Morning Report: 5/21/2013 - The Original Kings of County

Thanks to Dr. McMillan for today’s Morning Report!

Here’s the case:

Female passenger of MVC presents with abdominal pain. Home pregnancy test just positive.

Trauma in Pregnancy:

Both blunt and penetrating a significant cause of maternal injury.

Maternal Physiologic Changes

Plasma volume increase (normal hematocrit of 31-35% by late pregnancy)
Increase in cardiac output
Increase of baseline heart rate by 10-15 beats/min
Blood pressure falls in second and third trimesters
Minute ventilation increases (PaCO2 decreases)

Assessment and Treatment

Fetal distress may be present with completely normal maternal physiologic. Primary survey and resuscitation of mother, then assess fetus then on to secondary survey. Crystalloid and early blood product resuscitation, avoid pressors. Uterine displacement to the left side if possible.

Fetal Injury

Most common cause of fetal death Placental Abruption:

Vaginal bleeding (70%)	Uterine tetany
Uterine tenderness	Uterine irritability (contracts when palpated)
Uterine contractions	Ultrasonography specific but not sensitive

Uterine Rupture: suggested by peritoneal signs (may be difficult to appreciate due to expansion/attenuation of abdominal wall musculature), especially in presence of shock*

Continuous Fetal Monitoring: for those beyond 20 to 24 weeks gestation

No risk factors should be monitored for 6 hours
With risk factors monitored for 24 hours (admission mandatory)

Physiologic Indications of Fetal Trauma

Bradycardia	Absence of normal accelerations
Tachycardia	Recurrent decelerations
Decrease in baseline variability of heart rate	Frequent uterine activity

Other Issues

Indications for CT, FAST and DPL are same (catheter placement for DPL different)
Vaginal examination vital (exclude bleeding)
Amniotic fluid pH 7-7.5
Beware DIC (may send fibrinogen level along with coags)
Isoimmunization–Rh immunoglobulin should be given to all Rh-negative trauma patients (0.01mL of Rh-positive blood will sensitize 70% of Rh-negative mothers; and Kleihauer-Betke test is not sensitive)
Beware retroperitoneal bleeding-increased pelvic blood supply in pregnancy can contribute to more massive rapid retroperitoneal bleeding.

Overall: Initial management focused on resuscitation and stabilization of the mother.

Reference: American College of Surgeons Committee on Trauma. Trauma in Women. In: Advanced Trauma Life Support, Student Course Manual, American College of Surgeons; 8th edition (2002). Kilpatrick SJ. Trauma in Pregnancy. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013.

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital