Mother and Child

The unborn fetus: The unrecognized victim of trauma during pregnancy

BACKGROUND

Trauma is the leading cause of non-obstetric death in pregnancy. While maternal management is defined, few studies have examined the effects on the fetus.

METHODS

Following IRB approval, all pregnant females (2010-2017) at a level-1 trauma center were retrospectively reviewed. Maternal and fetal demographics, interventions, and clinical outcomes were analyzed.

RESULTS

There were 188 pregnancies in 5654 females. Maternal demographics were 26 ± 7 years old, gestational age at trauma 21 ± 12 weeks, 81% blunt mechanism, and maternal mortality 6%. Forty-one (22%) fetuses were immediately affected by the trauma including 20 (11%) born alive, 12 (7%) fetal demise, and 9 (5%) stillbirths. Of those that initially survived (n = 20), 5 (25%) expired during neonatal hospitalization. Two mothers returned immediately after trauma discharge with stillbirths for an overall infant mortality of 14% (n = 26). There were 84 patients with complete data to delivery including the 41 born at trauma and 43 born on a subsequent hospitalization. Those born at the time of trauma had significantly more delivery/neonatal complications and worse outcomes. Overall trauma burden to the fetus (preterm delivery, stillbirth, delivery/neonatal complication, or long-term disability) was 66% (56/84).

CONCLUSIONS

Trauma during pregnancy has significant immediate mortality and delayed effects on the unborn fetus. This study has uncovered a previously hidden burden and mortality of trauma during pregnancy.

LEVEL OF EVIDENCE

Level III.

Burns in Pregnancy

BACKGROUND

Treatment of a major burn injury during pregnancy must incorporate modifications in management resulting from gestational physiologic changes.

CASE

A 25-year-old woman, at 34 weeks of gestation, sustained a major burn injury at home. She required ventilatory support, invasive hemodynamic monitoring, and massive fluid resuscitation. Labor was augmented and a spontaneous vaginal delivery of a healthy neonate was achieved. Later, wound autografting was performed.

CONCLUSION

Pregnancy-induced physiologic changes affect key factors in the management of the burned patient, including airway management and hemodynamic support. Multidisciplinary management is essential to achieve the best possible outcome.

Burns in pregnancy

Pregnancy complicated by a thermal injury must be aggressively managed to provide a favorable outcome for the mother and her developing fetus. The MEDLINE database was used to search for English-language papers published after 1980 to evaluate the classification, complications, and treatment of thermal injuries in pregnancy. Additional sources were identified through cross-referencing. We reviewed these sources with particular attention to classification, complications, and treatment options. The incidence of serious thermal injury in pregnancy is low. Maternal and perinatal mortality increases significantly when greater than 50 percent of the total body surface area is burned. However, pregnancy does not seem to alter maternal outcome, and maternal survival is often accompanied by fetal survival. The delivery of a term infant is likely when the mother recovers from a thermal injury, and there is no evidence of fetal jeopardy or labor in the first week postburn. Acute management of thermal injuries in pregnancy is essential for maternal and fetal well-being. Obstetrical management should be individualized.

Motor vehicle accident during the second or third trimester of pregnancy

OBJECTIVE

To evaluate the need of immediate treatment, follow-up and consequences of different types of traffic accidents during pregnancy.

METHOD AND MATERIAL

A retrospective analysis covering five years involving thirty-five pregnant women involved in motor vehicle accidents at 22-39 weeks of gestation.

RESULTS

Fifteen of the 35 women were involved in frontal impact collisions, and suffered mild subjective and objective symptoms; all their fetuses survived and were delivered at term. Fifteen other women were involved in broadside collisions; two of these were riding a bicycle. These 15 women had clear objective findings like uterine contractions or tenderness, and some of them needed tocolytic therapy and hospitalization up to eight days. This was significantly longer than in those involved in frontal impact collisions. However, the broadside accidents did not have any adverse effect on pregnancy outcomes either. Five women were involved in serious accidents at speeds of 80-110 km/h, and one mother and her fetus died immediately because of rupture of the uterus and the cervical joint and spinal canal. Four other fetuses were found dead on arrival at hospital or soon after. In all cases the cause of fetal loss was placental abruption. The presence of fetal blood cells in maternal blood was evaluated in 15 of 35 patients, but was positive in only one.

CONCLUSION

Frontal collisions are associated with lower vehicular speed, less trauma and no acute or later effects on pregnancy, whereas broadside collisions and high speed (> 80 km/h) cause more symptoms. The latter type of accidents are associated with high risk of placental abruption and of fetal and maternal death. Fortunately the symptoms are evident immediately after the accident, and early hospital discharge is possible if no abnormalities are present during the first hours.

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.

Perioperative care of the pregnant surgical patient

Successful perioperative management of the pregnant surgical patient requires a multidisciplinary nursing approach to decrease perinatal morbidity and mortality. A comprehensive perioperative patient care plan and coordination with obstetric and neonatal team members enhance the surgical outcome for both the mother and her child.

Blunt abdominal trauma

This paper describes the assessment, investigation and management of patients suffering blunt abdominal trauma. Many of the structures within the abdominal cavity are highly vascular and damage following trauma can lead to life-threatening hypovolaemia. Initial assessment of the patient must follow the usual trauma protocols with identification and management of life-threatening conditions; specific procedures related to the abdomen are described. Although formal examination of the patient has traditionally been a medical responsibility, nurses are assuming more responsibility by working in triage or as nurse practitioners. Nurses working both in triage and within the Accident and Emergency department must be able to rapidly assess these patients and assist in their management.