Avaliação inicial e tratamento de trauma grave na gravidez

Abstract

Introduction: Assessment of the pregnant trauma patient presents unique challenges, as the presence of one fetus means that two patients are potentially at risk, both of whom require assessment and treatment. Severe trauma can be defined as an injury that has the potential to be fatal or life-changing. In a pregnant person, compression of the abdomen from a fall, intentional violence, or a low-speed motor vehicle accident can be considered a serious trauma, as it has the potential to cause detachment, which can be fatal to the mother and/or fetus. . Objectives: discuss the initial assessment and treatment of severe trauma during pregnancy. Methodology: Integrative literature review based on scientific databases from Scielo, PubMed and VHL, from January to April 2024, with the descriptors "Initial Assessment", "Treatment", "Severe Trauma", AND" Pregnancy Pulse".  Articles from 2019-2024 (total 69) were included, excluding other criteria and choosing 5 full articles. Results and Discussion: The initial objective is to evaluate the maternal airway, breathing and circulation and establish maternal cardiopulmonary stability. Maternal oxygen saturation (SatO2) must be maintained at ≥95 percent. Early intubation after preoxygenation is recommended if adequate maternal oxygenation has not been achieved; assume a difficult airway and high risk of gastric aspiration. The diaphragm is elevated in pregnancy, so if a thoracostomy tube is necessary, some experts suggest placing it one to two intercostal spaces above the usual landmark of the fifth intercostal space. Displacing the uterus approximately 30 degrees to the left, outside the vena cava, is critical to maximizing the effectiveness of cardiopulmonary resuscitation when the uterus is at or above the umbilicus. Any diagnostic test/procedure or treatment necessary to save the mother's life or treat her critical condition must be performed, even if potentially disadvantageous to the fetus. In singleton pregnancies, the uterus is a pelvic organ for the first 12 weeks of gestation. The top of the uterine fundus is palpable above the pubic symphysis at approximately 13 weeks, halfway to the umbilicus at approximately 16 weeks, at the level of the umbilicus at approximately 20 weeks of gestation, halfway between the umbilicus and the costal margin at approximately 24 to 28 weeks, and at the costal margin at >34 to 36 weeks. Fetal heart rate measurement is the minimum initial fetal assessment to determine whether the fetus is alive and, if alive, whether it is compromised (normal fetal heart rate is 110 to 160 beats per minute). It is important to compare maternal and fetal heart rates to ensure that the fetal heart rate, not the maternal heart rate, is being monitored. In pregnancies reaching ≥24 weeks of gestation, we suggest continuous rather than intermittent fetal and uterine monitoring when possible. The earliest gestational age compatible with ex-utero survival is 22 to 23 weeks of gestation, and some patients may consider continued monitoring with neonatal intervention and resuscitation at this age. Ultrasound examination of the fetus is indicated if the clinician believes the fetus may have been injured. It is also useful in determining the position of the placenta, gestational age, and possibly whether rupture of membranes or premature abruption has occurred. Once catastrophic trauma has been excluded, the clinician must determine whether the patient has any obstetric complications (e.g., abruption, uterine rupture, fetomaternal bleeding, premature birth, premature rupture of membranes). Most patients who develop adverse obstetric outcomes present with symptoms such as contractions, vaginal bleeding, or abdominal pain at initial presentation. Digital vaginal examination should be avoided in pregnancies greater than 20 weeks until placenta previa has been excluded by ultrasound examination, because disturbance of the placenta can cause massive hemorrhage. Vaginal examination should include assessment of bleeding, rupture of membranes, and labor. Conclusion: The traumatized pregnant woman is a unique patient, because two people are victimized simultaneously. Furthermore, the physiological adaptations of the maternal organism during pregnancy alter the normal pattern of response to the different variables involved in trauma. These changes in organic structure and function can influence the evaluation of traumatized pregnant women by changing the signs and symptoms of injuries, altering the approach and response to fluid resuscitation, as well as the results of diagnostic tests. Pregnancy can also affect the pattern and severity of injuries. The priorities in the care and treatment of traumatized pregnant women are the same as those for non-pregnant patients. The best care for the fetus is to provide adequate treatment for the mother, since the life of the fetus is totally dependent on the maternal anatomophysiological integrity.