Abdominal gunshot wounds in pregnancy

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..

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.

Neonatal minimal invasive management of a prenatal gunshot trauma: case report

Background

Prenatal penetrating gunshot trauma represents a challenging scenario for healthcare providers. Trauma is the leading non-obstetric cause of morbidity and mortality during pregnancy, and even though rare, firearm injuries have the most fatal outcomes and higher fetus mortality rates. Understanding the mechanism of injury in order to identify the possible injuries and adequate management is essential. In this paper, we discuss the case of a newborn with prenatal gunshot trauma, the treatment used, and the outcome of conservative and minimally invasive management.

Case presentation

We present the case of a male newborn, 37 weeks of gestational age and weighing 3050 g, delivered through an emergency cesarean section with prenatal gunshot trauma. Two skin wounds were found, one in the arm and another in the left thoracic region. The patient presented with respiratory distress, bilateral pneumothorax, and pneumoperitoneum, requiring high-frequency mechanical ventilation and the placement of bilateral thoracic drains. The pneumoperitoneum was attributed to pulmonary barotrauma, with no suspicion of abdominal hollow viscera lesion. A right thoracoscopy was performed after 24 h of conservative management for the removal of the foreign body. Both the mother and the baby had a positive outcome, with no further treatment needed.

Conclusions

For the improvement in the result of trauma events, an adequate intervention and coordinated efforts from multidisciplinary clinical and surgical teams are required. For gunshot wounds, entry, trajectory, the final position of the bullet, and pathological findings in images need to be analyzed before taking the patient to the operative room. Chosen with strict selection criteria, some patients could benefit from conservative management.

Prenatal gunshot wound, a rare cause of maternal and fetus trauma, a case report

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Trauma during pregnancy is an important cause of adverse fetal and maternal outcomes.

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Gunshot wounds to the gravid uterus are generally lethal for the fetus, and cause significant morbidity to the mother.

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Gunshot wounds in a pregnant woman must be handled by a multidisciplinary team.

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Training in maternal and infant resuscitative measures and surgical techniques are vital.

Background

Gunshot wounds in pregnant women, although rare, represent an important cause of fetal and maternal mortality. Understanding the mechanism of injury is essential to identify the possible injuries and to adequately manage the complexity of these emergency scenarios.

Case presentation

We present a case of a 27-year-old woman and her 37 week fetus who were the victims of a gunshot wound. The trajectory of the bullet injured not only the mother but also the developing fetus. An emergency c-section was performed and the bullet was removed from the infant's abdomen. The two patients fully recovered and on follow up controls both patients are doing well.

Conclusions

Trauma events, and particularly gunshot wounds in pregnant women requires promptly and adequate intervention. Coordinated efforts from multidisciplinary clinical teams are needed as well as the appropriate training in maternal and infant resuscitative measures and surgical techniques.

Trauma in pregnancy: anatomical and physiological considerations

Management of a pregnant trauma victim is a relatively rare but stressful event, not least due to the need to consider two patients. Initial management by a trauma team should follow a structured approach applicable to all trauma patients, combined with knowledge of the specific problems encountered in pregnancy. This review outlines important anatomical and physiological changes that occur during pregnancy and their relevance to initial assessment and treatment. It discusses the epidemiology of trauma in pregnancy, the presentation and manage ment of specific problems and the methods of fetal assessment.

The early management of gunshot wounds Part II: the abdomen, extremities and special situations

The management of gunshot wounds of the abdomen and extremities is evolving with centres who treat large volumes of such injuries tending to the application of a policy of selective non-operative management. This article discusses the management of gunshot wounds to the abdomen and extremities and reviews the evidence supporting these changing practices. Special situations such as wounding by shotguns or air rifles are also examined as are the special considerations needed when dealing with the gunshot injured pregnant women or in a child.

Maternal mortality due to trauma

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

Intrauterine head stab wound injury resulting in a growing skull fracture: a case report and literature review

INTRODUCTION

Penetrating injuries of the gravid uterus are rare complications of pregnancy with gunshot wounds most common than stab wounds. Fetal head injury is an unusual sequela of these penetrating traumas.

MATERIALS AND METHODS

We describe the case of a 20-year-old pregnant woman stabbed at the lower abdomen at 30th weeks of gestation. She was nonsurgically managed by serial examination and continuous fetal monitoring.

RESULTS

Spontaneous vaginal delivery occurred at term with good maternal and fetal outcome. The newborn examination revealed a right temporal swelling interpreted as a subcutaneous hemangioma. At 2 years and 6 months of life, the child was led to our attention with a pulsating bulge in the right temporal region. Clinical examination and imaging were indicative of a typical growing skull fracture. The child underwent neurosurgical procedure for repairing of the dural tear and bone defect according to the senior author's personal technique, described in details, with a good neurological and esthetic outcome.

CONCLUSION

Thirty-two cases of stab wounds to the pregnant uterus have been reported to date in medical literature with two cases of fetal head injury.Growing skull fractures are rare complications of head injury and only one case has been described in the perinatal period following blunt trauma to the mother's abdomen 2-3 weeks before birth.

The pathophysiology of trauma in pregnancy: A review

Emergency care of the pregnant patient with trauma presents a unique set of circumstances and challenges to physicians. Pregnancy causes anatomic and physiologic changes involving nearly every organ system in the body, making treatment of the pregnant trauma patient difficult. The other factors that make treatment complex are fear of harming the fetus, upsetting the patient, and/or lack of experience. The possibility of pregnancy should be considered in all women of reproductive age with trauma. A profound understanding of the pathophysiology of the pregnant trauma patient might aid in dealing with this complex problem.

Intrauterine penetrating direct fetal head trauma following gunshot injury: a case report and review of the literature

CASE REPORT

An unusual case of an intrauterine penetrating head injury due to a pellet from an airgun is described. A 28-year-old pregnant woman, at term, shot herself intravaginally with a toy BB gun. Following a spontaneous precipitous vaginal delivery, the neonate presented with persistent seizure disorder, meningitis, cerebritis, and a right parietal region scalp swelling. Imaging studies revealed intracranial hemorrhage, and the metallic pellet was adjacent to the right lateral ventricle, which was removed through a parietal craniotomy. Computed tomography of the brain after 1 week demonstrated early abscess formation in the left frontal operculum and a subdural empyema in the posterior fossa. The abscesses were evacuated, and the meningitis was treated vigorously with broad-spectrum antibiotics. Although well for the past 6 years, the child demonstrates significant mental handicap and developmental delay.

DISCUSSION

The pathogenesis, management, and medicolegal issues pertaining to the above case are discussed, and the relevant literature is briefly reviewed.

The role of placental pathology in the evaluation of interpersonal violence: a case of abdominal gunshot wound in a 27-week gravid uterus

We present a 17-year-old G1P0 Asian American woman with a previously undiagnosed pregnancy who sustained an intra-abdominal gunshot wound at 27 weeks' gestation. Within 2 hours of the traumatic event, the victim was taken emergently to the operating room for exploratory laparotomy. Findings included a gravid uterus with two entrance wounds and two small exit wounds with active bleeding from the right broad ligament. The fetus was bradycardic but viable, having suffered a gunshot wound to the left shoulder. Evaluation of the placenta revealed no sequelae from the acute event. Unexpectedly, two older, green, 7.0 cm retromembranous hematomas were present, both ringed by hemosiderin-laden macrophages. These hemorrhages clearly preceded the acute event. Although these findings seemed suspicious for a history of prior abuse or trauma, corroborative clinical data were unavailable at the time of initial placental evaluation. However, days later, the victim admitted to a history of interpersonal violence, with previous abuse from her boyfriend, a fatal victim of the same attack. The old retroplacental hemorrhages proved to be the only physical documentation of her previous abuse.

Trauma in pregnancy

Serious trauma in pregnancy is an uncommon event but is particularly challenging to the physician, due to the presence of a potential second patient. Responding to the challenge requires a knowledge of the physiological changes which may alter the maternal response to injury, as well as an understanding of the maternal-fetal relationship. Fetal outcome is dependent on maternal well-being, and thus timely and appropriate resuscitation of the mother is the first priority. Initial management of the pregnant trauma patient includes attention to the airway-breathing-circulation (ABC). Certain injuries are more common in pregnancy and are influenced by the presence of the gravid uterus. The physician needs an awareness of the common complications of pregnancy and additional skills may be required to diagnose and assess fetal viability. The principles of the perimortem section should be understood, as well as the social implications of domestic violence towards pregnant women.

Damage control for the obstetric patient

The management of trauma and hemorrhagic shock in the pregnant patient involves unique considerations owing to extensive alterations in physiology. In the third trimester of pregnancy, emergent delivery by cesarean section should be started within 4 minutes after the initiation of CPR for both maternal and fetal benefits. Stabilization of the maternal condition should take precedence over the fetal status in cases of penetrating or blunt trauma. Postpartum hemorrhage is managed by a succession of pharmacologic and surgical maneuvers prior to resorting to hysterectomy, particularly in a woman of low parity. Hepatic rupture and abdominal gestation are unique conditions to pregnancy that require damage control through a close partnership between the obstetrician and the surgeon.

Infant survival after cesarean section for trauma

HYPOTHESIS

Emergency cesarean sections in trauma patients are not justified and should be abandoned.

SETTING AND DESIGN

A multi-institutional, retrospective cohort study was conducted of level 1 trauma centers.

METHODS

Trauma admissions from nine level 1 trauma centers from January 1986 through December 1994 were reviewed. Pregnant women who underwent emergency cesarean sections were identified. Demographic and clinical data were obtained on all patients undergoing a cesarean section. Fetal distress was defined by bradycardia, deceleration, or lack of fetal heart tones (FHTs). Maternal distress was defined by shock (systolic blood pressure < 90) or acute decompensation. Statistical analyses were performed.

RESULTS

Of the 114,952 consecutive trauma admissions, more than 441 pregnant women required 32 emergency cesarean sections. All were performed for fetal distress, maternal distress, or both. Overall, 15 (45%) of the fetuses and 23 (72%) of the mothers survived. Of 33 fetuses delivered, 13 had no FHTs and none survived. Twenty infants (potential survivors) had FHTs and an estimated gestational age (EGA) of greater than or equal to 26 weeks, and 75% survived. Infant survival was independent of maternal distress or maternal Injury Severity Score. The five infant deaths in the group of potential survivors resulted from delayed recognition of fetal distress, and 60% of these deaths were in mothers with mild to moderate injuries (Injury Severity Score < 16).

CONCLUSIONS

In pregnant trauma patients, infant viability is defined by the presence of FHTs, estimated gestational age greater than or equal to 26 weeks. In viable infants, survival after emergency cesarean section is acceptable (75%). Infant survival is independent of maternal distress or Injury Severity Score. Sixty percent of infant deaths resulted from delay in recognition of fetal distress and cesarean section. These were potentially preventable. Given the definition of fetal viability, our initial hypothesis is invalid.

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.