Trauma in pregnant women: assessing detection of post-traumatic placental abruption on contrast-enhanced CT versus ultrasound

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.

Imaging of Acute Abdominopelvic Pain in Pregnancy and Puerperium-Part I: Obstetric (Non-Fetal) Complications

Acute abdominopelvic pain in pregnant and postpartum patients presents clinical and therapeutic challenges, often requiring quick and accurate imaging diagnosis. Ultrasound remains the primary imaging investigation. Magnetic resonance imaging (MRI) has been shown to be a powerful diagnostic tool in the setting of acute abdominal pain during pregnancy and puerperium. MRI overcomes some drawbacks of US, avoiding the ionizing radiation exposure of a computed tomography (CT) scan. Although CT is not usually appropriate in pregnant patients, it is crucial in the emergency evaluation of postpartum complications. The aim of this article is to provide radiologists with a thorough familiarity with the common and uncommon pregnancy and puerperium abdominal emergencies by illustrating their imaging appearances. The present first section will review and discuss the imaging findings for acute abdominopelvic pain of obstetric (non-fetal) etiology.

Trauma in the Obstetric Patient

The authors provide a concise, comprehensive overview of the unique anatomic and physiologic features of pregnancy as well as modification and considerations important for the management of the pregnant trauma patient.

Subchorionic Hemorrhage in the Second and Third Trimesters of Pregnancy: A Review

Importance

Subchorionic hemorrhage (SCH) in the second and third trimesters of pregnancy can be associated with maternal morbidity and fetal morbidity/mortality. Management of SCH in the second or third trimesters can be complicated, especially in the setting of a large SCH that requires hospitalization and blood transfusion.

Objective

The aim of this review is to describe SCH in second and third trimesters, risk factors, diagnosis, maternal and fetal outcomes, and management of this uncommon pregnancy complication.

Evidence Acquisition

A PubMed, Web of Science, and CINAHL search was undertaken with no limitations on the number of years searched.

Results

There were 123 abstracts and/or articles reviewed, with 48 articles being the basis of review. The only known risk factors for SCH are maternal factor deficiency and anticoagulation therapy. The diagnosis is usually made by ultrasound imaging. Subchorionic hemorrhage in second and third trimesters has been associated with several adverse fetal outcomes including preterm birth, preterm prelabor rupture of membranes, fetal growth restriction, fetal demise, and neonatal pulmonary morbidity. There is no proven treatment for SCH, although there are several investigational therapies reported.

Conclusions

Subchorionic hemorrhage can be complex and difficult to manage in the second and third trimesters. There are no recommendations or guidelines for management; however, serial growth ultrasounds, umbilical artery Doppler studies, and antenatal fetal testing should be considered particularly if the SCH is large or treatment requires a maternal blood transfusion.

Relevance

Subchorionic hemorrhage in the second and third trimester is associated with poor fetal outcomes and maternal morbidity, especially if the SCH is significant.

Clinical Value Study on Contrast-Enhanced Ultrasound Combined with Enhanced CT in Early Diagnosis of Primary Hepatic Carcinoma

Objective. To explore the clinical value of contrast-enhanced ultrasound combined with enhanced CT in the early diagnosis of primary hepatic carcinoma (PHC). Methods. 84 patients with suspected PHC in the early stage treated in our hospital from January 2020 to January 2022 were selected as the study subjects. All patients underwent contrast-enhanced ultrasound and enhanced CT examinations, and the surgery was performed for resection of lesions within 1 month. According to the results of postoperative pathology diagnosis, the benign group and the malignant group were included. The case data were viewed for the retrospective study to analyze the clinical application value by evaluating the diagnostic efficiency of contrast-enhanced ultrasound, enhanced CT, and their combination for PHC. Results. Among 84 suspected patients, 70 patients had PHC (malignant group) and 14 patients had other hepatic lesions (benign group) after postoperative histopathological examination. There was no significant difference in age, gender, clinical symptoms, and educational level between the two groups ( $P>0.05$ ), with obvious differences in the history of chronic hepatic disease, smoking, drinking, and infection of hepatitis B virus (HBV) between the two groups ( $P<0.05$ ). The enhancement time and regression time of the two groups were significantly different ( $P<0.05$ ), with no statistical difference in the enhancement pattern of photography ( $P>0.05$ ). For patients with PHC, the imaging features of the two inspection methods at arterial phase and lag phase were statistically different ( $P<0.05$ ). Taking pathologic findings as the gold standard, the accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of joint diagnosis were significantly higher than those of contrast-enhanced ultrasound and enhanced CT ( $P<0.05$ ), and the area under the curve of joint diagnosis was obviously larger than that of contrast-enhanced ultrasound and enhanced CT by placing the ROC curve for examination ( $P<0.05$ ). Conclusion. The combination of contrast-enhanced ultrasound and enhanced CT has a higher accuracy in the early diagnosis of PHC, and the diagnostic efficiency of contrast-enhanced ultrasound is higher than that of enhanced CT. In clinical practice, the physical condition and state of illness in patients should be fully considered, and the most suitable examination method should be selected to reduce their medical burden by taking into account their economic situation.

Doppler evaluation of normal and abnormal placenta

Doppler techniques are needed for the evaluation of the intraplacental circulation and can be of great value in the diagnosis of placental anomalies. Highly sensitive Doppler techniques can differentiate between the maternal (spiral arteries) and fetal (intraplacental branches of the umbilical artery) components of the placental circulation and assist in the evaluation of the placental functional units. A reduced number of placental functional units can be associated with obstetric complications, such as fetal growth restriction. Doppler techniques can also provide information on decidual vessels and blood movement. Abnormal decidual circulation increases the risk of placenta accreta. Doppler evaluation of the placenta greatly contributes to the diagnosis and clinical management of placenta accreta, vasa previa, placental infarcts, placental infarction hematoma, maternal floor infarction, massive perivillous fibrin deposition and placental tumors. However, it has a limited role in the diagnosis and clinical management of placental abruption, placental hematomas, placental mesenchymal dysplasia and mapping of placental anastomoses in monochorionic twin pregnancies. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasonographic measurement of the optic nerve sheath in the differential diagnosis and follow-up of migraine with and without aura: A pilot study

OBJECTIVE

Headache continues to be a common cause of emergency admissions. At first glance, primary headaches may not be distinguished from secondary headaches. This study aimed to evaluate the use of ultrasonic measurement of optic nerve sheath diameter (ONSD) in the clinical diagnosis of migraine patients during attack and during periods without attacks.

PATIENTS AND METHODS

This prospective study was conducted at the emergency department and neurology outpatient clinic of a tertiary hospital between October 2019 and January 2020. Patients diagnosed with episodic migraine and between ages 18-60 were included in the study. Migraine diagnosis and classification were based on criteria from the 2018 International Classification of Headache Disorders. ONSD measurement was performed with ultrasonography. ONSD measurements of the same migraine patients during attack and attack-free periods were compared with measurements of healthy volunteers.

RESULTS

A total of 82 participants consisting of 42 migraine patients and 40 control subjects were evaluated. In the control group, mean ONSD of the right eye was 4.88 ± 0.31 mm and mean ONSD of the left eye was 4.86 ± 0.31 mm. Mean ONSD measurement of the left eye was 4.80 ± 0.36 mm and mean ONSD of the right eye was 4.82 ± 0.37 during the attack period of the migraine patients. There was no significant difference between the migraine patients and the control group according to right and left eye ONSD measurements (attack-free period: p = 0.200, p = 0.448; attack period: p = 0.338, p = 0.660, respectively). There was no significant difference between ONSD measurements during the attack period and attack-free period in migraine patients (right eye p = 0.32; left eye p = 0.532).

CONCLUSION

The results of our study indicate that ONSD measurements may provide clinical insight into differential diagnosis preceding neuroimaging in migraine patients. On the other hand, since our study is the first on this topic, it should be noted that further studies are needed to come to a conclusion.

Nonfetal Imaging During Pregnancy: Placental Disease

Placenta is a vital organ that connects the maternal and fetal circulations, allowing exchange of nutrients and gases between the two. In addition to the fetus, placenta is a key component to evaluate during any imaging performed during pregnancy. The most common disease processes involving the placenta include placenta accreta spectrum disorders and placental masses. Several systemic processes such as infection and fetal hydrops can too affect the placenta; however, their imaging features are nonspecific such as placental thickening, heterogeneity, and calcifications. Ultrasound is the first line of imaging during pregnancy, and MR imaging is reserved for problem solving, when there is need for higher anatomic resolution.

The comparison of placental abruption coupled with and without preeclampsia and/or intrauterine growth restriction in singleton pregnancies

BACKGROUND

To compare the clinical features of placental abruption coupled with and without preeclampsia and/or intrauterine growth restriction in singleton pregnancies.

METHODS

A retrospective study of 229 cases of placental abruption was performed and the subjects were collected from Tianjin Central Hospital of Gynecology and Obstetrics between January 2016 and December 2017. The abruption cases were divided into two groups: the abruption with other conditions of ischemic placental disease (IPD group) and the abruption without them (non-IPD group). The clinical features, such as maternal age, gravidity, parity, gestational age at delivery, maternal complications, bleeding volume, fetal gender, sensitivity of ultrasonography, primary symptoms, onset-to-delivery time, mode of delivery, birth weight, and Apgar score at 1 min, were compared between two groups.

RESULTS

The primary symptoms in the top three were the central nervous system symptoms involving headache, dizziness or blurred vision (55.0%), decreased fetal movements (13.75%), and abdominal pain (10.0%) in IPD group, while in non-IPD group the top three were vaginal bleeding combined with abdominal pain (31.54%), abdominal pain (22.82%), and vaginal bleeding (16.11%). Compared with non-IPD group, the neonatal outcomes including birth weight, Apgar score at 1 min, and gestation age at delivery were significantly poorer in the IPD group (p < .000, p = .044, and p = .001, respectively). And the sensitivity of ultrasonography was significantly higher in non-IPD group (p = .002). In both preterm and term abruption in IPD group, compared with non-IPD group, it was significantly different in terms of gestation age at delivery, onset-to-delivery time, and birth weight (p < .05). In preterm abruption, IPD group had a significantly higher cesarean section rate than non-IPD group (p = .019). It seemed patients in IPD group had a higher incidence of uterine apoplexy and disseminated intravascular coagulation (DIC), but there was no statistical difference between the two groups in maternal complications including uterine apoplexy, blood transfusion, and DIC (p = .310, p = .585, and p = .121, respectively). It seemed preterm abruption had a poorer maternal prognosis than term abruption in IPD and non-IPD group, but the result had no significant difference (p > .05).

CONCLUSIONS

Placental abruption complicated with preeclampsia and/or intrauterine growth restriction had a poorer prognosis of newborns, while there was no significant difference in maternal prognosis. And patients with preeclampsia and/or intrauterine growth restriction deserved careful observation during pregnancy, especially when they had central nervous system symptoms of headache, visual changes, or dizziness.

Placental abruption and hemorrhage-review of imaging appearance

Placental and periplacental bleeding are common etiologies for antepartum bleeding. Placental abruption complicates approximately 1% of pregnancies and is associated with increased maternal, fetal, and neonatal morbidity and mortality. This article reviews the normal placental appearance on ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) and then discusses the different morphological appearance of placental and periplacental hematomas along with their mimics. Hematomas are classified based on the location as retroplacental, marginal subchorionic, preplacental (subamniotic), or intraplacental. Placenta-related bleeding is a common finding during first trimester ultrasound and its detection can help triage the pregnant females into low- and high-risk groups. This article reviews placenta related bleeding in the setting of trauma. Trauma can complicate pregnancy with potential severe maternal and fetal outcomes. CT is usually performed as part of the trauma workup and it can be challenging for placental evaluation. MRI can characterize the age of the hematomas and can differentiate hematomas from tumors.

Deuxième niveau de compétence pour l’échographie clinique en médecine d’urgence. Recommandations de la Société française de médecine d’urgence par consensus formalisé

La Société française de médecine d’urgence a élaboré en 2016 des recommandations formalisées d’experts définissant le premier niveau de compétence en échographie clinique en médecine d’urgence. Ce niveau est maintenant complété par un deuxième niveau correspondant à une pratique plus avancée utilisant des techniques non envisagées dans le premier niveau comme l’utilisation du Doppler et nécessitant aussi une pratique et une formation plus poussées. Des champs déjà présents dans le premier référentiel sont complétés, et de nouveaux champs sont envisagés. La méthodologie utilisée est issue de la méthode « Recommandations par consensus formalisé » publiée par la Haute Autorité de santé et de la méthode Delphi pour quantifier l’accord professionnel. Ce choix a été fait devant l’insuffisance de littérature de fort niveau de preuve dans certaines thématiques et de l’existence de controverses. Ce document présente les items jugés appropriés et inappropriés par les cotateurs. Ces recommandations définissent un deuxième niveau de compétence en ECMU.

Imaging findings of concealed intra-amniotic hemorrhage in the setting of placenta previa and placenta accreta spectrum disorder

Placental abruption is an important cause of feto-maternal hemorrhage, with significant impact on both fetal and maternal mortality. In most cases, it presents with abdominal pain and vaginal bleeding. However, vaginal bleeding may be absent with concealed intra-amniotic hemorrhage, as in cases with placenta previa, hence confounding this diagnosis. In such cases, imaging studies may be obtained to evaluate for abdominal pain in pregnancy; hence, radiologists should be aware of the ultrasound and magnetic resonance (MR) imaging appearance of intra-amniotic hemorrhage. This includes presence of markedly echogenic amniotic fluid on US. Hemorrhage signal intensity on MR imaging varies with the duration of bleeding. In acute to subacute cases, it will present as T1 isointense and T2 hypointense amniotic fluid. This case is the first report of MR imaging findings of acute concealed intra-amniotic hemorrhage.

Trauma in pregnancy

Trauma is the leading non-obstetric cause of death during pregnancy and approximately 6-8% of all pregnancies are complicated by injury, both accidental and intentional. The initial evaluation and management of the injured pregnant patient often requires a multidisciplinary, collaborative team to provide the optimal outcome for both mother and fetus. It is important to recognize that even minor mechanisms of injury may result in poor outcomes for both fetus and mother. Injured pregnant patients meeting admission criteria experience a progressive increase in the number of complications as well as the number of patients that require delivery. There exists opportunity to identify patients who require admission and provide supportive measures that may reduce the complications of prematurity. Patients that are admitted may benefit from a multidisciplinary approach including on-going care from obstetricians or maternal-fetal medicine physicians. Placental abruption is the most common pregnancy complication, and may occur with even minor mechanisms of injury. Increasing severity of trauma increases the frequency of abruption, admission, delivery, and fetal demise.