Trauma and Surgical Emergencies in the Obstetric Patient

Management of spinal trauma in pregnant patients: A systematic review of the literature

BACKGROUND

Despite the high incidence of spine trauma globally, traumatic spinal cord injury (tSCI) during pregnancy is considered a rare medical emergency. The literature on acute management of these patients is sparse compared with that of mothers with preexisting tSCI. This systematic review aims to evaluate management strategies for tSCI during pregnancy in improving neurologic, obstetric, and neonatal outcomes.

METHODS

A systematic review of PubMed/MEDLINE was performed without language restriction from inception until November 2, 2023 for patients who acquired tSCI during pregnancy. Excluded articles described postpartum trauma, trauma before pregnancy, or SCI of nontraumatic etiology such as neoplastic, vascular, hemorrhagic, or ischemic origin. Primary outcomes investigated were maternal American Spinal Injury Association (ASIA) grade, pregnancy termination, cesarean delivery, prematurity, and neonatal adverse events.

RESULTS

Data from 73 patients were extracted from 43 articles from 1955 to 2023. The mothers' median age was 24 years (interquartile range, 23-30 years), and the average gestational age at the time of injury was 21.1 ± 7.7 weeks. The thoracic spine was the most common segment affected (41.1%) and had the greatest proportion of complete tSCI (46.6%). Furthermore, ASIA score improvement was observed in 17 patients with 3 patients experiencing a 2-score improvement and 1 patient experiencing a 3-score improvement. Among these patients, 86% of ASIA B and 100% of ASIA C patients showed neurologic improvement, compared to only 17% of ASIA A patients. Surgically managed patients had a lower rate of neonatal adverse events than conservatively managed patients (11% vs. 34%).

CONCLUSION

Acute tSCI requires a coordinated effort between a multidisciplinary team with careful consideration. While maternal neurologic improvement was observed more often following a better ASIA grade on presentation, the presence of neonatal adverse events was less common in patients treated with surgery than in patients who were managed conservatively.

LEVEL OF EVIDENCE

Systematic Review; Level IV.

A pregnant woman with long-standing, retained intraabdominal glass shards who gave birth to a live infant with no complications: a case report

BACKGROUND

Most cases of traumatic injury during pregnancy involve blunt trauma, with penetrating trauma being uncommonly rare. In glass shard injuries, fragments often penetrate deeply, and multiple injuries may occur simultaneously; attention must be paid to the possibility of organ injury from the residual fragments. However, no case of this occurring during pregnancy has been reported yet.

CASE PRESENTATION

We present the case of a 34-year-old pregnant Cameroonian woman who retained intraabdominal glass shards following a penetrating injury at 13 weeks gestation and not diagnosed until 22 weeks gestation. Notably, this patient continued the pregnancy without complications and gave birth via cesarean section at 36 weeks gestation.

CONCLUSION

In pregnant women sustaining a penetrating glass trauma during pregnancy, careful attention should be paid to the fragments; in that case, computed tomography is a useful modality for accurately visualizing any remaining fragments in the body. Essentially, the foreign bodies in glass shard injuries during pregnancy should be removed immediately, but conservative management for term delivery is an important choice for patients at risk for preterm delivery.

Predictors of fetal delivery in pregnant trauma patients: A multicenter study

BACKGROUND

Pregnant trauma patients (PTPs) undergo observation and fetal monitoring following trauma due to possible fetal delivery (FD) or adverse outcome. There is a paucity of data on PTP outcomes, especially related to risk factors for FD. We aimed to identify predictors of posttraumatic FD in potentially viable pregnancies.

METHODS

All PTPs (≥18 years) with ≥24-weeks gestational age were included in this multicenter retrospective study at 12 Level-I and II trauma centers between 2016 and 2021. Pregnant trauma patients who underwent FD ((+) FD) were compared to those who did not deliver ((-) FD) during the index hospitalization. Univariate analyses and multivariable logistic regression were performed to identify predictors of FD.

RESULTS

Of 591 PTPs, 63 (10.7%) underwent FD, with 4 (6.3%) maternal deaths. The (+) FD group was similar in maternal age (27 vs. 28 years, p = 0.310) but had older gestational age (37 vs. 30 weeks, p < 0.001) and higher mean injury severity score (7.0 vs. 1.5, p < 0.001) compared with the (-) FD group. The (+) FD group had higher rates of vaginal bleeding (6.3% vs. 1.1%, p = 0.002), uterine contractions (46% vs. 23.5%, p < 0.001), and abnormal fetal heart tracing (54.7% vs. 14.6%, p < 0.001). On multivariate analysis, independent predictors for (+) FD included abdominal injury (odds ratio [OR], 4.07; confidence interval [CI], 1.11-15.02; p = 0.035), gestational age (OR, 1.68 per week ≥24 weeks; CI, 1.44-1.95; p < 0.001), abnormal FHT (OR, 12.72; CI, 5.19-31.17; p < 0.001), and premature rupture of membranes (OR, 35.97; CI, 7.28-177.74; p < 0.001).

CONCLUSION

The FD rate was approximately 10% for PTPs with viable fetal gestational age. Independent risk factors for (+) FD included maternal and fetal factors, many of which are available on initial trauma bay evaluation. These risk factors may help predict FD in the trauma setting and shape future guidelines regarding the recommended observation of PTPs.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Trauma in Pregnancy

Trauma is the leading cause of nonobstetric maternal death. Pregnant patients have a similar spectrum of traumatic injuries with a noted increase in interpersonal violence. A structured approach to trauma evaluation and management is recommended with several guidelines expanding on ATLS principles; however, evidence is limited. Optimal management requires understanding of physiologic changes in pregnancy, a team-based approach, and preparation for interventions that may including neonatal resuscitation. The principles of trauma management are the same in pregnancy with a systematic approach and initial maternal focused resuscitation..

Traumatic Injury in Pregnancy: A Propensity Score-Matched Analysis

INTRODUCTION

Trauma represents the leading cause of nonobstetrical maternal death. How in-hospital outcomes of acutely injured pregnant patients (PP) compares to that of similarly aged nonpregnant control groups (CGs) has not been described. We hypothesized that PPs suffering acute traumatic injuries would have worse outcomes compared to a matched CG.

MATERIALS AND METHODS

The American College of Surgeons Trauma Quality Improvement Program (TQIP) was used to identify traumatically injured females between 2017 and 2019. Propensity score matching on age, race, injury severity score , and type of trauma (blunt, penetrating, or other) was used to compare PPs and the CG. Primary outcomes were mortality, disposition, length of stay (LOS), and complications.

RESULTS

A total of 1078 traumatically injured pregnant females were identified. Propensity score matching resulted in 990 patients in the PP and CG cohorts. After matching, PPs were more likely to be assault victims (11% versus 6%, P < 0.001), had longer length of stay (LOS) (5 versus 3 d, P < 0.001), and were more likely to require mechanical ventilation (26% versus 16%, P < 0.001) or intensive care unit (ICU) admission (44% versus 32%, P < 0.001). PPs were more likely to proceed directly to the operating room (OR)(34% versus 15%, P < 0.001) and less likely to be discharged home from the emergency department (ED) (1% versus 12%, P < 0.001). Complications and mortality rates were similar among PPs.

CONCLUSIONS

After acute trauma, PPs did not have increased mortality or complications when compared to matched controls, although they were more likely to be victims of assault, directly proceed to the OR, require mechanical ventilation or ICU admission, and have longer LOSs.

Patient care during interfacility transport: a narrative review of managing diverse disease states

BACKGROUND

When critically ill patients require specialized treatment that exceeds the capability of the index hospitals, patients are frequently transferred to a tertiary or quaternary hospital for a higher level of care. Therefore, appropriate and efficient care for patients during the process of transport between two hospitals (interfacility transfer) is an essential part of patient care. While medical adverse events may occur during the interfacility transfer process, there have not been evidence-based guidelines regarding the equipment or the practice for patient care during transport.

METHODS

We conducted searches from the PubMed, Cumulative Index of Nursing and Allied Health (CINAHL), and Scopus databases up to June 2022. Two reviewers independently screened the titles and abstracts for eligibility. Studies that were not in the English language and did not involve critically ill patients were excluded.

RESULTS

The search identified 75 articles, and we included 48 studies for our narrative review. Most studies were observational studies.

CONCLUSION

The review provided the current evidence-based management of diverse disease states during the interfacility transfer process, such as proning positioning for respiratory failure, extracorporeal membrane oxygenation (ECMO), obstetric emergencies, and hypertensive emergencies (aortic dissection and spontaneous intracranial hemorrhage).

Comparison of the Injury Mechanism between Pregnant and Non-Pregnant Women Vehicle Passengers Using Car Crash Test Dummies

This paper analyzes the kinematics and applied forces of pregnant and non-pregnant women dummies sitting in the rear seat during a frontal vehicle collision to determine differences in the features of abdominal injuries. Sled tests were conducted at 29 and 48 km/h with pregnant and non-pregnant dummies (i.e., MAMA IIB and Hybrid III). The overall kinematics of the dummy, resultant acceleration at the chest, transrational acceleration along each axis at the pelvis, and loads of the lap belt and shoulder belt were examined. The belt loads were higher for the MAMA IIB than for the Hybrid III because the MAMA IIB had a higher body mass than the Hybrid III. The differences in the lap belt loads were 1119 N at 29 km/h and 1981-2365 N at 48 km/h. Therefore, for restrained pregnant women sitting in the rear seat, stronger forces may apply to the lower abdomen during a high-velocity frontal collision. Our results suggest that for restrained pregnant women sitting in the rear seat, the severity of abdominal injuries and the risk of a negative fetal outcome depend on the collision velocity.

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.

Predictive risk factors of adverse perinatal outcomes following blunt abdominal trauma in pregnancy

BACKGROUND

The primary objective was to identify predictive risk factors of preterm delivery following blunt abdominal trauma. The secondary objective was to identify risk factors of other adverse outcomes, Neonatal Intensive Care Unit (NICU) admission, placental abruption, fetal demise, and Cesarean Delivery (CD).

METHODS

This retrospective study included pregnant patients with gestational age (GA) ≥23 weeks who presented after blunt abdominal trauma to Richmond University Medical Center from October 2015 to January 2020. Patients were identified using the following diagnostic International diagnostic classification (ICD-10) codes: O9A.212, O9A.213, and 071.89, and excluded if trauma did not involve the abdomen, penetrating, <23 weeks, or incomplete records. Collected data points included maternal demographic factors, clinical laboratory values, maternal clinical findings at presentation, abdominal ultrasound, results of fetal monitoring, Abbreviated Injury Score (AIS) for abdomen, and Injury Severity Score (ISS). Univariate analyses were compared using the Student's t-test or Mann-Whitney U-test. Categorical data were compared using the chi-squared test or Fisher's exact test with P-value < .05 as significant.

RESULTS

154 patients were included in the final analysis. The incidence of the primary outcome, preterm delivery before 37 weeks, was 11.0% (17/154). The incidence of secondary outcomes following blunt abdominal trauma were abruption 0% (0/154), fetal demise 0.6% (1/154), CD 44% (68/154), NICU admission 24% (37/154). Maternal demographic factors, presence of uterine contractions, maternal clinical conditions (abdominal pain, abdominal tenderness, vaginal bleeding), hematologic and coagulation studies, ultrasound findings, fetal heart rate tracing category, AIS score for abdomen, and ISS score were not predictive of preterm delivery or other secondary outcomes.

CONCLUSION

The incidence of adverse maternal and neonatal outcomes is low following blunt abdominal trauma. Extended monitoring of asymptomatic patients including laboratory tests and coagulation profiles were not predictive of preterm labor or secondary adverse perinatal outcomes.

LEVEL OF EVIDENCE

Therapeutic/Care management, Level III.

Resuscitative Endovascular Balloon Occlusion of the Aorta in the Management of a Gunshot Wound and Rupture of the Uterus

Trauma is the leading cause of non-obstetrical maternal death. A 19-year-old woman at 20 weeks' gestation was brought to the emergency room after suffering a gunshot wound to the lower abdomen. Upon arrival, she was hemodynamically stable and imaging was obtained. CT revealed a rupture of the uterus with a partially extrauterine fetus, and the patient was immediately taken for an explorative laparotomy. Prior to the surgical start, the patient's blood pressure declined and, subsequently, a resuscitative endovascular balloon occlusion of the aorta (REBOA) was placed. The fetus and placenta were delivered and both uterine arteries and the inferior epigastric artery were ligated. Following an unremarkable postoperative course, she was discharged on hospital day 17. The mainstay approach to trauma in pregnancy should be to utilize focused imaging techniques to assess extent of trauma and provide adequate circulation to vital organs. Aortic balloon occlusion may be considered as a viable strategy to enhance resuscitation.

Comparison of Motor Vehicle Collision Injuries between Pregnant and Non-Pregnant Women: A Nationwide Collision Data-Based Study

We compared the independent predictive factors for moderate and severe injuries, along with characteristics and outcomes of motor vehicle collisions, between pregnant and non-pregnant women. Using 2001–2015 records from the National Automotive Sampling System/Crashworthiness Data System, we selected 736 pregnant women and 21,874 non-pregnant women having any anatomical injuries. Pregnant women showed less severe collisions, fewer fatalities, and less severe injuries in most body regions than non-pregnant women. In pregnant women, the rate of sustaining abbreviated injury scale (AIS) scores 2+ injuries was higher for the abdomen only. For non-pregnant women, rear seat position, airbag deployment, multiple collisions, rollover, force from the left, and higher collision velocity had a positive influence on the likelihood of AIS 2+ injuries, and seatbelt use and force from the rear had a negative influence. There is a need for further development of passive safety technologies for restraint and active safety features to slow down vehicles and mitigate collisions. The influencing factors identified may be improved by safety education. Therefore, simple and effective interventions by health professionals are required that are tailored to pregnant women.

Trauma and pregnancy: Is flow cytometry detection and quantification of fetal red blood cells useful?

OBJECTIVE

To assess whether positive flow cytometry quantification of fetal red blood cells is associated with adverse maternal and neonatal outcomes in cases of mild trauma during pregnancy.

STUDY DESIGN

A retrospective database study was conducted at a single tertiary center between 2013 and 2019. All pregnant women with viable gestation involved in trauma who underwent flow cytometry quantification of fetal red blood cells were included in the study. Flow cytometry was considered positive (≥0.03/≥30 ml). Composite adverse maternal and neonatal outcome was defined as one or more of the following: intrauterine fetal death, placental abruption, pre-term birth <37 weeks of gestation, immediate premature rupture of the membranes, and immediate delivery following trauma. Univariate analysis was performed followed by multivariate logistic regression analysis controlling for potential confounders, to assess the role of flow cytometry in predicting adverse maternal and neonatal outcome. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

During the study period 1023 women met inclusion and exclusion criteria. The mechanisms of injury were motor vehicle accident in 387 women (38%), falls in 367 (36%), direct abdominal injury in 353 (35%) and in 14 women (1%) other mechanism of injury. Flow cytometry was considered positive (≥0.03/≥30 ml) in 119 women (11.6%) with median result of 0.03 [0.03-0.04], and negative in 904 women (88.4%) ((≤0.03/≤30 ml) with median result of 0.01 [0.01-0.02]. Composite adverse outcome occurred in 8% of the women involved in trauma during pregnancy, with no difference between the groups with vs. without positive flow cytometry (4.2% vs. 8.5%; p = 0.1). Positive flow cytometry was not associated with any adverse maternal or neonatal outcome. This was confirmed on multivariate analysis controlling for potential confounders.

CONCLUSION

Flow cytometry result is not related to adverse maternal and fetal/neonatal outcome of women involved in minor trauma during pregnancy. We suggest that flow cytometry should not be routinely assessed in pregnant women involved in minor trauma.

A patient with Marfan's syndrome who developed an acute aortic dissection at 28 weeks of pregnancy treated with aortic root replacement

The patient was a 31-year-old pregnant woman who gave birth to her first child by vaginal delivery 7 years ago. She was diagnosed with Marfan's syndrome based on physical findings; however, the condition was not diagnosed before the onset. The patient developed acute aortic dissection at 28 weeks of pregnancy. A cesarean section was first performed to save the patient's life; then, a total hysterectomy was performed to prevent the risk of postpartum hemorrhage. Furthermore, aortic root replacement was performed using a temporary mechanical valve. The patient and her child have survived without any complications.

Association of Traumatic Injury With Adverse Pregnancy Outcomes in Taiwan, 2004 to 2014

IMPORTANCE

Literature has suggested that trauma among pregnant women is associated with an increased risk of adverse pregnancy outcomes. However, limited research has investigated the association of trauma with adverse pregnancy outcomes by using a national data set.

OBJECTIVE

To investigate the association between traumatic injury and adverse pregnancy outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study of pregnant women in Taiwan linked 3 data sets, the Taiwan Birth Registry, Household Registration Information, and National Health Insurance Research Database, from January 1, 2004, through December 31, 2014. Data, including the characteristics of pregnant women and infants, were extracted from the Taiwan Birth Registry data set; to obtain trauma data, this data set and the Household Registration Information data set were collectively linked to National Health Insurance Research Database data. The combined data set was analyzed from January to July 2019. Adverse pregnancy outcomes and premature delivery were defined using International Classification of Diseases, Ninth Revision, Clinical Modification codes.

EXPOSURES

The primary exposures of this study were 2 clinical variables related to injury during pregnancy: medical treatment in the emergency department (yes or no) and hospitalization (yes or no).

MAIN OUTCOMES AND MEASURES

The main outcome variable was adverse pregnancy outcomes, and the secondary outcome variable was premature delivery. Multivariate logistic regression models were used to investigate the association of injuries with adverse pregnancy outcomes after controlling for demographic characteristics and other pregnancy-related variables.

RESULTS

A total of 2 973 831 pregnant women (2 475 805 [83.3%] aged 20-34 years) were enrolled between 2004 and 2014, of whom 59 681 (2.0%) sought medical treatments due to injuries. Results of multivariate logistic regression models showed that women receiving emergency treatments more than once were 1.08 times as likely (adjusted odds ratio, 1.08; 95% CI, 1.05-1.10) to have adverse pregnancy outcomes than women who received no emergency treatment. Women with injury-related hospitalization were 1.53 times more likely (adjusted odds ratio, 1.53; 95% CI, 1.41-1.65) to have adverse pregnancy outcomes than women who did not sustain injuries. Furthermore, recurrent injuries were associated with a 572% increase in odds of premature delivery (adjusted odds ratio, 6.72; 95% CI, 2.86-15.80).

CONCLUSIONS AND RELEVANCE

In this study, trauma among pregnant women was associated with an increased risk of adverse pregnancy outcomes, as were hospitalization and emergency department visits due to injury.

Algorithm of Traumatic Brain Injury in Pregnancy (Perspective on Neurosurgery)

BACKGROUND

The maternal deaths due to obstetrical cases declined, but the maternal deaths that caused by nonobstetrical cases still increase. The study reported that traumatic cases in pregnancy are the highest causes of mortality in pregnancy (nonobstetrical cases) in the United States. Another study reported that 1 in 12 pregnant women that experienced traumatic accident and as many as 9.1% of the trauma cases were caused by traumatic brain injury (TBI). The female sex hormone has an important role that regulates the hemodynamic condition. Anatomical and physiological changes during pregnancy make the examination, diagnosis, and treatment of TBI different from non-pregnant cases. Therefore, it is very important to lead the algorithm for each institution based on their own resources.

CASE SERIES

A 37-year-old woman with a history of loss of consciousness after traffic accident. She rode a motorbike then hit the car. She was referred at 18 weeks' gestation. Glasgow Coma Scale (GCS) E1V1M4, isochoric of the pupil, reactive to the light reflex, and right-sided hemiparesis. The non-contrast head computed tomography (CT) scan revealed subdural hematoma (SDH) in the left frontal-temporal-parietal region, SDH of the tentorial region, burst lobe intracerebral hemorrhage, and cerebral edema. There was not a fetal distress condition. The next case, a 31 years old woman, in 26 weeks gestation, had a history of unconscious after motorcycle accident then she fell from the height down to the field about 3 m. GCS E1V1M3, isochoric of the pupil, but the pupil reflex decreased. Noncontrast CT scan revealed multiple contusion, subarachnoid hemorrhage, and cerebral edema. She had a good fetal condition.

DISCUSSION

We proposed the algorithm of TBI in pregnancy that we already used in our hospital. The main principle of the initial management must be resuscitating the mother and that also the maternal resuscitation. The primary and secondary survey is always prominent of the initial treatment.

CONCLUSION

The clinical decision depends on the condition of the fetal, the surgical lesion of the intracranial, and also the resources of the neonatal intensive care unit in our hospital.

Bioengineering Approaches for Placental Research

Research into the human placenta's complex functioning is complicated by a lack of suitable physiological in vivo models. Two complementary approaches have emerged recently to address these gaps in understanding, computational in silico techniques, including multi-scale modeling of placental blood flow and oxygen transport, and cellular in vitro approaches, including organoids, tissue engineering, and organ-on-a-chip models. Following a brief introduction to the placenta's structure and function and its influence on the substantial clinical problem of preterm birth, these different bioengineering approaches are reviewed. The cellular techniques allow for investigation of early first-trimester implantation and placental development, including critical biological processes such as trophoblast invasion and trophoblast fusion, that are otherwise very difficult to study. Similarly, computational models of the placenta and the pregnant pelvis at later-term gestation allow for investigations relevant to complications that occur when the placenta has fully developed. To fully understand clinical conditions associated with the placenta, including those with roots in early processes but that only manifest clinically at full-term, a holistic approach to the study of this fascinating, temporary but critical organ is required.

Combined Acetabulum Fracture and Hip Dislocation in an 18-Year-Old Female at 35-Week Gestation: A Case Report and Review of the Literature

Caring for an injured, pregnant patient can be a management challenge. We report the case of an 18-year-old female who sustained a left acetabulum fracture with a concurrent hip dislocation at 35 weeks' gestation following a motor vehicle accident. Through an interdisciplinary, team-based approach, the patient was guided through obstetric delivery and orthopedic surgical fracture fixation without complication. By being familiar with the unique challenges in management posed by pregnant patients, orthopedic surgeons can be better equipped to minimize morbidity and mortality in this patient population while maximizing clinical outcomes.

Analysis of prehospital perimortem caesarean deliveries performed by Helicopter Emergency Medical Services in the Netherlands and recommendations for the future

BACKGROUND

Prehospital perimortem caesarean delivery (PCD) is a rarely performed procedure. In this study, we aimed to examine all PCDs performed by the four Helicopter Emergency Medical Services in the Netherlands; to describe the procedures, outcomes, complications, and compliance with the recommended guidelines; and to formulate recommendations.

METHODS

We performed a population-based retrospective cohort study of all consecutive maternal out-of-hospital cardiac arrests that underwent PCD in the prehospital setting between May 1995 and December 2019. Registered data included patient demographics, operator background, advanced life support interventions, and timelines. Resuscitation performance was evaluated according to the 2015 European Resuscitation Guidelines.

RESULTS

Seven patients underwent a prehospital PCD. Three mothers died on the scene, while four were transported to a hospital but died in the hospital. Seven neonates were born by PCD. One neonate died on the scene and six were transported to a hospital. Three neonates were eventually discharged from the hospital. Among the three surviving neonates, the periods from dispatch to start of PCD were 13, 14, and 21 min.

CONCLUSIONS

There was a low incidence of maternal perimortem caesarean deliveries in The Netherlands. Only some neonates survived after PCD. It is recommended that PCD be performed as quickly as possible. Due to the delay, the mother has a far lower chance of survival than the neonate. In fatal cases, autopsy is strongly recommended.

Maxillofacial trauma in a pregnant patient: Contemporary management principles with a case report & review of literature

Trauma during pregnancy deserves special attention because of its management objectives, i.e. well-being of both pregnant woman and foetus. Maxillofacial trauma directly affects the nutrition of foetus by interfering with the normal functions in a pregnant woman such as mouth opening, mastication and breathing. Hence early restitution of form and function of maxillofacial skeleton is essential. However, the gravid status is associated with numerous anatomical and physiological changes which present with clinical dilemma related to imaging and treatment. A careful scrutiny of the patient's systemic and gestational status is absolutely essential before, during and after instituting any interventional procedures. We present a case of bilateral condyle fracture in a 30-year-old pregnant woman in the third trimester (32 weeks). She was treated with inter maxillary fixation using orthodontic brackets & elastics. After successful restitution of occlusion, the patient was advised aggressive physiotherapy which ensured normal mouth opening. Two weeks later, the patient delivered uneventfully. The patient was followed up at one month and 3 month and demonstrated restitution of normal occlusion, mouth opening and lower facial height. This article aims at analyzing the contemporary principles in management of maxillofacial trauma in a pregnant woman and clarifying the common misconceptions.

Neurosurgical Interventions for Neurotrauma in the Obstetric Population: A Systematic Review

Trauma requiring neurosurgical intervention in the obstetric population is rare. Provision of care must include consideration for both maternal and fetal well-being, and conflicts may arise. Management strategies to reduce elevated maternal intracranial pressure (ICP) and provide adequate surgical exposure, for example, may compromise uteroplacental perfusion. There is scarce literature to guide anesthetic care and few resources summarizing management of these uncommon cases. We conducted a systematic literature search for English publications of neurosurgical interventions on obstetric patients following trauma. We searched MEDLINE, EMBASE, and Google Scholar from inception to May 1, 2019. We identified 18 cases from 13 publications including 9 case reports and 4 case series. Median Glasgow coma scale on presentation was 6, good maternal outcome occurred in 39% of cases, and good fetal outcome occurred in 67% of cases. Qualitative review of the articles suggests an initially low Glasgow coma scale on admission commonly resulted in worse maternal and fetal outcomes. Delivery occurred postneurosurgical intervention in the majority of viable fetuses. Few details were available regarding anesthetic management, and ICP management strategies varied widely. Our review identified only a small number of case reports and case series. Maternal outcomes were generally poor, although the majority of fetal outcomes were good. Although there seems to be a relationship between outcomes and severity of maternal injury on presentation, it is difficult to draw conclusions or make recommendations because of limited data on perioperative anesthetic and ICP management strategies. Regardless of gestational age, maternal supremacy must be upheld. Our results are limited by the quality of the available research and potential selection bias.

Traumatic injury in female Drosophila melanogaster affects the development and induces behavioral abnormalities in the offspring

Traumatic injury (TI) during pregnancy increases the risk for developing neurological disorders in the infants. These disorders are a major concern for the well-being of children born after TI during pregnancy. TI during pregnancy may result in preterm labor and delivery, abruptio placentae, and/or fetomaternal hemorrhage. Drosophila melanogaster (fruit fly) is a widely used model to study brain and behavioral disorders in humans. In this study, we analyzed the effects of TI to female fruit flies on the development timing of larvae, social interaction and the behavior of offspring flies. TI to the female flies was found to affect the development of larvae and the behavior of offspring flies. There was a significant increase in the length of larvae delivered by traumatically injured maternal flies as compared to larvae from control maternal flies (without TI). The pupae formation from larvae, and the metamorphosis of pupae to the first generation of flies were faster in the TI group than the control group. Negative geotaxis and distance of the fly to its nearest neighbor are parameters of behavioral assessment in fruit flies. Negative geotaxis significantly decreased in the first generation of both male (p = 0.0021) and female (p = 0.0426) flies. The distance between the first generation of flies to its nearest neighbor was shorter in both male and female offspring flies in the TI group as compared to control group flies. These results indicate that TI to the female flies affected the development of larvae and resulted in early delivery, impaired social interaction and behavioral alterations in the offspring.

Special Populations: Disaster Care Considerations in Chronically Ill, Pregnant, and Morbidly Obese Patients

Special populations, which include the morbidly obese and patients with chronic, complex medical conditions that require long-term health care services and infrastructure, are at increased risk for morbidity and mortality when these services are disrupted during a disaster. Past experiences have identified significant challenges in restoring necessary care services to these patients following major environmental events. This article describes the impact of disasters on special populations, provides a framework for future disaster preparation and planning, and identifies areas in need of further research. Gravid patients, who are often overlooked in disaster planning and preparation, are also discussed.

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.

Anaesthesia for non-obstetric surgery in obstetric patients

Anaesthesia for pregnant patients presenting for non-obstetric surgery needs a thorough understanding of the physiological changes and altered pharmacokinetics of pregnancy. Considering the effects of surgery and anaesthesia on the foetus, only essential and emergency surgeries are performed during pregnancy. Surgical procedures in second trimester have the advantage of better foetal outcome. The primary concerns of maternal and foetal safety are achieved by a focused multidisciplinary team-based approach with respect to the surgical condition. Meticulous attention to preoperative patient counselling, airway management, haemodynamic stability, and thromboprophylaxis are the key factors in anaesthetic management. Choice of anaesthesia or anaesthetic drugs has minimal impact on the foetus provided utero-placental perfusion and uterine relaxation are maintained. Foetal monitoring when feasible and when done by a trained person enables to diagnose and treat the factors responsible for foetal heart rate variability. Anaesthetic technique needs to be modified according to the type of surgery.

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.

Pregnant trauma victims experience nearly 2-fold higher mortality compared to their nonpregnant counterparts

BACKGROUND

Trauma is the leading nonobstetric cause of death in women of reproductive age, and pregnant women in particular may be at increased risk of violent trauma. Management of trauma in pregnancy is complicated by altered maternal physiology, provider expertise, potential disparate imaging, and distorted anatomy. Little is known about the impact of trauma on maternal mortality.

OBJECTIVE

We sought to: (1) characterize nonviolent and violent trauma among pregnant women; (2) determine whether pregnancy is associated with increased mortality following traumatic injury; and (3) identify risk factors for trauma-related death in pregnant women.

STUDY DESIGN

We studied 1148 trauma events among pregnant girls and women and 43,608 trauma events among nonpregnant girls and women of reproductive age (14-49 years) who presented to any accredited trauma center in Pennsylvania for treatment of trauma-related injuries from 2005 through 2015, as captured in the Pennsylvania Trauma Outcome Study. Traumas were categorized as violent (eg, homicide or assault) or nonviolent (eg, motor vehicle accident or accidental fall). We used modified Poisson regression to estimate relative rate of trauma-related death, adjusting for demographic characteristics and severity of trauma.

RESULTS

Compared to nonpregnant women, pregnant women and girls had a lower injury severity score (8.9 vs 10.9, P < .001) and were significantly more likely to experience violent trauma (15.9% vs 9.8%, P < .001). Pregnant trauma victims had a 1.6-fold higher rate of mortality compared to their nonpregnant counterparts (P < .001), and were both more likely to be dead on arrival and to die during their hospital course (adjusted relative risk, 2.33, P < .001, and adjusted relative risk, 1.79, P = .004, respectively). Pregnancy was associated with increased mortality in both victims of nonviolent and violent trauma (adjusted relative risk, 1.69, P = .002, and adjusted relative risk, 1.60, P = .007, respectively). Pregnant trauma victims were less likely to undergo surgery (adjusted relative risk, 0.70, P = .001) and more likely to be transferred to another facility (adjusted relative risk, 1.72, P < .001). Even after adjusting for demographics and injury severity score, violent trauma was associated with 3.14-fold higher mortality in pregnant women and girls compared to nonviolent trauma (adjusted relative risk, 3.14, P = .003).

CONCLUSION

Pregnant women and girls are nearly twice as likely to die after trauma and twice as likely to experience violent trauma. Universal screening for violence and trauma during pregnancy may provide an opportunity to identify women at risk for death during pregnancy.

Hospital trauma level's association with outcomes for injured pregnant women and their neonates in Washington state, 1995-2012

Background:

Trauma occurs in 8% of all pregnancies. To date, no studies have evaluated the effect of the hospital's trauma designation level as it relates to birth outcomes for injured pregnant women.

Methods:

This population-based, retrospective cohort study evaluated the association between trauma designation levels and injured pregnancy birth outcomes. We linked Washington State Birth and Fetal Death Certificate data and the Washington State Comprehensive Hospital Abstract Recording System. Injury was identified using the International Classification of Diseases, Ninth Revision injury diagnosis and external causation codes. The association was analyzed using logistic regression to estimate odds ratios and 95% confidence intervals (CIs).

Results:

We identified 2492 injured pregnant women. Most birth outcomes studied, including placental abruption, induction of labor, premature rupture of membranes, cesarean delivery, maternal death, gestational age <37 weeks, fetal distress, fetal death, neonatal respiratory distress, and neonatal death, showed no association with trauma hospital level designation. Patients at trauma Level 1–2 hospitals had a 43% increased odds of preterm labor (95% CI: 1.15–1.79) and a 66% increased odds of meconium at delivery (95% CI: 1.05–2.61) compared to those treated at Level 3–4 hospitals. Patients with an injury severity score >9, treated at trauma Level 1–2 hospitals, had an aOR of low birth weight, <2500 g, of 2.52 (95% CI: 1.12–5.64).

Conclusions:

The majority of birth outcomes for injured patients had no association with hospitalization at a Level 1–2 compared to a Level 3–4 trauma center.

Trauma-induced delivery: A case report

The term “birth trauma” is one that is well ingrained into the lexicon of medical providers. There is ample information of the types of injuries that are incurred during the birth process. However, there is no uniformed term for the process of an unforeseen act that leads to a precipitous birth. We would like to show a case report of such an act. The infant's injuries were sustained while in utero and the trauma induced a medical team to deliver the infant due to non-reassuring heart tones. Also, we would like to introduce the term of “trauma-induced delivery” into the medical literature as a way to describe similar types of deliveries that are influenced by factors related to physical forces applied to the mother's body, either intentional or unintentional.

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Introduction of the term “trauma-induced delivery(ies)” into the literature

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Leading cause of non-obstetric maternal deaths has been from trauma.

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Around 7% of all pregnancies may have been affected by a traumatic event.

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Trauma-induced deliveries can be set off by accidents, physical abuse, or self-inflicted.

A 20-year review of pediatric pregnant trauma from a Level I trauma center

BACKGROUND

Trauma in pregnancy remains an important but understudied public health issue. We aimed to determine the prevalence of interpersonal violence in our pregnant trauma population (including pediatric) over the last 20 years, from our Level I trauma center.

METHODS

We conducted a descriptive, retrospective chart review to identify all pregnant trauma patients between Jan 1993 and Sept 2013. Pediatric was ≤18 years of age. We evaluated demographics, mechanism of injury, injury location, disposition, and outcome data.

RESULTS

We treated 438 pregnant patients at our center over 20 years. 378 (86%) were adult and 60 (14%) were pediatric. Intentional injuries occurred in 89 (20%) patients. The pediatric pregnant patients experienced a significantly higher proportion of intentional, interpersonal violence (33% vs. 18%, p = 0.007) compared to adults. Patients presenting after intentional, interpersonal violence had a higher mortality compared to non-intentional 5% vs 1% (p = 0.019).

CONCLUSIONS

Pediatric pregnant trauma patients remain at risk of interpersonal violence, especially firearm-related injury. Screening should be instituted by obstetricians and pediatricians for primary prevention.

Management of pregnancy and obstetric complications in prehospital trauma care: prehospital resuscitative hysterotomy/perimortem caesarean section

The need for prehospital resuscitative hysterotomy/perimortem caesarean section is rare. The procedures can be daunting and clinically challenging for practitioners. Maternal death can be averted by swift and decisive action. This guideline serves to inform prehospital practitioners about conducting maternal resuscitation following cardiac arrest, provides an evidence-based framework to support decision making and highlights areas for improvement in prehospital care.

Management of pregnancy and obstetric complications in prehospital trauma care: faculty of prehospital care consensus guidelines

This consensus statement seeks to provide clear guidance for the management of pregnant trauma patients in the prehospital setting. Pregnant patients sustaining trauma injuries have certain clinical management priorities beyond that of the non-pregnant trauma patients and that if overlooked may be detrimental to maternal and fetal outcomes.

Care of the Critically Ill Pregnant Patient and Perimortem Cesarean Delivery in the Emergency Department

BACKGROUND

Maternal resuscitation in the emergency department requires planning and special consideration of the physiologic changes of pregnancy. Perimortem cesarean delivery (PMCD) is a rare but potentially life-saving procedure for both mother and fetus. Emergency physicians should be aware of the procedure's indications and steps because it needs to be performed rapidly for the best possible outcomes.

OBJECTIVE

We sought to review the approach to the critically ill pregnant patient in light of new expert guidelines, including indications for PMCD and procedural techniques.

DISCUSSION

The prevalence of maternal cardiac arrest and survival outcomes of PMCD in the emergency department setting are difficult to estimate. Advanced cardiovascular life support protocols should be followed in maternal arrest with special considerations made based on the physiologic changes of pregnancy. The latest recommendations for maternal resuscitation are reviewed, including advance planning, rapid determination of gestational age, emergent delivery, and postprocedure considerations for PMCD.

CONCLUSIONS

Maternal resuscitation requires knowledge of physiologic changes and evidence-based recommendations. PMCD outcomes are best for both mother and fetus when the procedure is performed rapidly and efficiently in the appropriate setting. Emergency physicians should be familiar with this unique clinical scenario so they are adequately prepared to intervene in order to improve maternal and fetal morbidity and mortality.

Injury patterns and health outcomes among pregnant women seeking emergency medical care in Kumasi, Ghana: Challenges and opportunities to improve care

INTRODUCTION

In high-income countries, injury is the most common cause of non-obstetric death among pregnant women. However, the injury risk during pregnancy has not been well characterized for many developing countries including Ghana. Our study described maternal and fetal outcomes after injury at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, and identified associations between the prevalence of poor outcomes and maternal risk factors.

METHODS

We conducted a cross-sectional study to identify pregnant women treated for injury over a 12-month period at KATH in Kumasi, Ghana. Descriptive statistics were used to characterize the population. We identified the association between poor outcomes and maternal risk factors using multivariable Poisson regression.

RESULTS

There were 134 women with documented pregnancy who sought emergency care for injury (1.1% of all injured women). The leading injury mechanisms were motor vehicle collision (23%), poisoning (21%), and fall (19%). Assault was implicated in 3% of the injuries. Eleven women (8%) died from their injuries. The prevalence of poor fetal outcomes: fetal death, distress or premature birth, was high (61.9%). One in four infants was delivered prematurely following maternal injury. After adjusting for maternal and injury characteristics, poor fetal outcomes were associated with pedestrian injury (adjusted prevalence ratio (aPR) 2.5, 95% CI 1.5-4.6), and injury to the thoraco-abdominal region (aPR 2.1, 95% CI 1.4-3.3).

CONCLUSIONS

Injury is an important cause of maternal morbidity and poor fetal outcomes. Poisoning, often in an attempt to terminate pregnancy, was a common occurrence among pregnant women treated for injury in Kumasi. Future work should address modifiable risk factors related to traffic safety, prevention of intimate partner violence, and prevention of unintended pregnancies.

Epidemiology and outcomes of pregnancy and obstetric complications in trauma in the United Kingdom

OBJECTIVE

To understand the epidemiology of pregnancy and obstetric complications encountered in the management of pregnant trauma patients.

METHODS AND DESIGN

Retrospective analysis of national trauma registry for recording of pregnancy status or obstetric complication in cases of trauma. Sub-division of patient cohort by severity of trauma and stage of pregnancy. Comparison of data sets between pregnant trauma patients and age-matched non-pregnant female trauma patients to determine patterns of injury and impact upon clinical outcomes.

SETTINGS

National registry data for the United Kingdom.

OUTCOME

For the five year period between 2009 and 2014, a total of 15,140 female patients, aged between 15 years old and 50 years old were identified within the trauma registry. A record of pregnancy was identified in 173 patients (1.14%) from within this cohort. Mechanisms of injury within the cohort of pregnant trauma patients saw increased rate of vehicular collision and interpersonal violence, especially penetrating trauma. Higher abbreviated injury scores were recorded for the abdominal region in pregnancy than in the non-pregnant cohort. Maternal mortality rates were seen to be higher, when compared with the non-pregnant trauma patient. Foetal survival rate from this series was 56% following trauma. Foetal death in pregnant trauma patients most frequently occurred in the 2nd trimester. No cases of isolated foetal survival were recorded following maternal trauma.

CONCLUSIONS

Trauma to pregnant patients is rare in the United Kingdom, encountered in 1% of female trauma patients of child bearing age. Observations in altered mechanisms of injury and clinical outcomes were recorded. This provides useful information regarding the clinical management of pregnant trauma patients and offers potential areas to investigate to optimise their care, as well as to focus injury prevention measures.

LEVEL OF EVIDENCE

IV--Case series.

Essentials in cardiac arrest during cesarean section

Cardiac arrest during cesarean section is very rare. Obstetrical teams have low exposure to these critical situations necessitating frequent rehearsal and knowledge of its differential diagnosis and treatment. A 40-year-old woman pregnant with triplets underwent cesarean sections because of vaginal bleeding due to a placenta previa at 35.2 weeks of gestation. Spinal anesthesia was performed. Asystole occurred during uterotomy. Immediate resuscitation and delivery of the neonates eventually resulted in good maternal and neonatal outcomes. The differential diagnosis is essential and should include obstetric and non-obstetric causes. We describe the consideration of Bezold Jarisch reflex and amniotic fluid embolism as most appropriate in this case.

Use and impact of cardiac medication during pregnancy

ABSTRACT 

Cardiovascular disease is the most encountered cause of maternal death during pregnancy in the western world and an increase in maternal mortality due to cardiac causes has been observed. More women with congenital or acquired heart disease have the desire to become pregnant. Pregnancy is known to impose a major hemodynamic burden and also has impacts on the coagulation system. The risk of developing complications is clearly increased as compared with the normal population. For optimal management, it is crucial to have information on the effects of cardiac medications on the fetus. The focus of this article is to discuss the management of cardiac disease in pregnancy, as well as the known safety of cardiac medications for the mother and/or fetus.

Motor-vehicle injury in pregnancy and subsequent feto-maternal outcomes: of grave concern

OBJECTIVES

(1) To evaluate maternal and fetal outcome after motor-vehicle injury during pregnancy. (2) To determine if there was prenatal care provider counseling for seat belt use.

METHODS

Retrospective chart analysis of materno-fetal outcome following motor vehicle injury in 728 pregnant women between 2009 and 2012. Women attending antenatal clinics over these years were asked if they were counseled regarding correct seat belt use by prenatal health care providers during their antenatal visits.

RESULTS

In these pregnant women, 80 (11%) sustained minor injuries/sprains. 648 women (89%) had severe adverse materno-fetal pregnancy outcomes. Important causes being: (1) placental abruption 58.8%; (2) preterm labor (40%); and (3) uterine rupture (1.6%). There were 100 (13.7%) maternal and 78 (10.7%) fetal deaths. 91 (12.5%) perimortem cesarean deliveries were performed and 74 (81%) fetus survived, as did 31 women. Prenatal care provider counseling for seat belt use occurred in 44.8% of prenatal visit. Only 125 (21%) were using seat belt during the accident.

CONCLUSION

Important causes of adverse pregnancy outcome were: abruptio placenta, preterm labor and uterine rupture. There were 100 maternal and 78 fetal deaths with 97 preterm births. Counseling occurred in 44.8% of women. Those using seat belts during the accidents sustained minor injuries.