|Year : 2012 | Volume
| Issue : 1 | Page : 3-9
Trauma during pregnancy
Siddareddigari Velayudha Reddy1, Nawaz Ahmed Shaik2, Kesavachandra Gunakala2
1 Department of Anaesthesiology and Critical Care, Rajeev Gandhi Institute of Medical Sciences, Kadapa-516 002, Andhra Pradesh, India
2 Department of Obstetrics and Gynaecology, Rajeev Gandhi Institute of Medical Sciences, Kadapa-516 002, Andhra Pradesh, India
|Date of Web Publication||4-Aug-2012|
Siddareddigari Velayudha Reddy
Department of Anaesthesiology and Critical Care, Rajiv Gandhi Institute of Medical Sciences, Kadapa-516 002, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Trauma in pregnancy presents a unique challenge, because of the anatomical and physiological changes of pregnancy, and the assessment and treatment of pregnant patients differ accordingly. In this review article, the focus is on familiarizing the anesthesiologists with physiological changes of pregnancy, their effect on response to trauma, resuscitation, and anesthetic management of trauma patient during pregnancy.
Keywords: Obstetrics, pregnancy, prenatal injuries, trauma care
|How to cite this article:|
Reddy SV, Shaik NA, Gunakala K. Trauma during pregnancy. J Obstet Anaesth Crit Care 2012;2:3-9
| Introduction|| |
Trauma in pregnancy is currently a leading cause of nonpregnancy-related maternal deaths and fetal demise. The management of trauma in pregnancy requires a multidisciplinary team involving the anesthesiologist, obstetrician, and the trauma surgeon. Despite the high incidence of severe or moderately severe injury in obstetric patients, there is paucity of literature in anesthesiology journals regarding its diagnosis and management. Therefore, a randomized MEDLINE search for recent articles from 2000 to 2011 highlighting anesthetic, obstetric, and surgical considerations for management of trauma in pregnancy was performed and current recommendations from these have been incorporated in this review.
Trauma complicates approximately 6-7% of all pregnancies which may be associated with maternal and fetal morbidity and mortality.  The most common etiology for trauma in pregnancy are motor vehicle accidents, falls, violent assaults, and burn injuries. Management of the pregnant trauma victim requires a multidisciplinary approach in order to optimize outcomes for mother and fetus.  Anatomic, physiologic, changes, and existence of two lives should be considered while assessment, resuscitation, and stabilization of mother takes priority. Radiologic procedures should be used as indicated, minimizing fetal exposure to radiation. This review article discusses the anatomic, physiologic changes, assessment, and treatment of pregnant trauma patients.
| Clinical Significance of Physiological Changes of Pregnancy|| |
The effective management of pregnant trauma victims (PTVs) requires the clinician to consider and understand the unique changes in anatomy and physiology of pregnancy. During the first trimester of pregnancy, the bony pelvis protects the uterus and the fetus from direct injury. The uterus enlarges into the peritoneal cavity after the 12 th week of pregnancy, protecting other maternal abdominal organs, although it now becomes more susceptible to injury. The pathophysiology and location of maternal injuries in pregnancy may significantly different from those that commonly occur in the nonpregnant women. 
The relative hemodilution and hypervolemic state [Table 1] is protective for the PTV during hemorrhage,  because fewer red blood cells (RBC) are lost and almost 40% of maternal blood volume may be lost without manifestation of signs of maternal shock. Thus, cardiovascular changes during pregnancy may complicate the evaluation of intravascular volume, the assessment of blood loss, and the diagnosis of hypovolemic shock. Maternal hemodynamic measurements may not accurately reflect the status of the uteroplacental circulation. Heath care providers managing PTV should remember that pregnancy maximally dilates the uterine vasculature, so that autoregulation is compromised, and uterine blood flow is directly dependent on maternal mean arterial pressure (MAP). 
The hormonal effect of pregnancy increases the clotting factors [Table 1]. Increased levels of coagulation factors may improve hemostasis following trauma; however, at the same time parturients remain at increased risk for thromboembolic complications during periods of immobilization.  The buffering capacity during pregnancy is also diminished, hence PTVs rapidly develop metabolic acidosis during periods of hypoperfusion and hypoxia.
Normal respiratory changes of pregnancy are referred to as "physiological hyperventilation" characterized by increased tidal volumes, normal respiratory rate, and respiratory alkalosis.  Pregnancy-induced generalized weight gain, a high body mass index (BMI), laryngeal edema, tongue enlargement and significant increase in breast size have been associated with an increased risk of airway management including difficult intubation. Therefore, the use of a short handled laryngoscope has been widely recommended in obstetric patients. In addition, placing the patient in the sniffing position helps to keep the laryngoscope handle away from the breasts.  Furthermore, despite adequate visualization of vocal-cords at laryngoscopy, laryngeal edema may prevent the passage of a standard size endotracheal (ET) tube, hence a smaller size internal diameter ET tube is required for intubation.  The raise of diaphragm by 4 cm and enlargement of chest diameter by 2 cm decrease the FRC and hasten the development of hypoxemia. Care should be taken to consider these anatomic changes, when thoracic procedures such as thoracostomies are being performed in pregnancy. An elevated gastric acid content, with decreased pH, and reduced function of the gastro-esophageal sphincter secondary to the mechanical and hormonal effects of pregnancy predisposes to increased incidence of nausea, vomiting, and aspiration.
| Types of Trauma|| |
Head and neck injuries, respiratory failure, and hypovolemic shock constitute the most frequent causes of trauma-related maternal death and are most common in transportation accidents and falls in pregnancy. It has been empirically established that a Glasgow coma scale of 8 or less usually requires intubation and mechanical ventilation or both in PTVs. 
In contrast to nonpregnant women, abdominal trauma is more likely to occur than head injury during pregnancy. Maternal mortality from blunt trauma is estimated to be about 7%, while the fetus is at significant risk, especially if placental abruption or uterine rupture occurs.  The physical examination and evaluation of possible injury to the abdomen differs, because of the presence of a gravid uterus in pregnancy.
Penetrating trauma during pregnancy is primarily the result of stabbing or gunshot wounds. As pregnancy progresses, intra-abdominal organs change their position, with important implications. The bowel is pushed upward by the enlarged uterus, thus penetrating injury to the upper part of the abdomen is more likely to be associated with multiple gastrointestinal injuries. During the third trimester, penetrating injuries to the lower quadrants of the abdomen almost exclusively involve the uterus, and fetal injury may occur in 60% to 90% of cases. Gunshot wounds to the uterus carry a maternal mortality of 7% to 9% with fetal mortality of around 70%, while fetal mortality is still higher if injury is caused before 37 weeks of gestation. 
The preferred diagnostic modalities for evaluation during the first trimester of pregnancy are ultrasound,  diagnostic peritoneal lavage (DPL), and computed tomography (CT-scan). DPL is rarely used nowadays, since it is an invasive procedure. During the second and third trimesters, the injured pregnant patient can best be assessed by ultrasound or CT-scan.  Magnetic resonance imaging (MRI) seems to have no detrimental effect on mother and fetus. However, the major drawback of an MRI is the lack of portability and long examination times requiring removal of patient from close monitoring. 
Signs of obvious intra-abdominal injury like shock, peritoneal signs, and evisceration are confirmed by investigations. Gunshot and stab wounds to the abdomen are managed both in pregnant and nonpregnant patients with exploratory laparotomy. Specific indications for cesarean section during celiotomy include maternal shock near term, threat to life from any cause, mechanical limitation for maternal repair, irreparable uterine injury, hemodynamic instability in a potentially viable fetus, unstable thoracolumbar spine injury, and maternal cardiac arrest. 
The incidence of thermal injury during pregnancy is around 6.8% to 7.8% of all pregnancies.  The maternal and fetal outcome is related to the extent of burns, and the gestational age of the fetus. The rule of nine is used to determine the percentage burns according to total body surface area involved. Similar to the trauma victims, initial treatment of the parturient with thermal injury should involve attention to the airway, breathing, and circulation. Urgent delivery has been considered the treatment of choice in term or near term pregnant women with extended burn injury. , Pulmonary function can be directly or indirectly affected by thermal injury. Increased vascular permeability throughout the microcirculation may contribute to the development of pulmonary edema and acute respiratory distress syndrome.  Indications for early intubation include the presence of copious secretions, hypoxia, or upper airway edema that may subsequently progress to airway obstruction. So the trachea should be intubated before edema develops and intubation becomes technically difficult. Timely and aggressive resuscitation including early control of the airway with obstetric management including early delivery of the fetus is vital for optimal maternal and fetal outcome. 
Electrical injury: There are conflicting reports on fetal injury following electric shock. The clinical spectrum of electrical injury ranges from a transient unpleasant sensation felt by the mother and no effect on her fetus to fetal death either immediately or few days later. Several factors, such as the magnitude of the current and the duration of contact, are thought to affect outcome  [Table 2].
| Initial Assessment and Resuscitation|| |
The initial survey of trauma in pregnant patients consists of thorough evalusion, stabilization, and does not differ from evaluation of nonpregnant patients.  Volume resuscitation can be complicated by supine hypotension syndrome in the supine position, so patients should be resuscitated in the left lateral position. However, if the patient must remain supine, manual deflection of the uterus to the left or placement of a wedge under the patient's right buttock or 15° left tilt of the table on which patient is lying must be considered.  Recognition of hemorrhagic shock is at the center of advanced trauma life support. Hemorrhagic shock indicates the need for rapid operative treatment with the possibility of a "damage control" approach.
Resuscitation consists of maintenance of circulation, breathing, and airway (CAB).  Resuscitation during acute hemorrhage shock is controversial, but current recommendations are maintenance of blood composition by early transfusion of red blood cells, plasma, platelets, and limiting the crystalloid transfusion. Two large-bore (14 or 16-G) intravenous lines should be placed, and crystalloid in the form of lactated Ringers' solution or normal saline should be given as a 3:1 replacement for the estimated blood loss over the first 30-60 min of acute resuscitation. O-negative packed red cells are preferred if emergent blood transfusion is needed before the patient's own blood group is known. A urinary catheter should be placed to measure urine output and to observe hematuria. Oxygen should be administered by face mask or an endotracheal tube and oxygen saturation should be maintained at >90% with an oxygen partial pressure of 60 mmHg.
The goals of initial resuscitation consists of maintenance of systolic blood pressure at 80 to 100 mmHg, maintenance of functional values of pulse oximetry, hematocrit at 25%, to 36%, platelet count >50,000/cu mm, normal serum calcium, core body temperature > 35° C, avoiding an increase in serum lactate level and metabolic acidosis, along with providing adequate analgesia.
| Secondary Survey|| |
Following stabilization, a more detailed secondary survey of the patient, including fetal evaluation is performed. The patient should be questioned about seat belt used in motor vehicle accidents (MVA), fainting, pain, last menstrual period or gestational age of the fetus, vaginal bleeding, amniotic fluid leaking, and fetal movement. Physical examination should focus on abdominal tenderness and a search should be made for orthopedic injuries on other parts of the body.
If the mother's condition is stable, the status of the fetus and the extent of uterine injury determine further management. A potentially viable fetus showing no signs of distress should be monitored by fetal Doppler ultrasound and an external tocotransducer should be used to detect the onset of uterine contractions. If premature labor ensues, tocolytic therapy may be initiated. When a viable fetus shows signs of distress, despite successful resuscitative measures, a cesarean delivery must be performed expeditiously. A nonviable fetus may be managed conservatively in the uterus optimizing maternal oxygenation and circulation.
In the head and neck injury patients, if there is an uncertainty about the integrity of the cervical spine, fiberoptic awake intubation of the trachea should be considered.  If direct laryngoscopy is planned, an "in line stabilization" of the head and neck by an assistant to prevent extension and rotation of the cervical spine is indicated. , It is currently believed that succinylcholine can be used when there is an urgent need to secure the airway in the head-injured PTV depending upon the ICP levels either intravenous or inhalational induction should be considered. Nevertheless, aggressive maternal resuscitation should always be the initial highest priority, rather than concerns about intracranial pressure or neuroanesthesia, which often proves lifesaving for both the parturient and her fetus.  [Table 3].
| Anesthetic Considerations|| |
Anesthesiologists in practice at designated trauma centers are involved in the care of trauma patients beginning with airway maintenance and resuscitation in the emergency department (ED), proceeding through the operating room or to the intensive care unit (ICU). Anesthesia for trauma patient differs as most urgent cases may occur during off-hours, when the most experienced OR and anesthesia personnel may not be available. Patient information may be limited, and allergies, genetic abnormalities, and previous surgeries may create unexpected crises. Simple operations may become complicated, requiring special surgical and anesthesia equipment at short notice. Patients often have multiple injuries requiring complex procedures, which need to be prioritized during management. Occult injuries such as tension pneumothorax, can manifest unexpectedly. Successful management of these patients requires a good understanding of pathophysiology, supplemented by adequate preparation, and the ability to react quickly to the changing circumstances.
The recent literature documenting anesthetic, obstetric, and surgical management of PTVs is limited.  In general, the difficulty in perioperative management of reproductive age female trauma victims arises from an uncertain preoperative obstetric (possibly pregnant) status. The difficulty in perioperative management of PTVs also increases from elective, to urgent to emergent situations.  The anatomic and physiologic changes of pregnancy such as increased oxygen requirements and consumption, decreased functional residual capacity, high BMI, laryngeal edema, etc. may increase difficulty during perioperative management, while decreasing the "safe apnea interval" and the margin of safety. Assumption of a full stomach with increased risk for aspiration of gastric contents should prompt pharmacological prophylaxis in all parturients for prevention of aspiration. The use of general anesthesia has been steadily declining in obstetrics; however in selected cases it may still be necessary . When general anesthesia is planned, a crash induction with cricoid pressure, to decrease the risk of regurgitation and aspiration of gastric contents, is indicated. Lung denitrogenation with 100% oxygen is mandatory before rapid sequence induction during general anesthesia. 
Intravenous induction agents like, propofol and thiopental sodium, are vasodilators, inhibiting circulating catecholamines, and have negative inotropic effect. Their administration to a trauma patient with hemorrhagic shock may potentiate profound hypotension or even cardiac arrest. Etomidate is a frequently used alternative because of its cardiovascular stability; however, it also inhibits the circulating catecholamines and may produce hypotension. Ketamine continues to be a popular induction agent for trauma patients because of its central nervous system stimulating effect, though in hemodynamically compromised patients, its direct myocardial depressant effect may lead to cardiovascular collapse. Thus, all anesthetic agents must be used cautiously in PTV with life-threatening hypovolemia.
Succinylcholine remains the muscle relaxant of choice for its fast onset and fast offset actions for rapid-sequence induction. Administration of succinylcholine is associated with several adverse consequences and should be used judiciously. Alternatively, Rocuronium, with a safer cardiovascular profile, can be used in place of succinylcholine, to avoid the adverse effects of the latter and to provide rapid relaxation. 
Equipment to facilitate difficult intubation like gum elastic bougie, intubating stylet, esophageal combitube, and laryngeal mask airway (LMA) should be readily available whenever emergency airway management is performed. The most recent advanced trauma life support (ATLS) guidelines suggest that practitioners providing emergency airway management should proceed with the method of intubation with which they are most proficient.  In general, oral intubation is preferred to nasal intubation in an emergency, to avoid risks of injury to the brain from nasal instrumentation in the presence of a basilar skull or cribriform plate fracture.
Challenges related to satisfactory pain relief for trauma in pregnancy are related to multiple sites of injury requiring prolonged periods of care, complicated with psychological and emotional issues, and concerns for fetal well-being. Epidural analgesia provides adequate analgesia and hastens recovery following thoracoabdominal and orthopedic trauma.
| Monitoring|| |
The anesthesiologist should insist on adequate monitoring standards in both emergency room and the operating theatres, with mandatory electrocardiogram, blood pressure, oximetry, and capnometry. In addition, a tocotransducer to detect the onset of uterine contractions and cardiotocographic monitoring in viable fetus should be used. A correlation between the maternal bicarbonate level and fetal outcome has been suggested. Therefore, it may be useful to monitor the maternal serum bicarbonate level in addition to other hemodynamic parameters. In hemodynamically unstable trauma patients, invasive hemodynamic monitoring is mandatory. This usually consists of continuous intra-arterial blood pressure measurement and central vein cannulation. 
| Conclusion|| |
The experienced anesthesiologist can play an important role along with the multidisciplinary team, regarding prioritization of different surgical procedures on the trauma victim. Aggressive resuscitation of the mother should take priority over concerns for fetal well being. The secondary effects of trauma result in an increase in the morbidity and mortality of pregnant trauma victims, an anesthesiologist can play a major role in preventing these secondary effects.
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[Table 1], [Table 2], [Table 3]