Trauma in Women

Introduction
Physiology & Pregnancy
Injury in Pregnancy
Assessment & Management
Domestic Violence

Introduction
Pregnancy alters nearly every organ system in the body.
Remember that there are two patients.
But initial treatment priorities remain.
- best care for the fetus is to optomise the mother.
Do not withhold XRs
Consult surgeon/O+G early.

Physiology & Pregnancy

Anatomic
Uterus is intrapelvic until 12th week of gestation, then rises out of pelvis.
- by 20wks at umbilicus
--> small fetus still relatively protected by generous amniotic fluid
- by 34-36 wks at costal margin.
--> large & thin-walled
- fetal head engages pelvis during last 2 weeks.
--> pelvic injury may lead to skull / intracranial injury to fetus.
--> bowel pushed cephalid, so mostly in upper abdo (so largely protected)
--> but can be injured in a complicated fashion.

Placenta
Placenta is non-elastic
--> shear injury can lead to abruptio placentae.
--> vasculature maximally dilated throughout gestation but very sensitive to catecholamines
An abrupt drop in maternal circulation may compromise fetal oxygenation despite relatively normal maternal signs.

Blood Volume & Composition
Plasma volume increases steadily through gestation
- plateaus at 34 weeks.
Smaller increase in RBC volume
- and decreased haematocrit to 31-35% (late)
May lose 1200-1500mL before signs of hypovolaemia occur.
--> although fetus may become distressed / tachycardic.
WBC count increases to 15 or even 25.
Fibrinogen and clotting factors mildly elevated.
- prothrombin / partial thromboplastin shortened but bleeding & clotting unchanged.
Albumin drops to 22-28.

Haemodynamics
CO: increases by 1-1.5L/min due to increase in plasma volume & decrease in vascular resistance.
- supine position can decrease CO by 30% due to cava compression.
HR: Increases gradually by 10-15.
BP: 5-15mmHg fall in systolic and diastolic BP.
- may be hypotensive when supine.
Venous return: CVP is variable with pregnancy but response to volume same.
ECG: axis leftward by 15o., flat/inverted Ts in III,aVF, precordial leads, more ectopics.
Resp
: Minute ventilation increases, hypocapnoea is common (30)
- 35-40 may signal resp failure.
- O2 consumption is greater.
GI: gastric emptying is longer (assume a full stomach and avoid aspiration).
Urinary: GFR increases, creat and urea fall, system may dilate
Endocrine: Pituitary increases 30-50%, shock may cause necrosis.
Musculoskeletal: symphasis widens 4-8mm and sacroiliacs increse by 7th month.
Neuro: Eclampsia can mimic head injury.

Injury & Pregnancy

Fetal impact is buffered by uterus, abdo wall and amniotic fluid but fetal injury still very possible.
Lap belts associated with uterine rupture.
Penetrating missiles are slowed by uterus and anatomic changes means less maternal visceral injury but greater fetal injury.
Severity of maternal injury is major determinant of both mother and baby outcome.
- 80% of mothers with haemorrhagic shock will experience fetal death.
- watch even minor injuries for abruptio placentae.

Assessment & Management

Primary
ABCDEs as usual.
Shock may be aggravated by vena cava reducing venous return.
- transport on left side unless spinal injury suspected.
- can logroll and support 4-6inches on left if reqd.
May lose significant blood before signs occur (while fetus is suffering).
- early resuscitation and blood are indicated.
Peritoneal signs are difficult.
Uterine rupture suggested by: abnormal lie, easy palpation of fetus, inability to palpate fundus, or XR of abnormality / intraperitoneal air.
--> surgical exploration.
Abruptio placentae suggested by vaginal bleeding in 70%, uterine tenderness, frequent contractions, uterine tetany, uterine irritability.
- USS shows the lesion but is not definitive.
Hypovolaemia and pain may accompany these two injuries.
Continuous fetal monitoring at 20-24wks, Dopper at >10wks.

Adjuncts to Primary
Monitor on left side, CVP helpful, oximetry and ABG.
Early obstetric consultation.

Secondary
Same as for nonpregnant patients
Place DPL catheters above umbilicus.
Pay attention to uterine contractions
Obstetrician for pelvic exam.
- note for amniotic fluid in vagina, cervical change, presentation and bleeding.

Special Issues
Admission is manditory if abnormality in mother / fetus.
- ie vaginal bleeding, uterine irritability, abdo tenderness, pain or cramping, hypovolaemia, changes in fetal heart tones, or leakage of amniotic fluid.
Consider Rh immunoglobulin for all pregrant Rh-negative trauma pts unless injury remote from uterus.
Large engorged pelvic vessels can cause massive retroperitoneal bleeding.
While perimortem c-section may be successful if performed within 5 minutes for other causes of cardiac arrest, there is no data to support this in trauma as the fetus will have been compromised for a long period.

Domestic Violence
A major cause of injury.
17% of injured pregnant women were traumatised by another person (60% domestic)
Consider if:
- injuries inconsistent with history
- diminished self-image, suicide attempts
- self-abuse
- frequent ED visits
- symptoms suggest substance abuse
- self-blame for injury
- partner domineering and insists on being present.

Screen (65-70% sensitive)
1. Have you been kicked, hit, punched, or otherwise hurt by someone within the past year? If so whom?
2. Do you feel safe in your current relationship?
3. Is there a partner from a previous relationship who is making you feel unsafe now?