Page 752 - ACCCN's Critical Care Nursing

Pregnancy and Postpartum Considerations 729

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pregnant women with mechanical valves experience presentation to the emergency department. The
unacceptably high rates of valve thrombosis and ‘story’ of the injury should be considered in relation
embolism when switched to heparin, and so many to the presenting injury and likely mechanism of
cardiologists consider the risks associated with the injury; another potential sign is when the woman
continued use of warfarin in pregnancy to be lower appears evasive or reluctant to speak or disagree in
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than the risks of stopping it. Therefore a regimen that front of her partner. Pregnancy-related violence is
balances the risk of thrombosis with that of fetal loss associated with low birth weight babies, premature
and risk of haemorrhage should be implemented, labour and fetal trauma. 162
with some variation stopping warfarin for the l Musculoskeletal injuries: pregnancy hormones, pre-
whole first trimester or from 6–12 weeks gestation and dominantly relaxin, oestrogen and progesterone,
then resumed until close to delivery; replacing affect joints and ligaments making them more lax and
warfarin with unfractionated or low molecular weight pliable. This increased joint mobility explains why
heparin for the whole pregnancy or continuing pregnant women are more likely to experience joint
warfarin throughout pregnancy and replacing it with injury, pelvic instability, back pain and strained and
heparin for delivery only. Appropriate dosing sched- dislocated joints, and combined with the altered
ules for heparin have not been confirmed with low- centre of balance with the advancing uterus, explains
dose heparin considered inadequate and high doses why pregnant women readily fall off ladders, for
of unfractionated heparin not researched. 157 example when decorating the nursery.
l Secondary prevention of rheumatic heart disease: l Motor vehicle trauma: is the most common reason for
monthly IM penicillin, e.g. 1,200,000 units of benzyl a pregnant woman to present to an emergency depart-
penicillin, to minimise repeat acute rheumatic fever ment with trauma. Unfortunately, some pregnant
and associated further valve degeneration. 158 women believe there is no legal requirement to wear
a seatbelt when pregnant and this places them and
their fetus at increased risk. 163 Additionally, many
pregnant women are not informed on the correct posi-
tioning of a seatbelt during pregnancy, and incorrect
Practice tip positioning can increase the likelihood of placental
When caring for a pregnant woman with cardiac disease or abruption in a crash (Figure 26.3).
postcardiac surgery, differences in normal haemodynamic and Trauma in pregnancy presents a number of challenges, in
respiratory parameters in pregnancy must be considered. part due to consideration of the fetus, but also given the
impact of the physiological changes of pregnancy. Over-
whelmingly, the single principle of management is to
treat the mother. Trauma assessment of the pregnant
SPECIAL CONSIDERATIONS woman should include all the usual elements (see
Chapter 23) with the following additional components.
Any health condition resulting in ICU admission may
occur in a pregnant woman. The more common of these Initial Evaluation of the Pregnant Patient:
include physical trauma, pneumonia and mental health The Primary Survey
disorders and these are described in detail below. Consideration should be given to all women of
childbearing age as to whether she may be pregnant.
TRAUMA IN PREGNANCY Determination of the presence of a pregnancy and the
The term ‘trauma’ refers to any accidental or intentional
event resulting in injury, with motor vehicle crashes, falls
and domestic violence most prevalent amongst the preg-
nant trauma population. Although pregnancy is consid-
ered a period of low risk for traumatic injury as most
women choose not to embark on risk-taking behaviour
when pregnant, those who do continue to engage in risk-
taking behaviour, such as misuse of alcohol and other
substances, experience more injury. 159 Overall, the inci-
dence of trauma in pregnancy is estimated to be in the
range of 5–8% of all pregnancies, with motor vehicle
crashes responsible for about half, and falls and assault
accounting for roughly one quarter each. 160,161
Specific causes of injury in pregnant women include:
l Domestic violence: for women who experience domes-
tic violence, 30% occurs for the first time during preg-
nancy; homicide during pregnancy and the postpartum A B
period also occurs and intentional violence by an FIGURE 26.3 Positioning of a seatbelt during pregnancy. (A) Incorrect
intimate partner is a relatively common reason for positioning; (B) correct positioning. 163