Trauma in Pregnancy: A Systematic Approach

ABSTRACT

Trauma in pregnancy remains one of the major contributors to maternal and fetal morbidity and mortality. Potential complications include maternal injury or death, shock, internal hemorrhage, intrauterine fetal demise, direct fetal injury, abruptio placentae, and uterine rupture. The leading causes of obstetric trauma are motor vehicle accidents, falls, assaults, and gunshots, and ensuing injuries are classified as blunt abdominal trauma, pelvic fractures, or penetrating trauma. Many of the assessment and management aspects of obstetric trauma are unique to pregnancy, although initial evaluation and resuscitation should always be maternally directed. Once maternal stability is established, vigilant evaluation of fetal well-being becomes warranted. Continuous fetal heart monitoring, ultrasonography, computed tomography, open peritoneal lavage, and/or exploratory laparotomy may be indicated in a case of obstetric trauma. In view of the significant impact of trauma on the pregnant woman and her fetus, preventive strategies are paramount.

KEYWORDS

Trauma - pregnancy - uterine rupture - blunt trauma - pelvic fractures

REFERENCES

• 1 Centers for Disease Control and Prevention (CDC) . Maternal mortality—United States, 1982–1996.  MMWR Morb Mortal Wkly Rep. 1998;  47 705-707
• 2 Chames M C, Pearlman M D. Trauma during pregnancy: outcomes and clinical management.  Clin Obstet Gynecol. 2008;  51 398-408
• 3 Peckham C H, King R W. A study of intercurrent conditions observed during pregnancy.  Am J Obstet Gynecol. 1963;  87 609-624
• 4 Fildes J, Reed L, Jones N, Martin M, Barrett J. Trauma: the leading cause of maternal death.  J Trauma. 1992;  32 643-645
• 5 Harper M, Parsons L. Maternal deaths due to homicide and other injuries in North Carolina: 1992–1994.  Obstet Gynecol. 1997;  90 920-923
• 6 Dannenberg A L, Carter D M, Lawson H W, Ashton D M, Dorfman S F, Graham E H. Homicide and other injuries as causes of maternal death in New York City, 1987 through 1991.  Am J Obstet Gynecol. 1995;  172 1557-1564
• 7 El-Kady D, Gilbert W M, Anderson J, Danielsen B, Towner D, Smith L H. Trauma during pregnancy: an analysis of maternal and fetal outcomes in a large population.  Am J Obstet Gynecol. 2004;  190 1661-1668
• 8 Weiss H B. Pregnancy-associated injury hospitalizations in Pennsylvania, 1995.  Ann Emerg Med. 1999;  34 626-636
• 9 McFarlane J, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy. Severity and frequency of injuries and associated entry into prenatal care.  JAMA. 1992;  267 3176-3178
• 10 Stewart D E, Cecutti A. Physical abuse in pregnancy.  CMAJ. 1993;  149 1257-1263
• 11 Helton A S, McFarlane J, Anderson E T. Battered and pregnant: a prevalence study.  Am J Public Health. 1987;  77 1337-1339
• 12 Gazmararian J A, Lazorick S, Spitz A M, Ballard T J, Saltzman L E, Marks J S. Prevalence of violence against pregnant women.  JAMA. 1996;  275 1915-1920
• 13 Ribe J K, Teggatz J R, Harvey C M. Blows to the maternal abdomen causing fetal demise: report of three cases and a review of the literature.  J Forensic Sci. 1993;  38 1092-1096
• 14 American College of Obstetricians and Gynecologists . ACOG educational bulletin. Obstetric aspects of trauma management. Number 251, September 1998 (replaces Number 151, January 1991, and Number 161, November 1991).  Int J Gynaecol Obstet. 1999;  64 87-94
• 15 American College of Obstetrics and Gynecology . ACOG practice bulletin. Prevention of Rh D alloimmunization. Number 4, May 1999 (replaces educational bulletin Number 147, October 1990). Clinical management guidelines for obstetrician-gynecologists.  Int J Gynaecol Obstet. 1999;  66 63-70
• 16 Connolly A M, Katz V L, Bash K L, McMahon M J, Hansen W F. Trauma and pregnancy.  Am J Perinatol. 1997;  14 331-336
• 17 Higgins S D, Garite T J. Late abruptio placenta in trauma patients: implications for monitoring.  Obstet Gynecol. 1984;  63(3 Suppl) 10S-12S
• 18 Lavin Jr J P, Miodovnik M. Delayed abruption after maternal trauma as a result of an automobile accident.  J Reprod Med. 1981;  26 621-624
• 19 Pearlman M D, Tintinalli J E, Lorenz R P. Blunt trauma during pregnancy.  N Engl J Med. 1990;  323 1609-1613
• 20 Dahmus M A, Sibai B M. Blunt abdominal trauma: are there any predictive factors for abruptio placentae or maternal-fetal distress?.  Am J Obstet Gynecol. 1993;  169 1054-1059
• 21 Morris Jr J A, Rosenbower T J, Jurkovich G J et al.. Infant survival after cesarean section for trauma.  Ann Surg. 1996;  223 481-488 discussion 488-491
• 22 Pearlman M D, Tintinallli J E, Lorenz R P. A prospective controlled study of outcome after trauma during pregnancy.  Am J Obstet Gynecol. 1990;  162 1502-1507 discussion 1507-1510
• 23 Goodwin T M, Breen M T. Pregnancy outcome and fetomaternal hemorrhage after noncatastrophic trauma.  Am J Obstet Gynecol. 1990;  162 665-671
• 24 Richards J R, Ormsby E L, Romo M V, Gillen M A, McGahan J P. Blunt abdominal injury in the pregnant patient: detection with US.  Radiology. 2004;  233 463-470
• 25 Brown M A, Sirlin C B, Farahmand N, Hoyt D B, Casola G. Screening sonography in pregnant patients with blunt abdominal trauma.  J Ultrasound Med. 2005;  24 175-181 quiz 183-184
• 26 Esposito T J, Gens D R, Smith L G, Scorpio R. Evaluation of blunt abdominal trauma occurring during pregnancy.  J Trauma. 1989;  29 1628-1632
• 27 Kuhlmann R S, Cruikshank D P. Maternal trauma during pregnancy.  Clin Obstet Gynecol. 1994;  37 274-293
• 28 Gazmararian J A, Lazorick S, Spitz A M, Ballard T J, Saltzman L E, Marks J S. Prevalence of violence against pregnant women.  JAMA. 1996;  275 1915-1920
• 29 Sherer D M, Schenker J G. Accidental injury during pregnancy.  Obstet Gynecol Surv. 1989;  44 330-338
• 30 Kissinger D P, Rozycki G S, Morris Jr J A et al.. Trauma in pregnancy. Predicting pregnancy outcome.  Arch Surg. 1991;  126 1079-1086
• 31 Agnoli F L, Deutchman M E. Trauma in pregnancy.  J Fam Pract. 1993;  37 588-592
• 32 Härtl R, Ko K. In utero skull fracture: case report.  J Trauma. 1996;  41 549-552
• 33 Lee R V, Rodgers B D, White L M, Harvey R C. Cardiopulmonary resuscitation of pregnant women.  Am J Med. 1986;  81 311-318
• 34 Dandawate B, Eedarapalli P, Sawdy R. Cornual myometrial defect following blunt trauma in pregnancy: a case report.  Aust N Z J Obstet Gynaecol. 2007;  47 512-513
• 35 Nahum G. Uterine rupture in pregnancy. Jan 15, 2008. Accessed June 1, 2009 Available at http://emedicine.medscape.com/article/275854_overview
• 36 Mavroforou A, Koumantakis E, Michalodimitrakis E. Physicians' liability in obstetric and gynecology practice.  Med Law. 2005;  24 1-9
• 37 Murphy D J. Uterine rupture.  Curr Opin Obstet Gynecol. 2006;  18 135-140
• 38 Harrison S D, Nghiem H V, Shy K. Uterine rupture with fetal death following blunt trauma.  AJR Am J Roentgenol. 1995;  165 1452
• 39 Astarita D C, Feldman B. Seat belt placement resulting in uterine rupture.  J Trauma. 1997;  42 738-740
• 40 Buchsbaum H J. Accidental injury complicating pregnancy.  Am J Obstet Gynecol. 1968;  102 752-769
• 41 Williams J K, McClain L, Rosemurgy A S, Colorado N M. Evaluation of blunt abdominal trauma in the third trimester of pregnancy: maternal and fetal considerations.  Obstet Gynecol. 1990;  75 33-37
• 42 Plauché W C, Von Almen W, Muller R. Catastrophic uterine rupture.  Obstet Gynecol. 1984;  64 792-797
• 43 El Kady D, Gilbert W M, Xing G, Smith L H. Maternal and neonatal outcomes of assaults during pregnancy.  Obstet Gynecol. 2005;  105 357-363
• 44 Wolf M E, Alexander B H, Rivara F P, Hickok D E, Maier R V, Starzyk P M. A retrospective cohort study of seatbelt use and pregnancy outcome after a motor vehicle crash.  J Trauma. 1993;  34 116-119
• 45 Crosby W M, Costiloe J P. Safety of lap-belt restraint for pregnant victims of automobile collisions.  N Engl J Med. 1971;  284 632-636
• 46 Crosby W M, King A I, Stout L C. Fetal survival following impact: improvement with shoulder harness restraint.  Am J Obstet Gynecol. 1972;  112 1101-1106
• 47 Pearlman M D, Phillips M E. Safety belt use during pregnancy.  Obstet Gynecol. 1996;  88 1026-1029
• 48 Thackray L, Blackketter D. Three-point seatbelt maternal comfort and fetal safety. Proceedings of the Institution of Mechanical Engineers.  J Automobile Engineering. 2002;  216 173-180
• 49 McCormick R D. Seat belt injury: case of complete transection of pregnant uterus.  J Am Osteopath Assoc. 1968;  67 1139-1141
• 50 Pearlman M D, Viano D. Automobile crash simulation with the first pregnant crash test dummy.  Am J Obstet Gynecol. 1996;  175(4 Pt 1) 977-981
• 51 Johnson H C, Pring D W. Car seatbelts in pregnancy: the practice and knowledge of pregnant women remain causes for concern.  BJOG. 2000;  107 644-647
• 52 ACOG Committee on Obstetric Practice . ACOG Committee Opinion. Number 299, September 2004 (replaces No. 158, September 1995). Guidelines for diagnostic imaging during pregnancy.  Obstet Gynecol. 2004;  104 647-651
• 53 Almog G, Liebergall M, Tsafrir A, Barzilay Y, Mosheiff R. Management of pelvic fractures during pregnancy.  Am J Orthop (Belle Mead NJ). 2007;  36 E153-E159
• 54 Leggon R E, Wood G C, Indeck M C. Pelvic fractures in pregnancy: factors influencing maternal and fetal outcomes.  J Trauma. 2002;  53 796-804
• 55 Awwad J T, Azar G B, Seoud M A, Mroueh A M, Karam K S. High-velocity penetrating wounds of the gravid uterus: review of 16 years of civil war.  Obstet Gynecol. 1994;  83 259-264
• 56 Kissinger D P, Rozycki G S, Morris Jr J A et al.. Trauma in pregnancy. Predicting pregnancy outcome.  Arch Surg. 1991;  126 1079-1086
• 57 Hill D A, Lense J J. Abdominal trauma in the pregnant patient.  Am Fam Physician. 1996;  53 1269-1274
• 58 Muench M V, Canterino J C. Trauma in pregnancy.  Obstet Gynecol Clin North Am. 2007;  34 555-583 xiii
• 59 Grubb D K. Nonsurgical management of penetrating uterine trauma in pregnancy: a case report.  Am J Obstet Gynecol. 1992;  166 583-584
• 60 Poole G V, Martin Jr J N, Perry Jr K G, Griswold J A, Lambert C J, Rhodes R S. Trauma in pregnancy: the role of interpersonal violence.  Am J Obstet Gynecol. 1996;  174 1873-1877 discussion 1877-1878