Trauma dalam Kehamilan

dr. Firmansyah, SpOG(K)

Bagian Kebidanan dan Kandungan
RSUD Raden Mattaher
FK Unja Jambi
1

INSIDEN

7 percent of pregnant women will suffer physical trauma

during their pregnancy.
8%

in
40% in
52% in

first trimester
second trimester
third trimester

Causes of Trauma

Motor Vehicle Accident

54.6 %
Domestic abuse & Assault
22.3 %
Falls
21.8 %
Penetrating inj.
1.3 %

TYPES OF TRAUMA IN
PREGNANCY
Motor

vehicle accidents.
Falls and slips.
Burns.
Domestic Violence.
Penetrating Injuries.
Toxic Poisoning.
Sexual Assault.
Suicide and homicide

* most common mechanism of trauma

TRAUMA

IN

PREGNANCY

Trauma complicates approximately 1 in 12 pregnancies

It is the leading non-obstetrical cause of maternal death
Trauma has foetal complications as well, and has been reported
to increase the incidence of
- Spontaneous abortion (SAB)
- Preterm premature rupture of membranes
- Preterm birth (PTB)
- Uterine rupture
- Cesarean delivery
- Placental abruption
- Stillbirth
Placental abruption is major contributing factor in foetal death
Usually 1 in 3 pregnant women admitted to the hospital for
trauma will deliver during her hospitalization

UNINTENTIONAL TRAUMA : MOTOR VEHICLE CRASH (MVC)

Most common cause of trauma in pregnancy
Incidence
207 cases per 100,000 pregnancies
It is one of the leading causes of both maternal and foetal
mortality, with estimated mortality rates of 1.4 per 100,000 and 3.7
per 100,000 pregnancies, respectively
The majority of these admissions occur 20 weeks gestation
Risk factors
The major risk factor for adverse Trauma are improper/ No
seat belt use: in both front and rear collisions , Steering ,Dash
board injury.
The use of intoxicants while driving has also been reported as a
major risk factor
Driving two wheeler / sitting on back seat of it also responsible for
MVC

UNINTENTIONAL TRAUMA : MOTOR VEHICLE CRASH (MVC)

Obstetrical complications
The major obstetrical concern with MVC is the strain placed on
the uterus, which may result in placental abruption
Mechanism
Shear force (strain)

Tensile force (countercoup

mechanism)

Pregnant women involved in MVC appear to be at increased risk

for
- Emergency Caesarean delivery
- Preterm Birth
- Perinatal death

Right Posture and

fastened Seat belt with side
lock system is safe while
driving

SLIPS & FALLS DURING PREGNANCY

It is known that pregnancy increases joint laxity and weight
gain; can affect gait and predispose pregnant women to slips
and to falls
Dynamic
postural stability decreases with pregnancy,
especially during the third trimester
Approximately 1 in 4 pregnant women will fall at least once
while pregnant
Types of Injuries
The fracture of the lower extremity/ pelvis. spine are the
most commonly associated injuries.
Blunt injury to abdomen and pregnant uterus.
The majority of falls occur indoors and 39% involve falling from
stairs.
Falling on sharp object may lead to penetrating injury also.

SLIPS & FALL DURING PREGNANCY

Risk factors
Walking on slippery floors
Hurrying
Carrying heavy objects
Enlarged and distended abdomen prevents clear view of next
lower stair while going downGown / sari may entangle in steps.
Ghoonghat in Indian women also predispose falls and slips.
Obstetrical complication
A 4.4-fold increase in preterm labor
An 8-fold increase in placental abruption
A 2.1-fold increase in foetal distress
A 2.9-fold increase in foetal hypoxia

BURNS IN PREGNANCY
The impact of burns depends greatly on the burn depth and the
total body surface area affected
Risk factors
When total body surface area involved exceeds 40%, mortality
rate for both mother and foetus approaches 100%
Sepsis is a major contributor to mortality
Maternal and foetal mortality are significantly increased in cases
when smoke inhalation has occurred leading to maternal
hypoxia / Hyper carbon di oxymea / CO Poisoning.
Obstetric complications
Burns during the first trimester have been associated with
spontaneous abortion; The majority of these losses will occur
within 10 days of sustaining the burn
Thermal injury also appears to increase the risk of Preterm birth

ELECTROCUTION DURING PREGNANCY

Among 15 cases of severe electrocution during pregnancy, foetal

mortality May Be as high as 73%

POISONING DURING PREGNANCY

Poisoning relates mostly to intentional poisoning and / or
suicide attempts
Accidental poisoning is not as widely reported and its actual
incidence unclear

INTENTIONAL TRAUMA DURING PREGNANCY

The most common form of intentional trauma is domestic
violence (DV) or intimate partner violence (IPV)
Incidence
Frequency during pregnancy ranging from 1- 57 %
This wide range is due to inclusion of emotional, verbal, and/or
physical violence within the definition of DV/IPV
Risk factors
Maternal or intimate partner---- substance abuse
Low maternal educational level & low socioeconomic status
Unintended pregnancy
History of DV prior to pregnancy
Unmarried status

TYPES OF DOMESTIC VIOLENCE

Beating --- hurt on abdomenwith leg. Stick.
Pushing down from stairs.
Pushing her out of door
Torched with burning objects wood , candle , Hot Iron
,hot iron rod ,intentional Kerosene stove burn/ cooking
gas stove accident s
Sharp objects like kitchen knife,
NO food / drink even water for whole day and night.
Abusement.
Electric shock.
Pushing the head against pillar / wall.

INTENTIONAL TRAUMA DURING PREGNANCY

Adverse pregnancy outcomes associated with DV/IPV
Increased rate of Spontaneous abortion. APH , Uterine rupture
Preterm birth
Low birth weight .
Admissions of new born in Neonatal intensive care unit
Maternal Morbidity and mortality increases---- as incidence of
emergency operative delivery also increase.

PENETRATING TRAUMA IN PREGNANCY

In one study, penetrating trauma accounted for 9% of all pregnant
trauma admissions
Of those, 73% were handgun-, 23% knife-, and 4% shotgun related.
Fall on sharp object and bull horn injury are common in rural
Indian women
Penetrating trauma in pregnancy is associated with
- Increased foetal mortality (as high as 73%)
- Increased hospital stay,
- Complications such as intestinal perforation . Haemo peritoneum
due to intra abdominal organs like liver .spleen. Pregnant uterus. Big
vessels etc.

SUICIDE & HOMICIDE IN PREGNANCY

Incidence
Estimated rates of suicide and homicide in pregnancy were
about 2.0/100,000 and 2.9/100,000 live births, respectively
Suicide are more common in post natal period due to puerperal
psychosis and accounts for approximately 20% of postpartum
maternal deaths.
Interestingly, pregnancy may be protective in those women
who are otherwise at high risk for suicide or homicide
Risk factor
Substance abuse appears to be the best identifier for detecting
women at risk for suicide
Another major risk factor for attempting suicide, especially
during the postpartum period, is foetal or infant death
Often associated with / precipitated by DV/IPV

SUICIDE & HOMICIDE IN PREGNANCY

Risk factor
Unsuccessful suicide attempts have also been associated with
adverse pregnancy outcomes
Obstetric outcome
Women who attempted unsuccessful suicide had increased risk of
- Premature labor
- Cesarean delivery
- Need for Blood transfusion
- Increased respiratory distress syndrome in new born
- Low birthweight
Suicide attempt by intentional self-poisoning clearly affects both
foetus and mother; maternal death occurs in 1.8% of cases after
suicide attempts by ingestion of medication

MANAGEMENT
When caring for the pregnant patient who has suffered trauma, the
primary management goal is to stabilize the condition of the
mother, as foetal outcomes are directly correlated with early and
aggressive maternal resuscitation
Pregnant women should be immediately transported to a centre
that is:

(1) Capable of undertaking a timely and thorough trauma evaluation

(2) Facilities for management of life-threatening injuries are available
(3) having ICU for obstetrical emergency an New born

The initial maternal evaluation (primary survey) should follow

non-pregnant guidelines and include a full trauma history and
vital signs assessment as well as displacement of the gravid
uterus to one side by tilting the women in left lateral
position.
When possible, joint evaluation of the patient by Medical Jurist,
trauma managing and obstetrical team should be undertaken

When fetus is viable, Start fetal monitoring along with management

MANAGEMENT CONSIDERATIONS
Pregnancy should not lead to under diagnosis or under treatment of
trauma due to the fears of adverse foetal effects, e.g.
- Decision to do investigations (CT, X-Ray)
- Decision to undertake surgery etc.
When possible, uterus should be displaced to left side as it
- Relieves compression on IVC & Aorta
- Improves venous return and foeto placental circulation too
When foetus is viable, continuous foetal monitoring should be
initiated as soon as possible & foetal monitoring can be
discontinued after 4 hours if uterine contractions occur less
frequently than every 10 minutes, the foetal heart tracing is
reassuring, and there is no maternal abdominal pain or vaginal
bleeding
Simultaneous evaluation by trauma & obstetrical teams may be
indicated

MANAGEMENT CONSIDERATIONS
Personnel trained in difficult intubation should be readily
available, because
- Difficult airway
- Association with cervical spine injury
Penetrating injuries are more likely to affect the foetus,
especially those penetrating the pregnant uterus.
If a thoracostomy tube is indicated, it should be placed 1-2
intercostal spaces above usual fifth intercostal space landmark
to avoid abdominal placement & liver injury as the diaphragm is
lifted up by the pregnant uterus.
Pelvic fractures do not necessarily preclude vaginal delivery
If peritoneal lavage is indicated, an open technique is
preferred .
a placement of a Foley catheter and nasogastric tube

MANAGEMENT CONSIDERATIONS

In second- and third-trimester burn victims, delivery should be

considered if affected total affected body surface area is 50%

Focused Assessment with Sonography for Trauma (FAST) is

reliable during pregnancy
This targeted ultrasound assesses 4 areas for evidence of
free fluid: the subxiphoid; the right upper quadrant; the left
upper quadrant; and the suprapubic area

Perimortem cesarean section may be appropriate in setting

of imminent maternal death or after 4 min of properly
performed but unsuccessful cardiopulmonary resuscitation