trauma in woman

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Advanced Trauma Life Support 275

ELEVEN

11Trauma in WomenCHAPTER

OBJECTIVES:

Upon completion of this topic, the participant will be able to initially assess and manage the pregnant traumapatient and her fetus, and special problems in women. Specically, the student will be able to:

A. Identify the alterations of pregnancy and discuss effects on patient management.

B. Identify and discuss the mechanisms of injury to the pregnant patient and fetus.

C. Outline the priorities and assessment methods for both patients (mother and fetus).

D. Outline indications for operative intervention unique to the injured pregnant patient.

E. Recognize the potential for isoimmunization.

F. Identify patterns of domestic violence.


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276 American College of Surgeons

I. INTRODUCTION

The potential for pregnancy must be considered in

any girl or woman between the ages of 10 and 50years. Pregnancy causes major physiologic changesand altered anatomic relationships involving nearlyevery organ system of the body. These changes ofstructure and function may inuence the evaluationof the injured pregnant patient by altering the signsand symptoms of injury, the approach and respons-es to resuscitation, as well as the results of diagnos-tic tests. Pregnancy also may affect the patterns ofinjury or severity of injury. The doctor attending apregnant trauma patient must remember that thereare 2 patients. Nevertheless, initial treatment priori-ties for an injured pregnant patient remain the same

as for the nonpregnant patient. A thorough under-standing of the physiologic relationship between apregnant patient and her fetus is essential if the bestinterests of both are to be served. The best initialtreatment for the fetus is the provision of optimumresuscitation of the mother and the early assessmentof the fetus. Monitoring and evaluation techniquesshould allow not only assessment of the mother butalso of the fetus. The use of x-rays, if indicated dur-ing critical management, should not be withheldbecause of the pregnancy. A qualied surgeonand obstetrician should be consulted early in theevaluation of the pregnant trauma patient.

II. ANATOMIC AND PHYSIOLOGICALTERATIONS OF PREGNANCY

A. Anatomic

The uterus remains an intrapelvic organ until ap-proximately the 12th week of gestation, when it be-gins to rise out of the pelvis. By 20 weeks, the uterusis at the umbilicus. At 34 to 36 weeks, it reaches thecostal margin. During the last 2 weeks of gestation,the fundus frequently descends as the fetal head en-

gages the pelvis. As the uterus enlarges, the bowel ispushed cephalad, so that the bowel lies mostly in theupper abdomen. As a result, the bowel is somewhatprotected in blunt abdominal trauma, whereas theuterus and its contents (fetus and placenta) becomemore vulnerable. However, penetrating trauma tothe upper abdomen during late gestation can resultin complex intestinal injury due to this cephaladdisplacement.

During the rst trimester, the uterus is a thick-walled structure of limited size, conned within the

bony pelvis. During the second trimester, the uterusenlarges beyond its protected intrapelvic location,but the small fetus remains mobile and cushioned

by a relatively generous amount of amniotic uid.The amniotic uid itself could be a source of amni-otic uid embolism and disseminated intravascularcoagulation following trauma if the uid gains ac-cess to the intravascular space. By the third trimes-ter, the uterus is large and thin walled. In the vertexpresentation, the fetal head is usually within the pel-vis, with the remainder of the fetus exposed abovethe pelvic brim. Pelvic fracture(s) in late gestationmay result in skull fracture or serious intracranialinjury to the fetus. Unlike the elastic myometrium,the placenta has little elasticity. This lack of placen-tal elastic tissue predisposes to shear forces at the

uteroplacental interface, which may lead to abruptioplacentae. The placental vasculature is maximallydilated throughout gestation, yet it is exquisitelysensitive to catecholamine stimulation. Likewise, anabrupt decrease in maternal intravascular volumemay result in a profound increase in uterine vas-cular resistance, reducing fetal oxygenation despitereasonably normal maternal vital signs.

B. Blood Volume and Composition

1. Volume

Plasma volume increases steadily throughoutpregnancy and plateaus at 34 weeks gestation. Asmaller increase in red blood cell (RBC) volumeoccurs, resulting in a decreased hematocrit (phys-iologic anemia of pregnancy). In late pregnancy, ahematocrit of 31% to 35% is normal. With hemor-rhage, otherwise healthy pregnant patients maylose 1200 to 1500 mL of their blood volume beforeexhibiting signs and symptoms of hypovolemia.However, this amount of hemorrhage may be re-ected by fetal distress evidenced by an abnormalfetal heart rate.

2. Composition

The white blood cell (WBC) count increasesduring pregnancy. It is not unusual to see WBCcounts of 15,000/mm3 during pregnancy or ashigh as 25,000/mm3 during labor. Levels of serumbrinogen and other clotting factors are mildly el-evated. Prothrombin and partial thromboplastintimes may be shortened but bleeding and clottingtimes are unchanged. The serum albumin levelfalls to 2.2 to 2.8 g/dL during pregnancy, causinga drop in serum protein levels by approximately


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1.0 g/dL. Serum osmolarity remains at about 280mOsm/L throughout pregnancy.

C. Hemodynamics

1. Cardiac output

After the 10th week of pregnancy, cardiac outputcan be increased by 1.0 to 1.5 L/minute due to theincrease in plasma volume and decrease in vas-cular resistance of the uterus and placenta, whichduring the third trimester of pregnancy receive20% of the patients cardiac output. This increasedoutput can be greatly inuenced by the maternalposition in the second half of pregnancy. In thesupine position, vena cava compression may

decrease cardiac output by 30% due to decreasedvenous return from the lower extremities.

2. Heart rate

Heart rate increases gradually by 10 to 15 beats/minute throughout pregnancy, reaching a maxi-mum rate by the third trimester. This change inheart rate must be considered in interpreting thetachycardic response to hypovolemia.

3. Blood pressure

Pregnancy results in a 5- to 15-mm Hg fall in

systolic and diastolic pressures during the secondtrimester. Blood pressure returns to near-normallevels at term. Some women may exhibit hypo-tension (supine hypotensive syndrome) whenplaced in the supine position due to compressionof the inferior vena cava. This hypotension is cor-rected by relieving uterine pressure on the infe-rior vena cava as described in V., Assessment andManagement in this chapter. The normal changesin blood pressure, pulse, hemoglobin, and hema-tocrit during pregnancy must be interpreted care-fully in the pregnant trauma patient.

4. Venous pressure

The resting central venous pressure (CVP) is vari-able with pregnancy, but the response to volumeis the same as in the nonpregnant state. Venoushypertension in the lower extremities is presentduring the third trimester.

5. Electrocardiographic changes

The axis may shift leftward by approximately 15.Flattened or inverted T waves in leads III, AVF,

and the precordial leads may be normal. Ectopicbeats are increased during pregnancy.

D. RespiratoryMinute ventilation increases primarily as a resultof an increase in tidal volume due to increasedlevels of progesterone during pregnancy. Hypo-capnea (PaCO

2of 30 mm Hg) is therefore common

in late pregnancy. A PaCO2

of 35 to 40 mm Hg mayindicate impending respiratory failure during preg-nancy. Although the forced vital capacity uctuatesslightly during pregnancy, it is largely maintainedthroughout pregnancy due to equal and oppositechanges in inspiratory capacity (which increases)and residual volume (which decreases). Anatomic

alterations in the thoracic cavity appear to accountfor the decreased residual volume that is associatedwith diaphragmatic elevation with increased lungmarkings and prominence of the pulmonary vesselsseen on chest x-ray.

Oxygen consumption is increased during pregnan-cy. Therefore, it is important to maintain and ensureadequate arterial oxygenation during the resuscita-tion of the injured pregnant patient.

E. Gastrointestinal

Gastric emptying time is prolonged during preg-nancy, and the doctor should always assume thatthe stomach of a pregnant patient is full. Therefore,early gastric tube decompression is particularlyimportant to avoid aspiration of gastric contents.The intestines are relocated to the upper part of theabdomen and may be shielded by the uterus. Posi-tion of the patients spleen and liver are essentiallyunchanged by pregnancy.

F. Urinary

The glomerular ltration rate and the renal plasmablood ow increase during pregnancy. Levels ofcreatinine and serum urea nitrogen fall to approxi-mately one-half of normal prepregnancy levels.Glycosuria is common during pregnancy. There isa physiologic dilatation of the renal calyces, pelves,and ureters outside of the pelvis, which may persistfor several weeks following pregnancy. Because offrequent dextrorotation of the uterus, the right renalcollection system is often more dilated than the left.


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G. Endocrine

The pituitary gland increases in size and weight by

30% to 50% during pregnancy. Shock may causenecrosis of the anterior pituitary gland, resulting inpituitary insufciency.

H. Musculoskeletal

The symphysis pubis widens to 4 to 8 mm and thesacroiliac-joint spaces increase by the 7th month ofgestation. These factors must be considered in inter-preting x-rays of the pelvis.

I. Neurologic

Eclampsia is a complication of late pregnancy thatmay mimic head injury. Eclampsia should be con-sidered if seizures occur with associated hyperten-sion, hyperreexia, proteinuria, and peripheraledema. Expert neurologic and obstetric consultationfrequently is helpful in differentiating between ec-lampsia and other causes of seizures.

III. MECHANISMS OF INJURY

Most mechanisms of injury are similar to those inthe nonpregnant patient. However, certain differ-ences must be recognized in the pregnant patient.

A. Blunt Injury

The abdominal wall, uterine myometrium, and am-niotic uid act as buffers to direct fetal injury fromblunt trauma. Nonetheless, fetal injuries may occurwhen the abdominal wall strikes an object such asthe dashboard or steering wheel, or if the pregnantpatient is struck by a blunt instrument. Indirect in-

jury to the fetus may occur from rapid compression,deceleration, contrecoup effect, or a shearing forceresulting in abruptio placentae.

Seat belts decrease maternal injury and death bypreventing ejection. However, the type of restraintsystem affects the frequency of uterine rupture andfetal death. The use of a lap belt alone allows for-ward exion and uterine compression with possibleuterine rupture or abruptio placentae. A lap beltworn too high over the uterus could produce uter-ine rupture because of direct force transmission tothe uterus on impact. The use of shoulder restraintsin conjunction with the lap belt reduces the likeli-hood of direct or indirect fetal injury, presumablybecause of the greater surface area over which the

deceleration force is dissipated as well as the pre-vention of forward exion of the mother over thegravid uterus. Therefore, determination of the type

of restraint device worn by the pregnant patient, ifany, is important in the overall assessment.

B. Penetrating Injury

As the gravid uterus increases in size, the remainderof the viscera is relatively protected from penetrat-ing injury, while the likelihood of uterine injuryincreases. The dense uterine musculature in earlypregnancy can absorb a great amount of energyfrom penetrating missiles, which decreases mis-sile velocity and lessens the likelihood of injuryto other viscera. The amniotic uid and conceptus

also absorb energy and contribute to slowing of thepenetrating missile. The resulting low incidence ofassociated maternal visceral injuries accounts forthe generally excellent maternal outcome in the pen-etrating wounds of the gravid uterus. However, thefetus generally fares poorly when there is a penetrat-ing injury to the uterus.

IV. SEVERITY OF INJURIES

Severity of maternal injuries determines maternaland fetal outcome. Therefore, treatment methodsalso depend on the severity of maternal injuries.

All pregnant patients with major injuries requireadmission to a facility with trauma and obstetriccapabilities, since there is an increased maternaland fetal mortality rate in this group of patients.Eighty percent of pregnant females who survivehemorrhagic shock will experience fetal death. Eventhe pregnant patient with minor injuries should becarefully observed, since occasionally even minorinjuries may be associated with abruptio placentaeand fetal loss. Direct fetal injuries usually occur inlate pregnancy and are typically associated withserious maternal trauma.

V. ASSESSMENT AND MANAGEMENT

For optimal outcome of mother and fetus, it is rec-ommended to assess and resuscitate the motherrst, and then to assess the fetus before conducting asecondary survey of the mother.

A. Primary Survey and Resuscitation

1. Maternal

Assure a patent airway, adequate ventilation and


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oxygenation, and effective circulatory volume.If ventilatory support is required, intubation asdescribed in Chapter 2, Airway and Ventilatory

Management, is appropriate for the pregnant pa-tient and consideration should be given to hyper-ventilating her.

Uterine compression of the vena cava may reducevenous return to the heart, thereby decreasingcardiac output and aggravating the shock state.Therefore, unless a spinal injury is suspected,the pregnant patient should be transported andevaluated on her left side. If the patient is in asupine position, the patient can be logrolled 4to 6 inches to her left and supported with a bol-stering device. The uterus should be displaced

manually to the left side to relieve pressure onthe inferior vena cava. Because of the increasedintravascular volume, the pregnant patient canlose a signicant amount of blood before tachy-cardia, hypotension, and other signs of hypovo-lemia occur. Thus, the fetus may be in distressand the placenta deprived of vital perfusionwhile the mothers condition and vital signsappear stable. Crystalloid uid resuscitation andearly type-specic blood administration are indi-cated to support the physiologic hypervolemia ofpregnancy. Avoid administering vasopressors torestore maternal blood pressure, because these

agents further reduce uterine blood ow, result-ing in fetal hypoxia. As intravenous lines arestarted, blood samples are drawn for appropriatelaboratory analyses, including type and cross-match, toxicology studies, and brinogen levels.

2. Fetus

The abdominal examination during pregnancyis critically important, as rapid identication ofserious maternal injuries and fetal well-beingare dependent on a thorough evaluation. Uterinerupture is suggested by ndings of abdominal

tenderness, guarding, rigidity, or rebound ten-derness, especially if there is profound shock.Frequently, peritoneal signs are difcult to appre-ciate in advanced gestation due to expansion andattenuation of the abdominal wall musculature.Other abnormal ndings suggestive of uterinerupture include abdominal fetal lie (eg, obliqueor transverse lie), easy palpation of fetal parts dueto extrauterine location, and inability to readilypalpate the uterine fundus when there is fundalrupture). X-ray evidence of rupture includes ex-tended fetal extremities, abnormal fetal position,

or free intraperitoneal air. Diagnosis of uterinerupture mandates operative exploration.

Abruptio placentae may be suggested by vaginalbleeding (70% of the cases), uterine tenderness,frequent uterine contractions, uterine tetany,or uterine irritability (uterus contracts whentouched). Thirty percent of abruptions followingtrauma may not exhibit vaginal bleeding. Uterineultrasonography may demonstrate the lesion,but the test is not denitive. Late in pregnancy,abruption can occur following relatively minorinjuries.

In most cases of uterine rupture or abruptio pla-centae, the patient will complain of abdominalpain or cramping. Signs of hypovolemia can ac-company either of these injuries.

Initial fetal heart tones can be auscultated with aDoppler (10 weeks gestation). Continuous fetalmonitoring should be performed beyond 20 to24 weeks gestation. (See B., Adjuncts to PrimarySurvey and Resuscitation in this section.)

B. Adjuncts to Primary Survey andResuscitation

1. Maternal

If possible, the patient should be monitored onher left side after physical examination. Monitor-ing of the CVP response to uid challenge maybe valuable in maintaining the relative hypervol-emia required in pregnancy. Monitoring shouldinclude pulse oximetry and arterial blood gas de-terminations. Remember, maternal bicarbonate isnormally low during pregnancy.

2. Fetus

Obstetric consultation should be obtained sincefetal distress can occur at any time and without

warning. Fetal heart rate is a sensitive indicatorof both maternal blood volume status, as wellas fetal well-being. Fetal heart tones should bemonitored in every injured pregnant woman.Intermittent and repeated Doppler examinationcan be used to detect fetal heart tones after 10weeks gestation. Continuous fetal monitoringwith a cardiotocodynamometer is useful after 20to 24 weeks gestation. The normal range for fetalheart rate is between 120 to 160 beats/minute. Anabnormal fetal heart rate, repetitive decelerations,absence of accelerations or beat-to-beat variabil-


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ity, or frequent uterine activity may be a sign ofimpending maternal and/or fetal decompensa-tion (eg, hypoxia and/or acidosis) and should

prompt immediate obstetric consultation, if notalready obtained.

Indicated radiographic studies should be per-formed, because the benets certainly outweighpotential risk to the fetus. However, unnecessaryduplication of lms should be avoided.

C. Secondary Assessment

The maternal secondary survey should follow thesame pattern as in the nonpregnant patient. Indica-tions for abdominal CT, FAST, or DPL are the same.However, if DPL is performed, the catheter shouldbe placed above the umbilicus using the open tech-nique. Pay careful attention to the presence of uter-ine contractions suggesting early labor or tetaniccontractions suggesting premature separation of theplacenta. Evaluation of the perineum should includea formal pelvic examination, ideally performed by adoctor skilled in obstetric care. The presence of am-niotic uid in the vagina, evidenced by a pH of 7 to7.5, suggests ruptured chorioamniotic membranes.Cervical effacement and dilatation, fetal presenta-tion, and the relationship of the fetal presenting partto the ischial spines should be noted. Because vagi-

nal bleeding in the third trimester may indicate dis-ruption of the placenta and impending death of thefetus, a vaginal examination is vital. Repeated vagi-nal examinations should be avoided. The decisionregarding an emergency cesarean section should bemade in conjunction with an obstetrician.

Admission to the hospital is mandatory in thepresence of vaginal bleeding, uterine irritability,abdominal tenderness, pain or cramping, evidenceof hypovolemia, changes in or absence of fetal hearttones, or leakage of amniotic uid. Care should beprovided at a facility with appropriate fetal and ma-

ternal monitoring and treatment capabilities. Thefetus may be in jeopardy even with apparentlyminor maternal injury.

D. Defnitive Care

Obstetric consultation should be obtained wheneverspecic uterine problems exist or are suspected.

With extensive placental separation or with amni-otic uid embolization, widespread intravascularclotting may develop, causing depletion of brino-

gen (


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hypoxia. For other causes of maternal cardiac arrest,perimortem c-section occasionally may be success-ful if performed within 4 to 5 minutes of the arrest.

VII. DOMESTIC VIOLENCE

Domestic violence is a major cause of injury towomen during cohabitation, marriage, and preg-nancy regardless of ethnic background, culturalinuences, or socioeconomic status. Seventeen per-cent of injured pregnant patients experience traumaas the result of another person, and 60% of thesepatients have repeated episodes of domestic vio-lence. According to estimates from the United StatesDepartment of Justice (1994), 2 to 4 million per yearand almost half of all women over their lifetimes are

abused in some manner. As with child abuse, thisinformation must be identied and documented.These attacks can result in death and disability.They also represent an increasing number of emer-gency department visitations.

Indicators that may suggest the presence of domes-tic violence include:

1. Injuries inconsistent with stated history

2. Diminished self-image, depression, suicide at-tempts

3. Self-abuse

4. Frequent emergency department or doctorsofce visits

5. Symptoms suggestive of substance abuse

6. Self-blame for injuries

7. Partner insists on being present for interviewand examination and monopolizes discussion

These indicators only raise the suspicion of the po-tential for domestic violence and should serve toinitiate further investigation. Three questions, whenasked in a nonjudgmental manner and without thepatients partner being present, detect 65% to 70%of domestic violence victims. (See Table 1, PartnerViolence Screen.) Suspected cases of domestic vio-lence should be handled through local social serviceagencies or the state health and human servicesdepartment.

VIII. SUMMARY

Important and predictable anatomic and physiologicchanges occur during pregnancy that may inuencethe evaluation and treatment of the injured preg-nant patient. Vigorous uid and blood replacementshould be given to correct and prevent maternal aswell as fetal hypovolemic shock. A search should bemade for conditions unique to the injured pregnantpatient, such as blunt or penetrating uterine trauma,abruptio placentae, amniotic uid embolism, isoim-munization, and premature rupture of membranes.Attention also must be directed toward the fetus, thesecond patient of this unique duo, after its environ-ment is stabilized. A qualied surgeon and obstetri-

cian should be consulted early in the evaluation ofthe pregnant trauma patient.

Table 1Partner Violence Screen

1. Have you been kicked, hit, punched, or otherwise hurt by someone within thepast year? If so, by whom?

2. Do you feel safe in your current relationship?

3. Is there a partner from a previous relationship who is making you feel unsafenow?

Reprinted with permission, Feldhaus KM, Koziol-McLain J, Amsbury HL, et al: Accuracy of 3 brief screening questions

for detecting partner violence in the emergency department. Journal of the American Medical Association1997; 277:

13571361.


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RESOURCE

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