The
occurrence of trauma during pregnancy is recognized; yet at the same time often
overlooked by many providing medical care. According to recent data, among
women of childbearing age, trauma is the leading cause of death. Astoundingly,
trauma accounts for more than 20% of maternal deaths not related to childbirth.
Out of every 15 pregnant women, one of those is involved in a traumatic event
resulting in severe injury. Of those pregnant women affected by trauma, about
60% are related to homicide. Trauma in any patient presents the medical team
with multiple, complex issues, however the pregnant trauma patient is a much
greater challenge. Not only does one need to assess the extent of injury to the
mother, but also the magnitude of injury to the fetus, thus two lives are
potentially at risk.
The
physiological changes that are related to pregnancy adaptation are often
misguiding and difficult to discern from a true pathological process.
Understanding the normal maternal-fetal physiology is of critical significance
in the correct diagnosis, surgical intervention, and post-operative management
for these women affected by traumatic injury. During pregnancy, changes in
pertinent major organ system include the cardiovascular system, the pulmonary
system, the hematologic system, the gastrointestinal system, the genitourinary
system, and metabolism. The recognition of laboratory and clinical values in
women who are pregnant might also suggest a particular pathology in women who
are not pregnant. The proper assessments
of these are extremely important since it saves them from the risks of
potentially dangerous surgical interventions or diagnostic testing.
Changes
in Laboratory Values During Pregnancy
|
Value
|
Nonpregnant
|
Pregnant
|
|
Chloride
(mEq/L)
|
100-106
|
90-105
|
|
Bicarbonate
(mEq/L)
|
24-30
|
17-22
|
|
PCO2
(mm Hg)
|
35-50
|
25-30
|
|
PO2
(mm Hg)
|
98-100
|
101-104
|
|
Base
excess (mEq/L)
|
0.7
|
3-4
|
|
Arterial
pH
|
7.38
|
7.40-7.45
|
|
BUN
(mg/dL)
|
10
|
4-12
|
|
Creatinine
(mg/dL)
|
0.6
|
0.4-0.9
|
|
Creatinine
clearance (mL/min)
|
3.5
|
2.0-3.7
|
|
Osmolality
(mOsm/kg)
|
275
|
275-285
|
|
Alkaline
phosphatase (mU/mL)
|
13
|
25-80
|
|
SGOT†
(mU/mL)
|
10
|
10-40
|
|
Total
protein (g/dL)
|
6.0
|
5.5-7.5
|
|
Albumin
(g/dL)
|
3.5
|
3.0-4.5
|
|
Total
cholesterol (mg/dL)
|
120
|
250
|
|
Triglycerides
(mg/dL)
|
45-150
|
230
|
|
Hematocrit
(%)
|
37-48
|
32-42
|
|
Hemoglobin
(g/dL)
|
12-16
|
10-14
|
|
Leukocytes
(cells/mm3)
|
4300-10,800
|
5000-15,000
|
|
Lymphocytes
(%)
|
38-46
|
15-40
|
|
Fibrinogen
|
250-400
|
600
|
|
Platelets
|
150,000-350,000
|
130,000-350,000
|
|
Iron
saturation (%)
|
30-40
|
14-30
|
|
Ferritin
(ng/mL)
|
35
|
10-12
|
|
Erythrocyte
sedimentation rate (mm/h)
|
<
20
|
30-90
|
|
*Partial
pressure of oxygen
†Serum
glutamic-oxaloacetic transaminase
|
||
Central
Hemodynamics in Pregnancy
|
Hemodynamic
Parameters
|
Nonpregnant
(±
SD)
|
Pregnant
(±
SD)
|
Percent
Change
%
|
|
Heart
rate (beats per min)
|
71
(10)
|
83
(10)
|
+17
|
|
MAP
(mm HG)
|
86.5
(7.5)
|
90.3
(5.8)
|
NS*
|
|
Cardiac
output (L/min)
|
4.3
(0.9)
|
6.2
(1.0)
|
+43
|
|
SVR†
(dyne sec/cm5)
|
1520
(520)
|
1210
(266)
|
-21
|
|
LVSWI‡
(g m/m2)
|
41
(8)
|
48
(6)
|
NS
|
|
Central
venous pressure (mm Hg)
|
3.7
(2.6)
|
3.6
(2.5)
|
NS
|
|
PCWP
(mm Hg)
|
6.3
(2.1)
|
7.5
(1.8)
|
NS
|
|
COP
(mm Hg)
|
20.8
(1.0)
|
18
(1.5)
|
-14
|
|
*Not
significant
†Systemic
vascular resistance
‡
Left ventricular stroke work index
|
|||
There are four main factors in traumatic injury in a
pregnant woman that most accurately predict maternal and fetal morbidity and
mortality- hypoxia, infection, drug effects, and preterm delivery. First, as
with any traumatic injury, you must begin your primary survey with assessing
the airway, breathing, and circulation while providing resuscitation
interventions as needed. It is important to note that oxygen therapy should be
started on the mother even if she is stable since slight changes in blood oxygen
levels could be detrimental to the fetus. Circulation needs to be assessed
next. If the patient is pulseless, basic CPR should be implemented immediately.
If the patient remains pulseless after four minutes, an emergency cesarean
section should be suggested since the fetus is very unlikely to survive within
five to ten minutes of maternal death. Of great importance to acknowledge is
that a pregnant woman does not show signs of hypovolemia or shock until much
later in comparison to non-pregnant patients. Aggressive fluid resuscitation
should be given to stabilize these patients even if it is unsure if she has a
large amount of blood loss.
After the mother is stable and a secondary survey is
performed, the fetus needs to be promptly evaluated. Stabilizing the gravida,
the uterine size, gestational age, and the viability of the fetus needs to be
immediately determined by both physical exam and ultrasound. Women who are at
immediate risk for preterm birth should be given antenatal glucocorticoids.
Depending on the extent of the maternal trauma, the fetus can be greatly at
risk by maternal hypotension, hypoxemia, placental abruption, uterine rupture,
or fetal injury by trauma. Due to these great risks, continuous fetal heart
monitoring should be done for a minimum of four hours.
References:
Gregoire,
AS. "When The Trauma Patient Is Pregnant." Rn 60.2 (1997): 44.
CINAHL with Full Text. Web. 4 Feb. 2014.
from Traci Strand, PA-S, Y2
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