Pregnancy course and outcome following blunt trauma

Trauma in pregnancy: A narrative review of the current literature

INTRODUCTION

Trauma accounts for nearly half of all deaths of pregnant women. Pregnant women have distinct physiologic and anatomic characteristics which complicate their management following major trauma.

OBJECTIVE

This paper comprises a narrative review of the most recent literature informing the management of pregnant trauma patients.

DISCUSSION

The incidence of trauma during pregnancy is 6-8%. The focus of clinical assessment must be on the mother, starting with the primary survey. During airway management, clinicians should consider early intubation if necessary and utilize gastric tubes to minimize the risk of aspiration. Pregnant women experience progesterone-mediated hyperventilation, and normal PaCO2 levels may portend imminent respiratory failure. Clinicians should utilize left lateral tilt in hypotensive pregnant women to displace the uterus off the inferior vena cava. Ultrasonography is an attractive imaging modality for pregnant women which is specific for ruling in intraabdominal hemorrhage but not sufficiently sensitive to exclude this diagnosis. Clinicians should not hesitate to order computed tomography imaging in unstable patients if there is diagnostic ambiguity. Cardiotocographic monitoring simultaneously assesses uterine contractions and fetal heart rate and should last at least 4 h for pregnant women following even minor abdominal trauma if their fetus has achieved viable gestational age (approximately 24 weeks). In the event of cardiac arrest, peri-mortem cesarean section may improve outcomes for the mother and fetus alike. Unique specific complications include uterine rupture and placental abruption, which require emergent resuscitation and obstetrics consultation for definitive management. Emergency clinicians should maintain a low threshold for transfer to a tertiary care center given correlations between even isolated and relatively minor traumatic injuries with adverse fetal and maternal outcomes.

CONCLUSIONS

Trauma is a common cause of morbidity and mortality in pregnant women. Emergency clinicians must understand the evaluation and management of pregnant trauma patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Fetal and neonatal outcomes following maternal aortic balloon occlusion for hemorrhage in pregnancy: A review of the literature

BACKGROUND

Hemorrhage is a leading cause of maternal death worldwide, with increased risk in women with abnormal placentation. Aortic balloon occlusion (ABO), including resuscitative endovascular balloon occlusion, has been used for obstetrical hemorrhage for 20 years, and is associated with decreased operative blood loss, fewer transfusions, and lower rates of hysterectomy. However, the effect of aortic occlusion on fetal/neonatal outcomes is not well known.

METHODS

A literature review on ABO for obstetrical or traumatic hemorrhage was performed. Cases were included if fetal/neonatal outcomes were reported. Data were collected on timing of balloon inflation (predelivery or postdelivery), fetal/neonatal mortality, and Apgar scores. Secondary maternal outcomes included blood loss, need for hysterectomy, ABO-related complications, and mortality.

RESULTS

Twenty-one reports of ABO in 825 cases of obstetrical hemorrhage were reviewed (nine case reports/series and twelve comparative studies). 13.5% (111/825) had aortic occlusion prior to delivery of the fetus. Comparative cohorts included 448 patients who underwent iliac artery balloon occlusion (n = 219) or no vascular balloon occlusion (n = 229). The most common neonatal outcome reported was Apgar scores, with no difference in fetal/neonatal outcomes between ABO and non-ABO patients in any study. One neonatal mortality occurred in the sole reported case of ABO use in a pregnant trauma patient at 24 weeks gestation. One maternal mortality occurred because of aortic dissection. Five comparative studies reported significantly decreased blood loss in ABO patients compared to non-ABO patients, and four studies reported significantly lower rates of hysterectomy in ABO patients. ABO-related complications were reported in 1.6% of patients (13/825).

CONCLUSION

Obstetrical hemorrhage is a devastating complication, and ABO may potentially decrease blood loss and reduce the hysterectomy rate without compromising fetal and neonatal outcomes. Further research is needed to determine the safety of predelivery aortic occlusion as this occurred in 14% of the cases.

Predictors of obstetric complications following traumatic injuries in pregnancy

BACKGROUND

After a traumatic injury, the provision of appropriate, timely care to pregnant women jury is crucial for the health of both the mother and fetus. The aim of this study was to identify risk factors predicting post-traumatic obstetric complications in pregnant women who presented to the emergency department (ED) with traumatic injuries.

METHODS

We conducted a retrospective cohort study of pregnant women aged 18 y and older who were admitted to the trauma unit of our ED between 2017 and 2020. The data collected included maternal demographics, trauma mechanism, and pregnancy outcome. The patients were divided into two subgroups according to the presence or absence of trauma-related complications, and clinical features were compared between the two groups.

RESULTS

In total, 241 pregnant trauma patients were included in the study. The mean maternal age was 26.1 ± 4.4 y, and the mean gestational age the time of the trauma was 28.4 ± 6.8 wk. In the study, 17.8% (43/241) of patients experienced obstetric-related complications within the first 24 h post-trauma. The risk factors associated with obstetric complications were aged older than 35 y (odds ratio [OR] = 5.31,95% confidence interval [CI]: 1.77-15.96, p = 0.003), third trimester trauma (OR = 2.41,95% CI:1.14-5.12, p = 0.021), and abnormal obstetric ultrasonography (OR = 6.25,95% CI:2.03-19.22, p = 0.001).

CONCLUSION

Among pregnant patients who present to the ED after a traumatic injury, advanced maternal age, trauma in the third trimester, and abnormal obstetric ultrasonography findings should alert physicians to the possibility of post-traumatic complications (within the first 24 h after trauma) and the need for close monitoring.

Application of diversified and quantitative management model of exercise intervention in patients with gestational diabetes mellitus

Objective: The study aims to explore the application of diversified and quantitative management model of exercise intervention in patients with gestational diabetes mellitus (GDM). Methods: From January 2018 to July 2018, 150 pregnant women with GDM were recruited from HangZhou Maternity Hospital, and were randomly divided into control group (n = 75) and experimental group (n = 75). All patients were registered pregnancy exercise self-efficacy scale (P-ESES), fasting blood glucose (FBG), and 2-hour postpranational blood glucose (2hPG). Patients in control group received conventional sports, while patients in experimental group added multiple quantitative exercise intervention management mode until delivery (accumulated at least 30 min per day, the time of not less than 150 min per week). After 4 weeks of intervention, patients in both groups were measured P-ESES, FBG, and 2hPG levels. Results: A total of 12 patients dropped out of the study, was lost to follow-up or was admitted to another hospital; therefore, 138 cases (68 vs. 70) were included in analysis. There was no significant difference of P-ESES, FBG, and 2hPG of patients in baseline. After four weeks intervention, compared with the control group, the P-ESES score was significantly increased (p<.05), the overcoming movement disorder, overcoming emotional disorder, and overcoming support disorder scores were significantly improved (p<.05), and the levels of FBG and 2hPG were significantly decreased (p<.05) in experimental group. Finally, the coincidence rate of weight gain during pregnancy was increased, the rate of macrosomia delivery and cesarean section were decreased in experimental group (p<.05). Conclusion: Quantitative management model of multiform exercise therapy improved patients with GDM.

Traumatic bilateral ureteral tear in a pregnant woman after a motor vehicle crash: a case report

Bilateral ureteropelvic junction (UPJ) tears are rare. Trauma can obscure this diagnosis. The objective of this case report is to highlight the rapid diagnosis of this injury and care in the case of pregnancy. A 22-year-old pregnant female was ejected from her car and presented with abdominal pain. The patient got a computed tomography (CT)-chest, abdomen, pelvis (CT-CAP) revealing bilateral ureteral injury, which was confirmed on retrograde cystoscopy. Her injuries were treated with nephrostomy tubes with plans for definitive repair after pregnancy. Fetus remained stable throughout her care and the patient was discharged with no complications. Due to the rapid diagnosis and effective stabilization, the patient and fetus recovered well from the injuries and multiple procedures. While there are many explanations for bilateral UPJ tears, deceleration and hyperextension seem to be the two major mechanisms of this injury.

Guidance for Evaluation and Management of Blunt Abdominal Trauma in Pregnancy

Blunt abdominal trauma is the leading type of traumatic injury in pregnancy, with motor vehicle crashes, falls, and assault being the most common etiologies. Several adverse outcomes can occur in pregnancy, including placental abruption, preterm labor and preterm delivery, uterine rupture, and pelvic fracture. Understanding and integration of key anatomic and physiologic changes in pregnancy are key when evaluating a pregnant trauma patient. Pregnant women should be managed in a medical center with the ability to provide adequate care to both trauma patients-the pregnant woman and fetus. Multiple clinical providers are usually involved in the care of pregnant trauma patients, but obstetric providers should play a central role in the evaluation and management of a pregnant trauma patient given their unique training, knowledge, and clinical skills. An algorithm for management of trauma in pregnancy should be used at all sites caring for pregnant women. An alignment of policies within each system optimizes appropriate triage, integration of care, management, and monitoring of pregnant trauma patients and their fetuses. Ensuring effective protocols for prehospital and hospital treatment, as well as thorough training of involved health care providers, is essential in ensuring that optimal care is provided.

Placental abruption and long-term cardiovascular morbidity of the offspring

OBJECTIVE

While placental abruption is often associated with short-term adverse pregnancy outcomes, we sought to assess whether placental abruption increases the risk for long-term cardiovascular morbidity of the offspring.

METHODS

To study the long-term cardiovascular hospitalizations of offspring of patients with and without placental abruption, cardiovascular morbidity was assessed up to the age of 18 years according to a predefined set of ICD-9 codes associated with hospitalization of the offspring. Our data consist of deliveries which occurred between the years 1991 and 2014 in a tertiary medical center. Pregnancies following fertility treatments, multifetal pregnancies, and pregnancies with offspring with congenital anomalies, lack of prenatal care, and perinatal mortality were excluded from the study. We used Kaplan-Meier curve to compare cumulative morbidity incidence and Cox proportional hazards model to control for confounder.

RESULTS

During the study period, we examined 217,910 deliveries, out of which 0.46% (n = 1003) were effected by placental abruption. Compared to normal birth children, children born to mothers with placental abruption did not show a significantly higher cumulative incidence of long-term cardiovascular morbidity (1.0% vs. 0.6%; p = 0.127). Placental abruption was not noted as an independent risk factor for long-term cardiovascular morbidity of offspring in the Cox regression analysis, which adjusted for confounders.

CONCLUSION

Our study does not support the association between placental abruption and risk for long-term cardiovascular morbidity of the offspring.

Parachuting and pregnancy: what do we know about pregnant skydivers and the risks they are taking?

OBJECTIVE

There is little medical knowledge about the risks of skydiving during pregnancy. Some national parachuting associations ask for a doctor's permission; others recommend not jumping at all during pregnancy. This article provides survey data and a literature review of pregnancy and parachuting/skydiving related issues to help the pregnant skydiver and her obstetrician make an informed decision. Survey data presented include pregnancy, delivery, and parachuting information from skydivers who jumped during pregnancy.

DESIGN

International retrospective anonymous online questionnaire considering the Checklist for Reporting Results of Internet E-Surveys (CHERRIE). The PubMed database was searched with using the terms "skydive," "pregnancy," and "parachute" (query April 2013).

SETTING

Web page questionnaire on skydivers' epidemiology, experience, and pregnancy-related information.

PARTICIPANTS

Fifty-seven parous female skydivers.

ASSESSMENT OF RISK FACTORS

Information on athletes' experience, weather conditions, obstetric history (gravida, gestational week), delivery mode was obtained.

MAIN OUTCOME MEASURES

Epidemiology of pregnant skydivers and literature review to provide information on skydiving risks.

RESULTS

Women do actively decide to skydive while pregnant. The majority of our participants were between 25-year-old and 35-year-old primips with 100 to 1000 jumps experience, answering the questionnaire from a European IP address. Precautions are taken in terms of weather conditions, gear, or sports partner. The literature review found no relevant literature regarding the question. Literature is searched for risk factors that come close to the ones in skydiving (ie, oxygen saturation, shock forces, and others). Further studies are needed to show the long-term effect of stress or low O2 saturation on antenatal programming, or short-term hypoxia and pregnancy outcome in pregnant skydiving women and their offspring.

CONCLUSIONS

Pregnancy itself is a risk factor for injuries. Injuries in pregnancy are clearly associated with an unfavorable pregnancy outcome. The recommendation "do not skydive during pregnancy" is the safest approach. A possible lesser risk alternative to skydiving could be wind-tunnel training.

CLINICAL RELEVANCE

This article provides insights into the pregnant skydiver's decision making regarding the sports. In combination with the literature review, we provide up-to-date easy to understand information on the possible risk factors. This is a valuable source of information for the care providers of female skydivers to understand and compare the risk factors of this sport. With this information, the professional recommendation and relationship are strengthened. This article also guides the need for further research. Possible research areas include pregnancy and sports-related risk factors, placentation and prenatal programming, physical and psychological factors associated with skydiving.

Blunt abdominal trauma to a pregnant woman resulting in a child with hemiplegic spastic cerebral palsy and permanent eye damage

Background

In today's life trauma is a common and important complication of pregnancy and remains one of the major contributors to maternal and fetal morbidity and mortality.

Case presentation

The authors reported a case of 4 years old child with hemiplegic spastic cerebral palsy and permanent left eye damage due to antenatal trauma. He was an off spring to a 33 years old woman gravida 6 para 5 from western Sudan, who sustained a domestic blunt abdominal trauma during her routine daily activities. The abdominal trauma occurred during the third trimester at 36^th week gestation of the pregnancy when the mother hit herself by the woody part of an axe non intentionally.

Conclusions

The findings from this case conclude that relatively minor trauma can have significant adverse effects on the fetus and can be devastating.

Trauma during pregnancy

Traumatic injuries in pregnancy are both common and burdensome. Optimal management includes proper triage, maternal resuscitation, fetal monitoring, and diagnostic imaging.

Socio-demographic characteristics of women sustaining injuries during pregnancy: a study from the Danish National Birth Cohort

OBJECTIVES

To describe adverse birth outcomes associated with hospital-treated injuries that took place among women in the Danish National Birth Cohort.

DESIGN

Longitudinal cohort study.

SETTING

Denmark.

PARTICIPANTS

90 452 women and their offspring selected from the Danish National Birth Cohort.

PRIMARY AND SECONDARY OUTCOME MEASURES

To determine if injured women were more likely to deliver an infant preterm, with low birth weight, stillborn or have a spontaneous abortion, the authors estimated HRs. ORs were generated to assess APGAR scores and infants born small for gestational age (SGA). Models were adjusted for maternal smoking and drinking during pregnancy, household socioeconomic status, eclampsia/pre-eclampsia or gestational diabetes status during pregnancy and maternal age at birth; estimates for preterm birth were also adjusted for prior history of preterm birth.

RESULTS

In the cohort of 90 452 pregnant women, 3561 (3.9%) received medical treatment for an injury during pregnancy. Injured pregnant women were more likely to deliver infants that were stillborn or have pregnancies terminated by spontaneous abortion. The authors did not detect an adverse effect between injuries sustained during pregnancy and delivery of preterm, low birth weight or SGA infants, or infants with an APGAR score of <7.

CONCLUSIONS

The study shows that injuries occurring among women from an unselected population may not have an adverse effect on birth weight, gestational age, APGAR score or SGA status but may adversely affect the risk of stillbirth and spontaneous abortions in some situations.