Midw2105 BETTER

Trauma in pregnancy

Leading non-obstetric cause of maternal death

Common causes of trauma in pregnancy

Attempted suicide; motor vehicle accidents; falls; assault; blunt force; penetrating trauma; burns

Major complications of trauma in pregnancy

Preterm birth; placental abruption; uterine rupture; fetomaternal haemorrhage; fetal loss

Priority in maternal trauma

Maintain cardiopulmonary function and oxygenation to the woman and baby

Trauma management priority

Treat the woman's condition first

Airway assessment in trauma

Assess ability to talk/phonate; swelling; bleeding; crepitus; cervical spine injury; burns

Airway management in trauma

Intubation; spinal immobilisation; surgical airway if required

Breathing assessment in trauma

Assess bilateral breath sounds; respiratory effort; respiratory rate; oxygen saturation

Breathing management in trauma

Supplemental oxygen and emergency treatment based on injury

Circulation assessment in trauma

Assess colour; consciousness; bleeding; pulse; blood pressure

Circulation management in trauma

Direct pressure to bleeding; IV access; isotonic crystalloid; treat injury

Disability assessment in trauma

Assess consciousness; pupils; glucose; trauma signs; movement of all four extremities

GCS <8 management

Intubate; cranial imaging; optimise oxygenation

Exposure assessment in trauma

Remove clothing; avoid hypothermia; perform head-to-toe examination

Position after trauma >20 weeks

Left lateral position to reduce inferior vena cava compression

Alternative to left lateral positioning

Manual uterine displacement

Why left lateral positioning matters in maternal collapse

Reduces vena cava compression and improves effectiveness of CPR

Fetal wellbeing after trauma

CTG after 24 weeks gestation

Anaphylaxis

Anaphylaxis

Life-threatening emergency caused by an immune response to an allergen

Onset of anaphylaxis

Can occur within 10 minutes of allergen exposure

Routes of allergen exposure

Contact; inhalation; consumption

Effect of anaphylaxis on blood vessels

Vasodilation causing fluid accumulation and swelling

Severe complication of anaphylaxis

Pulmonary oedema causing respiratory collapse

Immunological anaphylaxis pathway

Allergen activates B cells → IgE antibodies → IgE binds mast cells → repeat exposure triggers cytokine release

Prevention of anaphylaxis

Avoid known triggers

Signs of anaphylaxis

Swelling; runny nose; hives; itching; pain; lightheadedness; diarrhoea; vomiting; shortness of breath; hoarseness

Initial management of anaphylaxis

Remove trigger and follow DRSABCD

Key treatments for anaphylaxis

Oxygen; adrenaline; IV fluids

Additional treatments for anaphylaxis

Bronchodilators; antihistamines; corticosteroids

Monitoring during anaphylaxis

Maternal vital signs and fetal condition

When expedited birth may be considered in anaphylaxis

If the woman continues to deteriorate

Maternal collapse and cardiac arrest

Maternal collapse

Sudden deterioration that may progress from shock and loss of consciousness to cardiac arrest or death

Causes of maternal collapse

Cardiac; respiratory; neurological; placental; uterine; haemorrhage; trauma; sepsis causes

A–H causes of maternal collapse

A anaesthetic/accident; B bleeding; C cardiac; D drugs; E embolic; F fever; G general/hypoxia/electrolytes; H hypertension

Amniotic fluid embolism

Amniotic fluid/fetal material enters maternal circulation causing an anaphylactic reaction and cardiorespiratory collapse

DIC

Disseminated intravascular coagulation causing widespread clotting followed by depletion of platelets/clotting factors and uncontrolled bleeding

Why cardiac arrest is more complex in pregnancy

Reduced venous return from uterine compression and physiological changes of pregnancy

Position during maternal CPR

Left tilt or manual uterine displacement to reduce vena cava compression

Chest compression considerations in pregnancy

Chest compressions may need to be positioned higher

Defibrillation in pregnancy

Shocks are appropriate

Cardiac arrest resuscitation

DRSABCDE and CPR

Amiodarone in pregnancy cardiac arrest

Notes state NO amiodarone

Emergency caesarean consideration during arrest

Notes indicate consideration after approximately 4 minutes of CPR without return of pulse

Multiple pregnancy

Multiple pregnancy

Pregnancy involving more than one fetus

Risk of multiple pregnancy

Increased significantly compared with singleton pregnancy

Risk factors for multiple pregnancy

Genetic predisposition; previous multiple pregnancy; high parity; advanced maternal age; assisted reproductive technology

Dizygotic twins

Twins arising from two or more fertilised eggs

Monozygotic twins

Twins arising when one fertilised egg splits into two or more identical fetuses

Chorionicity

Number of placentas present in a multiple pregnancy

Dizygotic chorionicity

Always diamniotic/dichorionic

Monozygotic DCDA timing

Division during the first 3 days after ovulation

Monozygotic MCDA timing

Division approximately 4–8 days after fertilisation

Monozygotic MCMA timing

Division approximately 8–12 days after fertilisation

Conjoined twins

Result from later division of the zygote

Early ultrasound in twins

Helps determine zygosity and chorionicity and assists care planning

Complications of multiple pregnancy

Low birth weight; preterm birth; placenta previa; placental abruption; IUGR; pre-eclampsia; GDM; anaemia; malpresentation; birth asphyxia; PROM; GBS; PPH

Twin-to-twin transfusion syndrome

Blood is transferred from one twin to the other through vessels in a shared placenta

Twin-to-twin transfusion risk

Occurs in monochorionic twins

Effect of twin-to-twin transfusion

Disproportionate growth between twins

Preterm birth management in twins

Tocolytics; antibiotics; corticosteroids; magnesium sulphate as indicated

Antenatal care for multiple pregnancy

Multidisciplinary care with increased surveillance and scans

Key early assessment in multiple pregnancy

Dating and determining chorionicity

Birth options for twins

Elective induction or caesarean birth may be offered

Vaginal birth for DCDA twins

Can be considered when the first twin is cephalic

Fetal monitoring during twin birth

CTG recommended

Postnatal consideration after twin birth

Support transition to parenting more than one baby and consider mode of birth and recovery needs

Prematurity

Preterm birth

Birth before 37 completed weeks

Extremely preterm

Less than 28 weeks

Very preterm

28 to less than 32 weeks

Moderate preterm

32 to 33+3 weeks

Late preterm

34 to 36+6 weeks

Major risks of prematurity

IVH; NEC; sepsis; thermoregulation difficulties; nutrition difficulties

Preterm infant skin

Immature epidermis causes thermal instability; fluid loss; skin breakdown; infection risk

Respiratory problems in preterm infants

Respiratory distress and apnoea due to immature respiratory systems

Other challenges of prematurity

Feeding difficulties and developmental challenges

Temperature complications in prematurity

Hypothermia due to limited physiological reserves and immature thermoregulation

Why hypothermia is dangerous in preterm infants

Energy is diverted from growth and healing toward heat production

Neutral thermal environment

Environment where normal temperature is maintained with minimal metabolic and oxygen expenditure

Common complications of preterm infants

Respiratory challenges; thermal instability; feeding difficulties; jaundice

Preterm infant nutrition

Immature gastrointestinal system and difficulties maintaining suck-swallow coordination

Neonatal thermoregulation

Why newborns lose heat easily

Immature thermoregulation; high surface-area-to-weight ratio; limited energy reserves

Effect of neonatal hypothermia

Increased oxygen consumption; metabolic acidosis; increased mortality risk

Non-shivering thermogenesis

Heat production through brown adipose tissue in response to cold stress

Brown adipose tissue

Tissue around the neck

Preterm brown fat

Reduced brown fat stores make preterm infants less effective at thermogenesis