Wanita 21 tahun, hamil 7 bulan dibawa ke IGD karena penurunan kesadaran. 1 jam lalu terlibat kecelakaan lalu lintas.Nampak jelas dari ke 2 telinganya keluar darah. Tensi saat ini 170/100 mm hg, nadi 65/1’, laju nafas 34/1 dalam.Perdarahan pervaginam +. Apa yang anda lakukan untuk korban ini ?

Dual goals in managing pregnant trauma

Physiological changes of pregnancy• Response to hypovolemia

Types of injuries most commonly associated

Initial assessment and management

Trauma prevention in pregnancy

32,810 pregnant women sustain injuries in motor vehicle crashes / year in the U.S., a rate of 9 per 1000 live births.1

Motor vehicle collisions, 70% of acute injuries. This is followed by falls and direct assault .

Hypervolemia begins at ± week 10 of gestation and peaks at about a 45% increase from baseline at week 28.

Red cell mass increases to a lesser extent physiologic anemia of pregnancy.

Cardiac output is increased by 1.0 to 1.5 L/min at week 10 of pregnancy and remains elevated until the end of pregnancy.

Heart rate increased by 10 to 20 beats/min in the second trimester, accompanied by decreases in systolic and diastolic blood pressures of 10 to 15 mm Hg.

A pregnant patient may lose 30% to 35% of circulating blood volume before manifesting hypotension or clinical signs of shock.

Vasoconstriction and tachycardia• Reduction of uterine blood flow by 20–30%• Fetal heart rate and blood flow decreases• Fetus becomes hypoxemic

After week 12 of gestation, the uterus becomes an intra-abdominal organ susceptible to direct injuries.

The gravid uterus also causes passive stretching of the abdominal wall and peritoneum as it enlarges and may lead to diminished sensitivity to injury and irritation from intraperitoneal blood.

At or about weeks 18 to 20 of gestation, the expanding mass of the gravid uterus may give rise to the "supine hypotension syndrome," venous return and cardiac output are diminished by compression of the maternal inferior vena cava in the supine position Placement of IV lines in the femoral region and lower extremity should be avoided

Diaphragm elevates by as much as 4 cm, and tidal volume increases by 40% as ↘residual volume 25% and ↘Functional residual capacity .

impair the ability of a pregnant trauma patient to compensate for respiratory compromise.

There is delayed gastric emptying during pregnancy. ↗gastroesophageal reflux and the potential for aspiration .

The liver is typically unaffected by pregnancy, and the most common cause of abdominal hemorrhage remains splenic injury.

• Tilt or rotate backboard 20–30o to patient’s left

• Elevate right hip 4–6 inches with towel Manually displace uterus to left

Attend to maternal airway, breathing, and circulation as a priority for both mother and fetus.

Maintain patient in the left lateral decubitus position.

Blood typing and Rh status in laboratory studies.

Attempt to establish fetal age. Looking for any peritoneal signs such as

guarding, rebound, distension, rigidity.

Determine if Rh0 (D) immunoglobulin administration is indicated.

Perform imaging as for non pregnant patients.

Initiate fetal monitoring as soon as possible and continue for at least 4–6 h even if patient is apparently uninjured.

Screen for potential intimate partner violence.

Complete blood count Blood typing, and Rh status Coagulation profiles with levels of fibrin

degradation products and fibrinogen

At week 12 pubic symphysis, At week 20 level of the umbilicus. The uterus then expands

approximately 1 cm beyond the umbilicus per additional week of gestation.

Assessing fetal age will help determine fetal viability.

Fluid in the vagina with a pH of 7 is suggestive of amniotic fluid, whereas fluid with a pH of 5 is consistent with vaginal secretions.

A branchlike pattern, or "ferning," seen upon drying of vaginal fluid on a microscope slide.

uterine tenderness uterine contractions vaginal bleeding direct or indirect maternal abdominal

trauma. if the mother is Rh negative and the

fetus is Rh positive, as little as 0.1 microliter of fetal blood can sensitize the mother6 and endanger this pregnancy and subsequent ones.

The Apt test is a qualitative determination of the presence of fetal hemoglobin in maternal blood.

The Kleihauer-Betke test applies acid elution to an aliquot of maternal blood, and then maternal and fetal red blood cells are counted under the microscope.

Should be given to all Rh-negative pregnant women with abdominal trauma within 72 hours ,7 except ;

(1) prior maternal sensitization(2) a known Rh-negative fetus (3) a known Rh-negative father 50 micrograms IM for gestation of 12 weeks and 300

micrograms IM for gestation of 13 weeks, or 300 micrograms IM for all gestational ages.

50-microgram dose is effective for up to 5 microliters of fetomaternal hemorrhage.

Tetanus Prophylaxis. Diagnostic Imaging Adverse fetal effects

due to radiation exposure are negligible for doses of <5 rad, and this is the accepted cumulative dose limit during pregnancy. Radiograph after 20 weeks gestation are safe ( Rosen and Barkin 1998).

Abruption can occur after 48 hours after injury (ENA 2007). No vaginal bleeding if the abruption is partial (ATLS 2008).

Treated same as for other victims• Defibrillation settings are same• Drug dosages are same• Fluid volume needed increases

4 liters normal saline rapid infusion during transport

If mother unsalvageable:• Continue CPR • Notify hospital of possible cesarean section

10% experience abuse during pregnancy• Proximal and midline injuries

Face and neck most common• Low birth weight• Abused by spouse or boyfriend: 70–85%

(U.S.)

Proper seat-belt use

Report domestic violence

Counseling for domestic violence

Patient education • Multiple changes associated with pregnancy

Physiological, anatomical, emotional

Thank YouMatur Nuwun