TRAUMA AND SURGERY IN THE PREGANANT PATIENT PRINCIPLES OF SURGERY-2009 NICHOLAS LEYLAND,BASc,MD,MHCM,FRCSC CHIEF OF OBSTETRICS AND GYNAECOLOGY, MEDICAL DIRECTOR OF THE WOMEN’S, CHILDREN’S AND FAMILY HEALTH.
Download ReportTranscript TRAUMA AND SURGERY IN THE PREGANANT PATIENT PRINCIPLES OF SURGERY-2009 NICHOLAS LEYLAND,BASc,MD,MHCM,FRCSC CHIEF OF OBSTETRICS AND GYNAECOLOGY, MEDICAL DIRECTOR OF THE WOMEN’S, CHILDREN’S AND FAMILY HEALTH.
TRAUMA AND SURGERY IN THE PREGANANT PATIENT PRINCIPLES OF SURGERY-2009 NICHOLAS LEYLAND,BASc,MD,MHCM,FRCSC CHIEF OF OBSTETRICS AND GYNAECOLOGY, MEDICAL DIRECTOR OF THE WOMEN’S, CHILDREN’S AND FAMILY HEALTH PROGRAM ST.JOSEPH’S HEALTH CENTRE, ASSOCIATE PROFESSOR OF OB/GYN, UNIVERSITY OF TORONTO Surgery and Trauma in the Pregnant Patient Learning objectives: 1)TRAUMA IN PREGNANCY 2)THE ACUTE ABDOMEN IN PREGNANCY 3)CASES 5) UPDATE LEYLAND Trauma in Pregnancy-Incidence: • Trauma occurs in 6-7% of pregnancies • 4.6-8.3% of Traumas are complicated by pregnancy Maternal mortality rate • 3.5% – Mortality rate is similar for non-pregnant women Fetal mortality rate • 1% in minor trauma • 15% in major trauma • Overall fetal death rate from trauma = 1/30000 pregnancies “THERAPEUTIC PARALYSIS” Maternal Physiology: Surgical Implications: • • • • Cardiovascular Changes; CO ^ 50%,Blood Vol^ 50% Maternal rbc ^ 30% ‘Dilutional Anaemia’ WBC ^ 12000, Labour 20,000 GI: Appendix (localization), Progesterone Decreased motility,^ alk phosphatase, no change in Transaminases • Respiratory Changes: e.g. Decreased pCO2 General Management Principles Maternal Assessment • Primary Survey – ABCs…Fetus • Lateral Tilt – Supine position can cardiac output by 30% – 15° tilt is appropriate – Can decrease effect of CPR General Management Principles Fetal Assessment • Ultrasound – – – – – GA Placentation/Abruption Fetal viability Extent of fetal trauma/demise BPP? • Celestone as indicated • Initiate FHM after patient is stabilized • Vaginal exam to rule out PROM General Management Principles Maternal Assessment • Rhogam: – Administer within 72 hrs – 10-30% of trauma have evidence of admixture – Betke-Kleihaurer test to determine quantity of hemorrhages – 90% of hemorrhages are < 30 cc • Anterior placed placentas have higher risk General Management Principles Maternal Assessment • Exploratory Laparotomy – usually necessary in penetrating trauma – C/S may be required to attain adequate surgical exposure • Tetanus – As usual Imaging & Radiation Harmful effects: 1. Cell death and teratogenesis – – – – – High doses of radiation before implantation is likely lethal In humans, high dose growth restriction, microcephaly, mental retardation Effects are greatest at 8-15 wks gestation No proven effects before 8 wks or after 25 wks Risks are not increased until radiation exposure = 5 rad Imaging & Radiation Fetal Radiation Exposure in typical trauma Fetal Exposure CXR (2 views) Abdo XR (3 views) CT Head/Chest CT Abdo 0.02-0.07 100 <1 3.5 mrad mrad rad rad Total 4.8 rad ACOG guidelines suggest that imaging is safe when exposure is ≤ 5 rad Blunt Trauma • MVAs and abuse most common • Fetal death can follow direct blunt trauma or maternal death – Specifically head trauma and ejection from vehicle • Abdominal contents shifted in pregnancy – Retroperitoneal & splenic injury more frequent – GI injuries less frequent Blunt Trauma - Consequences • Placental Abruption – – – – In up to 40% of severe blunt trauma In up to 3% of minor blunt trauma Contractions q10min = 20% risk of abruption Abruption confers 50% fetal mortality • Uterine rupture – Increases with force and gestation – Fetal death frequent here, but maternal death 10% • Pelvic Fracture – Consider fetal skull fracture – MAST trousers contraindicated – If stable vaginal delivery still feasible • Pre-Term Labour … Blunt Trauma – Pre Term Labour Can PTL be predicted after blunt abdominal trauma? • 85 patients over 3 yrs with non-catastrophic trauma Findings • Preterm Labour in 13 (15%) • Presence of Abdo pain or Contractions do not predict PTL • Domestic abuse victims were more likely to have repeated trauma (Pak 1998) MVAs Frequency • In USA, 2% of all live births have been exposed to a reported MVA Seatbelts • Up to 25% of pregnant drivers are unrestrained. • Seatbelts positioned improperly cause a 3-4 fold increase in energy transmission through the uterus MVAs Airbags • No large scale data of airbags in pregnancy • Pregnancy is not an indication for deactivation of airbags Pregnant Crash Test Dummy: Penetrating Trauma • Uterus may serve to protect maternal organs – Visceral injury from penetrating trauma in pregnancy = 38% vs 90% – Of GSWs to abdomen, death in pregnancy is 1/3 rate of non-pregnant – Fetal death rate: 71% of GSWs, 42% stabs • Penetrating trauma is generally an indication for exploratory laparotomy • Half the women had perinatal deaths due to either maternal shock, uteroplacental injury, or direct fetal injury. A Unified Approach Is there a need for a standardized protocol for obstetrical patients who experience trauma? The low incidence of trauma during pregnancy leaves trauma teams at risk of ignoring steps that may prevent adverse outcomes. An organized approach of stabilizing the injured gravida and then initiating ultrasound and EFM in pregnancies beyond 24 wks will ensure the best outcome for the mother and her unborn child. It is now a requirement in Australia for a level 1 trauma centre to have a protocol detailing the management of pregnant patients after trauma. A Unified Approach Issues to consider • Delayed monitoring during primary survey and imaging – Average time to clear c-spine estimated at 36 minutes • Access to FHR monitor in ER may not be available – Estimated that 15% of ERs in USA have this • Other activities in resuscitation room may preclude continuous access to FH, or hinder ability to hear it • Patients transferred to labour floor for ongoing monitoring may not receive optimal management of non-obstetrical issues – Eg. Soft tissue injury, Physiotherapy, occupational therapy, etc. TRAUMA IN PREGNANCYKey Points: • Trauma occurs in 6-7% of pregnancies • Physiologic changes of pregnancy may confuse the picture • ABCs should not be abandoned in managing a pregnant trauma patient • Consider Rhogam, Celestone, PROM, and initial FH monitoring • Education regarding proper use of seatbelts in pregnancy is paramount • Consideration of a standardized trauma protocol or record for obstetrical use may be warranted. TRAUMA IN PREGNANCYKey Points: • Investigations ….LEYLAND’S AXIOM… “IF AN INVESTIGATION IS INDICATED DO IT” • Fetal viability….24 weeks • Fetal monitoring….OBS/PERINATOLOGY • Transfer to regional center ONLY after maternal stabilization TRAUMA IN PREGNANCY: Head Trauma • Dead Mother = Dead Fetus Case • ID: 21 y/o G1 P0 @ 18/40 • HPI: – – – – – Sudden onset of colicky right sided pain Anorexia No BM x 3 days, emesis x 1 Warmth x 2 days No dysuria, no gross hematuria, no PV bleeding Case • O/E: – BP: 110/55; HR: 110 regular; RR: 18; Temp: 37.9 – Abdo: uterine height of 20 cm, tender over right side of abdomen w/ rebound – V/E: N Case • DDx: – – – – – – – – Appendicitis UTI Renal calculi Cholecystitis Ovarian cyst / torsion Ligamentous pain Cecal diverticulitis Acute iliitis Case • Investigations? • Labs: – Hb 130, WBC 14, Plt 350 – Lytes, Cr, liver tests all normal – Urine R&M – trace protein, no leuks, no bacteria, trace blood • Imaging: – Fetal U/S – BPP 8/8 – RLQ U/S - compressible blind-ended tubular structure w/ a maximal diameter of 9 mm, wall thickened to 5 mm Appendicitis - Background • Of the most common causes of the acute abdo • Peaks in 2nd and 3rd decades of life, M>F • Anatomy: – Lies in the RLQ of the abdomen – Exceptions: • Malrotation (LUQ) • Pregnancy (RLQ-RUQ) Epidemiology • Incidence – 0.05-0.07% • Perforation – 20-55% (versus 4-19% in general population) • Fetal mortality – 1.5-9% w/o perf (up to 36% w/ perf) • Overall correct diagnosis 50-86% Clinical • Symptoms non-specific initially • Initially dull, poorly localized periumbilical pain • Localizes to McBurney’s point • Nausea/vomiting • Low grade fever ~38 (if rupture, fever higher) • Eventually +/- peritoneal signs Labs/Imaging • Labs: elevated WBC, no abnormalities that indicated an alternate dx (liver functions, BHCG, etc) • CT: 95% spec and sens • U/S: 81% spec, 86% sens Management • Surgical • Preop – Hydration – Abx prophylaxis • Non-perfed: cefazolin 1 g IV, metronidazole 500 mg IV • Perfed: ceftriaxone 1 g IV, metronidazole 500 mg IV • Delaying intervention for >24 hrs, risks perfs • Risk of preg comps (SA or prematurity) w/ laparotomy decrease with gestational age • May do laparotomy or laparoscopy G.I. DISEASE IN PREGNANCY: APPENDICITIS • Fetal Mortality and Maternal Morbidity rates are directly correlated to the delay in diagnosis and treatment****** Acute cholecystitis - Background • A syndrome with: – – – – RUQ pain Fever Leukocytosis Assoc w/ GB inflammation usually due to gallstone (in preg – 90%) Epidemiology • Incidence of <0.1% in pregnancy • Maternal mortality 0-1% – 15% with pancreatitis • Fetal mortality 10-20% – 60% with pancreatitis Clinical • RUQ/epigastric pain, steady and severe >46 hours • Nausea/vomiting, anorexia • Fatty food ingestion exacerbates pain 1 hour after intake • Ill looking, tachycardic, febrile, lie still, peritoneal signs, +ve Murphy’s sign (inspiratory arrest) +/- jaundice Pathophysiology • Pregnancy predisposes to accumulation of GB stones by: – Increasing viscosity of bile – Increasing the number of micelles on which cholesterol crystals precipitate – Relaxing the GB leading to stasis • Increased risk of cholelithiasis stays for up to 5 years postpartum Labs/Imaging • Labs: – Elevated WBC w/ left shift – Elevated bili and ALP, +/- high AST/ALT/amylase • U/S: – – – – – Cholelithiasis Wall thickening >4.5 mm Sonographic Murphy’s sign Dilation of GB Sens 88%, spec 80% • HIDA scan – Sens 97%, spec 90% Management • IV hydration • Analgesia – Demerol preferred over morphine (morphine may produce spasm of sphincter of Oddi) • NPO • Abx – Metronidazole 500 mg IV q8h – Ceftriaxone 1 g IV q24h Management • Surgery is safest to perform during TM2 • Laparoscopic cholecystectomy has been performed during pregnancy but safety is uncertain • Patients w/ choledocholithiasis or pancreatitis can be mx w/ ERCP w/ sphincterotomy • If preg and have gallstones but asymptomatic – no surgery • Pre-preg if have symptoms consistent w/ gallstones consider cholecystectomy G.I. DISEASE IN PREGNANCY: BOWEL OBSTRUCTION • Morbidity and Mortality related to the delay in diagnosis* • Previous Surgery and Adhesions--3d TM • Volvulus, Hernia, Intussusception • Signs and Symptoms = • Diagnosis Serial Assessments and Serial AXRs • Management? CASE 2 • “THE MOOSE STORY” CASE 2 • • • • “THE MOOSE STORY” NOW IN THE NEUROSURGICAL ICU CONSULTS OBS RE CT, ANGIOGRAPHY CONSIDERATION OF TERMINATION? CASE 2 • “THE MOOSE STORY” • THE HAPPY ENDING………. CASE 3 • 30 YR OLD WOMAN AT 24 WEEKS GESTATION MVA HIT FROM BEHIND • HAD SEAT BELT ON, NO HEAD INJURY • O/E VSS, BRUISED AND TENDER ABDOMEN • FETAL HEART TONES HEARD • WHAT ARE THE ISSUES HERE? CASE 3 • MATERNAL CONSIDERATIONS FIRST! • FETUS SECONDARY • MONITORING IF FETUS VIABLE • FETAL MATERNAL TRANSFUSION BETKE-KLEIHAUER • SURGICAL DELIVERY IF FETAL DISTRESS AND MOTHER IS STABLE SURGERY IN THE PREGNANT PATIENT Learning objectives: 1)TRAUMA IN PREGNANCY 2)THE ACUTE ABDOMEN IN PREGNANCY 3)CASES THANKS! SURGERY IN THE PREGNANT PATIENT • AVOID “THERAPEUTIC PARALYSIS” • IF AN INVESTIGATION IS INDICATED FOR DIAGNOSIS ---DO IT! • NEVER COMPROMIZE THE MATERNAL CARE FOR THE SAKE OF THE FETUS! • THERE ARE VERY FEW DRUGS OR INVESTIGATIVE TESTS WHICH CAUSE SERIOUS FETAL DAMAGE