Predictors of fetal mortality in pregnant trauma patients

A Survey on the Management of Patients with Severe Traumatic Brain Injury During Pregnancy: The MAMA Study

BACKGROUND

Trauma, including traumatic brain injury (TBI), is the leading cause of nonobstetric maternal mortality during pregnancy. Few data are available regarding the optimal management of pregnant patients with TBI, leading to a lack of dedicated guidelines. We performed an international survey to examine the management of severe TBI in pregnant patients, focusing on monitoring, therapy, and intensive care practices.

METHODS

This survey, endorsed by the World Society of Emergency Surgery, was composed of a questionnaire with 79 items divided into four sections: (1) general information (items 1-7), (2) management of the maternal-fetal unit (items 8-43), (3) management of intracranial hypertension (items 44-76), and (4) specific considerations (items 77-79).

RESULTS

One hundred and twenty-two physicians from 110 centers in 35 countries responded. The main findings related to TBI care in pregnant patients included the following: (1) a lack of availability of a specific TBI protocol in pregnancy; (2) an increase in the utilization of magnetic resonance imaging as the primary neuroimaging tool; (3) higher hemoglobin thresholds for transfusion; and (4) a lower utilization of therapeutic hypothermia, neuromuscular blocking agents, and barbiturate coma. We also report large variability in the timing of cesarean section in pregnant patients with TBI (≥ 23 weeks of gestation) needing an emergency craniotomy (simultaneously 23% vs. later cesarean section 50.8%).

CONCLUSIONS

Great variability in the management of pregnant patients with severe TBI was identified worldwide from the results of our survey. These findings, highlighting the lack of robust evidence on this topic, will be helpful to stimulate future investigations and to promote educational efforts on this difficult scenario.

Prehospital Trauma Compendium: Management of Injured Pregnant Patients- A Position Statement and Resource Document of NAEMSP

The assessment and management of critically injured pregnant trauma patients represents a high-risk, low-frequency event. One in every 12 pregnant patients experience physical trauma during their pregnancy, but only 0.1% experience major trauma with an injury severity score (ISS) greater than fifteen. It is crucial that emergency medical services (EMS) clinicians understand the anatomic and pathophysiologic changes that impact morbidity and mortality for pregnant trauma patients so they can effectively provide life-saving interventions and resuscitation for this patient population.

Incidence and Outcomes of Pregnant Trauma Patients With Positive Urine Toxicology: A Southern California Multicenter Study

Background: The use of illicit substances during pregnancy has increased 4-fold in the past two decades, negatively impacting both mother and fetus. The rate and clinical outcomes of substance use in pregnant trauma patients (PTPs) are not well studied. We sought to evaluate clinical outcomes of PTPs with positive urine toxicology, hypothesizing a higher rate of in-hospital maternal complications for PTPs with a positive urine toxicology ((+)Utox) compared to those testing negative ((-)Utox). Methods: PTPs (≥18 years old) were included in this multicenter retrospective study between 2016 and 2021. We included patients with known urine toxicology results and compared (+)Utox vs (-)Utox PTPs. Results: From 852 PTPs, 84 (9.8%) had a (+)Utox with the most common illicit substance being THC (57%) followed by methamphetamine (44%). (+)Utox PTPs had higher rates of blunt head injury (9.5% vs 4.2%, P = .028), extremity injury (14.3% vs 6.5%, P = .009), domestic violence (21.4% vs 5.9%, P < .001), suicide attempt (3.6% vs 0.3%, P < .001), and uterine contractions (46% vs 23.5%, P < .001). Abnormal fetal heart tracing, premature rupture of membranes and placental injury were similar between groups (all P > .05). The rate of maternal complications was similar in both groups (all P > .05). Conclusion: In this study, the rate of (+)Utox in PTPs was 9.8%. The (+)Utox group had similar rates of maternal complications but more commonly experienced uterine contractions which may be related to the physiology of drugs such as methamphetamines. PTPs with (+)Utox also more commonly were victims of domestic violence and suicide attempt, which merits further prevention research efforts.

Incidence of fracture hospitalization and surgery during pregnancy in Finland-1998-2017: a retrospective register-based cohort study

INTRODUCTION

The aim of this study was to assess the incidence of all major fractures and surgery during pregnancy and the outcomes of pregnancy in Finland between 1998 and 2017.

MATERIALS AND METHODS

A retrospective cohort study using nationwide data from the Finnish Care Register for Health Care and the Finnish Medical Birth Register. As participants we included all women aged between 15 and 49 years from January 1, 1998 to December 31, 2017 and their ≥ 22-week pregnancies.

RESULTS

Of a total 629,911 pregnancies, 1813 pregnant women were hospitalized with a fracture diagnosis, yielding an incidence of 247 fractures/100,000 pregnancy-years. Of these, 24% (n = 513/2098) were treated operatively. The most common fractures were fractures of the tibia, ankle, and the forearm, which made up half of all fractures. The incidence of pelvic fractures was 6.8/100,000 pregnancy-years, with an operation rate of 14%. The stillbirth rate of all fracture patients was low at 0.6% (n = 10/1813), although this was 1.5-fold the overall stillbirth rate in Finland. Lumbosacral and comminuted spinopelvic fractures resulted in preterm delivery in 25% (n = 5/20) of parturients, with a stillbirth rate of 10% (n = 2/20).

CONCLUSION

The incidence of fracture hospitalization during pregnancy is lower than in the general population, and fractures in this population are more often treated conservatively. A higher proportion of preterm deliveries and stillbirths occurred in women with lumbosacral and comminuted spinopelvic fractures. Maternal mortality and stillbirth rates remain low among women with fractures leading to hospitalization or surgery during pregnancy.

Major trauma in pregnancy: prediction of maternal and perinatal adverse outcomes

BACKGROUND

Trauma, largely the consequence of motor vehicle crashes, is the leading cause of pregnancy-associated maternal mortality. Prediction of adverse outcomes has been difficult in pregnancy given the infrequent occurrence of traumatic events and anatomic considerations unique to pregnancy. The injury severity score, an anatomic scoring system with weighting dependent on severity and anatomic region of injury, is used in the prediction of adverse outcomes in the nonpregnant population but has yet to be validated in pregnancy.

OBJECTIVE

This study aimed to estimate the associations between risk factors and adverse pregnancy outcomes after major trauma in pregnancy and to develop a clinical prediction model for adverse maternal and perinatal outcomes.

STUDY DESIGN

This was a retrospective analysis of a cohort of pregnant patients who sustained major trauma and who were admitted to 1 of 2 level 1 trauma centers. Three composite adverse pregnancy outcomes were evaluated, namely adverse maternal outcomes and short- and long-term adverse perinatal outcomes, defined as outcomes occurring within the first 72 hours of the traumatic event or encompassing the entire pregnancy. Bivariate analyses were performed to estimate the associations between clinical or trauma-related variables and adverse pregnancy outcomes. Multivariable logistic regression analyses were performed to predict each adverse pregnancy outcome. The predictive performance of each model was estimated using receiver operating characteristic curve analyses.

RESULTS

A total of 119 pregnant trauma patients were included, 26.1% of whom met the severe adverse maternal pregnancy outcome criteria, 29.4% of whom met the severe short-term adverse perinatal pregnancy outcome definition, and 51.3% of whom met the severe long-term adverse perinatal pregnancy outcome definition. Injury severity score and gestational age were associated with the composite short-term adverse perinatal pregnancy outcome with an adjusted odds ratio of 1.20 (95% confidence interval, 1.11-1.30). The injury severity score was solely predictive of the adverse maternal and long-term adverse perinatal pregnancy outcomes with odds ratios of 1.65 (95% confidence interval, 1.31-2.09) and 1.14 (95% confidence interval, 1.07-1.23), respectively. An injury severity score ≥8 was the best cutoff for predicting adverse maternal outcomes with 96.8% sensitivity and 92.0% specificity (area under the receiver operating characteristic curve, 0.990±0.006). An injury severity score ≥3 was the best cutoff for the short-term adverse perinatal outcomes, which correlates with a 68.6% sensitivity and 65.1% specificity (area under the receiver operating characteristic curve, 0.755±0.055). An injury severity score ≥2 was the best cutoff for the long-term adverse perinatal outcomes, yielding a 68.3% sensitivity and 72.4% specificity (area under the receiver operating characteristic curve, 0.763±0.042).

CONCLUSION

For pregnant trauma patients, an injury severity score of ≥8 was predictive of severe adverse maternal outcomes. Minor trauma in pregnancy, defined in this study as an injury severity score <2, was not associated with maternal or perinatal morbidity or mortality. These data can guide management decisions for pregnant patients who present after trauma.

The impact of minor trauma during pregnancy on maternal and neonatal outcomes: A tertiary centre experience

Introduction

The aim of this study was to evaluate the impact of minor trauma during pregnancy on maternal and fetal outcomes in patients managed in a tertiary setting.

Materials and methods

A retrospective single centre case-controlled study was performed between 2005 and 2017 in a university affiliated tertiary obstetric and trauma centre. All pregnant women of 13-36 weeks gestation that presented to the department of emergency medicine with an Injury Severity Score of <9 were identified. Maternal and neonatal outcomes were compared with a control group of non-trauma pregnant women during the study at a ratio of 1:4. Variables found significant on univariate analysis were included in a multivariate regression analysis.

Results

There were 388 patients allocated to the study group and 2528 to the control group. The groups were demographically similar, however trauma was more common amongst first-time mothers and those pregnant with twins. On univariate analysis, minor trauma was associated with lower gestation age at delivery, lower birth weight, more caesarean sections, lower Apgar scores at 1 and 5 min, longer neonatal hospital admissions and an increased incidence of neonatal intensive care admission. On multivariate analysis, minor trauma remained associated with an earlier gestational age at birth (OR 0.863, 95% CI 0.787-0.946, p = 0.002).

Conclusion

Pregnant women who sustained minor trauma during pregnancy should be considered at high-risk of early labour.

Management of the Pregnant Trauma Patient: A Systematic Literature Review

INTRODUCTION

Trauma during pregnancy is the leading cause of non-obstetric maternal death and complicates up to 5%-7% of pregnancies. This systematic review without meta-analysis explores the current literature regarding the assessment and management of pregnant trauma patients to provide evidence-based recommendations to guide the general surgeon regarding the prognostic value of laboratory testing including Kleihauer-Betke testing, duration of maternal and fetal monitoring, the use of tranexamic acid, the safety of radiographic studies, and the utility of perimortem cesarean section to improve maternal and fetal mortality.

MATERIALS AND METHODS

A systematic search of MEDLINE (Ovid), the Cochrane Library (Wiley), and Embase (Elsevier) was performed. The reference lists of included studies were reviewed for relevant citations.

RESULTS

Of the 45 studies included in this review, there was reasonable evidence to suggest that the minimally injured pregnant trauma patient should be observed for a minimum of 4 h, CT scans to rule out traumatic injury are necessary and safe, perimortem cesarean sections should be performed as soon as maternal cardiac arrest occurs.

CONCLUSIONS

We recommend delivery by perimortem cesarean section as soon as possible after maternal cardiac arrest, to provide TXA to the hemorrhaging pregnant trauma patient, to obtain trauma CT scans as indicated, and to observe the injured pregnant patient for a minimum of at least 4 h. Additional high-quality studies focusing on the prognostic potential of KB tests and other laboratory studies are needed.

Traumatic Brain Injury in Pregnancy

Objective The present paper aims to provide a review on the main complications involving traumatic brain injury (TBI) during pregnancy and on the vegetative state after TBI.

Methods A systematic review was performed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria checklist.

Results Seven studies were included, of which four were case reports, one was a follow-up, one was a comparative study, and one was a literature review.

Discussion Presence of neurological deficits such as hemiparesis, neonatal seizures, cerebral palsy, hemorrhage or hydrocephalus was observed in children of mothers who suffered trauma during pregnancy. The prolongation of a pregnancy in these victims, even in brain death, is within the reach of current medicine. Ethical issues must be considered when deciding to prolong a pregnancy of a woman in brain death.

Conclusion For the evaluation of pregnant women with TBI, there is a protocol that can be followed in the emergency care service. The cases reported in the literature suggest that there is no clear limit to restrict support to a pregnant patient in a vegetative state. Further studies should be done to elucidate this matter.

[The (severely) injured pregnant patient from the perspective of trauma surgery]

BACKGROUND

Trauma is the leading cause for nonpregnancy-linked maternal mortality in pregnant women, even though the exact incidence for accidents in pregnancy is unknown. Trauma management concepts applied for nonpregnant adult patients are just as valid for injured and severely injured pregnant women but in addition trauma management has to consider the unique physiological and pathophysiological conditions for a favorable maternal and fetal outcome.

OBJECTIVE

Overview of current data about the epidemiology, injury mechanisms, maternal and fetal outcome and recommendations on the management of injured pregnant women based on a systematic literature search.

RESULTS

Currently, there is no evidence indicating an association between maternal injury severity, the physiological condition and the fetal outcome. Practice guidelines for trauma management in pregnancy recommend prioritization of maternal treatment and resuscitation for optimal initial treatment of the fetus. The current recommendations for trauma room management in pregnancy, surgical treatment, including damage control surgery, are based on weak evidence.

CONCLUSION

The examination, stabilization and treatment of injured pregnant women has priority for fetal survival and outcome. The management of severe trauma in pregnancy requires a multidisciplinary expertise and team approach consisting of surgeons, anesthetists, radiologists, obstetricians and neonatologists, so that for a severely injured gravida, the decision for admission to designated trauma centers is already preclinically made. The principles of management and treatment of severely injured pregnant women should adhere to the treatment principles of nonpregnant trauma victims.

Management of Pelvic Ring Injury Patients With Hemodynamic Instability

Pelvic ring injuries (PRI) are among the most difficult injuries to deal with in orthopedic trauma. When these injuries are accompanied by hemodynamic instability their management becomes significantly more complex. A methodical assessment and expeditious triage are required for these patients followed by adequate resuscitation. A major triage decision is whether these patients should undergo arterial embolization in the angiography suit or prompt packing and pelvic stabilization in the operating room. Patient characteristics, fracture type and injury characteristics are taken into consideration in the decision-making process. In this review we discuss the acute evaluation, triage and management of PRIs associated with hemodynamic instability. An evidence based and protocol driven approach is necessary in order to achieve optimal outcomes in these patients.

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.

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.

Blunt traumatic injury during pregnancy: a descriptive analysis from a level 1 trauma center

PURPOSE

The precise incidence of trauma in pregnancy is not well-known, but trauma is estimated to complicate nearly 1 in 12 pregnancies and it is the leading non-obstetrical cause of maternal death.

METHODS

A retrospective study of all pregnant women presented to national level 1 trauma center from July 2013 to June 2015 was conducted. Descriptive and inferential statistics applied for data analysis.

RESULTS

Across the study period, a total of 95 pregnant women were presented to the trauma center. The average incidence rate of traumatic injuries was 250 per 1000 women of childbearing age presented to the Hamad Trauma Center. The mean age of patients was 30.4 ± SD 5.6 years, with age ranging from 20 to 42 years. The mean gestational age at the time of injury was 24.7 ± 8.7 weeks which ranged from 5 to 37 weeks. The majority (47.7%) was in the third trimester of the pregnancy. In addition, the large majority of injuries was due to MVCs (74.7%) followed by falls (15.8%).

CONCLUSIONS

Trauma during pregnancy is not an uncommon event particularly in the traffic-related crashes. As it is a complex condition for trauma surgeons and obstetrician, an appropriate management protocol and multidisciplinary team are needed to improve the outcome and save lives of both the mother and fetus.

Accuracy of massive transfusion as a surrogate for significant traumatic bleeding in health administrative datasets

BACKGROUND

Due to the challenge of identifying need for intervention in bleeding patients, there is a growing interest in prediction modeling. Massive transfusion (MT; 10 or more packed red cells in 24 h) is the most commonly studied dependent variable, serving as a surrogate for severe bleeding and its prediction guides the need for intervention. The critical administration threshold (CAT; 3 packed red cells in 1 h) has been proposed as an alternative. In this study, we aim to compare the classification accuracy of these two surrogates for hemorrhage-related outcomes in health administrative datasets.

METHODS

We performed a secondary analysis of major trauma patients from the prospectively collected Ottawa Trauma Registry, from September 2014 to September 2017. We conducted a logistic regression analysis utilizing need for hemostasis or hemorrhagic death as dependent variables. We compared classification accuracy in terms of sensitivity, specificity, positive predictive value, negative predictive value and AUC. CAT + and MT + status is not mutually exclusive.

RESULTS

We studied 890 major trauma patients, including 145 CAT + and 48 MT + patients. CAT + demonstrated a superior association for the composite outcome of 24-hour hemorrhage-related mortality and need for hemostasis (AUC 0.815 vs. 0.644, p < 0.0001). This performance was driven by a substantial difference in sensitivity, noted to be 70.0% (95% CI 62.1-77.9%) for CAT + but only 30.0% (95% CI 22.1-37.9%) for MT+. CAT + and MT + demonstrated specificities of 92.9% (95% CI 91.1-94.7%) and 98.9% (98.1-99.6%) respectively.

CONCLUSION

This study illustrates the concepts of survivorship and competing risk bias for massive transfusion. Utilizing a composite outcome of need for hemostasis and early hemorrhagic death, we demonstrate that CAT + is more accurate for identifying significantly bleeding patients.

The Pregnant Trauma Patient

Trauma is the leading non-obstetric cause of maternal death. Optimal management of the pregnant trauma patient requires a multidisciplinary approach. The anaesthetist and critical care physician play a pivotal role in the entire continuum of fetomaternal care, from initial assessment, resuscitation and intraoperative management, to postoperative care that often involves critical care support and patient transfer. Primary goals are aggressive resuscitation of the mother and maintenance of uteroplacental perfusion and fetal oxygenation by the avoidance of hypoxia, hypotension, hypocapnia, acidosis and hypothermia. Recognizing and understanding the mechanisms of injury, the factors that may predict fetal outcome, and the pathophysiological changes that can result from trauma, will allow early identification and treatment of fetomaternal injury. This in turn should improve morbidity and mortality. A framework for the acute care of the pregnant trauma patient is presented.

Lateral Compression-I Pelvic Ring Injury: Not Benign to the Developing Fetus

OBJECTIVE

To determine whether certain patterns of pelvic ring injury are associated with more frequent intrauterine fetal demise (IUFD).

DESIGN

Retrospective review.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Of 44 pregnant patients with pelvic and/or acetabular fractures, 40 had complete records that allowed determination of fetal viability. χ2 tests were used for categorical variables (Fisher exact tests when expected cell counts were fewer than 5), and t tests were used for continuous variables.

MAIN OUTCOME MEASUREMENTS

Fetal or maternal death.

RESULTS

Sixteen patients had isolated acetabular fractures, 25 had isolated pelvic ring injuries, and 3 had acetabular fractures with concomitant pelvic ring injuries. Maternal and fetal mortality were 2% and 40%, respectively. No patients with isolated acetabular fractures experienced IUFD, compared with 68% (15/22) of those with isolated pelvic ring injuries (P < 0.0001). Eight (53%) of 15 IUFDs were associated with lateral compression (LC)-I pelvic ring injuries (Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen 61-B2). Of the 13 LC-I pelvic ring injuries, 8 (62%) resulted in IUFD. Pelvic ring stability, Young-Burgess classification, and operative treatment were not associated with IUFD. Maternal Glasgow Coma Scale (average 13.2) and Injury Severity Score (average 18.2) at admission were predictive of IUFD.

CONCLUSIONS

The most frequent pelvic fractures in gravid trauma patients are LC-I. Although the rate of maternal mortality was low, the risk of IUFD was quite high (40%). LC-I pelvic ring injuries often had catastrophic outcomes, with IUFD in 62% of cases.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

Update on open reduction and internal fixation of unstable pelvic fractures during pregnancy: case reports

This article aims to report four cases of unstable pelvic fractures in pregnant women treated by open reduction and internal fixation.

Cases report

The study included four cases of pregnant women with unstable pelvic fractures; their outcomes were analyzed and discussed. Data were obtained from two University Hospitals. The mean age of women was 23 years; most (3/4) were primiparous, with a mean pregnancy age of 23 weeks. Two women had Malgaigne-type fractures and the other two had symphyseal disjunction associated with acetabular fractures. All fractures were treated surgically. One foetus was dead on admission to hospital. The other three developed well, along with their mothers. Good evolution was only possible with careful pre-, peri-, and postoperative care for the mother, as well as foetal assessment by a multidisciplinary team. In complex cases such as those presented in the present study, pre-, peri-, and postoperative care are mandatory, as well as the presence of a multidisciplinary team. The mother's life always takes priority in acute clinical pictures, as it offers the best chance of survival to both mother and child.

[Trauma and pregnancy: Is the Kleihauer-Betke test really useful?]

OBJECTIVE

To evaluate the pertinence of Kleihauer-Betke (KB) test, in case of abdominal trauma during pregnancy in forecast of fetal outcomes, according to trauma severity.

METHODS

A single-center retrospective study conducted between January 2014 and April 2016 in a maternity type III and a trauma center, which included the pregnant women admitted for abdominal trauma. The trauma's severity was assessed using the guidelines of the Society of Obstetricians and Gynaecologists of Canada. The impact of a positive KB test, defined as>0.1%, was analyzed. Adverse outcome was defined as one or more of the following complications: intrauterine fetal death, placental abruption, pre-term birth<37 weeks of gestation, and fetal or neonatal anemia.

RESULTS

During the study period, 265 pregnancies involved into an abdominal trauma were included: 69% with a minor trauma and 31% with a severe trauma. Of all patients, 5.6% presented a positive KB test, among then 15.4% had an adverse outcome. There was no significant difference in the rate of adverse outcomes in the positive KB group and the KB negative group either in the overall population (P=0.16), in the minor trauma population (P=1) or in the major trauma population (P=0.14). The predictive positive values were respectively in the global population, in the minor trauma group and in the severe trauma group 15.4%, 0% and 25%.

CONCLUSIONS

The KB test does not seem to be useful in case of trauma during pregnancy to define adverse outcome.

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.

Guidelines for the Management of a Pregnant Trauma Patient

OBJECTIVE

Physical trauma affects 1 in 12 pregnant women and has a major impact on maternal mortality and morbidity and on pregnancy outcome. A multidisciplinary approach is warranted to optimize outcome for both the mother and her fetus. The aim of this document is to provide the obstetric care provider with an evidence-based systematic approach to the pregnant trauma patient.

OUTCOMES

Significant health and economic outcomes considered in comparing alternative practices.

EVIDENCE

Published literature was retrieved through searches of Medline, CINAHL, and The Cochrane Library from October 2007 to September 2013 using appropriate controlled vocabulary (e.g., pregnancy, Cesarean section, hypotension, domestic violence, shock) and key words (e.g., trauma, perimortem Cesarean, Kleihauer-Betke, supine hypotension, electrical shock). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English between January 1968 and September 2013. Searches were updated on a regular basis and incorporated in the guideline to February 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

This guideline is expected to facilitate optimal and uniform care for pregnancies complicated by trauma. Summary Statement Specific traumatic injuries At this time, there is insufficient evidence to support the practice of disabling air bags for pregnant women. (III) Recommendations Primary survey 1. Every female of reproductive age with significant injuries should be considered pregnant until proven otherwise by a definitive pregnancy test or ultrasound scan. (III-C) 2. A nasogastric tube should be inserted in a semiconscious or unconscious injured pregnant woman to prevent aspiration of acidic gastric content. (III-C) 3. Oxygen supplementation should be given to maintain maternal oxygen saturation > 95% to ensure adequate fetal oxygenation. (II-1B) 4. If needed, a thoracostomy tube should be inserted in an injured pregnant woman 1 or 2 intercostal spaces higher than usual. (III-C) 5. Two large bore (14 to 16 gauge) intravenous lines should be placed in a seriously injured pregnant woman. (III-C) 6. Because of their adverse effect on uteroplacental perfusion, vasopressors in pregnant women should be used only for intractable hypotension that is unresponsive to fluid resuscitation. (II-3B) 7. After mid-pregnancy, the gravid uterus should be moved off the inferior vena cava to increase venous return and cardiac output in the acutely injured pregnant woman. This may be achieved by manual displacement of the uterus or left lateral tilt. Care should be taken to secure the spinal cord when using left lateral tilt. (II-1B) 8. To avoid rhesus D (Rh) alloimmunization in Rh-negative mothers, O-negative blood should be transfused when needed until cross-matched blood becomes available. (I-A) 9. The abdominal portion of military anti-shock trousers should not be inflated on a pregnant woman because this may reduce placental perfusion. (II-3B) Transfer to health care facility 10. Transfer or transport to a maternity facility (triage of a labour and delivery unit) is advocated when injuries are neither life- nor limb-threatening and the fetus is viable (≥ 23 weeks), and to the emergency room when the fetus is under 23 weeks' gestational age or considered to be non-viable. When the injury is major, the patient should be transferred or transported to the trauma unit or emergency room, regardless of gestational age. (III-B) 11. When the severity of injury is undetermined or when the gestational age is uncertain, the patient should be evaluated in the trauma unit or emergency room to rule out major injuries. (III-C) Evaluation of a pregnant trauma patient in the emergency room 12. In cases of major trauma, the assessment, stabilization, and care of the pregnant women is the first priority; then, if the fetus is viable (≥ 23 weeks), fetal heart rate auscultation and fetal monitoring can be initiated and an obstetrical consultation obtained as soon as feasible. (II-3B) 13. In pregnant women with a viable fetus (≥ 23 weeks) and suspected uterine contractions, placental abruption, or traumatic uterine rupture, urgent obstetrical consultation is recommended. (II-3B) 14. In cases of vaginal bleeding at or after 23 weeks, speculum or digital vaginal examination should be deferred until placenta previa is excluded by a prior or current ultrasound scan. (III-C) Adjunctive tests for maternal assessment 15. Radiographic studies indicated for maternal evaluation including abdominal computed tomography should not be deferred or delayed due to concerns regarding fetal exposure to radiation. (II-2B) 16. Use of gadolinium-based contrast agents can be considered when maternal benefit outweighs potential fetal risks. (III-C) 17. In addition to the routine blood tests, a pregnant trauma patient should have a coagulation panel including fibrinogen. (III-C) 18. Focused abdominal sonography for trauma should be considered for detection of intraperitoneal bleeding in pregnant trauma patients. (II-3B) 19. Abdominal computed tomography may be considered as an alternative to diagnostic peritoneal lavage or open lavage when intra-abdominal bleeding is suspected. (III-C) Fetal assessment 20. All pregnant trauma patients with a viable pregnancy (≥ 23 weeks) should undergo electronic fetal monitoring for at least 4 hours. (II-3B) 21. Pregnant trauma patients (≥ 23 weeks) with adverse factors including uterine tenderness, significant abdominal pain, vaginal bleeding, sustained contractions (> 1/10 min), rupture of the membranes, atypical or abnormal fetal heart rate pattern, high risk mechanism of injury, or serum fibrinogen < 200 mg/dL should be admitted for observation for 24 hours. (III-B) 22. Anti-D immunoglobulin should be given to all rhesus D-negative pregnant trauma patients. (III-B) 23. In Rh-negative pregnant trauma patients, quantification of maternal-fetal hemorrhage by tests such as Kleihauer-Betke should be done to determine the need for additional doses of anti-D immunoglobulin. (III-B) 24. An urgent obstetrical ultrasound scan should be undertaken when the gestational age is undetermined and need for delivery is anticipated. (III-C) 25. All pregnant trauma patients with a viable pregnancy who are admitted for fetal monitoring for greater than 4 hours should have an obstetrical ultrasound prior to discharge from hospital. (III-C) 26. Fetal well-being should be carefully documented in cases involving violence, especially for legal purposes. (III-C) Obstetrical complications of trauma 27. Management of suspected placental abruption should not be delayed pending confirmation by ultrasonography as ultrasound is not a sensitive tool for its diagnosis. (II-3D) Specific traumatic injuries 28. Tetanus vaccination is safe in pregnancy and should be given when indicated. (II-3B) 29. Every woman who sustains trauma should be questioned specifically about domestic or intimate partner violence. (II-3B) 30. During prenatal visits, the caregiver should emphasize the importance of wearing seatbelts properly at all times. (II-2B) Perimortem Caesarean section 31. A Caesarean section should be performed for viable pregnancies (≥ 23 weeks) no later than 4 minutes (when possible) following maternal cardiac arrest to aid with maternal resuscitation and fetal salvage. (III-B).

Trauma in pregnancy and its consequences in Kermanshah, Iran from 2007 to 2010

OBJECTIVE

Nowadays, with decreased mortality of pregnant women by obstetrical causes, trauma has become a leading cause of morbidity and mortality in pregnant women. This study was carried out to determine the frequency of trauma in pregnancy and related causes and selected consequences in pregnant women of Kermanshah, Iran from 2007 to 2010.

METHODS

In this descriptive-analytical study, all pregnant women who suffered trauma and were admitted to Imam Reza, Taleghani, and Motazedi hospitals located in Kermanshah from 2007-2010 were studied. Sampling was done by census method and medical records of all eligible patients were studied. Data analysis was done by the SPSS software for Windows 9ver. 16.0).

RESULTS

There were 102 cases of trauma in pregnancy registered in this time period. Mean age of the cases was 26 years. Most cases (43%) were in their third trimester of pregnancy upon admission. Most trauma cases were of blunt traumas (68%). In 68 cases (66.67%), trauma resulted in maternal injury (independent of pregnancy) and 13 cases (12.75%) resulted in obstetrical or fetal injuries. Maternal injuries showed significant difference (P= 0.02) in different years. Motor vehicle accidents with a frequency of 47% were the most common cause of trauma.

CONCLUSION

Trauma in pregnancy can be a leading cause of injury and fatality in mother and fetus. The most common type of injury was motor vehicle accidents. Therefore, any strategy that can decrease the rate of motor vehicle accident in a community can decrease mortalities of women (even pregnant or non-pregnant).

Trauma in pregnancy: an updated systematic review

We reviewed recent data on the prevalence, risk factors, complications, and management of trauma during pregnancy. Using the terms "trauma" and "pregnancy" along with specified mechanisms of injury, we queried the PubMed database for studies reported from Jan. 1, 1990, through May 1, 2012. Studies with the largest number of patients for a given injury type and that were population-based and/or prospective were included. Case reports and case series were used only when more robust studies were lacking. A total of 1164 abstracts were reviewed and 225 met criteria for inclusion. Domestic violence/intimate partner violence and motor vehicle crashes are the predominant causes of reported trauma during pregnancy. Management of trauma during pregnancy is dictated by its severity and should be initially geared toward maternal stabilization. Minor trauma can often be safely evaluated with simple diagnostic modalities. Pregnancy should not lead to underdiagnosis or undertreatment of trauma due to unfounded fears of fetal effects. More studies are required to elucidate the safest and most cost-effective strategies for the management of trauma in pregnancy.

Pregnancy and trauma: analysis of 139 cases

OBJECTIVE

The aim of this study was to examine the diagnoses and treatment methods and demographical and clinical characteristics of pregnant women who were exposed to trauma and in additon, review of the literature was carried out in this regard.

MATERIAL AND METHODS

One hundred thirty-nine pregnant women who presented at the Yüzüncü Yıl University between January 2006 and September 2009 with local or general body trauma complaints were analysed retrospectively.

RESULTS

The average age of the cases was 26.72±6.29 years and the age group ranging from 21-34 composed the majority. When they were studied according to their etiologies, falls during daily activities formed 43.9%. When they were analyzed in terms of their gestational weeks, 64.46% were in the 3(rd) trimester. Pregnant cases with trauma resulted in maternal (3 cases) and fetal (9 cases) loss. It was found that 19 cases who had imaging techniques involving radiation and whose gestation was continuing had a problem-free gestation period and healthy children.

CONCLUSION

It is mandatory to evaluate both mother and fetus together when trauma exposure is in question, the general well-being of the fetus should be provided and the mother should be informed about the presence of advanced trauma life support.

Nitroglycerin prevents coagulopathies and foetal death associated with abnormal maternal inflammation in rats

Inflammation-associated foetal loss is often linked to maternal coagulopathies. Here, we characterised the role of maternal inflammation in the development of various systemic maternal coagulopathies and foetal death during mid-to-late gestation in rats. Since nitric oxide (NO) functions as an inhibitor of platelet aggregation and anti-oxidant, we also tested whether the NO mimetic nitroglycerin (glyceryl trinitrate, GTN) prevents inflammation-associated coagulopathies and foetal death. To induce chronic inflammation, pregnant Wistar rats were injected with low-doses of lipopolysaccharide (LPS; 10-40 μg/kg) on gestational days (GD) 13.5-16.5. To determine whether the effects of inflammation are mediated by tumour necrosis factor-α (TNF-α), the TNF-α inhibitor etanercept was injected on GD 13.5 and 15.5. Controls consisted of rats injected with saline. GTN was administered to LPS-treated rats via daily application of a transdermal patch on GD 12.5-16.5. Using thromboelastography (TEG), various coagulation parameters were assessed on GD 17.5; foetal viability was determined morphologically. Reference coagulation parameters were established based on TEG results obtained from control animals. LPS-treated rats exhibited distinct systemic coagulopathies: hypercoagulability, hypocoagulability, hyperfibrinolysis, and disseminated intravascular coagulation (DIC) stages I and III. A specific foetal death coagulation phenotype was observed, implicating TEG as a potential tool to identify inflammation-induced haemostatic alterations associated with pregnancy loss. Treatment with etanercept reduced the incidence of coagulopathy by 47%, while continuous delivery of GTN prevented foetal death and the inflammation-induced coagulopathies. These findings provide a rationale for investigating the use of GTN in the prevention of maternal coagulopathies and inflammation-mediated foetal death.

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

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

Trauma in pregnancy

Although serious trauma during pregnancy is uncommon, it remains a major cause of maternal and fetal death and presents a variety of patient care challenges. The anatomic and physiologic changes of pregnancy can affect both the nature of an injury and the body's response to it. Here, the author describes the mechanisms of traumatic injury during pregnancy, discusses the normal changes of pregnancy and their implications in the care of pregnant trauma patients, and offers strategies for assessment and treatment.

Open-book pelvic fracture in late pregnancy

Pelvic fractures in pregnancy are a relatively rare event. Special consideration needs to be considered when evaluating these patients. We present a case of a 15-year-old pregnant teenager who was an unrestrained passenger in a motor vehicle collision who sustained an open-book pelvic fracture. Care of the patient requires a coordination of care between the patient and the fetus.

Trauma in the obstetrical patient

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

Perinatal Outcomes of Traumatic Injuries During Pregnancy

Traumatic injuries although uncommon (affect 6% to 7% of all pregnancies) are associated with poor maternal, fetal, neonatal, and infant outcomes. The magnitude of the problem is most likely largely underestimated secondary to lack of standardized reporting. Newer data are available that stratify maternal risk by type of injury sustained, and may assist in evaluation of the pregnant trauma victim. Long-term adverse events after maternal discharge for a traumatic injury are emerging, and suggest closer monitoring of the patient for preterm labor, growth restriction, and placental abruption during the affected pregnancy.

Predictors of Fetal Outcome in Pregnant Trauma Patients: A Five-Year Institutional Review

Injury Severity Score (ISS) and lactate are controversial in predicting fetal outcome. A retrospective review was conducted to determine whether ISS and lactate are valuable in predicting fetal survival in injured pregnant patients. Injured pregnant women were identified by ICD-9 codes from our Trauma Registry, Emergency Department Registry, and hospital medical records. Records were reviewed for demographic data, mechanism of injury, ISS, Glascow Coma Scale, lactate, vital signs, and maternal/fetal outcome. To determine statistical analysis, χ2 and t test analysis was performed. From 2001 to 2005, 294 women reported injuries. Most patients (51.7%) were discharged from the Emergency Department, yet 18 per cent were admitted to Trauma Surgery. The average maternal and gestational age was 23.4 years and 19.6 weeks, respectively. Seventy-two (33.3%) patients were in the first trimester. The majority of patients (88.1%) were involved in blunt trauma, and 10 (3.9%) had poor fetal outcome (nine fetal deaths and one hydrops fetalis). There were no maternal deaths. Maternal age, first trimester, elevated lactate, and high ISS were significant risk factors for poor fetal outcome (P = 0.044, P = 0.0173, P = 0.0001, and P = 0.0001, respectively). Specific parameters (ISS, lactate, maternal age, and gestational age) may be helpful in predicting poor fetal outcome and directing patient management.

[Traumatic uterine rupture: a rare complication of motor vehicle accidents during pregnancy. A case report]

The rupture of gravid uterus is a rare complication concerning less than one percent of the pregnant women involved in a motor vehicle accident. The authors report the case of a 39-year woman, gravida 4, referred for an uterine rupture with intrauterine fetal death at 24 weeks gestation, following a car crash. The surgical laparotomic exploration in emergency showed a wide fundal uterine tear with placental abruption. The placenta and the fetus were found in the abdominal cavity. A conservative surgical treatment could be realized. Principles of management, which must be quick and co-ordinated, are reminded.

The Consequences of High-Risk Behaviors: Trauma During Pregnancy

BACKGROUND

Trauma during pregnancy places two lives at risk. Knowledge of risk factors for trauma during pregnancy may improve outcomes.

METHODS

We reviewed the charts of 188 such patients admitted to a Level I trauma center from 1996 to 2004. A comparison was made of injury severity and outcome from a cohort of nonpregnant female trauma patients selected with a similar temporal occurrence and age range.

RESULTS

Motor vehicle collisions comprised 160 cases, 67 using a restraint device. Of 84 patients tested, 45 tested positive for intoxicants, 16 positive for 2 or more intoxicants. A significant trend toward less testing through the study period was observed (p = 0.0002). Injury severity was assessed by Revised Trauma Score (RTS). RTS <11 or admission to operating room or intensive care units (OR/ICU) classified patients as severely injured. The six maternal fatalities had an RTS <11 or OR/ICU disposition. Fetal outcomes included 155 live in utero, 18 live births, and 15 fatalities correlating with injury severity by either criteria (p < 0.0001). Of the fetal fatalities, 7 occurred with RTS = 12, but only 3 fatalities occurred in the 147 cases not admitted to OR/ICU. Gestational age correlated (p < 0.0001) with fetal outcomes. The 18 live births had mean gestational ages of 35 +/- 4 weeks as compared with fetal fatalities at 20 +/- 9 weeks, and fetuses alive in utero at 22 +/- 9 weeks gestation. Coagulation tests prothrombin time (PT), international normalized ratio (INR) (both p < 0.008), and partial thromboplastin time (PTT) (p < 0.0001) correlated with maternal outcome. A matched cohort of nonpregnancy trauma cases during the same time frame indicated that, despite a significantly higher percentage of severely injured patients, fewer fatalities occurred. This might reflect a greater risk for the pregnant trauma patient.

CONCLUSIONS

This study of trauma in pregnancy cases revealed a high percentage with risk behaviors. There was a significant trend toward less intoxicant testing in recent years. Coagulation tests were the most predictive of outcomes. Lower gestational age correlated with fetal demise.

Long-term fetal outcomes in pregnant trauma patients

BACKGROUND

Trauma during pregnancy is associated with significant maternal and fetal morbidity and mortality, typically occurring during the hospital admission. Less is known about the delayed effects of trauma on pregnancy outcome once the patient has been discharged from the hospital with a viable fetus.

METHODS

A retrospective cohort study was conducted of pregnant trauma patients who were discharged from the trauma center with a viable fetus. Risk of preterm delivery (PTD) and low birth weight (LBW) were compared between injured patients (Injury Severity Score > 0) and those without identified injury (Injury Severity Score = 0), for the remainder of pregnancy.

RESULTS

Even after trauma center discharge, injured patients had a nearly 2-fold higher risk of PTD (relative risk, 1.9; 95% confidence interval, 1.1-3.3) and LBW (relative risk, 1.8; 95% confidence interval, 1.04-3.2) for the remainder of the pregnancy. The risk was higher with increasing injury severity and among those injured early in gestation.

CONCLUSION

The risk of PTD and LBW in pregnant trauma patients who were discharged from trauma centers with a viable fetus remains increased throughout the remainder of the pregnancy. A history of trauma during gestation is a risk factor for poor pregnancy outcome.

Association of maternal fractures with adverse perinatal outcomes

OBJECTIVE

We sought to assess the effects of fracture injuries on maternal and fetal/neonatal outcomes in a large obstetric population.

STUDY DESIGN

We performed a retrospective cohort study using a database in which maternal and neonatal hospital discharge summaries were linked with birth and death certificates to identify any relation between maternal fractures and maternal and perinatal morbidity. Fracture injuries and perinatal outcomes were identified with the use of the International Classification of Diseases, 9th revision, Clinical Modification codes. Outcomes were further subdivided on the basis of anatomic site of fracture.

RESULTS

A total of 3292 women with > or = 1 fractures were identified. Maternal mortality (odds ratio, 169 [95% CI, 83.2,346.4]) and morbidity (abruption and blood transfusion) rates were increased significantly in women who were delivered during hospitalization for their injury. Women who were discharged undelivered continued to have delayed morbidity, which included a 46% increased risk of low birth weight infants (odds ratio, 1.5 [95% CI, 1.3,1.7]) and a 9-fold increased risk of thrombotic events (odds ratio, 9.2 [95% CI, 1.3,65.7]) Pelvic fractures had the worst outcomes.

CONCLUSION

Fractures during pregnancy are an important marker for poor perinatal outcomes.

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.

Trauma during pregnancy

Trauma is the leading nonobstetrical cause of maternal death. The effect of trauma on the pregnant woman and unborn fetus can be devastating. The major causes of maternal injury are blunt trauma, penetrating trauma, burns, falls, and assaults. There are specific changes associated with pregnancy that are important for the clinician to consider when providing care to these patients. Initial management of traumatic injuries during pregnancy is essential for maternal and fetal well-being. This review outlines common causes of maternal trauma, the initial assessment of the pregnant trauma patient, and ongoing care for the pregnant trauma patient and unborn fetus.