Accidental injury complicating pregnancy

Different neurocognitive controls modulate obstacle avoidance through pregnancy

Understanding why falls during pregnancy occur at over 25% rate over gestation has clinical impacts on the health of pregnant individuals. Attention, proprioception, and perception of the environment are required to prevent trips and falls. This research aimed to understand how the changes to these neurocognitive processes control obstacle avoidance through gestation. Seventeen pregnant participants were tested five times in 6-week intervals. Participants walked an obstacle course (OC), and we analyzed the crossings over obstacles that were set to 10% of participants' body height. Participants also performed an attentional network test (ANT: performance of specific components of attention), an obstacle perception task (OP: ability to visually define an obstacle and translate that to a body posture), and a joint position sense task (JPS: ability to recognize and recreate a joint position from somatosensation). In the OC task, average leading and trailing foot crossing heights significantly reduced by 13% and 23% respectively, with no change in variation, between weeks 13 and 31 of pregnancy, indicating an increased risk of obstacle contact during this time. The variability in minimum leading foot distances from the obstacle was correlated with all three neurocognition tasks (ANT, OP, and JPS). Increased fall rates in the second and third trimesters of pregnancy may be driven by changes in attention, with additional contributions of joint position sense and environmental perception at various stages of gestation. The results imply that a holistic examination on an individual basis may be required to determine individual trip risk and appropriate safety modifications.

Guidelines for the Management of a Pregnant Trauma Patient

OBJECTIVE

Physical trauma affects 1 in 12 pregnant women and has a major impact on maternal mortality and morbidity and on pregnancy outcome. A multidisciplinary approach is warranted to optimize outcome for both the mother and her fetus. The aim of this document is to provide the obstetric care provider with an evidence-based systematic approach to the pregnant trauma patient.

OUTCOMES

Significant health and economic outcomes considered in comparing alternative practices.

EVIDENCE

Published literature was retrieved through searches of Medline, CINAHL, and The Cochrane Library from October 2007 to September 2013 using appropriate controlled vocabulary (e.g., pregnancy, Cesarean section, hypotension, domestic violence, shock) and key words (e.g., trauma, perimortem Cesarean, Kleihauer-Betke, supine hypotension, electrical shock). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English between January 1968 and September 2013. Searches were updated on a regular basis and incorporated in the guideline to February 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

This guideline is expected to facilitate optimal and uniform care for pregnancies complicated by trauma. Summary Statement Specific traumatic injuries At this time, there is insufficient evidence to support the practice of disabling air bags for pregnant women. (III) Recommendations Primary survey 1. Every female of reproductive age with significant injuries should be considered pregnant until proven otherwise by a definitive pregnancy test or ultrasound scan. (III-C) 2. A nasogastric tube should be inserted in a semiconscious or unconscious injured pregnant woman to prevent aspiration of acidic gastric content. (III-C) 3. Oxygen supplementation should be given to maintain maternal oxygen saturation > 95% to ensure adequate fetal oxygenation. (II-1B) 4. If needed, a thoracostomy tube should be inserted in an injured pregnant woman 1 or 2 intercostal spaces higher than usual. (III-C) 5. Two large bore (14 to 16 gauge) intravenous lines should be placed in a seriously injured pregnant woman. (III-C) 6. Because of their adverse effect on uteroplacental perfusion, vasopressors in pregnant women should be used only for intractable hypotension that is unresponsive to fluid resuscitation. (II-3B) 7. After mid-pregnancy, the gravid uterus should be moved off the inferior vena cava to increase venous return and cardiac output in the acutely injured pregnant woman. This may be achieved by manual displacement of the uterus or left lateral tilt. Care should be taken to secure the spinal cord when using left lateral tilt. (II-1B) 8. To avoid rhesus D (Rh) alloimmunization in Rh-negative mothers, O-negative blood should be transfused when needed until cross-matched blood becomes available. (I-A) 9. The abdominal portion of military anti-shock trousers should not be inflated on a pregnant woman because this may reduce placental perfusion. (II-3B) Transfer to health care facility 10. Transfer or transport to a maternity facility (triage of a labour and delivery unit) is advocated when injuries are neither life- nor limb-threatening and the fetus is viable (≥ 23 weeks), and to the emergency room when the fetus is under 23 weeks' gestational age or considered to be non-viable. When the injury is major, the patient should be transferred or transported to the trauma unit or emergency room, regardless of gestational age. (III-B) 11. When the severity of injury is undetermined or when the gestational age is uncertain, the patient should be evaluated in the trauma unit or emergency room to rule out major injuries. (III-C) Evaluation of a pregnant trauma patient in the emergency room 12. In cases of major trauma, the assessment, stabilization, and care of the pregnant women is the first priority; then, if the fetus is viable (≥ 23 weeks), fetal heart rate auscultation and fetal monitoring can be initiated and an obstetrical consultation obtained as soon as feasible. (II-3B) 13. In pregnant women with a viable fetus (≥ 23 weeks) and suspected uterine contractions, placental abruption, or traumatic uterine rupture, urgent obstetrical consultation is recommended. (II-3B) 14. In cases of vaginal bleeding at or after 23 weeks, speculum or digital vaginal examination should be deferred until placenta previa is excluded by a prior or current ultrasound scan. (III-C) Adjunctive tests for maternal assessment 15. Radiographic studies indicated for maternal evaluation including abdominal computed tomography should not be deferred or delayed due to concerns regarding fetal exposure to radiation. (II-2B) 16. Use of gadolinium-based contrast agents can be considered when maternal benefit outweighs potential fetal risks. (III-C) 17. In addition to the routine blood tests, a pregnant trauma patient should have a coagulation panel including fibrinogen. (III-C) 18. Focused abdominal sonography for trauma should be considered for detection of intraperitoneal bleeding in pregnant trauma patients. (II-3B) 19. Abdominal computed tomography may be considered as an alternative to diagnostic peritoneal lavage or open lavage when intra-abdominal bleeding is suspected. (III-C) Fetal assessment 20. All pregnant trauma patients with a viable pregnancy (≥ 23 weeks) should undergo electronic fetal monitoring for at least 4 hours. (II-3B) 21. Pregnant trauma patients (≥ 23 weeks) with adverse factors including uterine tenderness, significant abdominal pain, vaginal bleeding, sustained contractions (> 1/10 min), rupture of the membranes, atypical or abnormal fetal heart rate pattern, high risk mechanism of injury, or serum fibrinogen < 200 mg/dL should be admitted for observation for 24 hours. (III-B) 22. Anti-D immunoglobulin should be given to all rhesus D-negative pregnant trauma patients. (III-B) 23. In Rh-negative pregnant trauma patients, quantification of maternal-fetal hemorrhage by tests such as Kleihauer-Betke should be done to determine the need for additional doses of anti-D immunoglobulin. (III-B) 24. An urgent obstetrical ultrasound scan should be undertaken when the gestational age is undetermined and need for delivery is anticipated. (III-C) 25. All pregnant trauma patients with a viable pregnancy who are admitted for fetal monitoring for greater than 4 hours should have an obstetrical ultrasound prior to discharge from hospital. (III-C) 26. Fetal well-being should be carefully documented in cases involving violence, especially for legal purposes. (III-C) Obstetrical complications of trauma 27. Management of suspected placental abruption should not be delayed pending confirmation by ultrasonography as ultrasound is not a sensitive tool for its diagnosis. (II-3D) Specific traumatic injuries 28. Tetanus vaccination is safe in pregnancy and should be given when indicated. (II-3B) 29. Every woman who sustains trauma should be questioned specifically about domestic or intimate partner violence. (II-3B) 30. During prenatal visits, the caregiver should emphasize the importance of wearing seatbelts properly at all times. (II-2B) Perimortem Caesarean section 31. A Caesarean section should be performed for viable pregnancies (≥ 23 weeks) no later than 4 minutes (when possible) following maternal cardiac arrest to aid with maternal resuscitation and fetal salvage. (III-B).

Maternal mortality due to trauma

Maternal mortality is an important indicator of adequacy of health care in our society. Improvements in the obstetric care system as well as advances in technology have contributed to reduction in maternal mortality rates. Trauma complicates up to 7% of all pregnancies and has emerged as the leading cause of maternal mortality, becoming a significant concern for the public health system. Maternal mortality secondary to trauma can often be prevented by coordinated medical care, but it is essential that caregivers recognize the unique situation of providing simultaneous care to 2 patients who have a complex physiologic relationship. Optimal management of the pregnant trauma victim requires a multidisciplinary team, where the obstetrician plays a central role. This review focuses on the incidence of maternal mortality due to trauma, the mechanisms involved in traumatic injury, the important anatomic and physiologic changes that may predispose to mortality due to trauma, and finally, preventive strategies that may decrease the incidence of traumatic maternal death.

A major public health issue: the high incidence of falls during pregnancy

The objectives of this population based cohort study of 3997 women was to determine the incidence of falling and risk factors related to falls during pregnancy. Birth certificate data identified women who had delivered a child within the previous 2 months. Subjects were reached either by phone, internet or mailed surveys. The women were asked about health issues and activities at the time of the fall. Of the 3997 participants, 1070 reported falling at least once (27%) during their pregnancy. Of those 1070 35% fell two or more times, 20% sought medical care and 21% had two or more days of restricted activity. Women aged 20-24 years had an almost two fold risk of falling more than those over 35 years (odds ratio 1.9; 95% confidence interval 1.4, 2.7). Characteristics of falls included: indoors (56%), on stairs (39%) and falling from a height greater than three feet (9%) (not mutually exclusive). Though 27% of women fell while pregnant, 10% experienced two or more falls. Pregnant women should be aware of the risk factors of and situations related to falls. There is an urgent need for primary prevention in this high risk group.

Do resuscitation-related injuries kill infants and children?

Occasionally, individuals accused of inflicting fatal injuries on infants and young children will claim some variant of the "CPR defense," that is, they attribute the cause of injuries found at autopsy to their "untrained" resuscitative efforts. A 10-year (1994-2003) historical fixed cohort study of all pediatric forensic autopsies at the Miami-Dade County Medical Examiner Department was undertaken. To be eligible for inclusion in the study, children had to have died of atraumatic causes, with or without resuscitative efforts (N(atraumatic) = 546). Of these, 382 had a history of cardiopulmonary resuscitation (CPR; average age of 4.17 years); 248 had CPR provided by trained individuals only; 133 had CPR provided by both trained and untrained individuals; 1 had CPR provided by untrained individuals only. There was no overlap between these 3 distinct groups. Twenty-two findings potentially attributable to CPR were identified in 19:15 cases of orofacial injuries compatible with attempted endotracheal intubation; 4 cases with focal pulmonary parenchymal hemorrhage; 1 case with prominent anterior mediastinal emphysema; and 2 cases with anterior chest abrasions. There were no significant hollow or solid thoracoabdominal organ injuries. There were no rib fractures. The estimated relative risk of injury subsequent to resuscitation was not statistically different between the subset of decedents whose resuscitative attempts were made by trained individuals only, and the subset who received CPR from both trained and untrained individuals. In the single case of CPR application by an untrained individual only, no injuries resulted. The remaining 164 children dying from nontraumatic causes and who did not undergo resuscitative efforts served as a control group; no injuries were identified. This study indicates that in the pediatric population, injuries secondary to resuscitative efforts are infrequent or rare, pathophysiologically inconsequential, and predominantly orofacial in location. In our population, CPR did not result in any rib fractures or significant visceral injuries. Participation of nonmedical or untrained individuals in resuscitation did not increase the likelihood of injury.

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.

Trauma in pregnancy: assessment and treatment

Women between the ages of 10 and 50 year-old have the potential for pregnancy; therefore this condition must be taken into consideration when a woman is examined in the Emergency Room after sustaining a traumatic event. Pregnancy produces significant physiologic and anatomic changes in every system of the female body. The evaluation of the traumatized pregnant patient, the approach, and the interpretation of the diagnostic tests results must be accompanied by the full knowledge of all changes that take place during pregnancy. In the same context, although the physician treating a pregnant trauma victim must remember that there are two patients, the treatment priorities are the same as for the non-pregnant trauma patient. The best initial treatment for the fetus is the optimum resuscitation of the mother. A thorough exam should take place to discover unique conditions that might be present in any pregnant patient such as blunt or penetrating injury to the uterus, placental abruption, amniotic fluid embolism, isoimmunization, and premature rupture of membranes. The obstetrician should be present at all times and be considered a part of the trauma team in the evaluation and treatment of a pregnant trauma patient.

Falls in workers during pregnancy: risk factors, job hazards, and high risk occupations

BACKGROUND

Although falls are a major source of trauma during pregnancy and 70% of pregnant women are employed, information on falls among pregnant workers is lacking. Study objectives were to estimate fall prevalence and risk factors among pregnant workers.

METHODS

This retrospective cohort study used birth certificates to identify recently pregnant women. Data were collected via phone, internet, and mail surveys. The primary outcome investigated was a fall at work during pregnancy. Adjusted odds ratios (aOR) and confidence intervals (CI) were calculated.

RESULTS

Of the 2,847 employed women, 26.6% (757) fell during their pregnancy and 6.3% (179) fell at work. Walking on slippery floors, hurrying, or carrying an object occurred in 66.3% of work falls.

CONCLUSION

The service and teaching industry should be evaluated for risk reduction. Future research should determine if counseling during pregnancy will reduce falls in the workplace.

The epidemiology of traumatic injury-related fetal mortality in Pennsylvania, 1995-1997: the role of motor vehicle crashes

METHODS

Rates and causes of traumatic injury-related fetal deaths in Pennsylvania were determined from a manual review of all fetal death certificates filed from 1995 to 1997 (7,131 cases).

RESULTS

Thirty one traumatic injury cases were identified (6.5/100,000 live births). Most cases (94%) could be identified from the diagnosis code of 760.5 (maternal injury) and 87% contained narratives indicating specific injury mechanisms. Motor vehicles were the leading cause of injury (81%). Placental separation was the leading diagnosis (42%).

CONCLUSIONS

The ICD-9-CM code 760.5 appears to be a specific indicator of traumatic fetal death, though it is not known how sensitive an indicator it is. Though not usually E-coded, the death certificates contained enough information to allow ascertainment of injury mechanism. These are very conservative estimates of the burden of the problem. The major role that motor vehicle injuries have on reported traumatic fetal injury deaths was shown and a significant new challenge for child passenger safety advocates is indicated.

Trauma in pregnancy

Trauma is a major cause of maternal death in pregnancy. The pregnant woman who has been involved in an episode leading to her arrival in an accident and emergency department presents with specific problems that often require specialist attention. The correct initial management of such patients should not be beyond the capabilities of an average trauma team and such management is clearly taught as part of the Advanced Trauma Life Support course now available in the UK. This review outlines the physiological changes associated with pregnancy that become important during resuscitation and definitive care. It discusses the presentation and management of specific problems, and the safety--or otherwise--of commonly administered drugs. Only the initial resuscitation of the patient is considered; specialist obstetric care is beyond the scope of the article.

Blunt abdominal trauma: are there any predictive factors for abruptio placentae or maternal-fetal distress?

OBJECTIVES

Our objectives were to determine the incidence of abruptio placentae and fetal distress in pregnant women with noncatastrophic blunt abdominal trauma and to determine the utility of historical factors, clinical presentation, coagulation profile, and fetal monitoring in predicting fetal and maternal morbidity.

STUDY DESIGN

We reviewed 233 consecutive hospitalizations for noncatastrophic blunt abdominal trauma. Outcome variables included abruptio placentae, fetal distress, preterm birth, and abnormal laboratory values.

RESULTS

Preterm delivery (< 34 weeks) occurred within 1 week of trauma in only two patients (< 1%). Fetal distress was diagnosed between 4 and 48 hours after observation in four women (1.7%). These four patients had frequent contractions, but none had abruptio placentae at delivery. Six patients (2.6%) had abruptio placentae. None of these had fetal distress. All had a good neonatal outcome. Coagulation studies and Kleihauer-Betke tests were not predictive of fetal or maternal morbidity.

CONCLUSION

Noncatastrophic blunt abdominal trauma is associated with a low frequency of abruptio placentae, fetal distress, maternal coagulopathy, and poor neonatal outcome. Prolonged monitoring is indicated only when there is evidence of impending abruptio placentae. Kleihauer-Betke testing is necessary only for patients who are Rh negative. Coagulation profiles are not clinically helpful. Routine hospitalization beyond 4 hours is not warranted.

Fetal trauma: relation to maternal injury

Conventional surgical wisdom is that fetal death is a predictable consequence of severe maternal injury. In order to define the natural history of maternal-fetal trauma and better formulate management strategies, we reviewed our recent experience with 32 cases of maternal trauma at a major trauma center. There were three cases of fetal death; two were associated with severe maternal injury, but one had no significant injury to the mother. All cases had placental injury. Conversely, there were five cases of severe maternal trauma but only two unsuccessful pregnancy outcomes. We conclude that the extent of maternal injury does not necessarily correlate with the degree of fetal injury. Lethal placental or direct fetal injury can occur even in the absence of significant maternal injury. In selected cases, fetal salvage after maternal-fetal trauma may be achieved by early delivery and prompt pediatric surgical intervention.

Trauma during pregnancy--a review of management

The assessment and management of 22 pregnant patients who were admitted after trauma to Westmead Hospital between July, 1987 and October, 1988 was reviewed. Thirteen of the 22 patients were victims of motor vehicle accidents. Despite the fact that an injury research unit, responsible for the clerking and review of all trauma patients, is well established at our institution, only 6 patients in this series had been assessed in this fashion. Although a number of important obstetric investigations (albeit uncommon in the accident and emergency room situation) are well described in the literature, these were not performed in a number of patients. A protocol for the management of such patients is recommended so that more standardized and appropriate care might be given to the injured pregnant patient.

Penetrating abdominal wounds in pregnancy

Despite the fact that penetrating abdominal wounds in late pregnancy are becoming increasingly common, there are few such reports in the medical literature. We report the case of a Cambodian woman injured in the border fighting between the Vietnamese and Khmer troops in 1980. Our case is unique in that the fetus survived with a relatively minor fragment wound in the leg. To our knowledge, this is the first report of such a case.

Severe road traffic injuries in the third trimester of pregnancy

We report 9 women in the third trimester of pregnancy who were severely injured in road traffic accidents. There were 3 accelerated labours and half the babies died. Immediate obstetric interference was often impractical and did not improve fetal survival. Noteworthy injuries of the central nervous system were associated with very high fetal mortality. Fractures of the pelvis were not nearly as disastrous as the literature suggests. The first consideration in management should be the well being of the severely injured mother, since the injuries that would kill the fetus are not likely to be amenable to surgery. The only justification for intervention for the sake of the fetus that survives the moment of impact is to salvage it from its dying mother's body.

Trauma in the pregnant patient

The tragedy of major trauma to the pregnant woman presents the dilemma of managing two lives. An understanding of the pregnant patient's altered response to trauma and attention to detail in applying appropriate diagnostic tests will help to guarantee a successful outcome. Liberal use of consultation is suggested for medical and legal reasons. Obstetric consultation is highly recommended to document pregnancy and to assist in assessing fetal well-being. The obstetrician can perhaps provide reassurance to the mother and the family by demonstrating fetal heart tones with the Doppler instrument and can then further provide the necessary counseling and follow-up regardless of the outcome of the pregnancy. The pregnant patient with significant trauma should be closely observed and records carefully documented. Patients with minor injuries usually do not require admission, whereas more significant injuries require longer periods of observation. Admission criteria include vaginal bleeding, uterine irritability, abdominal tenderness or pain, evidence of hypovolemia, a change in or absence of fetal heart tones, or leakage of amniotic fluid. Management should primarily be directed toward guaranteeing the health of the mother, which better insures the health of the fetus.

Neonatal death following in utero traumatic splenic rupture

Perinatal death due to maternal injury is unusual unless associated with extensive maternal trauma or death. An unusual case of neonatal death due to in utero traumatic splenic rupture in the absence of significant maternal injury is presented. The case alerts physicians responsible for neonatal care to the existence of treatable causes of neonatal distress following maternal trauma.

Diagnostic peritoneal lavage for blunt trauma in pregnant women

Twelve pregnant women underwent diagnostic peritoneal lavage for suspected blunt abdominal trauma. Peritoneal lavage was both safe and accurate. The lavage was negative in four patients. Two of these patients survived without clinical evidence of abdominal injuries. The absence of abdominal injuries was confirmed at autopsy in the two patients who subsequently died. Peritoneal lavage was positive for hemoperitoneum in eight patients. All eight had significant abdominal injuries.