What is the leading cause of mortality in pregnancy?
When in a woman's LIFE is she most likely to get injured?
during the 3rd trimester of pregnancy; assuming a woman becomes pregnant, then on average more injuries happen during the 3rd trimester than any other time
Which group of pregnant women is the largest group that gets injured?
pregnant teens--not to be insensitive but probably b/c they are the most careless
Major trauma (i.e. life-threatening to MOM) are associated with a _____% fetal loss whereas minor trauma is associated with a ____ % fetal loss
4-50 %; 1-5%
Do most fetal losses result from major or minor trauma?
minor trauma, because they are more common; however, a major trauma is more likely to kill than a minor trauma
The presence of this hormone in pregnancy may be responsible for trauma
relaxin, it loosens the joints to the point of possible instability = fall
What is true of the frequency of domestic violence in pregnant vs. non pregnant women?
domestic violence is increased in pregnancy for many reasons; thus, it is an important cause of trauma of pregnancy
The majority of trauma centers see (choose blunt or penetrating) trauma 70% of the time and it is usually caused by _____
blunt; motor vehicle accidents
What are the top 3 causes of blunt trauma
1) MVA 2) falling especially after 20 weeks (big belly + relaxin = fall) 3) domestic violence
Why might a pregnant woman be more likely to die of a MVA than a nonpregnant woman?
a pregnant woman is less likely to wear a seatbelt because of her belly; 1/3 to 1/2 don?t wear them or don?t wear them correctly
These are very likely TQ's: in trauma (i.e. MVA) the most common cause of MATERNAL DEATH is ___________ whereas the most common cause of fetal death is __________. The second most common cause of fetal death is ____________
Head injury to mom = #1? Maternal shock is most likely cause of death in fetus; second most likely cause in trauma situation is placental abruption
T/F many fetuses (feti?) die of direct head trauma
false, direct head trauma = <1% of fetal death
What physical properties of the placenta and myometrium allow for shearing in MVA which causes placental abruption
The differences in elasticity, placenta is inelastic and myometrium is elastic
T/F: the risk of placental abruption increases with abberant implantation of the blastocyst, i.e. placenta previa
False, the rates of placental abruption are independent of the location of the placenta in the uterus
A woman presenting to the office with a firm abdomen that has unrelenting pain, hypertonicity and dark blood coming out of her vagina likely has ____________
When do most falls in pregnant women occur?
after 20 weeks
This is the second most common type of blunt injury
What is the classic presentation of placental abruption?
hard abdomen, persistent pain, hypertonicity, and dark vaginal bleeding
T/F: we have a terrible relationship but if we have a kid, things will get better, they're so cute!
false, women who report domestic abuse when non-pregnant report increased rates of domestic abuse when pregnant
Domestic abuse is the ______ most common cause of blunt trauma in pregnancy
What is the most likely cause of penetrating trauma in pregnancy?
gunshot wounds > stabbing
Why is it unlikely that a pregnant woman stabbed in the first 12 weeks would suffer DIRECT injury to the fetus?
The fetus is protected by the bony pelvis during the first 12 weeks; however, the risk for maternal shock is still the same and that is a common cause of fetal death
Why are pregnant women who are stabbed less likely to suffer a lower GI injury than nonpregnant?
because lower GI organs are pushed out of the way by the gravid uterus
What is the total increase in blood volume in most women?
Why do pregnant women suffer from physiologic anemia?
because they have increased volume but no increase in RBC mass (there is no decrease in RBC's, just dilution)
Given that a pregnant woman is physiologically anemic, will she display signs of shock before or after a nonpregnant woman when hemorrhaging?
after, the physiologic anemia has nothing to do with the signs of shock, these are based on total volume loss and vascular collapse, since a pregnant woman has more blood she will show signs later
What happens to a woman's blood pressure in supine position?
hypotensive because of compression of the IVC and AORTA
What are 2 reasons that a woman is likely to get a DVT in her lower leg?
Pregancy is a hypercoagulable state, compression of IVC decreases venous drainage of LE leading to greater stasis
A pregnant woman undergoing cholecystectomy should be placed in this position:
left lateral recumbent
What happens to tidal volume in pregnancy? What happens to functional residual capacity in pregnancy?
If a pregnant woman gets a pneumothorax what should you be mindful of when placing the chest tube?
The fact that her diaphragm is more superior than normal, you will have to place the chest tube higher than where you normally would to get into the diaphragmatic recesses
Name 2 organs unaffected by pregnancy
liver and spleen
What is the most likely organ to cause intra-abdominal hemorrhage from injury in non-pregnant women? In pregnant women?
spleen and spleen; highly vascular organ
if mom dies how long do you have to get the baby out?
5 min, after that you "really don't want to get the baby out"
What is of utmost importance in saving the baby in a trauma situation?
How long should fetal monitoring be done in minor trauma? Major trauma?
minor trauma = 4-6 hours; major trauma = 24 hours
According to the all or none theory, what dose of rads is safe in first trimester?
stay under 5-10 (i.e. if doing xray for trauma)
What level of energy is safe for cardioversion in all 3 trimesters?
Are CT scans okay in a pregnant woman?
yes but keep under 5-10 rads
Which is more sensitive for placental abruption, US or CT?
CT so you should prob do that even though US is safer for the baby
In a pregnant woman with trauma why would you do a Kleihauer-Betke assay? The administration of which drug depends on the results?
To see how much fetal and maternal blood mixed, you may need to give Rhogam
A baby is usually not delivered by c-section below _____ weeks because he/she won't survive
If CPR to a pregnant mother is inneffective and the fetus is > 32 weeks what do you do?
c-section, the baby will live and the mother will have greater cardiac filling
What condition represents the 4th leading cause of maternal mortality overall? What were those other 3 again?
ectopic pregnancy; head trauma (MVA), falls, domestic violence
Why has the rate of ectopic pregnancy quadrupled since 1970?
That's when "they" came up with chlamydia! But really, the rates of PID from gonorrhea and the clap have greatly increased and scarring leads to ectopic pregnancies
What is the most important risk factor for ectopic pregnancy?
Pelvic inflammatory disease
Where is the most common location (be specific) for ectopic pregnancy
What is a heterotopic pregnancy?
This is when there are 2 implantations (i.e. twins) but one implants in the uterus and one in the tube
Why isn't vaginal bleeding particularly common in ectopic pregnancies?
Because they bleed into the peritoneum
What is the classic presentation of ectopic pregnancy?
abdominal/pelvic pain, vaginal bleeding, amenorrhea
Why would a patient with ectopic pregnancy have tachycardia, diaphoresis, and orthostatic BP changes?
These are signs of hypovolemia = she has internal bleeding
In ectopic pregnancies, the adnexal mass that is palpated is the:
corpus luteum! And is contralateral--that doesn?t exactly make sense to me but just go with it
Board review question, like ectopic pregnancy, this BUG can mimic appendicitis:
Yersenia enterocolitica --not on test
In your DDx of an ectopic pregnancy you need to r/o an adnexal torsion, how would you do this?
see if there is blood flow to the ovary
Any woman presenting with pelvic pain should be considered ________
PREGNANT UNTIL PROVEN OTHERWISE
If a woman is pregnant with pelvic pain you should think _________
ECTOPIC UNTIL PROVEN OTHERWISE
What is the gold standard for diagnosing an ectopic pregnancy?
QUANtitative s-hCG and ultrasound
What should a quantitative s-hCG do in 48 hours in a normal pregnancy?
What are the medical and surgical options in treating ectopic pregnancies?
medical = methotrexate to inhibit folate metabolism and if surgical laparoscopy > laparatomy
What 5 features make a patient a candidate for methotrexate as an option for Tx of ectopic pregnancy?
Mass is less than 3.5 cm, not ruptured, no cardiac motion is seen, the pt has no C/I (liver dz, immunodeficiency, or sensitivity), also this is best for pts that wish to remain fertile
What is the DOC for ectopic pregnancy? How is it dosed?
methotrexate, surface area of the patient
If you have treated a woman with ectopic pregnancy with methotrexate, how do you know that it worked? When would you do surgery?
You follow up with serial HCG's until negative, you should expect an increase for a few days but they should decline by day 7, if they have declined give another dose or do surgery
If you remove an ectopic pregnancy by salpingostomy, should you let the wound heal by primary or secondary intention?
secondary intention, that is DON'T SEW IT! If you sew it, it leads to a reaction that can lead to increased risk of future ectopics
If a woman is Rh negative and has an ectopic pregnancy what should you give her (this is a lay up and half)