Trauma in pregnancy

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.

Functional Outcome of Lower Limb Long Bone Trauma Management in Pregnant Mothers: A Prospective Study of 30 Cases From a Tertiary Care Centre in North India

INTRODUCTION

The occurrence of orthopedic injuries during pregnancy carries considerable morbidity and mortality for both the mother and fetus. Successful care of lower limb fractures during pregnancy requires a multidisciplinary approach. Both operative and non-operative treatments must be taken into account by the treating orthopedic physician. There is limited literature available on the management of these lower limb fractures in pregnancy, and peri-operative management of this obstetric and orthopedic trauma is largely unclear. Trauma during pregnancy is a common cause of non-obstetrical maternal death, having a significant public health burden to both the mother and child. The aims and objectives of this study were to review the common causes of lower limb long bone trauma during pregnancy and their functional outcome in terms of morbidity and mortality. This study evaluates various operative and conservative methods of treatment to provide a comprehensive management approach to pregnant patients with lower limb trauma.

MATERIALS AND METHODS

A prospective study on functional outcomes of 30 pregnant females who were admitted with lower limb long bone fractures from 2017 to 2021 was done. The patients were randomly selected intra-operatively for various procedures based on the surgeon's preference. All patients were followed for two years or till union occurred, and the radiographic union score for tibial (RUST) and modified radiographic union score for tibial (mRUST) fracture criteria were used to assess bony union clinico-radiologically.  Results: During this study, the mean age of patients was 27 years (range 19-38), having right-side (53.33%) predominance with road traffic accidents (n=22) and falls (n=6) as the most common causes of injury. Two cases of domestic violence were also reported. In our study, the maximum number of cases was 17-25 weeks of their gestation; 12 (40%) patients had tibial fractures, and 18 (60%) had femoral fractures. Six tibial fractures were handled conservatively, while all femoral fractures required surgical intervention. Out of 18 femoral fractures, which were treated surgically, dynamic compression plating was done in 15 (83.33%) patients, while interlock nailing was done in three patients. Six tibial fractures have been operated upon, two (66.66%) with dynamic compression plating and four (33.33%) with an interlocking nail.

CONCLUSION

A multidisciplinary approach in terms of both operative and non-operative methods must be taken into account for treating pregnant mothers by the orthopedic physician while carefully weighing the benefits and risks of both procedures. Based on the pattern and displacement of the fracture, many prenatal fractures can be treated conservatively. Another alternative that is frequently safe is to postpone the surgical procedure until childbirth. The physiologic changes associated with pregnancy and any potential dangers to the fetus must be taken into account by the orthopedic surgeon when fractures necessitate surgical intervention. The surgeon is responsible for the patient's correct placement, the C-arm's use, the radiation dose, and the intra-operative fetal monitoring, as well as the danger brought on by anesthetics, antibiotics, analgesics, and anticoagulants.

Outcomes for advanced aged (35 and older) versus younger aged pregnant trauma patients: A multicenter study

BACKGROUND

Effects of advanced maternal age (AMA) pregnancies (defined as ≥35 years) on pregnant trauma patients (PTPs) are unknown. This study compared AMA versus younger PTPs, hypothesizing AMA PTPs have increased risk of fetal delivery (FD).

METHODS

A retrospective (2016-2021) multicenter study included all PTPs. Multivariable logistic regression was used to evaluate risk of FD after trauma.

RESULTS

A total of 950 PTPs were included. Both cohorts had similar gestational age and injury severity scores. The AMA group had increased injuries to the pancreas, bladder, and stomach (p < 0.05). There was no difference in rate or associated risk of FD between cohorts (5.3% vs. 11.4%; OR 0.59, CI 0.19-1.88, p > 0.05).

CONCLUSION

Compared to their younger counterparts, some intra-abdominal injuries (pancreas, bladder, and stomach) were more common among AMA PTPs. However, there was no difference in rate or associated risk of FD in AMA PTPs, thus they do not require increased observation.

Thoracoabdominal impalement injury during pregnancy

Trauma has emerged as the leading cause of death during pregnancy. Penetrating abdominal trauma in pregnancy requires a rigorous clinical evaluation to establish a complete assessment of obstetric and non-obstetric lesions. In the case of major trauma, treatment is essentially carried out in a trauma centre with a multidisciplinary team to improve maternal and fetal prognosis. This is a case of a 20-year-old primigravid woman, 33 weeks and 4 days age of gestation, who was admitted for impaled foreign body. She was brought to the emergency department for a penetrating wound of the chest and abdomen after being accidentally impaled by a metre-long, inch-thick steel rod. Emergency laparotomy, caesarean section and thoracotomy were performed. The aim of this report is to discuss the assessment, management and role of the multidisciplinary team in the management of a pregnant trauma patient.

Obstetric complications on deployed operations: a guide for the military surgeon

Modern military general surgeons tend to train and then practice in 'conventional' surgical specialties in their home nation; however, the reality of deployed surgical practice, either in a combat zone or on a humanitarian mission, is that they are likely to have to manage patients with a broad range of ages, conditions and pathologies. Obstetric complications of war injury include injury to the uterus and fetus as well as the mother and both placental abruption and uterine rupture are complications that military surgeons may have little experience of recognising and managing. On humanitarian deployments, fetomaternal complications are a common reason for surgical intervention. We report a recent patient's story to highlight the obstetric training needs of military surgeons.

Trauma in pregnancy

Although serious trauma during pregnancy is uncommon, it remains a major cause of maternal and fetal death and presents a variety of patient care challenges. The anatomic and physiologic changes of pregnancy can affect both the nature of an injury and the body's response to it. Here, the author describes the mechanisms of traumatic injury during pregnancy, discusses the normal changes of pregnancy and their implications in the care of pregnant trauma patients, and offers strategies for assessment and treatment.

Trauma in pregnancy

The care of the pregnant trauma patient provides unique challenges and holds profound implications for both fetal and maternal outcomes. The management of these patients is influenced by unique anatomic and physiologic changes, increased concern for deleterious radiation and medication exposures, and the need for multidisciplinary care. This article reviews the critical features necessary in the assessment, diagnosis, treatment, and disposition of pregnant trauma patients with a focus on recent developments reported in the literature as pertinent to emergency management.