Fetomaternal hemorrhage following trauma

Spontaneous massive fetomaternal hemorrhage: two case reports and a literature review of placental pathology

BACKGROUND

Massive fetomaternal hemorrhage (FMH) is a rare event during pregnancy that may cause severe fetal anemia or death.

CASE PRESENTATION

This paper reports two cases of fetomaternal hemorrhage with unexplained reasons. Both cases required emergency caesarean sections for non-reassuring fetal status and were treated with neonatal blood transfusion. Fetomaternal hemorrhage was confirmed via maternal Kleihauer-Betke test.

CONCLUSION

We found parenchymal pallor, increased nucleated red blood cells (nRBCs), and syncytial knots (SKs) in the placentas, which are compatible with fetal anemia. Immunohistochemical staining indicated VEGF, CD34, and CD31 expression in the endothelial cells of the capillaries, characteristic of massive FMH placenta. This article also reviews the particular histopathological changes in FHM placenta according to the placental lesion classification system.

Fetomaternal hemorrhage: evaluation of recurrence within a large integrated healthcare system

BACKGROUND

Fetomaternal hemorrhage is associated with severe fetal morbidity and mortality. The recurrence risk of fetomaternal hemorrhage is unknown.

OBJECTIVE

We sought to establish the recurrence rate of fetomaternal hemorrhage in a large integrated healthcare system over a 10-year period.

STUDY DESIGN

In this retrospective study within the Kaiser Permanente Northern California medical system, cases of fetomaternal hemorrhage were defined by either an elevated fetal hemoglobin level as determined by flow cytometry for a concerning pregnancy outcome (preterm delivery, perinatal demise, neonatal anemia, or transfusion within the first 2 days of life) or by perinatal demise with autopsy findings suggestive of fetomaternal hemorrhage. The outcomes of subsequent pregnancies were reviewed for features of recurrence.

RESULTS

Within the 2008 to 2018 birth cohort of 375,864 pregnancies, flow cytometry testing for fetal hemoglobin levels was performed in 20,582 pregnancies. We identified 340 cases of fetomaternal hemorrhage (approximately 1 in 1100 births). Within the cohort of 340 affected pregnancies, perinatal loss was recorded for 80 (23.5%) pregnancies and 50 (14.7%) pregnancies delivered neonates who required transfusion. The affected patients had 225 subsequent pregnancies of which 210 were included in the analysis. Of these, 174 (82.9%) advanced beyond the threshold of viability and were delivered within our healthcare system. There was 1 case of recurrent fetomaternal hemorrhage identified. The recurrent case involved a spontaneous preterm delivery of an infant who was noted to have an elevated reticulocyte count but was clinically well.

CONCLUSION

Within our large integrated healthcare system, approximately 1 in 1100 pregnancies was affected by fetomaternal hemorrhage within a 10-year period, which is comparable with previous studies. We identified 1 case of recurrence, yielding a recurrence rate of 0.5%. This infant did not have features of clinically important fetomaternal hemorrhage. This information can inform counseling of patients with affected pregnancies.

Trauma in Pregnancy

Although trauma in pregnancy is rare, it is one of the most common causes of morbidity and mortality to pregnant women and fetus. Pathophysiology of trauma is generally time sensitive, and this is still true in pregnant patients, with the additional challenge of rare presentation and balancing the management of two patients concurrently. Successful resuscitation requires understanding the physiologic changes to the woman throughout the course of pregnancy. Ultimately, trauma management is best approached by prioritizing maternal resuscitation.

Demographic and Behavioral Predictors of Severe Fetomaternal Hemorrhage: A Case-Control Study

BACKGROUND

Fetomaternal hemorrhage (FMH) signifies failure of the placental barrier with whole blood transfer. Fetal anemia following FMH is associated with significant morbidity and mortality. If FMH is identified early, fetal anemia can be treated to minimize adverse outcomes. Risk factors for FMH are not known, limiting efforts to provide targeted screening for FMH.

OBJECTIVE

To identify maternal and/or pregnancy characteristics associated with FMH that are recognizable prior to fetal morbidity.

METHODS

This is the first published case-control study of FMH. Cases were identified from a prospectively maintained database of all hospital births between 1988 and 2010. Each case was matched to 4 controls by date and time of birth, allowing for assessment of a wide range of clinical and demographic data. Logistic regression modeling was used to assess the association between demographic and clinical characteristics and the diagnosis of FMH.

RESULTS

A total of 23 mother-baby pairs impacted by FMH and 92 matched controls were evaluated. Compared to controls, case mothers were more likely to have private insurance and to work outside the home and at night during pregnancy. Cases were more likely to be delivered preterm, but preterm labor was not more common among cases. There was no difference in race/ethnicity of cases compared to controls.

CONCLUSIONS

Severe FMH is associated with significant morbidity and mortality of the affected neonate. Women with FMH were more likely to work outside the home during pregnancy than women with normal pregnancies. This finding has implications for third-trimester screening of pregnant women who work in strenuous fields.

Acute and chronic fetal anemia as a result of fetomaternal hemorrhage

Introduction. Fetomaternal hemorrhage represents a transfer of fetal blood to the maternal circulation. Although many etiologies have been described, most causes of fetomaternal hemorrhage remain unidentified. The differentiation between acute and chronic fetomaternal hemorrhage may be accomplished antenatally and may influence perinatal management. Case. A 36-year-old gravida 6 para 3 presented at 37 and 5/7 completed gestational weeks with ultrasound findings suggestive of chronic fetal anemia such as right ventricular enlargement, diminished cerebral vascular resistance, and elevated middle cerebral artery end-diastolic velocity. On the other hand, signs of acute fetal decompensation such as deterioration of the fetal heart tracing, diminished biophysical score, decreased cord pH, and increased cord base deficit were noted. Following delivery, the neonate's initial hemoglobin was 4.0 g/dL and the maternal KB ratio was 0.015 indicative of a significant fetomaternal hemorrhage. Discussion. One should consider FMH as part of the differential diagnosis for fetal or immediate neonatal anemia. We describe a unique case of FMH that demonstrated both acute and chronic clinical features. It is our hope that this case will assist practitioners in differentiating acute FMH that may require emergent delivery from chronic FMH which may be able to be expectantly managed.

Fetal-maternal hemorrhage: a case and literature review

Nearly all pregnancies include an insignificant hemorrhage of fetal blood into the maternal circulation. In some cases, the hemorrhage is large enough to compromise the fetus, resulting in fetal demise, stillbirth, or delivery of a severely anemic infant. Unfortunately, the symptoms of a significant fetal-maternal hemorrhage can be subtle, nonspecific, and difficult to identify at the time of the event. We present the case of a severely anemic newborn who was delivered in our facility with an extensive literature review.

Practice management guidelines for the diagnosis and management of injury in the pregnant patient: the EAST Practice Management Guidelines Work Group

Trauma during pregnancy has presented very unique challenges over the centuries. From the first report of Ambrose Pare of a gunshot wound to the uterus in the 1600s to the present, there have existed controversies and inconsistencies in diagnosis, management, prognostics, and outcome. Anxiety is heightened by the addition of another, smaller patient. Trauma affects 7% of all pregnancies and requires admission in 4 of 1000 pregnancies. The incidence increases with advancing gestational age. Just over half of trauma during pregnancy occurs in the third trimester. Motor vehicle crashes comprise 50% of these traumas, and falls and assaults account for 22% each. These data were considered to be underestimates because many injured pregnant patients are not seen at trauma centers. Trauma during pregnancy is the leading cause of nonobstetric death and has an overall 6% to 7% maternal mortality. Fetal mortality has been quoted as high as 61% in major trauma and 80% if maternal shock is present. The anatomy and physiology of pregnancy make diagnosis and treatment difficult.

Trauma in the obstetrical patient

Trauma complicates approximately 6-7% of all pregnancies and is associated with significant maternal and fetal morbidity and mortality. While the majority of trauma is minor, it is minor trauma that contributes to the majority of fetal mortality. Since virtually every organ system is affected anatomically and physiologically by pregnancy, it is important for healthcare providers who care for trauma victims to be aware of these changes. While assessment and resuscitation considers the existence of two patients, stabilization of the mother takes priority. Diagnostic and radiologic procedures should be used as indicated, with fetal exposure to radiation limited as much as possible. Management of the pregnant trauma victim requires a multidisciplinary approach in order to optimize outcome for mother and fetus. This review discusses the epidemiology, assessment and treatment of pregnant trauma patients and reviews areas where prevention efforts may be focused.

[Intra-uterine fetal death by knife: case report]

INTRODUCTION

Opened injuries by knife are rare in pregnant women and are responsible of foetal death in most cases.

OBSERVATION AND COMMENTARY

We report a case of a 27-years woman, in her 8th months of pregnancy, victim of three knife punchs in her right iliac fossa. An emmergent laparotomy revealed deep wounds in the uterus and its right vascular pedicles, and a right external iliac artery lesion. Hysterectomy was performed and the extracted fetus was dead. He had two wounds in skull and back. Foetal death is common in opened knife injuries especially at the end of pregnancy. On one hand, the fetus has an abdominal situation that expose him to penetrating lesions. On the other hand, the uterus is richly vascularized during this period of pregnancy, thus any uterine or pedicular wound could result in a maternal hemorrhagic shock and hence a poor foetal and maternal prognosis.

CONCLUSION

Knife injuries in pregnant women could compromise the foetal prognosis. Managmanent should be early and requires a close collaboration between resuscitators, obstetricians and vascular surgeons.

Orthopaedic trauma in the pregnant patient

Trauma affects up to 8% of pregnancies and is the leading cause of death among pregnant women in the United States. A pregnancy test is mandated for all females of childbearing age who are involved in trauma. Orthopaedic trauma in the pregnant patient is managed similarly to that for all trauma patients. Initial resuscitation efforts should focus on the pregnant patient because stable patient vital signs provide the best chance for fetal survival. In the stable patient, fetal assessment and a pelvic examination are mandatory. Radiographs as well as abdominal ultrasound of the patient and fetal ultrasound are useful. No known biologic risks are associated with magnetic resonance imaging, and no specific fetal abnormalities have been linked with standard low-intensity magnetic resonance imaging. Emergency surgery can be safely performed in most pregnant patients. Avoiding patient hypotension and using left lateral decubitus positioning increase the likelihood of success for the patient and fetus. An experienced multidisciplinary team consisting of an obstetrician, perinatologist, orthopaedic surgeon, anesthesiologist, radiologist, and nursing staff will optimize the treatment of both the pregnant patient and her fetus.

Treatment Options in Fetomaternal Hemorrhage: Four Case Studies

BACKGROUND

Significant fetomaternal hemorrhage (FMH) is an uncommon event that places the fetus at risk of severe morbidity and mortality. Symptoms and signs at presentation are subtle and, if promptly recognized, appropriate management may permit the fetus to escape serious injury.

CASES

Four cases of significant FMH were diagnosed in the high-risk obstetrical unit at Mount Sinai Hospital, Toronto, during 2003. Three of the women complained of reduced fetal movements and were investigated initially with a non-stress test, a Kleihauer-Betke test, and ultrasound, including Doppler of the middle cerebral artery. These women all required emergency Caesarean section for non-reassuring fetal status. One fetus was treated by intravascular transfusion. Another identified case was transfused postnatally. One asymptomatic case was identified after spontaneous vaginal birth and also treated by neonatal transfusion. Neurological outcomes were good in all four cases.

CONCLUSIONS

Reduced fetal movements may be the only complaint of FMH. Increased awareness is required to ensure a diagnosis is made. When a non-stress test for reduced fetal movement is non-reactive, a Kleihauer-Betke test should be ordered, as well as detailed ultrasonography, including fetal Doppler studies. The perinatal prognosis for FMH may improve by facilitating the appropriate use of fetal blood transfusion or delivery by Caesarean section.

Trauma in pregnancy

The anatomic and physiologic changes make treatment of the pregnant trauma patient complex. The fetus is the challenge, because, in pregnancy, trauma has little effect on maternal morbidity and mortality. Aggressive resuscitation of the mother, in general, is the best management for the fetus, because fetal outcome is directly related to maternal outcome. Recent literature has attempted, with little success, to identify factors that may predict poor fetal outcomes. Cardiotocographic monitoring should be initiated as soon as possible in the emergency department to evaluate fetal well-being. Other key points include: Maternal blood pressure and respiratory rate return to baseline as pregnancy approaches term. Initial fetal health may be the best indicator of maternal health. Inferior vena cava compression in the supine patient may cause significant hypotension. Maternal acidosis may be predictive of fetal outcome. Kleihauer-Betke testing is not necessary in the emergency department. Early ultrasonographic evaluation can identify free intraperitoneal fluid and assess fetal health. Necessary radiographs should not be withheld at any period of gestation. Radiation beyond 20 weeks' gestation is safe. Patients with viable gestations require at least 4 hours of CTM monitoring after even minor trauma.

Is the incidence of fetal-to-maternal hemorrhage increased in patients with third-trimester bleeding?

OBJECTIVE

If a pregnancy is complicated by third-trimester bleeding, is there a higher risk of fetal-to-maternal hemorrhage that might necessitate the administration of additional anti-D immune globulin to prevent alloimmunization in the patient who is Rh D-negative? The study objective was to analyze prospectively the incidence of fetal-to-maternal hemorrhage in pregnancies that were complicated by third trimester bleeding compared with three control groups.

STUDY DESIGN

Pregnancies that were complicated by third-trimester bleeding, preterm premature rupture of the membranes, and preterm labor were identified prospectively on admission. A group of preterm patients with no complications was also collected prospectively. Patients with any history and/or clinical evidence of trauma were excluded. Kleihauer-Betke tests were performed with all patients, and the results were blinded until study completion. Sample size calculations were performed to determine the minimum number of cases needed in each group.

RESULTS

A total of 403 patients were collected during the study period: 91 patients had third-trimester bleeding, 101 patients had preterm premature rupture of the membranes, 116 patients had preterm labor, and 95 patients were in the no complication group. There was no statistical difference identified in the Kleihauer-Betke test results between any of the study groups.

CONCLUSION

The incidence of fetal-to-maternal hemorrhage does not appear to be increased in pregnancies that are complicated by third-trimester bleeding when compared to noncomplicated control subjects or to other obstetrically complicated pregnancies. This information would suggest that the routine administration of additional anti-D immune globulin (beyond the current recommended protocol) to women who are Rh D-negative whose pregnancies are complicated by third-trimester bleeding is not indicated.

Effect of fundal pressure on maternal to fetal microtransfusion at the time of cesarean delivery

AIM

To determine if fundal pressure at the time of cesarean delivery increases the amount of transplacental microtransfusion from mother to infant.

METHODS

Pregnant women undergoing cesarean delivery were randomized to the standard uterine fundal pressure at the time of hysterotomy versus no fundal pressure. Babies of patients randomized to no fundal pressure were delivered with either vacuum or forceps. The proportion of placental alkaline phosphatase between maternal and cord blood was then determined and compared between the groups.

RESULTS

Eighty-four women were randomized into two groups (44 in the pressure and 40 in the no pressure groups). There was no difference between the groups in demographic variables, or indications for cesarean. There was no difference in percentage of umbilical cord blood placental alkaline phosphatase between the pressure and no pressure groups (0.06 +/- 0.2 vs 10 +/- 0.29 IU, P = 0.43).

CONCLUSIONS

Fundal pressure at the time of cesarean delivery does not increase the amount of transplacental microtransfusion, suggesting that modifying the method of cesarean would not decrease the chances of vertical transmission in HIV positive pregnant women.

Pelvic fractures in pregnancy: factors influencing maternal and fetal outcomes

BACKGROUND

The purpose of this study was to determine factors influencing maternal and fetal outcomes associated with pelvic fractures in pregnancy.

METHODS

A literature review of pelvic and acetabular fractures during pregnancy was performed, providing 101 cases for analysis (1 case report was included). Factors influencing maternal and fetal mortality were evaluated.

RESULTS

Pelvic and acetabular fractures during pregnancy were associated with a high maternal (9%) and a higher fetal (35%) mortality rate. Automobile-pedestrian collisions had a trend toward a higher maternal mortality rate, and vehicular collisions had a trend toward a higher fetal mortality rate, compared with falls. Injury severity influenced both maternal and fetal outcomes. Fracture classification (simple vs. complex), fracture type (acetabular vs. pelvic), the trimester of pregnancy, and the era of literature reviewed did not influence mortality rates. When considering potential causes of fetal death, direct trauma to the uterus, placenta, or fetus was not associated with a higher fetal mortality rate, compared with maternal hemorrhage. Pelvic and acetabular fracture surgery has rarely been reported in this patient population.

CONCLUSION

Pelvic and acetabular fractures in pregnancy continue to be associated with a high fetal mortality rate. Mechanism of injury and injury severity appeared to influence mortality rates, whereas the fracture classification, the fracture type, the trimester of pregnancy, and the era of literature reviewed did not.

RhD isoimmunization and current management modalities

OBJECTIVE

To review the literature on current perspectives and treatment of RhD isoimmunization.

DATA SOURCES

A search was conducted on MEDLINE and CINAHL, and supplemental articles/ bulletins were obtained from cited references and the Web site of the American College of Obstetricians and Gynecologists. Recent texts also were reviewed. Key search words: isoimmunization, Rho (d) immune globulin, fetal erythroblastosis, intrauterine blood transfusions, alloimmunization.

STUDY SELECTION

Articles and comprehensive works from indexed journals in the English language relevant to key words and published after 1995 were evaluated. Historically relevant periodicals and texts were also reviewed and selected.

DATA EXTRACTION

Data were extracted and organized under the following headings: testing of the antepartum patient, antepartum treatment of isoimmunization, testing of the postpartum patient, anti-D immune globulin, antepartum anti-D immune globulin prophylaxis, other antepartum and obstetric indications for anti-D immune globulin administration, postpartum anti-D immune globulin prophylaxis, nursing implications, and future possibilities.

DATA SYNTHESIS

RhD isoimmunized pregnancies continue to contribute to worldwide perinatal and neonatal morbidity and mortality. This review describes the basic knowledge necessary to care for these pregnancies and the current management modalities.

CONCLUSIONS

The management options for RhD compromised gestations continue to evolve almost as quickly as technological advances are made. Multiple areas of research in this field have surfaced, and nurses can become valuable members of these research teams. The literature also indicates that with the available knowledge and resources, the current rate of RhD isoimmunization can be further decreased with closer adherence to proposed management guidelines by all health care professionals.

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.

Pelvic fractures in pregnant multiple trauma patients

OBJECTIVE

To study the outcome of pelvic fractures and fetuses in pregnant patients involved in blunt multiple trauma.

DESIGN

Retrospective follow-up study.

SETTING

Level I trauma center.

PATIENTS

Pregnant multiple trauma patients with pelvic fractures between 1974 and 1998.

INTERVENTIONS

Conservative and operative treatment of pelvic fractures adapted to the clinical status of the mother.

MAIN OUTCOME MEASURES

Clinical, functional, and social outcomes were evaluated.

RESULTS

Out of 4,196 patients with blunt multiple trauma treated between 1974 and June 1998, seven demonstrated the combination of blunt multiple trauma, pregnancy, and pelvic fractures. These patients had a mean Injury Severity Score of 29.9 points. Five mothers and three fetuses survived their injuries. All dead fetuses died on the scene. One surviving fetus was found to have hydrocephalus unrelated to the injury; the remaining fetuses had an uneventful delivery and were healthy. In two of the three patients whose fetuses survived, the treatment of the pelvic fracture was modified for the sake of fetal well-being. In all of these patients, acceptable outcome was achieved.

CONCLUSION

Modification of the treatment of the pelvic fracture in pregnant women with multiple trauma may be necessary to minimize the risk of fetal injury. In our experience with these rare cases, this modified treatment did not severely alter the clinical outcome of the mother's pelvic fracture.

Motor vehicle crashes, pregnancy loss and preterm labor

Trauma during pregnancy is remarkably common, and is greatly underestimated in terms of its contribution to both maternal and perinatal morbidity and mortality. Motor vehicle crashes, falls, assaults, including domestic violence, are all important mechanisms of injury, and clinical algorithms have been developed to manage the injured pregnant women. Focus on recognition and management of the most common injuries seen in pregnant women, namely abruptio placentae and uterine rupture are addressed through hemodynamic stabilization and continuous fetal and uterine contraction monitoring in the women injured beyond 24 weeks' gestation.

Fetomaternal haemorrhage discovered after trauma and treated by fetal intravascular transfusion

Fetomaternal haemorrhage can occur spontaneously, or after abdominal trauma. We describe a case of fetomaternal haemorrhage diagnosed at 27 weeks gestation after blunt trauma. The Kleihauer-Betke smear on admission and during the first week was positive, ranging between 3% and 5%. Cordocentesis revealed a fetal haemoglobin of 8.8 gm/dl. An intravascular fetal transfusion was performed. The weeks until delivery and the neonatal period were unremarkable. Fetal anaemia can be a serious complication of fetomaternal haemorrhage, however, intravascular fetal transfusion is an effective treatment when this occurs. The Kleihauer-Betke test should be performed in every patient with a history of abdominal trauma during pregnancy.

Fetal complications related to minor maternal trauma

The active lifestyle of pregnant women, in combination with the increased incidence of violence in society, place women at greater risk for accidental injury during pregnancy. This identification of increased risk has altered the health care management of mother and fetus after injury. The health care provider treating this patient population must perform thorough maternal-fetal assessments and be suspicious of fetal compromise, even in the face of maternal stability.

Massive fetomaternal hemorrhage

We evaluated the potential prognostic factors for fetomaternal hemorrhage (FMH). Sinusoidal heart rate pattern and decrease in fetal movement are considered important signs of FMH. However these findings were detected in only two of six cases of FMH and were thought to be late signs of FMH. Fetal hemoglobin levels in the maternal circulation for infants born alive following FMH were less than 5%. Our findings suggest that this amount of blood loss could cause fetal death.

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.

Exercise and pregnancy: a review

The effects of pregnancy on the maternal cardiorespiratory system include increases in oxygen consumption, cardiac output, heart rate, stroke volume, and plasma volume. The increase in oxygen reserve seen in early pregnancy is reduced later, suggesting that maternal exercise may present a greater physiologic stress in the third trimester. Evidence suggests that weight-bearing exercise produces a greater decrease in oxygen reserve than nonweight-bearing exercise. Furthermore, to maintain a heart rate below 140 beats per minute during pregnancy, the intensity of weight-bearing exercise must be reduced. Nonweight-bearing, water-based exercise results in smaller fetal heart rate changes and a lower maternal heart rate than the same exercise performed on land. Exercising in the supine position in late pregnancy has raised concerns because cardiac output in the supine position is lower than in the lateral position at rest, presumably because the gravid uterus partially obstructs the inferior vena cava. Sustained exercise produces a training effect on the mother, although reported associations between this effect and the experience of labor are not consistent. Short-term changes in fetal heart rate provide circumstantial evidence that physical activity can influence the fetus. Acute effects of exercise that can potentially affect the fetus include hyperthermia, changes in uteroplacental flow, reduced levels of maternal glucose, and increased uterine contractions. Moderate to high levels of sustained maternal exercise have been associated with reduced birthweight. Much research remains to be done on the effects of specific exercise regimens during pregnancy, the effects on previously sedentary women, and the long-term health consequences to the offspring of women who perform vigorous exercise during pregnancy.

[Trauma and pregnancy]

The medical care provided to a pregnant trauma patient by a trauma specialist should be supplemented by a careful evaluation of the pregnant woman by an obstetrician. Motor vehicle accidents account for two-thirds of all trauma events during pregnancy, and both blunt abdominal trauma and trauma to the skull are associated with high mortality of the fetus. The severity of the trauma is an important prognostic factor for survival of both mother and fetus. Fetal injury can be caused even by apparently mild forms of maternal trauma. For early diagnosis of an abruptio placentae after blunt trauma to the abdomen, continuous monitoring of the fetal heart rate and uterine contractions is very useful. Monitoring should be continued for at least 4 h, and whenever the frequency of uterine contractions exceeds one per 15 min or tenderness of the abdomen or vaginal bleeding is present, the pregnant trauma patient should be carefully monitored under hospital conditions for at least 24 h. Extensive burns are rarely encountered during pregnancy. There is a direct correlation between the extent of the burns and survival of the fetus. When more 30% of the maternal body surface is affected by burns, fetal mortality exceeds 50%. In the third trimester, when survival chances of the fetus are better than 50%, premature delivery of the fetus should be considered whenever the mother has suffered extensive burns.

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.

Underutilization of Rh prophylaxis in the emergency department: a retrospective survey

STUDY OBJECTIVE

To determine the practice of emergency physicians with regard to the issue of Rh isoimmunization.

DESIGN

A retrospective chart review.

SETTING

A university-affiliated tertiary care hospital emergency department.

TYPE OF PARTICIPANTS

Pregnant women presenting with a risk factor for Rh sensitization.

MEASUREMENTS AND MAIN RESULTS

One hundred thirty-eight patient encounters were analyzed descriptively as to whether they were candidates for Rh immune prophylaxis, and if so, whether it was given. Most (68%) were hospitalized. Of those, all were Rh typed, but two patients were not given Rh immune globulin (RhIG) when indicated. Of those discharged from the ED, most (86%) were not Rh typed, and none was administered RhIG.

CONCLUSION

This study demonstrates a need for increased attention to the potential for Rh isoimmunization in patients presenting to the ED.

A prospective controlled study of outcome after trauma during pregnancy

In a prospective cohort study, 85 women who suffered varying degrees of trauma during pregnancy (12 to 41 weeks) were compared with a control group of pregnant women matched for gestational age. Fetomaternal transfusion occurred significantly more frequently in the study group (30.6% vs 8.2%, p less than 0.05). Study subjects whose placentas were anteriorly placed were at increased risk for fetomaternal transfusion on comparison with other placental positions (47% vs 23.5%, p less than 0.05). Immediate adverse outcomes including abruptio placentae occurred frequently in the study group (9.4%) and were not predictable on the basis of injury severity. When immediate adverse outcomes were excluded, there was no difference in pregnancy outcome. Four hours of cardiotocographic monitoring used as a screening tool was found to be an extremely sensitive but nonspecific indicator of immediate adverse outcomes. On the basis of these findings, it is recommended that routine screening for fetomaternal transfusion occur in all pregnant women who suffer trauma during pregnancy beyond 11 weeks' gestation and that a minimum of 4 hours of cardiotocographic monitoring occur in women greater than 20 weeks' gestation.

Pregnancy outcome and fetomaternal hemorrhage after noncatastrophic trauma

Two hundred five consecutive cases of noncatastrophic trauma occurring during the second half of pregnancy were evaluated prospectively. Pregnancy complications as a result of trauma occurred in 18 of 205 patients (8.8%): premature labor (n = 10), placental separation (n = 5), fetal injury (n = 1), and fetal death (n = 2). Multiple regression analysis of the data base showed obstetric findings (contractions, uterine tenderness, and bleeding) on presentation to be highly associated with complications (17/88; 19.3%). In their absence complications were rare (1/117; 0.9%). Detectable fetomaternal hemorrhage was significantly more common in trauma patients (18/205) than in control subjects (2/110) (p less than 0.01), but its role in managing trauma patients was limited to detection of rare massive hemorrhage (1/205) and detection of rare hemorrhage exceeding that covered by the standard Rho (D) immune globulin dose (2/205). Fetomaternal hemorrhage need not be quantitated in patients who lack obstetric findings on presentation. Despite rare reports of delayed abruptio placentae, it is doubtful that prolonged observation (greater than 2 to 3 hours) in the hospital is necessary in patients who lack obstetric findings on initial presentation.

Clinical use of the Kleihauer-Betke test

Results of all Kleihauer-Betke (KB) tests performed in 1988, at a center with 4,201 deliveries, were reviewed. Two hundred and twenty-seven tests were performed on maternal specimens from 205 patients. Eighteen (8.8%) of the 205 patients had positive test results. Medical records were available for 147 (71.7%) of the patients, including 17 of the 18 patients with a positive result. Indications for testing were: vaginal bleeding (33%), maternal trauma (31%), unexplained fetal death (5%), Rh incompatibility (3%), fetal distress (3%), and miscellaneous (24%). Most of the tests were performed antepartum. In only one case, and without clear benefit, did the KB test prompt a clinical intervention. At least two of the 18 patients with positive test results had probable false positive results due to maternal hemoglobin F. Such false positive KB test results may be misleading. Further evaluation of the role of the KB test in obstetrical management is needed.