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Increased levels of progesterone and estrogen inhibit gastrointestinal
motility. In addition, there is a decrease competency of the
gastroesophageal sphincter, which increases the potential for aspiration.
As the uterus enlarges, it displaces the intestines upward and laterally,
stretching the peritoneum and making the abdominal physical
examination unreliable.
To accommodate both maternal and fetal metabolic and circulatory
requirements, renal blood flow increases by 25 to 50% during gestation.
Blood urea nitrogen (BUN) and serum creatinine are reduced. Also,
the kidneys enlarge by hypertrophy and hyperemia as early as the
10th week of gestation secondary to hormonal and mechanical factors.
The neurologic changes of pregnancy include a 25 to 40% decrease in
anesthetic requirements. This means that loss of consciousness can
occur even at "sedative" doses.
ASSESSMENT OF THE MOTHER.
The priorities for care of an injured pregnant patient are the same as
for a non-pregnant patient. It starts with the primary survey (ABCD)
soon when an injured pregnant patient comes to the emergency and
trauma department.
The Advanced Trauma Life Support protocol (ATLS) provides a suitable
framework for assessment and resuscitation of the trauma pregnant
patient.
Some special important modifications are focusing on the anatomical
and physiological changes during pregnancy.
PRIMARY SURVEY according ABCDE-sequence:
Airway, breathing and circulation.
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The airways must be patent and free and avoidance of regurgitation
and aspiration of gastric contents.
Stabilization of the neck and the head using hard collar or sand bags
etc. Breathing with high flow oxygen via mask and ensuring adequate
ventilation.
Prevention of aortocaval compression is also essential to optimize
maternal and fetal hemodynamics. Pregnant patients beyond 20 weeks'
gestation should not be left supine during the initial assessment.
Hypovolemia should be suspected before it becomes apparent because
of the relative pregnancy induced hypervolemia and hemodilution that
may mask significant blood losses. Treatment of any life-threatening
thoracic injuries.
Circulation must be maintained after blood aspiration for group and
cross-matching and routine investigations.
Rigorous fluid therapy with crystalloid and blood if indicated.
Positioning of the pregnant patient in an acceptable position to avoid
any compression or signs of shock.
SECONDARY SURVEY.
The secondary survey consists of obtaining a complete history, including
an obstetrical history, performing a physical examination, and evaluating
and monitoring the fetus. The obstetrical history is important because
the identification of comorbid factors may alter management decisions.
During this stage of management the mother must be examined properly
from head to toe for any evidence of injury. The assessment of the
fetus is an important step during the secondary survey.
Pelvic and rectal examinations should be performed. Aside from the
usual secondary survey, assessment of the injured pregnant patient
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should rule out vaginal bleeding, ruptured membranes, a bulging
perineum, the presence of contractions, and an abnormal fetal heart
rate and rhythm.
Radiographs should be avoided, unless there is an absolute need to xrays to detect life-threatening maternal injury. Sometimes fetal irradiation
could be minimized by use of abdominal shields. The greater risk to
the fetus is at 8 – 15 weeks of gestation. A teratogenic risk to the fetus
has been estimated and established at 5-10 rad of radiation.
Abdominal surgery is sometimes indicated to treat dangerous maternal
injuries and this should not be delayed.
The site of laparotomy incision must be well selected and properly
placed. If the pregnant uterus is at the umbilicus, a vertical midline
incision could be made above it. And if the uterus is at term the
incision could be made over its dome taking in consideration not to
cause any damage to the uterus or fetus.
ASSESSMENT OF THE FETUS
The assessment of the fetus is an important part of the secondary
Survey of the mother. It is preferred that an obstetrician should be
consulted to look for the fetus with the emphasis on three key questions:
1. Is the fetus potentially viable (over 24-25 weeks of gestation)?
2. Has there been damage to the fetal environment?
3. Are there signs of fetal distress?
Many pregnant women know their obstetric history and they could
present useful information about their pregnancy.
The duration of pregnancy can be estimated by knowing the date of
the last menstruation and by fundal height.
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The presence of uterine contractions could be felt by abdominal
palpation. Vaginal bleeding is suggestive of placental abruption or
placenta praevia. The onset of labor should be considered. when
moderate intensity contractions occur regularly (e.g. every 5 min).
Uterine rupture should be suggested if fetal parts separate from the
uterus are palpated.
Leakage of amniotic fluid is suggestive for rupture of the chorioamniotic
membranes.
Doppler-ultrasonography is very useful in the assessment of heart rate
of the fetus, gestational age and viability.
The heart beat is visible from 7 weeks of gestation. Ultrasound provides
also information on placental position, abruption and the presence of
intra-amniotic haemorrhage.
The normal fetal heart rate is 120-160 beats \ min. Clear signs of etal
distress are bradycardia of less than 100 beats \ min and loss of beatto- beat variation. Cardiotocogram can be used to monitor heart rate
and uterine contractions. The conscious mother could feel and record
fetal movements.
Continuous monitoring is advocated for between 4h and 48 h for all
pregnant patients carrying a viable fetus following blunt trauma.
Fetomaternal haemorrhage is highly suggestive when fetal blood cells
are detected in the maternal circulation (Kleihauer test).
This condition is usually associated with anemia and presents a poor
prognosis for the fetus. All rhesus negative pregnant women with
fetomaternal haemorrhage should receive anti-D immunoglobulin to
prevent rhesus immunization.
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SURGICAL INTERVENTION IN TRAUMA DURING PREGNANCY
The main indication for surgical intervention after trauma in pregnancy
is the treatment of maternal injuries, especially internal haemorrhage
and penetrating trauma. Urgent caesarean section is indicated for fetal
distress, placental abruption and for cases with burns greater than 50%
in the second or third trimester. Uterine rupture requires emergency
laparotomy.
BLUNT TRAUMA
Pregnant patients injured in road traffic accidents sustaining blunt
traumas have an overall maternal mortality of 7.5% and fetal mortality
of 13.5%. Head injury and intra-abdominal injury were the commonest
cause of maternal death. Maternal death was the commonest cause of
fetal death, and placental abruption was the second common cause.
There are several important considerations when addressing blunt
thoracoabdominal trauma in the pregnant patient. The physical
examination may be unreliable because the enlarged uterus displaces the
abdominal content and stretches the peritoneum thus perhaps diminishing
the response to peritoneal irritation. The evaluation of possible injury
to the abdomen is different because of the presence of the gravid
uterus. The preferred diagnostic modalities for evaluation during the
first trimester of pregnancy are ultrasound, diagnostic peritoneal lavage
(DPL), and CT-scan, inthat order. Because the first trimester is the
period of organogenesis, ultrasound is preferable for the detection of
hemoperitoneum. Injuries to abdominal organs including liver, spleen,
kidneys and intestines occurs in 15.6-26.2% of pregnant patients after
blunt abdominal trauma.
Blunt trauma cause also pelvic fractures and often associated with
massive retroperitoneal bleeding from dilated pelvic veins. Injury to
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the lower urinary tract can be found in pelvic fractures in 10-15 %.
Blunt abdominal trauma could rarely cause direct fetal injury with rare
head injury and long bone fractures of the fetus.
Pregnant women with minor traumas should be safely observed. Those
pregnant patients with major traumas, shock, altered mental status or
neurological deficit should be admitted and require further diagnostic
studies (Ultrasound, CT scanning and rarely peritoneal lavage) to
exclude intra-abdominal injury.
PLACENTAL ABRUPTION
The majority of placental abruptions occur within 48h after abdominal
trauma. Placental abruption could also be precipitated by shock from
other causes and may occur following the rise in venous pressure that
occurs distal to compression of the inferior vena cava in the supine
position. The incidence of placental abruption in injured pregnant
patients ranges between 7-65%. Placental abruption after trauma
occurs in 2 to 4% of minor accidents and in up to 50% of major
injuries. Abruption can occur with little or no external signs of injury
to the abdominal wall.
The clinical signs of placental abruption include vaginal bleeding,
uterine tenderness, uterine irritability, titanic contractions and rising
fundal height, with or without maternal shock and mostly with signs
of fetal distress.
The diagnosis of placental abruption is confirmed by ultrasound. The
management and decision for further therapeutic steps and urgent
emergency surgery should be made in cooperation with an obstetrician.
UTERINE RUPTURE
This is a rare emergency condition, but more common in cases with
previous caesarean section most likely because of the old uterine scar.
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The symptoms of uterine rupture are sudden onset of sharp, lower
abdominal pain and cessation of contractions, vaginal bleeding and
maternal shock. The examination of the abdomen reveals loss of fetal
heart sound and fetal movements. Plain x-rays show uterus and separate
fetus with extended extremities and sometimes free intraperitoneal air.
The emergency treatment includes urgent resuscitation steps and
immediate surgical intervention. If the repair of the uterus is not
possible, caesarean hysterectomy could be necessary.
PENETRATING TRAUMA
The common forms of penetrating traumas are stab and gunshot injuries.
The pattern of injury in pregnancy is altered by the presence of the
gravid uterus.
In gunshot wound the bullet causes injury to the uterus and additional
injuries of other abdominal organs may occur. Gunshot injury of fetus,
umbilical cord and /or placenta result mostly in a high fetal mortality.
Because the bowel is pushed upward by the enlarged uterus, penetrating
injury to the upper part of the abdomen is more likely to be associated
with multiple gastrointestinal injuries. Organs involved in decreasing
frequency are the small bowel, liver, colon, and stomach. During the
third trimester, injuries to the lower quadrants of the abdomen almost
exclusively involve the uterus. This may be advantageous to the mother
because the uterus and amniotic fluid absorb most of the energy of the
missile, resulting in less destruction to other organs. If the uterus is
involved in penetrating trauma, fetal injury may occur in 60 to 90% of
cases. Gunshot wounds to the uterus carry a maternal mortality of 7 to
9% and a fetal mortality of around 70%. Fetal mortality is higher if
injury is caused before 37 weeks of gestation. Abdominal stab injuries
in pregnancy have relatively better prognosis for mother and fetus
than gunshot injuries.
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Urgent exploration of the penetrating wound is indicated in all cases.
In minor penetrating trauma without evidence of fetal distress and
uterine injury, all attempts should be made to preserve the pregnancy.
BURNS INJURY.
Burn injuries to pregnant women are fortunately not so common. The
severity of the burns and age of gestation are decisive for prognosis
for mother and fetus. The survival is optimal in the first trimester with
less than 50 % burns.
A higher rate of complications and mortality is found in pregnant
patients with greater than 50 % burns and in the second or third
trimester of pregnancy. In such cases immediate fetal delivery is
indicated to avoid mostly certain maternal death.
Treatment priorities are the same when managing pregnant and
nonpregnant burn victims. Maintenance of a normal intravascular
volume, avoidance of hypoxia, and prevention of infection are
important. Burned areas of tissue should be debrided and cleaned.
Silver sulfadiazine cream should be used sparingly because of the risk
of kernicterus associated with sulfonamide absorption.
In cases of electrical burns, fetal mortality is high at 73% even with a
rather low electrical current because of the fetus' lack of resistance to
electrical shock. This is probably related to the fact that the fetus is
floating in amniotic fluid with a low resistance to current. No matter
how trivial their injury may seem, fetal monitoring and ultrasound
assessment are indicated for all pregnant victims of electrical shock.
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Acute Abdominal Pain
Abdominal pain is common and often inconsequential. Acute and
severe abdominal pain, however, is almost always a symptom of intraabdominal disease. It may be the sole indicator of the need for surgery
and must be attended to swiftly: Gangrene and perforation of the gut
can occur < 6 h from onset of symptoms in certain conditions (eg,
interruption of the intestinal blood supply from a strangulating
obstruction or an arterial embolus). Abdominal pain is of particular
concern in patients who are very young or very old and those who
have HIV infection or are taking immunosuppressants.
Generally people react to pain differently. Some, particularly elderly
people, are stoic, whereas others exaggerate their symptoms. Infants,
young children, and some elderly people may have difficulty localizing
the pain.
Pathophysiology
Visceral pain comes from the abdominal viscera, which are innervated
by autonomic nerve fibers and respond mainly to the sensations of
distention and muscular contraction—not to cutting, tearing, or local
irritation. Visceral pain is typically vague, dull, and nauseating. It is
poorly localized and tends to be referred to areas corresponding to the
embryonic origin of the affected structure.
Foregut structures (stomach, duodenum, liver, and pancreas) cause upper
abdominal pain.
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