Download Chapter 11 Trauma in Women

Chapter 11
Trauma in Women
A: Anatomic
12 weeks
- rise out of pelvis
20 weeks
- at umbilicus
34-36 weeks - at the costal margin
2nd trimester- amniotic fluid embolism
3rd trimester - abruptio placentae
B. Blood Volume and Composition
1.Volume: 1200-1500 ml -signs of hypovolemia
2. Increased in WBC, fibrinogen , clotting
factors
3. Decreased in Hb, PT, aPTT, albumin
4. Blood pressure falls 5-15 mmHg

in 2nd trimester
5. CVP is variable
6. ECG: flattened or inverted T waves

in leads II, III, AVF
C. respiratory
Increased in tidal volume
Decreased in residual volume
Hypocapnea ( Pco2 of 30 mmHG)

in late pregnancy
D. Musculoskeletal
7th months: the symphysis pubis widens (4-8mm)

The sacroiliac-joint space increased
Mechanism of Injury
A. Blunt Injury
 1. Direct Injury
 2. Indirect Injury

Abrutio Placentae & Uterine Rupture

Seat belt: forward flexion and uterine
compression
B. Penetrating Injury
 Dense uterine musculature & Amnion
 Low incidence of maternal visceral injury
Assessment and Management
A: Primary Survey and Resuscitation
1. Maternal: Hyperventilation

4 - 6 inches elevation of right buttock

Fetus may be in shock before

maternal hypovolemia shock
signs

Vasopressors - fetal hypoxia
B: Fetus: Uterine rupture

Abruptio placentae

Continued fetal heart tones

20 -24 wks of gestation
B. Adjuncts to primary survey
Maternal:
Monitor on her left side after physical examination
Monitor of the CVP response to fluid
Maternal bicarbonate is usually low
Fetus:
20-24 wks heart tones: 120- 160 beats / min
Continous monitor with cardiotocodynamometry
Consultation if abnormal fetal heart rates

C. Secondary Assessment
1. DPL: perform above the umbilicus

Presence of uterine contractions
2.Vaginal Examination:
 Amniotic fluid with PH of 7 - 7.5 :

ruptured of chorioamniotic membrane
 Bleeding in 3rd trimester:

disruption of placenta

impending fetal death
The fetus may be in jeopardy even with apparent, minor
maternal injury
D. Definite Care
Uterine rupture: shock or no s/s
Placental abruptio: leading cause of fetal death

30% no vaginal bleeding
All pregnant Rh-negative trauma patient should
considered for RH immunoglobulin therapy.
Initial management is directed at resuscitation and
stabilization of the pregnant patient.
Perimortem c/s may be successful if it is done
within 4-5 mins arrest.
Radiography in Pregnant Women
No fetus risk: 5 - 10 rad.
The maximum risk attributable to 10 rad of exposure is
approx. 0.1 %
After 20th weeks of gestation: cause no fetal abnormalities.
Routine C-spine, CXR, Pelvis obtained with shielding:
negligible fetal exposure
CT beam in direct line to fetus: 3 - 9 rad.
CT scan above uterus: < 3 rad to fetus.
Radiography to fetus varies:
1. The type of study
2. The size of patient
3. Position of the fetus
4. Type of machine
5. Method of shielding
6. The number of section obtained
7. Fetal/uterine size
8. Coned x-ray beam aimed > 10 cm away from
 fetus are not dangerous.
Estimated Radiation Dose to the Pelvic
Uterus/ Radiography
Type of examination
Dose (mrad)
Low dose group
Head
C- spine
T-Spine
CXR
Extremities
<1
<1
<1
<1
<1
High Dose Group
L-spine
Pelvis
Hip and Femoral ( proximal)
IVP
Urethrocystography
Abdomen ( KUB)
204 - 1260
190 - 357
124 - 450
503 - 880
1500
200 - 503
Upper-Limit Fetal Dose From Angiography
and CT Scan Studies
 Type of examination











Angiography
Cerebral
Cardiac Cath
Aortography
CT scanning
Head ( 1 cm slices)
Chest ( 1 cm slices)
Upper abdomen( 20 1-cm slices
> 2.5 cm from uterus)
Lower Abdomen ( 10 1-cm slices
directly over the uterus/fetus
Dose (mrad)
< 100
< 500
< 100
< 50
< 1000
< 3000
3000 - 9000