uterus and separation of the separation of the placenta from the placenta from the underlying decidua underlying decidua basalis basalis

TRAUMATIC PLACENTAL

ABRUPTION

Caused by Caused by deformation of the deformation of the elastic myometrium elastic myometrium around the relatively around the relatively around the relatively around the relatively elastic placenta elastic placenta

1% to 6% of minor 1% to 6% of minor injuries

injuries

50% of major injuries50% of major injuries

Deceleration and Deceleration and increased intrauterine increased intrauterine pressure

(10)

TRAUMATIC PLACENTAL

ABRUPTION

More likely when speed More likely when speed > 30 mph

> 30 mph

Occult without Occult without tenderness or bleeding tenderness or bleeding

Higher % of DICHigher % of DIC

Contractions, FHR Contractions, FHR abnormalities abnormalities

Tocolytics obfuscate Tocolytics obfuscate findings

findings

Additional notes on lethal

intrauterine trauma

Lethal placental or direct fetal injury can Lethal placental or direct fetal injury can occur though maternal injuries are minor occur though maternal injuries are minor or insignificant

or insignificant

Live birth is not the total story as some Live birth is not the total story as some yy babies die in the neonatal period from babies die in the neonatal period from cerebral contusions, lacerations and skull cerebral contusions, lacerations and skull fractures

fractures

Where there is abruption or fetal death Where there is abruption or fetal death observe mother for DIC

observe mother for DIC

UTERINE RUPTURE

< 1% of all severe cases of blunt trauma< 1% of all severe cases of blunt trauma

Associated with a direct impact of Associated with a direct impact of substantive force

substantive force

Findings identical to abruption withFindings identical to abruption withFindings identical to abruption with Findings identical to abruption with maternal and fetal deterioration maternal and fetal deterioration

Factors that predispose: prior uterine Factors that predispose: prior uterine scar, multiple gestation, hydramnios scar, multiple gestation, hydramnios

Relative resistance in early pregnanciesRelative resistance in early pregnancies

UTERINE RUPTURE

Complete disruption of the myometrial wall Complete disruption of the myometrial wall with or without extrusion of the fetus, with or without extrusion of the fetus, placenta, or umbilical cord into the placenta, or umbilical cord into the abdominal cavity

abdominal cavity

Avulsion of the uterine vasculature with Avulsion of the uterine vasculature with intraperitoneal or retroperitoneal intraperitoneal or retroperitoneal hemorrhage

hemorrhage

Less than full thickness injury to the Less than full thickness injury to the myometrial wall, serosal hemorrhage or myometrial wall, serosal hemorrhage or abrasions

abrasions

Complete uterine avulsion ( from an Complete uterine avulsion ( from an improperly placed lap belt

(11)

UTERINE RUPTURE

> 75% of full thickness ruptures occur in the > 75% of full thickness ruptures occur in the fundus

fundus

Peritoneal irritation: guarding, rigidity, Peritoneal irritation: guarding, rigidity, distention and rebound tenderness distention and rebound tenderness

Ab l f l li

Abnormal fetal lieAbnormal fetal lie

SonographySonography

Peritoneal lavagePeritoneal lavage

CT and MRICT and MRI

A primary repair soon after rupture may A primary repair soon after rupture may yield a salvageable uterus

yield a salvageable uterus

PELVIC FRACTURES

Associated with significant morbidity and Associated with significant morbidity and mortality

mortality

May cause problems at deliveryMay cause problems at delivery

Retroperitoneal bleeding which extends to Retroperitoneal bleeding which extends to

h b d li d i l i

the broad ligament and simulates uterine the broad ligament and simulates uterine vascular injury

vascular injury

Disruption of the bladder and urethra with Disruption of the bladder and urethra with hematuria and inability to urinate

hematuria and inability to urinate

< 10% will have a large healing callus, < 10% will have a large healing callus, severe dislocation, or unstable pelvis severe dislocation, or unstable pelvis precluding vaginal delivery

precluding vaginal delivery

FETAL ASSESSMENT IN

TRAUMA

FETAL VIABILITY > 24 WEEKS FETAL VIABILITY > 24 WEEKS

FETUS ALIVE FETUS ALIVE FETAL MONITORING FETAL MONITORING CONTINUE MONITORING CONTINUE MONITORING CONTINUE MONITORING CONTINUE MONITORING Minimum of 4

Minimum of 4--6 hrs for minor trauma6 hrs for minor trauma Minimum of 24 hrs for severe trauma Minimum of 24 hrs for severe trauma Throughout period of maternal instability Throughout period of maternal instability

Secondary evaluation of the fetus by ultrasound Secondary evaluation of the fetus by ultrasound Rh immunoglobulin in Rh negative mother Rh immunoglobulin in Rh negative mother

FETAL INJURY

FDIU from direct injury, FDIU from direct injury, maternal shock, pelvic maternal shock, pelvic fracture, maternal head fracture, maternal head

i j h i

injury or hypoxia injury or hypoxia

Skull and brain injuries Skull and brain injuries most common if the most common if the head is engaged in the head is engaged in the pelvis

pelvis

Contrecoup injuries Contrecoup injuries also occur

(12)

ELECTRONIC FETAL HEART

RATE MONITORING

Another ‘VITAL SIGN’ of the motherAnother ‘VITAL SIGN’ of the mother

Predictive of placental abruptionPredictive of placental abruption

Contractions more than 1 every 10 minutes Contractions more than 1 every 10 minutes within 4 hours of trauma 20% abruption within 4 hours of trauma 20% abruption within 4 hours of trauma, 20% abruption within 4 hours of trauma, 20% abruption

Duration of post trauma monitoring is Duration of post trauma monitoring is unknown

unknown

Logical to continue if clinical condition Logical to continue if clinical condition warrants

warrants ( ( contractions, vaginal contractions, vaginal bleeding, tenderness, non

bleeding, tenderness, non--reassuring FHR, reassuring FHR, serious maternal injury, ROM)

serious maternal injury, ROM)

Fetal Monitoring at Surgery

Prior to 24 weeks just preoperative and Prior to 24 weeks just preoperative and postoperative checks of FHR

postoperative checks of FHR

After 24 weeks intraoperative FHR After 24 weeks intraoperative FHR monitoring may be performed when monitoring may be performed when monitoring may be performed when monitoring may be performed when feasible. However, a plan must be agreed feasible. However, a plan must be agreed upon prior to surgery as to what to do if the upon prior to surgery as to what to do if the FHR is abnormal and the patient and FHR is abnormal and the patient and family must concur. Most OBs do not want family must concur. Most OBs do not want to perform a CS intraoperative of a thoracic to perform a CS intraoperative of a thoracic case for abnormal FHR

(13)

FETOMATERNAL

HEMORRAHGE

FMB in 10% to 30% of FMB in 10% to 30% of trauma cases trauma cases Bleed < 15 mL in 90%Bleed < 15 mL in 90%

Placental ‘fractures’ or Placental ‘fractures’ or ‘tears’ may occur ‘tears’ may occur

Administer Rh Administer Rh immunoglobulin to Rh immunoglobulin to Rh negative women unless negative women unless the KB is negative the KB is negative

Laparoscopy in Pregnancy

BenefitsBenefits

lessened depression from narcotic lessened depression from narcotic requirements

requirements

l i k f d li ti

lower risk of wound complications lower risk of wound complications diminished postoperative maternal diminished postoperative maternal hypoventilation

hypoventilation

more rapid maternal recovery more rapid maternal recovery

Laparoscopy in Pregnancy

RisksRisks

uterine injury from placement of gas uterine injury from placement of gas infusion needle or the trocar

infusion needle or the trocar

i d i t bd i l

increased intrabdominal pressure increased intrabdominal pressure having an effect on vascular flow having an effect on vascular flow

fetal or unknown effects from a CO fetal or unknown effects from a CO₂₂ pneumoperitoneum ( in animals this does pneumoperitoneum ( in animals this does not occur with N

not occur with N₂₂O)O)

Endoscopy in Pregnancy

EGD is not a problem and may be very EGD is not a problem and may be very beneficial

beneficial

Sigmoidoscopy is not a problemSigmoidoscopy is not a problem

P d i t t i di t d

Panendoscopy is not contraindicatedPanendoscopy is not contraindicated ECG, pulse oximetry, stabilization of ECG, pulse oximetry, stabilization of VS all are mandatory

VS all are mandatory

Transfusion and oxygen may be Transfusion and oxygen may be needed

(14)

PENETRATING TRAUMA IN

THE OBSTETRICAL PATIENT

Knife and gunshot are the most common Knife and gunshot are the most common penetrating injuries

penetrating injuries

Associated with aggravated assault, suicide Associated with aggravated assault, suicide or attempts to cause abortion

or attempts to cause abortion or attempts to cause abortion or attempts to cause abortion

Visceral injury 15Visceral injury 15--40% (non OB 8040% (non OB 80--90%)90%)

Disparate risk for the fetus and the motherDisparate risk for the fetus and the mother Uterus size protects maternal organs Uterus size protects maternal organs The uterine mass and contents ‘ shield’ The uterine mass and contents ‘ shield’ maternal organs, reducing velocity and maternal organs, reducing velocity and deflecting path

deflecting path

PENETRATING ABDOMINAL

TRAUMA IN THE OBSTETRICAL

PATIENT

Maternal death rate from gunshot wounds Maternal death rate from gunshot wounds to the abdomen is two thirds less than in to the abdomen is two thirds less than in nonpregnant victims 3.9% vs. 12.5% nonpregnant victims 3.9% vs. 12.5% The maternal death rate from abdominal The maternal death rate from abdominal stab wounds is also diminished by the so stab wounds is also diminished by the so--called protective effects of the gravid called protective effects of the gravid uterus

uterus

HIGH VELOCITY PENETRATING

WOUNDS IN GRAVID WOMEN IN

THE Lebanese Civil war

Visceral injuries present when: entrance Visceral injuries present when: entrance wound is in upper abdomen or the back wound is in upper abdomen or the back

Entry wound is anterior and below the Entry wound is anterior and below the fundus, no visceral injuries

fundus, no visceral injuries

Perinatal death in 50% from maternal shock, Perinatal death in 50% from maternal shock, uteroplacental or direct fetal injury

uteroplacental or direct fetal injury

PENETRATING WOUNDS

GUNSHOT GUNSHOT Internal injuries Internal injuries 82%82% 12.5% mortality 12.5% mortality Pregnant abdomen

Pregnant abdomen 71% fetal mortalitygg 71% fetal mortalityyy 3.9% maternal mortality 3.9% maternal mortality STABBING

STABBING Pregnant abdomen

Pregnant abdomen 42% fetal mortality42% fetal mortality 0% maternal mortality 0% maternal mortality

(15)

SHARP TRAUMA AND

PREGNANCY

AIRWAY AIRWAY BREATHING BREATHING CARDIAC CARDIAC CARDIAC CARDIAC DRUGS DRUGS

Electronic Fetal Heart Monitoring Electronic Fetal Heart Monitoring

Assess for Labor Assess for Labor

Assess for Rupture of Membranes Assess for Rupture of Membranes

SHARP TRAUMA AND

PREGNANCY

Check on tetanus status Check on tetanus status Kleihauer

Kleihauer--Betke stain (Fetaldex) Betke stain (Fetaldex) –– {Rh immune globulin} {Rh immune globulin} {Rh immune globulin} {Rh immune globulin}

Diagnostic radiologic studies for foreign Diagnostic radiologic studies for foreign

bodies bodies

Open Peritoneal Lavage Open Peritoneal Lavage

Cesarean section for: Cardiac arrest, Cesarean section for: Cardiac arrest, Abruptio placenta, Fetal distress, Abruptio placenta, Fetal distress, abdominal or Uterine exploration and abdominal or Uterine exploration and

repair repair

Fetal Status Abdominal gunshot wound during pregnancy

DEAD ALIVE

Entrance wound Above fundus

OR Bullet not in uterus Entrance wound below fundus OR Bullet in Fetal injuries OR compromise Bullet not in uterus

uterus Observation Celiotomy Repair of Injuries No fetal Injuries OR compromise Exploration, Cesarean Section Explore if necessary Await Spontaneous Delivery

FAST

Focused Assessment for the Sonographic Focused Assessment for the Sonographic

examination of the Trauma patient examination of the Trauma patient

The fourth operation is to place the transducer The fourth operation is to place the transducer

4 cm superior to the symphysis pubis and 4 cm superior to the symphysis pubis and 4 cm superior to the symphysis pubis and 4 cm superior to the symphysis pubis and sweep inferiorly as in a transverse section to sweep inferiorly as in a transverse section to obtain a coronal view of the full bladder and obtain a coronal view of the full bladder and both sides of the pelvis.

both sides of the pelvis.

Helpful in determining volume and location of Helpful in determining volume and location of

intra

intra--abdominal fluid and for peritoneal abdominal fluid and for peritoneal lavage

(16)

DIAGNOSTIC GUIDELINES FOR

PERITONEAL LAVAGE

ASPIRATE

ASPIRATE bloodblood > 10 ml> 10 ml

5 ml is equivocal 5 ml is equivocal fluid

fluid enteric fluidenteric fluid LAVAGE LAVAGE RBC’s > 100,000/mmRBC’s > 100,000/mm33 50,000 is equivocal 50,000 is equivocal WBC’s > 500/mm WBC’s > 500/mm33 200 is equivocal 200 is equivocal Amylase > 20 IU/L Amylase > 20 IU/L Bile

Bile confirmed biochemicallyconfirmed biochemically

KNIFE WOUNDS

Prognosis is better than gunshotPrognosis is better than gunshot

Decision to perform laparotomy Decision to perform laparotomy –– individualizedindividualized

Explore upper abdominal sitesExplore upper abdominal sites

In gyn stabs do not penetrate the peritoneum in 1/3 In gyn stabs do not penetrate the peritoneum in 1/3

f ith

of cases, more common with pregnancy of cases, more common with pregnancy

Fistulogram or detection of bowel spillageFistulogram or detection of bowel spillage

IVP for bladder or ureteral injuryIVP for bladder or ureteral injury

Amniocentesis for blood and bacteriaAmniocentesis for blood and bacteria

Uterine vessels are lateralUterine vessels are lateral

KNIFE WOUNDS

The violent nature of the

crime is demonstrated by the numerous stab wounds The number wounds. The number and location of the stab wounds suggests extreme anger with a sexual motivation. The assailant in this case was a former boyfriend

Burns

A burn injury usually results from an energy transfer to the body. There are many types of burns caused by thermal, radiation, chemical, or electrical contact.

thermal burns - burns due to external heat

sources which raise the temperature of the skin and tissues and cause tissue cell death or charring. Hot metals, scalding liquids, steam, and flames, when coming in contact with the skin, can cause thermal burns.

(17)

Burns

radiation burns - burns due to prolonged

exposure to ultraviolet rays of the sun, or to other sources of radiation such as x-ray.

chemical burns - burns due to strong acids

or alkalis coming into contact with the skin or alkalis coming into contact with the skin and/or eyes.

electrical burns - burns from electrical

current, either alternating current (AC) or direct current (DC).

BURNS

< 4% are pregnant women< 4% are pregnant women

Pregnancy does not alter the incidence of Pregnancy does not alter the incidence of burns

burns

Complications: SAB, preterm labor, fetalComplications: SAB, preterm labor, fetalComplications: SAB, preterm labor, fetal Complications: SAB, preterm labor, fetal death

death

When TBSA 70When TBSA 70--80% 80% -- maternal mortality is maternal mortality is 50

50--90%90%

Fluid loss is greatest in the first 12 hoursFluid loss is greatest in the first 12 hours

When TBSA > 50% When TBSA > 50% -- fetal survival is fetal survival is negligible

negligible

BURNS

Fetal loss occurs within the first week

after the burn

Fetal loss in 1

stst

trimester

Fetal survival tied to maternal survival

in the 2

ndnd

trimester

Fetal outcome related to gestational

age in the 3

rdrd

trimester

BURN TYPES

Management is based on depth of burn and Management is based on depth of burn and

size of area burned size of area burned Partial

Partial--Thickness burn (old 1Thickness burn (old 1stst_{and 2}_{and 2}ndnd_degree)_degree) with sufficient epithelials for spontaneous with sufficient epithelials for spontaneous repair

repair repair repair Full

Full--Thickness burn ( old third degree) total Thickness burn ( old third degree) total destruction of skin does NOT allow destruction of skin does NOT allow spontaneous repair

spontaneous repair

Minor burn: partial thickness < 10% BSA Minor burn: partial thickness < 10% BSA Major burn: partial or full thickness > 10% Major burn: partial or full thickness > 10%

BSA BSA

(18)

TBSA CALCULATION

Head

Head 9%9%

Upper Extremity ( each)

Upper Extremity ( each) 9%9% Lower Extremity (each)

Lower Extremity (each) 18%18% Anterior Trunk Anterior Trunk 18%18% Posterior Trunk Posterior Trunk 18%18% Neck Neck 1%1% Moderate burn 10 Moderate burn 10--19%19% Severe burn 20 Severe burn 20--39%39% Critical burn > 39% Critical burn > 39%

Crude Mortality rates following

maternal burn injuries

% Body surface Maternal Perinatal% Body surface Maternal Perinatal

InjuredInjured Mortality MortalityMortality Mortality

2020--39%39% 3% 113% 11--27%27%

4040--59%59% 2727--50%50% 45 45 –– 53% 53%

> 60%> 60% 9292--100% 100%100% 100%

THERMAL INJURY

Women with 2Women with 2ndnd_{or 3}_{or 3}rdrd_{trimester burns over}_{trimester burns over} 50% of their body should be delivered 50% of their body should be delivered immediately because maternal death immediately because maternal death

th i i l t t i d f t l

otherwise is almost certain and fetal otherwise is almost certain and fetal survival rate is not improved by waiting survival rate is not improved by waiting

First trimester SAB is common, it is caused First trimester SAB is common, it is caused by septicemia

by septicemia

Adequate shock management and early Adequate shock management and early excision with grafting reduces maternal excision with grafting reduces maternal mortality figures

(19)

THERMAL INJURY

Labor is usually spontaneous with delivery Labor is usually spontaneous with delivery of a stillborn

of a stillborn

Contributory factors are: hypovolemia, Contributory factors are: hypovolemia, pulmonary injury, septicemia and intensely pulmonary injury, septicemia and intensely catabolic state

catabolic state

Skin contracture may be painful Skin contracture may be painful subsequently and necessitate surgical subsequently and necessitate surgical decompression and split skin autografts decompression and split skin autografts

Loss or distortion of the nipples may cause Loss or distortion of the nipples may cause breast feeding difficulties

breast feeding difficulties

BURN MANAGEMENT

Fluids and Electrolytes Fluids and Electrolytes –– sufficient for sufficient for maintenance of blood pressure and urinary maintenance of blood pressure and urinary output of 30

output of 30--50 ml per hr.50 ml per hr.

Hemodynamic and ventilatory stabilityHemodynamic and ventilatory stabilityHemodynamic and ventilatory stability, Hemodynamic and ventilatory stability, prevent hypoxia or hypotension

prevent hypoxia or hypotension

Evaluate fetus Evaluate fetus –– if possible, minimize fetal if possible, minimize fetal compromise

compromise

Sepsis prevention, debridement, topical Sepsis prevention, debridement, topical antibiotics, early ambulation

antibiotics, early ambulation

Hospital Admission for an OB

Smoke inhalation

Smoke inhalation Electrical burns Electrical burns

Burns of both hands or both feet, Burns of both hands or both feet, Partial

Partial--thickness burns that cover more than thickness burns that cover more than 10% of the surface area

10% of the surface area Full

Full--thickness burns on more than 2% of the thickness burns on more than 2% of the surface area. The depth of the injury is surface area. The depth of the injury is estimated by appearance and sensation. estimated by appearance and sensation.

Smoke Inhalation

A major cause of morbidity and mortality in burn patients.

In pregnancy, the fetus is at special risk

because of its relatively hypoxic state (ie, normal umbilical vein PaO2 = 27 mm Hg).g)

The pathophysiology of inhalation injury relates to impaired maternal ventilation (eg, upper airway obstruction from edema), increased diffusion distance (eg, interstitial alveolar edema), and acute functional anemia from carbon monoxide poisoning. Carbon monoxide binds more efficiently to hemoglobin than does oxygen.

(20)

Smoke Inhalation

In addition to displacing oxygen, carbon monoxide impairs the release of oxygen from oxyhemoglobin. Very little carbon monoxide is needed to cause serious hypoxia. One part carbon monoxide per 1500 parts air can result in blood concentrations of carboxyhemoglobin of 5-10%. Car exhaust is 5-7% carbon monoxide. Carboxyhemoglobin values less than 15% usually are well tolerated, whereas values greater than 30% cause severe maternal syncope and fetal death.

Specific Pregnancy Concerns

Iodine absorption from povidoneIodine absorption from povidone--iodineiodine

Diuretics for hypertension because of uterine Diuretics for hypertension because of uterine blood flow

blood flow

Silvadene use because of sulfonamide Silvadene use because of sulfonamide absorption and h perbilir binemia absorption and h perbilir binemia absorption and hyperbilirubinemia absorption and hyperbilirubinemia

Liberal use of but careful choice of antibioticsLiberal use of but careful choice of antibiotics

Body positioning to avoid aortocaval Body positioning to avoid aortocaval compression

compression

Local or regional anessthesia, Local or regional anessthesia, nondepolarizing muscle relaxant nondepolarizing muscle relaxant

Tocolytic Therapy in Burn

management

Tocolytic therapy is unwise, Indomethacin Tocolytic therapy is unwise, Indomethacin may be used for a limited time

may be used for a limited time

Betamimetics may cause myocardial Betamimetics may cause myocardial ischemia pulmonary edema

ischemia pulmonary edema ischemia, pulmonary edema, ischemia, pulmonary edema, hyperglycemia and hypokalemia hyperglycemia and hypokalemia

Magnesium may be better toleratedMagnesium may be better tolerated

No specific recommendations on steroid No specific recommendations on steroid therapy for fetal lung maturity

therapy for fetal lung maturity

Vaginal birth is preferredVaginal birth is preferred

Burn Scar

Burn scar during pregnancy undergoes Burn scar during pregnancy undergoes

considerable softening and therefore can stretch considerable softening and therefore can stretch

Skin contracture following abdominal burn scar Skin contracture following abdominal burn scar may be painful during subsequent pregnancy may be painful during subsequent pregnancy and may necessitate surgical decompression and may necessitate surgical decompression yy gg pp and split scar

and split scar autograftautograft

Loss or distortion of the breast nipple may Loss or distortion of the breast nipple may cause a problem in breast feeding

cause a problem in breast feeding only if both only if both nipples are involved; if one is affected the other nipples are involved; if one is affected the other breast should be sufficient

(21)

Electrical Accidents

ESSENTIALLY AN “ ALL OR NONE’ ESSENTIALLY AN “ ALL OR NONE’ PHENOMENON FOR THE FETUS PHENOMENON FOR THE FETUS

AND THE MOTHER AND THE MOTHER

There is anecdotal information and small There is anecdotal information and small studies indicating higher spontaneous studies indicating higher spontaneous abortion rates and increased stillbirths abortion rates and increased stillbirths after electrical accidents in pregnancy after electrical accidents in pregnancy

ELECTRICAL INJURIES

Depends on entry and exit points of the Depends on entry and exit points of the current

current

Serious maternal injury results from Serious maternal injury results from cardiac dysrythmias or respiratory arrest cardiac dysrythmias or respiratory arrest

Serial ultrasound for amniotic fluid volume Serial ultrasound for amniotic fluid volume is recommended in cases of lightning is recommended in cases of lightning injuries where some babies have been injuries where some babies have been IUGR with oligohydramnios

IUGR with oligohydramnios

North American 110 V is likely safer than North American 110 V is likely safer than European 220 V

European 220 V

ELECTRICAL INJURIES

Thermal or conductive in natureThermal or conductive in nature

Unsuspecting deep tissue necrosis, Unsuspecting deep tissue necrosis, cardiac injury, and rhabdomylolysis cardiac injury, and rhabdomylolysis

T t i l t ti ith k l t l

Tetanic muscle contractions with skeletal Tetanic muscle contractions with skeletal fractures

fractures

Respiratory arrestRespiratory arrest

PERIMORTEM CESAREAN

Immediate Maternal survival is in questionImmediate Maternal survival is in question

Attempts at delivery of the viable fetus Attempts at delivery of the viable fetus should be begun within 4 minutes after should be begun within 4 minutes after gg maternal cardiac arrest

maternal cardiac arrest

CPR should be continued during and after CPR should be continued during and after the procedure when the potential for the procedure when the potential for maternal survival exists

maternal survival exists

Staff should not waste time preparing a Staff should not waste time preparing a sterile field

(22)

PERIMORTEM CESAREAN

Attempts at delivery usually should be Attempts at delivery usually should be undertaken at any time after maternal undertaken at any time after maternal death if signs of fetal life are present death if signs of fetal life are present

Cesarean delivery will further compromise Cesarean delivery will further compromise maternal stability secondary to blood loss maternal stability secondary to blood loss maternal stability secondary to blood loss maternal stability secondary to blood loss

C/S should NOT be performed in an C/S should NOT be performed in an unstable mother in anticipation of cardiac unstable mother in anticipation of cardiac arrest

arrest

If maternal CPR is successful, stop the If maternal CPR is successful, stop the C/S attempt as in utero resuscitation is C/S attempt as in utero resuscitation is likely

likely

BRAIN DEATH DURING

PREGNANCY

Prolonging gestation in an attempt to Prolonging gestation in an attempt to salvage neonatal survival is possible salvage neonatal survival is possible

Aggressive maternal hemodynamic, Aggressive maternal hemodynamic, respiratory, metabolic and tocolytic respiratory, metabolic and tocolytic support is required

support is required

Delivery when maternal condition dictates Delivery when maternal condition dictates or fetal maturity established

or fetal maturity established

Complex ethical issues for the family, Complex ethical issues for the family, healthcare providers and community healthcare providers and community require individualization of considerations require individualization of considerations

ABUSE AND DOMESTIC

VIOLENCE

Physical Violence ( does not include Physical Violence ( does not include psychological, verbal, sexual or rape) psychological, verbal, sexual or rape)

U S 1998 1 3% in the past 12 mo 22 1% U S 1998 1 3% in the past 12 mo 22 1% U.S. 1998 1.3% in the past 12 mo 22.1% U.S. 1998 1.3% in the past 12 mo 22.1% ever

ever

Sexual Violence ( sexual assault, attempted Sexual Violence ( sexual assault, attempted or completed forced sex)

or completed forced sex)

U.S. 1995 0.2% in the past 12 mo 5.5% U.S. 1995 0.2% in the past 12 mo 5.5%

ever ever

(23)

ABUSE AND DOMESTIC

VIOLENCE

154 acts of violence per 1000 pregnant 154 acts of violence per 1000 pregnant women in the first 16 weeks of pregnancy women in the first 16 weeks of pregnancy

170 acts of violence per 1000 pregnant 170 acts of violence per 1000 pregnant women in the last 6 months of pregnancy women in the last 6 months of pregnancy women in the last 6 months of pregnancy women in the last 6 months of pregnancy

Further increases noted in the first several Further increases noted in the first several months postpartum

months postpartum

< 10% seek medical attention< 10% seek medical attention

INCREASED RISK FOR ABUSE

Social instabilitySocial instability

youth, single, separated, divorced, limited youth, single, separated, divorced, limited education, unemployed, unplanned education, unemployed, unplanned pregnancy

pregnancy

Unhealthy LifestyleUnhealthy Lifestyle

poor diet, emotional problems, substance poor diet, emotional problems, substance abuse

abuse

Physical ProblemsPhysical Problems

acute and chronic medical problems, use of acute and chronic medical problems, use of prescription drugs prescription drugs

Domestic

Abuse

(24)

DOMESTIC ABUSE

Generally, abuse decreases early in Generally, abuse decreases early in pregnancy and picks up again later in pregnancy and picks up again later in pregnancy

pregnancy

Risk of chorioamnionitis and preterm Risk of chorioamnionitis and preterm delivery is increased

delivery is increased delivery is increased delivery is increased

Late onset prenatal care is most commonLate onset prenatal care is most common

Tend to stay with the abuserTend to stay with the abuser

Location of abuse to head, face, extremitiesLocation of abuse to head, face, extremities

Should be considered to be emotionally Should be considered to be emotionally abused

abused

DOMESTIC ABUSE

An Abuse Assessment System will be An Abuse Assessment System will be

more productive in identifying all forms more productive in identifying all forms of abuse than the standard history and of abuse than the standard history and yy physical examination

physical examination

41% versus 14% for any abuse 41% versus 14% for any abuse 15% versus 3% for recent abuse 15% versus 3% for recent abuse 10% versus 1% for during pregnancy 10% versus 1% for during pregnancy 4% versus 0% for sexual abuse 4% versus 0% for sexual abuse

WHAT CONSTITUTES ABUSE?

AbrasionsAbrasions

BruisesBruises

Lacerated WoundsLacerated Wounds

BitBit

Signs of direct Signs of direct violence violence

AsphyxiaAsphyxia

NecrophiliaNecrophilia

BitesBites

Intercrural Intercrural intercourse intercourse

Genital injuryGenital injury

Anal intercourseAnal intercourse

Signs of restraintSigns of restraint

NecrophiliaNecrophilia

BestialityBestiality

SadismSadism

MasochismMasochism

Forced transmission Forced transmission of disease

(25)

GENITAL INJURY

Rates for genital injury are similar for Rates for genital injury are similar for consensual ( 74%) and non

consensual ( 74%) and non--consensual first consensual first intercourse (78%)

intercourse (78%)

For consensual For consensual –– lacerations of the hymen lacerations of the hymen or fossa navicularis

or fossa navicularis or fossa navicularis or fossa navicularis

For nonFor non--consensual consensual –– erythema of the fossa erythema of the fossa navicularis and labia minora

navicularis and labia minora

For forced digital penetration 93% with For forced digital penetration 93% with lacerations and erythema of the fossa lacerations and erythema of the fossa navicularis, vagina, cervix, fourchette, and navicularis, vagina, cervix, fourchette, and labia minora

labia minora

GENITAL INJURY

Placement of objects into the vagina Placement of objects into the vagina

Light bulbs Light bulbs Bottles Bottles Hairbrush Hairbrush Vegetables Vegetables Wooden structures Wooden structures Illegal abortions Illegal abortions

SEXUAL ASSAULT

Only 10Only 10--20 % of instances are reported20 % of instances are reported

Needs antimicrobial prophylaxis and Needs antimicrobial prophylaxis and pregnancy prevention ( if not pregnant) pregnancy prevention ( if not pregnant)

The need for psychological counseling for The need for psychological counseling for p yp y gg gg the rape victim and her family can not be the rape victim and her family can not be overemphasized

overemphasized

Associated physical trauma is less in the Associated physical trauma is less in the gravid rape victim

gravid rape victim

One third of sexual assaults in pregnancy One third of sexual assaults in pregnancy occur after 20 weeks

occur after 20 weeks

Sexual

Assault

(26)

PROPHYLAXIS FOR ADULT VICTIMS

OF SEXUAL ASSAULT

ANTIBIOTIC PROPHYLAXIS ANTIBIOTIC PROPHYLAXIS

Ceftriaxone 125 mg IM

Ceftriaxone 125 mg IM Spectinomycin 2g IM Spectinomycin 2g IM OR Cefixime 400 mg OR Cefixime 400 mg po Azithromycin 1 g po + Metronidazole 2 g po Azithromycin 1 g po + Metronidazole 2 g po po po po OR Erythromycin

OR Erythromycin--base 500 mg po qid x 7base 500 mg po qid x 7 HepB and HIV testing and prophylaxis HepB and HIV testing and prophylaxis

PREVENTION OF PREGNANCY PREVENTION OF PREGNANCY

2 OC tabs ( 50 microg EE) q 12 hr x2 OR 2 OC tabs ( 50 microg EE) q 12 hr x2 OR 3 OC tabs ( 35 microg EE) q 12 hr x2 + 3 OC tabs ( 35 microg EE) q 12 hr x2 +

antiemetic antiemetic

PREGNANT SEXUAL

ASSAULT VICTIMS

Lifetime prevalence of forced sexual Lifetime prevalence of forced sexual contact is 5%

contact is 5%

Rape victims have higher incidence of:Rape victims have higher incidence of:

STDs UTIs vaginitis drug use multiple STDs UTIs vaginitis drug use multiple STDs, UTIs, vaginitis, drug use, multiple STDs, UTIs, vaginitis, drug use, multiple hospitalizations

hospitalizations

8% of adolescents report sexual assault:8% of adolescents report sexual assault:

Family member 46% Family member 46% Spouse or boyfriend 33% Spouse or boyfriend 33%

RAPE

8080--90% are not reported to authorities90% are not reported to authorities

One every 6One every 6--7 minutes in the U.S. 260,000 in 7 minutes in the U.S. 260,000 in 2000

2000

33% of women will have been sexually 33% of women will have been sexually assa lted

assa lted assaulted assaulted

Victim 16Victim 16--24 years old woman24 years old woman

Assailant 25Assailant 25--44 years old male44 years old male

Usually same race as the assailantUsually same race as the assailant

50% of assailants are known to the victim50% of assailants are known to the victim

(27)

RAPE

50% occur in the victim’s home50% occur in the victim’s home

Generally a violent act of man to womanGenerally a violent act of man to woman

Increasing numbers of woman to manIncreasing numbers of woman to man

Rape is not a sexual act; it is an act of angerRape is not a sexual act; it is an act of angerRape is not a sexual act; it is an act of anger Rape is not a sexual act; it is an act of anger or rage

or rage

Same sex rape occurs where access to the Same sex rape occurs where access to the opposite sex is limited

opposite sex is limited

People targeted for discrimination are at People targeted for discrimination are at higher risk

higher risk

RAPE AND TRAUMA

ConfusionConfusion

Social withdrawlSocial withdrawl

TearfulnessTearfulness

NervousnessNervousness

NumbnessNumbness

HostilityHostility

FearFear

Inappropriate Inappropriate laughter laughter

RAPE EVALUATION

Too extensive a subject to discuss hereToo extensive a subject to discuss here

Engage rape crisis servicesEngage rape crisis services

Sexual Assault Nurse ExaminerSexual Assault Nurse Examiner

Forensic specimensForensic specimens

Prophylactic therapy Prophylactic therapy –– remember Hep B remember Hep B and HIV

and HIV

Pregnancy prophylaxisPregnancy prophylaxis

Post traumatic stress disorderPost traumatic stress disorder

Legal aspectsLegal aspects

Criteria for identification and

assessment of self

assessment of self--inflicted

inflicted

trauma

AdolescentsAdolescents

SingleSingle

Emotionally immatureEmotionally immatureEmotionally immatureEmotionally immature

Lacking a strong support systemLacking a strong support system Half are in their first pregnancy Half are in their first pregnancy

Fatality rate much lower than in the non Fatality rate much lower than in the non--pregnant about 1:6

(28)

Trauma Figures

Maternal

Maternal no traumano trauma Trauma after hospitalTrauma after hospital Preterm labor Preterm labor 77..11%% 1414..44%% 1818..44%% PROM PROM 11..66%% 22..44%% 11..99%% Abruption Abruption 00..99%% 88..00%% 11..55%% Death Death 00..0101%% 00..99%% 00..0606%% Uterine rupture Uterine rupture 00..0606%% 00..0606%% 00..0404%% Transfusion Transfusion 00..33%% 44..22%% 00..66%%

(29)

Violence against women

figures

Maternal

Maternal no traumano trauma Trauma after hospitalTrauma after hospital Preterm labor Preterm labor 55..44%% 1616..44%% 1010..55%% PROM PROM 11..55%% 22..55%% 22..33%% Abruption Abruption 00..99%% 55..44%% 22..11%% Death Death 00..0101%% 00..77%% 00..1717%% Uterine rupture Uterine rupture 00..0707%% 00..77%% 00..1111%% Transfusion Transfusion 00..33%% 22..55%% 00..77%%

MVA trauma figures

Maternal

Maternal No crash Uninjured Not severe SevereNo crash Uninjured Not severe Severe Preterm labor 6.6% Preterm labor 6.6% 51.3%51.3% 24.6% 13.1%24.6% 13.1% PROM PROM 2.0%2.0% 2.7% 2.3% 1.2%2.7% 2.3% 1.2% Abruption Abruption 1.4%1.4% 8.5%8.5% 7.4% 13.1%7.4% 13.1% Preterm Birth 8.0% 13.9% 12.1% 5.0% Preterm Birth 8.0% 13.9% 12.1% 5.0% Fetal distress 9.4% 12.2% 12.0% 20.2% Fetal distress 9.4% 12.2% 12.0% 20.2%

Prehospital care of the injured

gravida

AIRWAY AIRWAY

increased oxygen consumption increased oxygen consumption

BREATHING BREATHING CIRCULATION CIRCULATION

Watch for tachycardia, air hunger, Watch for tachycardia, air hunger,

vasoconstriction, perspiration vasoconstriction, perspiration

DISABILITY DISABILITY Stabilize the C

Stabilize the C--spine and tilt the uterusspine and tilt the uterus EVALUATE

EVALUATE

Prehospital Care of Road Traffic

Casualties

At some time in their career many doctors At some time in their career many doctors will have to deal with a road traffic crash will have to deal with a road traffic crash

Safety for yourself at the incident scene isSafety for yourself at the incident scene isSafety for yourself at the incident scene is Safety for yourself at the incident scene is the first priority

the first priority

Doctors untrained in prehopsital care Doctors untrained in prehopsital care should concentrate on giving good first aid, should concentrate on giving good first aid, working under the direction of ambulance working under the direction of ambulance service staff

(30)

Prehospital Care of Road

Traffic Casualties

Providing excellent medical treatment at a road Providing excellent medical treatment at a road crash requires specific training and experience crash requires specific training and experience

Patients with airway and breathing problems may Patients with airway and breathing problems may need immediate (

need immediate ( prehospitalprehospital) advanced medical) advanced medical need immediate (

need immediate ( prehospitalprehospital) advanced medical ) advanced medical intervention

intervention

Treatment should be aimed at promoting Treatment should be aimed at promoting

oxygenation and preserving clot, with rapid patient oxygenation and preserving clot, with rapid patient movement to a hospital with the appropriate movement to a hospital with the appropriate facilities to provide definitive care

facilities to provide definitive care

THE TRAUMA CHAIN FOR

TRAFFIC CASUALITIES

BYSTANDER FIRST AID

BYSTANDER FIRST AID EMERGENCY SERVICES EMERGENCY SERVICES

ROADSIDE CRITICAL INTERVENTION ROADSIDE CRITICAL INTERVENTION TRANSPORT TO APPROPRIATE UNIT TRANSPORT TO APPROPRIATE UNIT TRANSPORT TO APPROPRIATE UNIT TRANSPORT TO APPROPRIATE UNIT EARLY RESUSCITATION

EARLY RESUSCITATION RAPID DIAGNOSIS RAPID DIAGNOSIS

EARLY SPECIALIST INTERVENTION EARLY SPECIALIST INTERVENTION INTENSIVE CARE

INTENSIVE CARE REHABILITATION REHABILITATION

INITIAL IN HOSPITAL THERAPY

OF THE TRAUMATIZED

GRAVIDA

OXYGEN OXYGEN FLUID INFUSIONS FLUID INFUSIONS CENTRAL LINE CENTRAL LINE CENTRAL LINE CENTRAL LINE FOLEY DRAINAGE FOLEY DRAINAGE STOMACH DECOMPRESSION STOMACH DECOMPRESSION UTERINE DISPLACEMENT UTERINE DISPLACEMENT

FETAL MONITORING AND ULTRASOUND FETAL MONITORING AND ULTRASOUND

ASSESSMENT ASSESSMENT

LABORATORY EVALUATION OF THE

OBSTETRIC TRAUMA VICTIM

CBC CBC URINALYSIS URINALYSIS TYPE AND CROSSMATCH TYPE AND CROSSMATCH

ELECTROLYTES ELECTROLYTES GLUCOSE GLUCOSE BUN BUN CREATININE CREATININE AMYLASE AMYLASE KLEIHAUER

(31)

Critical Physiologic changes of

Pregnancy affect assessment of the

injured gravida

CARDIOVASCULAR CARDIOVASCULAR

supine position reduces venous return supine position reduces venous return Relative tachycardia is normal

Relative tachycardia is normal

Blood loss will exceed 30% TBV before Blood loss will exceed 30% TBV before hypotension is manifest

hypotension is manifest

retroperitoneal bleeds may not be readily retroperitoneal bleeds may not be readily manifest

manifest

Critical Physiologic changes of

injured gravida

ECG ECG Flattened T waves Flattened T waves

Possible inversion in lead III Possible inversion in lead III Possible inversion in lead III Possible inversion in lead III Possible Q waves in III and AVF Possible Q waves in III and AVF GASTROINTESTINAL

GASTROINTESTINAL

Risk of aspiration increased with Risk of aspiration increased with anesthesia or unconsciousness anesthesia or unconsciousness