Intrauterine penetrating direct fetal head trauma following gunshot injury: a case report and review of the literature

Maternal and Neonatal Outcomes of Gunshot Wounds in Pregnancy: A Systematic Review of Case Reports

A systematic review was performed to compare adverse maternal and neonatal outcomes among pregnant patients with gunshot wounds (GSW) to the abdominopelvic vs other region(s) at > 20 weeks gestation. A search of Medline Ovid, Elsevier Embase, EBSCO CINAHL, and Cochrane Library in July 2022 and reference searches resulted in 1742 studies, which were screened. The 41 included studies reported outcomes for 59 pregnant patients with GSW, of which 31 (52.5%) had an isolated abdominopelvic GSW and 28 (47.5%) had an extremity, thorax, head/neck, back/spine, poly-site, or other/unknown GSW. Stillbirth occurred in 26.7% of abdominopelvic GSW and 26% of non-abdominopelvic GSW. Maternal death occurred in 3.7% of abdominopelvic GSW and 10.7% of non-abdominopelvic GSW. Neonatal death occurred in 9.1% of abdominopelvic GSW and 5.3% of non-abdominopelvic GSW. Further research is needed to standardize the approach for the evaluation and management of patients with GSW in pregnancy.

Recognition and management of traumatic fetal injuries

Trauma during pregnancy is the leading non-obstetric cause of morbidity and mortality, and accounts for five per 1000 fetal deaths. Direct fetal injury due to trauma during pregnancy is rare, and limited information is available about how to optimize fetal outcomes after injury. Early recognition and appropriate management of direct fetal trauma may improve outcomes for the fetus. There are currently no available guidelines to direct management of the injured fetus. We provide a detailed literature review of the management and outcomes of direct fetal injury following blunt and penetrating injury during pregnancy, and describe a suggested initial approach to the injured pregnant patient with a focus on evaluation for fetal injury. We identified 45 reported cases of blunt trauma resulting in direct fetal injury, with 21 surviving past the neonatal period, and 33 of penetrating trauma resulting in direct fetal injury, with 24 surviving past the neonatal period. Prenatal imaging identified fetal injury in 19 cases of blunt trauma and was used to identify bullet location relative to the fetus in 6 cases. These reports were used to develop management algorithms for the injured fetus.

Intracranial gunshot wounds in utero: case report and review

BACKGROUND AND IMPORTANCE

We present a rare case of an in utero intracranial gunshot wound with survival of the baby and neurosurgical intervention in the first 6 h of life.

CLINICAL PRESENTATION

A pregnant 19-year old sustained multiple gunshot wounds and underwent an emergency cesarean section. At the time of delivery, there was a penetrating wound noted to the uterus and to the left side of the baby's head. The baby was taken urgently for craniotomy. Thorough washout was performed, and a pericranial graft was harvested from the frontal vertex to assist in dural closure. The largest displaced bone fragment was soaked in betadine and sutured back into place. The baby was observed for several days and then discharged home with normal neurological examination.

CONCLUSION

There are scattered reports of in utero intracranial gunshot wounds in the literature dating back to the nineteenth century; however, our case appears to be the first reported that involved urgent surgical intervention.

Fetal gunshot brain injury leading to late postnatal hydrocephalus

A male fetus was delivered by emergent caesarean section after a term pregnant mother was caught in crossfire and sustained gunshot injury to her abdomen. Examination of the infant was unremarkable except for a small laceration of the scalp at the anterior fontanelle. Skull radiography showed a dense bullet shaped opacity in the brain. He was managed conservatively and was discharged home on full feeds with normal neurological examination. He developed seizures and progressive hydrocephalus, and underwent a ventriculoperitoneal (VP) shunt placement at 5 weeks of age. At 13 months of age the bullet was removed. To our knowledge this is the first report of fetal brain injury with intact bullet in the brain with survival. This case provides the context for a discussion about factors that contribute to survival and favorable prognosis of infants with fetal penetrating gunshot brain injury.

Intrauterine Fetal Traumatic Brain Injury Following Motor Vehicle Accident; A Case Report and Review of the Literature

Trauma, especially traumatic injuries due to car accidents are one of the causes of maternal and fetal mortality and morbidity during pregnancy. Fetus brain injuries are usually caused fetus death. We herein report a pregnant woman in 28 weeks of gestation. The fetus was found to be normal during in-hospital. At birth, the female neonate demonstrated developmental delay and neurological deficits (hypotonicity). Neuroimaging after birth revealed extreme dilatation of lateral ventricles, hypoplasia and aplasia of the brain. In 4 months, she had multiple morbidities including developmental delay, hypotonia, blindness, oropharyngeal dysphagia and simple partial seizure. Motor and response to stimulation was normal. Appropriate seatbelt usage can protect the fetus from sustaining severe intracranial injuries. 

Intrauterine Arrow Injury

Injury of a pregnant lady risks both mother and fetus. Various modes of injuries are possible. But arrow injury is not usually heard of in today's world. We have reported a male child delivered with a cut injury on the face. It was caused by a penetrating arrow hitting his mother in her lower abdomen at term. The injury of the baby was repaired successfully.

Gunshot wound of the fetus

We report here a fetus, who was delivered via cesarean section in 32th gestational week from a 37-year-old mother and sustained multiple gunshots. Post-natal evaluation revealed eight entry-exit holes and the baby was transferred to our clinic.Upon admission, peripheral pulses were nonpalpable, appropriate fluid administration and blood transfusion were conducted and further examinations revealed bladder perforation. Bladder was repaired over a suprapubic catheter and bullet holes were primarily sutured. Left foot drop was observed on follow up and the patient was discharged with no further complication. Although the maternal and the fetal morbidity and mortality rates are high in intrauterine gunshot wounds, appropriate management may provide survival as seen in our case.

Intrauterine head stab wound injury resulting in a growing skull fracture: a case report and literature review

INTRODUCTION

Penetrating injuries of the gravid uterus are rare complications of pregnancy with gunshot wounds most common than stab wounds. Fetal head injury is an unusual sequela of these penetrating traumas.

MATERIALS AND METHODS

We describe the case of a 20-year-old pregnant woman stabbed at the lower abdomen at 30th weeks of gestation. She was nonsurgically managed by serial examination and continuous fetal monitoring.

RESULTS

Spontaneous vaginal delivery occurred at term with good maternal and fetal outcome. The newborn examination revealed a right temporal swelling interpreted as a subcutaneous hemangioma. At 2 years and 6 months of life, the child was led to our attention with a pulsating bulge in the right temporal region. Clinical examination and imaging were indicative of a typical growing skull fracture. The child underwent neurosurgical procedure for repairing of the dural tear and bone defect according to the senior author's personal technique, described in details, with a good neurological and esthetic outcome.

CONCLUSION

Thirty-two cases of stab wounds to the pregnant uterus have been reported to date in medical literature with two cases of fetal head injury.Growing skull fractures are rare complications of head injury and only one case has been described in the perinatal period following blunt trauma to the mother's abdomen 2-3 weeks before birth.