Blunt traumatic injury during pregnancy: a descriptive analysis from a level 1 trauma center

Trauma in pregnancy: A narrative review of the current literature

INTRODUCTION

Trauma accounts for nearly half of all deaths of pregnant women. Pregnant women have distinct physiologic and anatomic characteristics which complicate their management following major trauma.

OBJECTIVE

This paper comprises a narrative review of the most recent literature informing the management of pregnant trauma patients.

DISCUSSION

The incidence of trauma during pregnancy is 6-8%. The focus of clinical assessment must be on the mother, starting with the primary survey. During airway management, clinicians should consider early intubation if necessary and utilize gastric tubes to minimize the risk of aspiration. Pregnant women experience progesterone-mediated hyperventilation, and normal PaCO2 levels may portend imminent respiratory failure. Clinicians should utilize left lateral tilt in hypotensive pregnant women to displace the uterus off the inferior vena cava. Ultrasonography is an attractive imaging modality for pregnant women which is specific for ruling in intraabdominal hemorrhage but not sufficiently sensitive to exclude this diagnosis. Clinicians should not hesitate to order computed tomography imaging in unstable patients if there is diagnostic ambiguity. Cardiotocographic monitoring simultaneously assesses uterine contractions and fetal heart rate and should last at least 4 h for pregnant women following even minor abdominal trauma if their fetus has achieved viable gestational age (approximately 24 weeks). In the event of cardiac arrest, peri-mortem cesarean section may improve outcomes for the mother and fetus alike. Unique specific complications include uterine rupture and placental abruption, which require emergent resuscitation and obstetrics consultation for definitive management. Emergency clinicians should maintain a low threshold for transfer to a tertiary care center given correlations between even isolated and relatively minor traumatic injuries with adverse fetal and maternal outcomes.

CONCLUSIONS

Trauma is a common cause of morbidity and mortality in pregnant women. Emergency clinicians must understand the evaluation and management of pregnant trauma patients.

Predictors of Adverse Pregnancy Outcomes Following Traumatic Injuries

OBJECTIVE

After traumatic injury in pregnant women, providing timely and appropriate management for high-risk patients is crucial for both pregnant women and fetuses. This study aimed to identify risk factors that predict adverse pregnancy outcomes after traumatic injury.

METHODS

A retrospective cohort study including 317 pregnant patients who experienced trauma was conducted. The collected data included general demographics, injury mechanisms and adverse pregnancy outcomes. Patients were divided into two subgroups based on the absence or presence of trauma-related adverse pregnancy outcomes. Univariate and multivariate logistic regressions were conducted to estimate the associations between clinical variables and adverse pregnancy outcomes.

RESULTS

A total of 41 (12.93%) patients experienced adverse pregnancy outcomes within the first 24 h post-trauma. This study revealed that age >35 years (OR=14.995, 95% CI: 5.024-44.755, P<0.001), third trimester trauma (OR=3.878, 95% CI: 1.343-11.204, P=0.012), abdominal pain (OR=3.032, 95% CI: 1.221-7.527, P=0.017), vaginal bleeding (OR=3.226, 95% CI: 1.093-9.523, P=0.034), positive scan in focused assessment with sonography for trauma (FAST) positive (OR=8.496, 95% CI: 2.825-25.555, P<0.001), 9≤ injury severity score (ISS) <16 (OR=3.039, 95% CI: 1.046-8.835, P=0.041) and ISS≥16 (OR=5.553, 95% CI: 1.387-22.225, P=0.015) increased the probability of posttraumatic adverse pregnancy outcomes. Maternal age, gestational age at delivery, vaginal bleeding and positive FAST results were risk factors for abnormal delivery.

CONCLUSION

Advanced maternal age, third trimester, and positive FAST results should alert multidisciplinary trauma teams to closely monitor patients to prevent adverse pregnancy outcomes.

Management of the Pregnant Trauma Patient: A Systematic Literature Review

INTRODUCTION

Trauma during pregnancy is the leading cause of non-obstetric maternal death and complicates up to 5%-7% of pregnancies. This systematic review without meta-analysis explores the current literature regarding the assessment and management of pregnant trauma patients to provide evidence-based recommendations to guide the general surgeon regarding the prognostic value of laboratory testing including Kleihauer-Betke testing, duration of maternal and fetal monitoring, the use of tranexamic acid, the safety of radiographic studies, and the utility of perimortem cesarean section to improve maternal and fetal mortality.

MATERIALS AND METHODS

A systematic search of MEDLINE (Ovid), the Cochrane Library (Wiley), and Embase (Elsevier) was performed. The reference lists of included studies were reviewed for relevant citations.

RESULTS

Of the 45 studies included in this review, there was reasonable evidence to suggest that the minimally injured pregnant trauma patient should be observed for a minimum of 4 h, CT scans to rule out traumatic injury are necessary and safe, perimortem cesarean sections should be performed as soon as maternal cardiac arrest occurs.

CONCLUSIONS

We recommend delivery by perimortem cesarean section as soon as possible after maternal cardiac arrest, to provide TXA to the hemorrhaging pregnant trauma patient, to obtain trauma CT scans as indicated, and to observe the injured pregnant patient for a minimum of at least 4 h. Additional high-quality studies focusing on the prognostic potential of KB tests and other laboratory studies are needed.

High-intensity exercise during pregnancy – A position paper by the European Board and College of Obstetrics and Gynaecology (EBCOG)

Most guidelines recommend regular physical exercise to all pregnant women. However, because of the anatomical and physiological changes which occur during pregnancy, high-intensity exercise and forms of extreme sports can place the pregnant woman and her fetus at risk of harm.

A multidisciplinary approach to rescue a full-term pregnant and her fetus after blunt abdominal trauma: A case report and literature review

Blunt abdominal trauma due to motor vehicle crash is one of the leading causes of mortality during pregnancy. Though the trauma team plays a critical role in the initial management, a multidisciplinary contribution is essential to ensure the safety of the mother and her fetus. This case report followed the multidisciplinary approach for the management of a 32-year-old female during the last week of pregnancy. She sustained blunt trauma causing maternal and fetal distress due to abruption of the placenta with a large intrauterine and retroplacental hemorrhage, retro-hepatic and retroperitoneal hemorrhage, pseudoaneurysm of uterine arteries leading to postpartum hemorrhage. Immediate intervention and management at a Level 1 trauma center led to survival of both the mother and infant.

Predictive risk factors of adverse perinatal outcomes following blunt abdominal trauma in pregnancy

BACKGROUND

The primary objective was to identify predictive risk factors of preterm delivery following blunt abdominal trauma. The secondary objective was to identify risk factors of other adverse outcomes, Neonatal Intensive Care Unit (NICU) admission, placental abruption, fetal demise, and Cesarean Delivery (CD).

METHODS

This retrospective study included pregnant patients with gestational age (GA) ≥23 weeks who presented after blunt abdominal trauma to Richmond University Medical Center from October 2015 to January 2020. Patients were identified using the following diagnostic International diagnostic classification (ICD-10) codes: O9A.212, O9A.213, and 071.89, and excluded if trauma did not involve the abdomen, penetrating, <23 weeks, or incomplete records. Collected data points included maternal demographic factors, clinical laboratory values, maternal clinical findings at presentation, abdominal ultrasound, results of fetal monitoring, Abbreviated Injury Score (AIS) for abdomen, and Injury Severity Score (ISS). Univariate analyses were compared using the Student's t-test or Mann-Whitney U-test. Categorical data were compared using the chi-squared test or Fisher's exact test with P-value < .05 as significant.

RESULTS

154 patients were included in the final analysis. The incidence of the primary outcome, preterm delivery before 37 weeks, was 11.0% (17/154). The incidence of secondary outcomes following blunt abdominal trauma were abruption 0% (0/154), fetal demise 0.6% (1/154), CD 44% (68/154), NICU admission 24% (37/154). Maternal demographic factors, presence of uterine contractions, maternal clinical conditions (abdominal pain, abdominal tenderness, vaginal bleeding), hematologic and coagulation studies, ultrasound findings, fetal heart rate tracing category, AIS score for abdomen, and ISS score were not predictive of preterm delivery or other secondary outcomes.

CONCLUSION

The incidence of adverse maternal and neonatal outcomes is low following blunt abdominal trauma. Extended monitoring of asymptomatic patients including laboratory tests and coagulation profiles were not predictive of preterm labor or secondary adverse perinatal outcomes.

LEVEL OF EVIDENCE

Therapeutic/Care management, Level III.

Epidemiology of pregnant patients with major trauma in Victoria

OBJECTIVE

Trauma is one of the most common contributors to maternal and foetal morbidity and mortality. The aim of the present study was to describe the characteristics and outcomes of major trauma in pregnant patients using a population-based registry.

METHODS

Registry-based study using data from the Victorian State Trauma Registry (VSTR), a population-based database of all hospitalised major trauma (death due to injury, Injury Severity Score [ISS] ≥12, admission to an intensive care unit [ICU] for more than 24 h and requiring mechanical ventilation for at least part of their ICU stay or urgent surgery) in Victoria, Australia, from 1 July 2007 to 30 June 2019. Pregnant patients with major trauma were identified on the VSTR. We summarised patient data using descriptive statistics.

RESULTS

Over the 12-year study period, there were 63 pregnant major trauma patients. Fifty-two (82.5%) patients sustained injuries resulting from road transport collisions. The maternal survival rate was 98.4% and the foetal survival rate was 88.9%. Thoracic injury was the most common injury (25/63), followed by abdominal injury (23/63). Eighty-six percent of the third trimester patients (19/22) were transported directly to a major trauma service with capacity for definitive care of the pregnancy.

CONCLUSION

The present study demonstrated road transport injury was the most common mechanism of injury and both maternal survival rates and foetal survival rates were high. This information is essential for trauma care system planning and public health initiatives to improve the clinical management and outcomes of pregnant women with major trauma.

Stair-Related Injuries Among Pregnant Women Treated in United States Emergency Departments

OBJECTIVES

Falls are one of the leading causes of trauma during pregnancy, and most falls occur on stairs. The purpose of this study was to describe stair-related falls among pregnant women who were treated in United States emergency departments during a 10-year period.

METHODS

This study utilized a cross-sectional analysis of National Electronic Injury Surveillance System (NEISS) data, 2008-2017. Emergency department visits by pregnant women aged 12 years and older were identified using case narratives.

RESULTS

From 2008 to 2017, 1466 cases of pregnant women who had sustained stair-related falls were reported to NEISS, equating to a national estimate of 57,512 over the 10-year study period. Variables examined included age, body part injured, location of injury, discharge disposition, gestation, mechanism of injury, and other fall-associated hazards and symptoms. Most injuries involved contusions or abrasions, other injuries commonly reported were sprains/strains and contusions/abrasions. Wet/icy conditions represented hazards associated with 4.1% of all injuries. Severe obstetric symptoms, such as decreased fetal movement and vaginal bleeding, were described in study narratives.

CONCLUSIONS

Falls are a leading cause of injury among women of childbearing age and stair-related falls comprise a large proportion of maternal falls. Physiological changes associated with pregnancy can put gravid women at greater risk for falls. Healthcare providers can provide women anticipatory guidance that may reduce their risk for falls as they progress in pregnancy.

[The (severely) injured pregnant patient from the perspective of trauma surgery]

BACKGROUND

Trauma is the leading cause for nonpregnancy-linked maternal mortality in pregnant women, even though the exact incidence for accidents in pregnancy is unknown. Trauma management concepts applied for nonpregnant adult patients are just as valid for injured and severely injured pregnant women but in addition trauma management has to consider the unique physiological and pathophysiological conditions for a favorable maternal and fetal outcome.

OBJECTIVE

Overview of current data about the epidemiology, injury mechanisms, maternal and fetal outcome and recommendations on the management of injured pregnant women based on a systematic literature search.

RESULTS

Currently, there is no evidence indicating an association between maternal injury severity, the physiological condition and the fetal outcome. Practice guidelines for trauma management in pregnancy recommend prioritization of maternal treatment and resuscitation for optimal initial treatment of the fetus. The current recommendations for trauma room management in pregnancy, surgical treatment, including damage control surgery, are based on weak evidence.

CONCLUSION

The examination, stabilization and treatment of injured pregnant women has priority for fetal survival and outcome. The management of severe trauma in pregnancy requires a multidisciplinary expertise and team approach consisting of surgeons, anesthetists, radiologists, obstetricians and neonatologists, so that for a severely injured gravida, the decision for admission to designated trauma centers is already preclinically made. The principles of management and treatment of severely injured pregnant women should adhere to the treatment principles of nonpregnant trauma victims.

[Acute treatment of pregnant women after severe trauma-a retrospective multicenter analysis]

BACKGROUND

For the medical team, the management of pregnant trauma patients is a particular challenge. The aim of this study is to compile this data and to determine differences between pregnant and not pregnant trauma patients.

MATERIALS AND METHODS

We carried out a retrospective data analysis from the TraumaRegister DGU® with a comparison of 102 pregnant and 3135 not pregnant women of child-bearing age (16-45 years) from 2016-2018 who were treated in a trauma center. All patients were delivered to the resuscitation room and received intensive care treatment.

RESULTS

In Germany, Austria and Switzerland 3.2% of all trauma patients (102 women) were pregnant. Women with an average age of 29 years suffered most often trauma as a result of a road traffic accident. Major trauma (Injury Severity Score [ISS] ≥16 points) was seen in 24.5% of the pregnant women and 37.4% of the nonpregnant women. A computer tomography (whole body computer tomography) was carried out in 32.7% of all pregnant women but in 79.8% of the nonpregnant women. As a result of the trauma, 2.9% of the pregnant and 3.5% of the not pregnant women died. The standardised mortality rate (SMR) was 0.42 in pregnant women and 0.63 in nonpregnant women.

CONCLUSION

For the first time there is data regarding incidence, trauma mechanism, prehospital and in-hospital care as well as intensive care of pregnant trauma patients in Germany, Austria and Switzerland. Further research regarding foetal outcome and trauma-related injuries in pregnant women is needed to develop an adjusted management for these patients ready to implement in trauma centres. Gynaecologists and obstetricians should be implemented in the trauma room team when needed.

Combined Acetabulum Fracture and Hip Dislocation in an 18-Year-Old Female at 35-Week Gestation: A Case Report and Review of the Literature

Caring for an injured, pregnant patient can be a management challenge. We report the case of an 18-year-old female who sustained a left acetabulum fracture with a concurrent hip dislocation at 35 weeks' gestation following a motor vehicle accident. Through an interdisciplinary, team-based approach, the patient was guided through obstetric delivery and orthopedic surgical fracture fixation without complication. By being familiar with the unique challenges in management posed by pregnant patients, orthopedic surgeons can be better equipped to minimize morbidity and mortality in this patient population while maximizing clinical outcomes.