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Blunt Trauma In Pregnancy

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Autor:  anton  19 November 2010
Tags:  Trauma,  Pregnancy
Words: 3472   |   Pages: 14
Views: 269

BLUNT TRAUMA IN PREGNANCY

AUTOMOBILE ACCIDENTS

Trauma affects 6-7% of pregnancies in the U.S. 60 - 67% related to automobile accidents.

Fetal mortality after maternal blunt trauma is 34 - 38%. The two major causes of fetal death after maternal blunt trauma are: Maternal shock/death, and placental abruption.

The pregnant trauma patient presents a unique challenge because care must be provided for two patients, the mother and the fetus. It is vital that the nurse know and understand the anatomical and physiological changes that occur during pregnancy. She must be aware of these changes, and how they can mask or mimic injury, and very importantly that fetal distress or loss can occur even when the mother has incurred no abdominal injuries.

Regardless of the apparent severity of injury in blunt trauma, all pregnant women should be evaluated in a medical setting.

Only viable fetuses are monitored, because no obstetric intervention will alter the outcome of a pre-viable fetus. Determination of fetal viability is subject to institutional variation: an estimated gestational age of 20 - 26 weeks and an estimated fetal weight of 500g. Are commonly used thresholds of viability. Therefore, patients who have minor trauma and who are at less than 20 weeks gestation do not require specific intervention or monitoring. All pregnant women beyond 20 weeks' gestation should undergo a minimum of 4 - 24 hours, and in some cases as long as 48 hours of monitoring. Fetal distress may be the first sign of maternal hemodynamic compromise and fetal distress, and to identify possible placenta abruption.

Resuscitation of the more serious trauma patient must focus on the mother because the most common cause of fetal death is maternal shock or death. It is important to remember that the mother will maintain her vital signs at the expense of the fetus. Because plasma volume is increased by 50% and the mother is able to shunt blood away from the uterus, maternal shock may not manifest itself until maternal blood loss exceeds 30%.

Initial ABC assessment:

Airway and breathing: All pregnant trauma patients should receive supplemental oxygen, because the fetus is extremely sensitive to hypoxia and because the oxygen reserve is significantly diminished in the pregnant patient.

Because the heavy uterus may compress the great vessels when a pregnant women is supine, causing a decrease in blood pressure, thus a decrease in stroke volume, and consequently a decrease in uterine blood flow, the patient should be placed on her side, if she must lay supine, place a small pillow under one hip, this will tilt the uterus off the inferior vena cava, improving blood flow throughout the woman's body and to the placenta.

Survival of the fetus depends on adequate uterine perfusion and delivery of oxygen. Uterine circulation has no auto-regulation system, uterine blood flow is directly related to maternal blood pressure. To maximize uterine perfusion and oxygenation to the fetus supplemental oxygen and IV fluids are administered and continued until hypovolemia, hypoxia, and fetal distress resolve.

In general, pregnancy does not affect the decision to intubate, although the risk of aspiration is increased - related to decreased gastric tone, delayed gastric emptying, and cephalad displacement of intra-abdominal organs. The use of medications for rapid-sequence intubation in pregnancy is not will studied, however no absolute contraindications exist.

If a chest tube is placed, enter the chest 1 or 2 interspaces higher than usual, because the diaphragm is elevated during pregnancy.

Circulation:.

Rule out occult sources of bleeding, because maternal blood flow is maintained at the expense of fetal blood flow.

If blood is needed on an emergency basis, use Rh-negative blood unless the patients's Rh status is known.

After initial stabilization, other maternal injuries are evaluated, and fetal heart tones are assessed by Doppler or ultrasonography.

Secondary assessment

Physical:

The findings of the physical examination in the pregnant woman with blunt trauma are not reliable in predicting adverse obstetric outcomes. Nurses must be aware of pregnancy induced physiologic changes when making assessments. For example, The pregnant woman's blood volume increases to provide exchange of nutrients, oxygen and waste products within the placenta and as a reserve for blood loss at birth. Therefore maternal blood pressure does not accurately reflect uterine perfusion or fetal injury. Pregnant women can lose up to 30% (2L) of their blood volume before their vital signs change. The nurse must also recognize that significant blood loss can occur in the uterine wall or retroperitoneal space without external bleeding.

Compared with nonpregnant persons who experience trauma, pregnant women have a higher incidence of serious abdominal injury but a lower incidence of chest and head injuries. Maternal pelvic fractures, particularly in late pregnancy, are associated with bladder injury, urethral injury, retroperitoneal bleeding, and fetal skull fracture. After 12 weeks of gestation, the maternal uterus and bladder are no longer exclusively pelvic organs and are more susceptible to direct injury.

Abdominal examination:

.Inspect for ecchymosis, especially across the lower abdomen, which may indicate a possible seatbelt injury.

Palpate for uterine contractions or tenderness. Occasional uterine contractions are the most common finding after trauma in pregnant women. In 90% of the cases this usually resolves within a few hours. Note that because of peritoneal stretching in the third trimester decreases the density of afferent pain fibers, abdominal tenderness may be masked.

Sterile speculum examination:

Perform these in the absence of vaginal bleeding:

Test the fluid for pH and ferning. A pH of 7 indicates amniotic fluid. Vaginal secretions are more acidic, with a pH around 5.

Examine for vaginal lacerations, or bone fragments, which signify and open pelvic fracture.

Laboratory studies:

Complete blood count: Pregnancy-induced leukocytosis peaks to levels of 12,000 - 18,000 cubic millimeter during the third trimester. During labor, levels as high as 25,000 per cubic millimeter may occur.

Blood volume increases during pregnancy but the plasma increases at a greater amount then erythrocytes.

Blood typing and cross matching.

Rhesus factor (Rh) status should be determined. In Rh-negative pregnant women, administration of RhoGAM is unnecessary after insignificant superficial injury confined to an extremity. After any other trauma, the immune globulin should be administered within 72 hours to all Rh-negative women, including those who are at less than 12 weeks of gestation and those who have minimal injuries. One dose of immune globulin is sufficient in 90% of cases of fetal-maternal hemorrhage, because most fetal-maternal hemorrhages are less than 30mL of blood.

Assessment of coagulation profile - most coagulation factors rise throughout pregnancy, although laboratory values remain unchanged except fo fibrinogen levels, which nearly double in value.

Kleihauer-Betke testing: This test is used to detect fetal-to-maternal hemorrhage. In the event of fetal distress, a positive test may indicate life-threatening hemorrhage in the fetal circulation. In addition, the test is useful in Rh-negative mothers because the standard dose of RhoGAM (300mcg) covers only up to 15mL of fetal red cells. In major trauma, additional fetal red cells may come into contact with maternal blood, and the Kleihauer-Betke test helps the physician to determine how much additional RhoGAM to administer.

Electrocardiography (ECG):

The ECG may change as the diaphragm elevates.

It may show a left-axis deviation with flattened T waves and, possibly, a Q wave.

Do not mistake these changes for the ischemic or traumatic changes in blunt chest trauma.

Medications:

Medications used in trauma may have fetal effects, although most are pregnancy category B or C.

Good resources for adverse effects of medications in pregnancy are available. Tetanus toxoid should be given as indicated.

Based on limited data, tocolytic drugs probably should be avoided after trauma. Regular contractions may signify placental abruption. Administration of tocolytic drugs could compromise the fetus be delaying the diagnosis of placental abruption and consequently delaying delivery.

Dopamine, a drug routinely used to achieve hemodynamic stability in trauma patients, causes uteroplacental vasoconstriction and may lead to fetal death.

Complications:

Rupture of amniotic membranes can lead to chorioamnionitis, preterm labor, and cord prolapse.

Retroperitoneal hemorrhage, uterine rupture - diagnosed with maternal hypotension, palpation of fetal part, radiographic findings- and amniotic fluid embolism may lead to acute respiratory distress syndrom.

Placental abruption is the most feared complication in cases of trauma. It is caused when shearing forces lead to a separation of the placenta from the uterus. It occurs in 38-66% of major injuries and in 2 - 4% of minor injuries. It is the most common cause of fetal death when the mother survives the trauma. It carries a 67 - 75% fetal mortality rate.

Most cases of abruption become evident with in several hours after trauma, but may be delayed for as long as 24 - 48 hours after the traumatic incident.

Diagnosis is made with 2 of the following 3 criteria:

Tenses abdomen with uterine hypotonia

Maternal hypertension or hypotension

Ultrasonographic evidence of abruption

Fetal distress is the most reliable indicator of active or impending abruption. The occurrence of eight or more uterine contractions per hour for more than 4 hours is associated with placental abruptions. Ultrasonography is an insensitive tool and causes more than 50% of abruptions to be missed because the density of a fresh clot of blood behind the placenta is the same as the placenta itself.

Amniocentesis can be used to make the ultimate diagnosis in desperate situations.

Uterine rupture is associated with a fetal mortality rate approaching 100%. Maternal mortality of 10% is usually a result of associated injuries.

Fetal injury is the leading cause of fetal death in cases of maternal death. Direct fetal trauma is rare because of the protection from the uterus and amniotic fluid. Skull fracture is the most common direct fetal injury, with a mortality rate of 42%.

Prevention:

Despite advances in trauma management, the fetal and maternal mortality rates after traumatic injury have not declined. Because current management does little to affect mortality, prevention is key to increasing maternal and fetal survival.

Although motor vehicle crashes are responsible for most severe maternal injuries and fetal losses form trauma, pregnant women have low rates of seat belt use. Proper seat belt use is the most significant modifiable factor in decreasing maternal and fetal injury and mortality after motor vehicle crashes. Seat belt-restrained women who are in motor vehicle crashes have the same fetal mortality rate as women who are not in motor vehicle crashes, but unrestrained women who are in crashes are 2.8 times more likely to lose their fetuses.

Prenatal care must include three-point seat belt instruction. The lap belt should be placed under the gravid abdomen, snugly over the thighs, with the shoulder harness off to the side of the uterus, between the breasts and over the midline of the clavicle. Seat belts placed directly over the uterus can cause fetal injury, pregnant patients should be instructed to seek care immediately after any blunt trauma.

.

REFERENCES:

Introduction to Maternity & Pediatric Nursing, Fourth Edition; Gloria Leifer, MA, Copyright 2003, Elsevier Science (USA).

http://www.aafp.org

http://www.med.umich.edu

BLUNT TRAUMA

AUTOMOBILE ACCIDENTS

BLUNT TRAUMA:

Affects 6 - 7% of pregnant women.

60 - 67% are related to automobile accidents.

Regardless of the severity of injury all pregnant women should be evaluated in a medical setting.

EVALUATION

Nurses need to know and understand the anatomical and physiological changes that occur during pregnancy.

-They can mask or mimic injury.

-Fetal distress or loss can occur even when the mother has incurred no abdominal injuries

and/or is asymptomatic.

-Mother will maintain her vital signs at the expense of the fetus.

INITIAL ASSESSMENT:

Supplemental oxygen:

-Oxygen reserve is significantly diminished in pregnant patients, especially in third trimester.

-Fetus is extremely sensitive to hypoxia.

-Women should be placed on her side because the heavy uterus may compress the great vessels while lying supine - causing decreased uterine blood flow. If the patient must lay supine, place a small pillow under one hip - this will tilt the uterus off the inferior vena cava.

Uterine circulation has no auto-regulation system, uterine blood flow is directly related to maternal blood pressure. Survival of the fetus depends on adequate uterine perfusion and delivery of oxygen. Therefore IV fluids are administered along with the supplemental oxygen.

Intubation:

-Pregnancy does not affect the decision to intubate.

-Risk of aspiration increases related to pregnancy induced, decreased gastric tone, delayed gastric emptying, and displacement of intra-abdominal organs.

-Chest tube is placed 1 or 2 interspaces higher than usual, related to diaphragm elevation during pregnancy.

Rule out occult sources of bleeding:

-Remember maternal blood flow is maintained at the expense of fetal blood flow.

-Pregnancy increases maternal blood volume to provide exchange of nutrients, oxygen and

waste products within the placenta and as a reserve for blood loss at birth. Pregnant

women can lose up to 30% (2L) of their blood before seeing any signs or symptoms of

blood loss.

-If blood is needed on an emergency basis, use Rh-negative blood unless the patients Rh

status is known.

SECONDARY ASSESSMENT

Monitoring:

Only viable fetuses are monitored - no obstetric intervention will alter the outcome of a pre-viable fetus.

Determination of a viable fetus:

Subject to institutional variation. Common thresholds:

-estimated gestational age 20 - 26 weeks

-estimated weight of 400 - 500g.

-ultrasonography is the most accurate method to determine gestational age.

A minimum of 4 - 24 hours and possibly as long as 48 hours.

Fetal distress may be the first sign of maternal hemodynamic compromise as well as fetal distress and to identify placenta abruption.

Physical:

Physical examination in the pregnant women with blunt trauma are not reliable in predicting adverse obstetric outcomes. Because of the physiological and anatomical changes in pregnancy.

-As previously mentioned the increase in blood volume, can allow a significant blood loss to go undetected. A blood loss can occur in the uterine walls or retroperitoneal space without external bleeding.

-Palpate the abdomen for contractions and or tenderness - uterine contractions are the most common finding after trauma. In 90% of the cases they are resolved in a few hours.

-Peritoneal stretching in the third trimester decreases the density of afferent pain fibers, abdominal tenderness may be undetected.

Lab tests:

-CBC - pregnancy induced leukocytosis peaks to levels of 12,000 - 18,000 cubic millimeter during the third trimester. During labor, levels as high as 25,000 per cubic millimeter may occur.

-Blood volume increases, however, blood plasma increases at a greater value then erythrocyte.

-Coagulation profile - lab values remain the same for all coagulation factors except fibrinogen, which usually doubles.

-Rh status should be determined. Blood loss related to an extremity RhoGAM is unnecessary. All other trauma RhoGAM should be administered within 72 hours. I including those less than 12 weeks pregnant.

-If there is no vaginal bleeding - the Ph of vaginal secretions should be tested. A pH of 7 indicates amniotic fluid. Vaginal secretions are more acidic, with a pH of 5.

-Kleihauer - Betke testing - is done to detect fetal-to-maternal hemorrhage, and is useful in deciding how much RhoGAM to administer. One dose covers up to 15mL of fetal RBC.

-Electrocardiogram - The EKG may change as the diaphragm elevates during pregnancy. Possible left axis deviation with flattened T waves,, and possibly Q waves. - Do not mistake these changes for ischemic or traumatic changes in blunt chest trauma.

Medications:

-Tocolytic drugs should be avoided after trauma, in most cases. Regular contractions may signify placental abruption, a delay in diagnosis could be fatal to the fetus.

-Dopamine - a drug routinely used to achieve hemodynamic stability in trauma patients causes uteroplacental vasoconstriction and may lead to fetal death.

-Tetanus toxoid should be given as indicated.

COMPLICATIONS

-Rupture of amniotic membranes can lead to chorioamnionitis, preterm labor, and cord prolapse.

-Retroperitoneal hemorrhage, uterine rupture - diagnosed with maternal hypotension, palpation of fetal part, radiographic findings- and amniotic fluid embolism may lead to acute respiratory distress syndrom.

-Placental abruption is the most feared complication in cases of trauma. It is caused when shearing forces lead to a separation of the placenta from the uterus. It occurs in 38-66% of major injuries and in 2 - 4% of minor injuries. It is the most common cause of fetal death when the mother survives the trauma. It carries a 67 - 75% fetal mortality rate.

Most cases of abruption become evident with in several hours after trauma, but may be delayed for as long as 24 - 48 hours after the traumatic incident.

Diagnosis is made with 2 of the following 3 criteria:

Tenses abdomen with uterine hypotonia

Maternal hypertension or hypotension

Ultrasonographic evidence of abruption

Fetal distress is the most reliable indicator of active or impending abruption. The occurrence of eight or more uterine contractions per hour for more than 4 hours is associated with placental abruptions. Ultrasonography is an insensitive tool and causes more than 50% of abruptions to be missed because the density of a fresh clot of blood behind the placenta is the same as the placenta itself.

Amniocentesis can be used to make the ultimate diagnosis in desperate situations.

-Uterine rupture is associated with a fetal mortality rate approaching 100%. Maternal mortality of 10% is usually a result of associated injuries.

-Fetal injury is the leading cause of fetal death in cases of maternal death. Direct fetal trauma is rare because of the protection from the uterus and amniotic fluid. Skull fracture is the most common direct fetal injury, with a mortality rate of 42%.

Prevention:

Despite advances in trauma management, the fetal and maternal mortality rates after traumatic injury have not declined. Because current management does little to affect mortality, prevention is key to increasing maternal and fetal survival.

Although motor vehicle crashes are responsible for most severe maternal injuries and fetal losses form trauma, pregnant women have low rates of seat belt use. Proper seat belt use is the most significant modifiable factor in decreasing maternal and fetal injury and mortality after motor vehicle crashes. Seat belt-restrained women who are in motor vehicle crashes have the same fetal mortality rate as women who are not in motor vehicle crashes, but unrestrained women who are in crashes are 2.8 times more likely to lose their fetuses.

Prenatal care must include three-point seat belt instruction. The lap belt should be placed under the gravid abdomen, snugly over the thighs, with the shoulder harness off to the side of the uterus, between the breasts and over the midline of the clavicle. Seat belts placed directly over the uterus can cause fetal injury, pregnant patients should be instructed to seek care immediately after any blunt trauma.



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