Depending on definitions used, 10 to 20 percent of gravidas suffer physical trauma (Jain, 2015; Lucia, 2016). Moreover, injury-related deaths are the most commonly identified nonobstetrical cause of maternal mortality (Brown, 2013a; Horon, 2001). In a California study of 4.8 million pregnancies, almost 1 in 350 women were hospitalized for injuries from assaults (El Kady, 2005). From Parkland Hospital, motor vehicle accidents and falls accounted for 85 percent of injuries sustained by 1682 pregnant women (Hawkins, 2007). From the National Violent Death Reporting System, Palladino and colleagues (2011) found 2.0 pregnancy-associated suicides per 100,000 live births. The rate was 2.9 per 100,000 for pregnancy-associated homicides. Notably, intimate-partner violence may be linked to these suicides (Martin, 2007). Finally, injury prevention and education of high-risk patients may help to decrease morbidity (Chisolm, 2017; Lucia, 2016).
According to the CDC, intimate-partner violence describes physical, sexual, or psychological harm by a current or former partner or spouse (Breiding, 2015). Such violence affects 1 in 5 women each year. One goal in violence prevention for Healthy People 2010 was the reduction of physical abuse directed at women by male partners. The Pregnancy Risk Assessment Monitoring Systems (PRAMS) report showed some improvement in these areas (Suellentrop, 2006).
Even more appalling is that physical violence directed at women continues during pregnancy. Abuse is linked to poverty, poor education, and use of tobacco, alcohol, and illicit drugs (Centers for Disease Control and Prevention, 2008). Unfortunately, abused women tend to remain with their abusers, and the major risk factor for intimate-partner homicide is prior domestic violence (Campbell, 2007). Finally, women seeking pregnancy termination have a higher incidence of intimate-partner violence (Bourassa, 2007).
The woman who is physically abused tends to present late, if at all, for prenatal care. In one study, pregnant women hospitalized in California as a result of assault had significantly increased perinatal morbidity rates (El Kady, 2005). Immediate sequelae included uterine rupture, preterm delivery, and maternal and perinatal death. Subsequent outcomes included increased rates of placental abruption, preterm and low-birthweight newborns, and other adverse outcomes. Silverman and associates (2006) reported similar results from PRAMS, which included more than 118,000 pregnancies in 26 states.
Preventatively, the American College of Obstetricians and Gynecologists (2012) recommend universal screening for intimate-partner violence at the initial prenatal visit, during each trimester, and again at the postpartum visit (Chap. 9, Alcohol). Others recommend a case-finding approach based on clinical suspicion (Robertson-Blackmore, 2013).
According to the National Intimate Partner and Sexual Violence Survey (Black, 2014), an estimated 1.2 million women will be sexually assaulted each year. Satin and coworkers (1992) reviewed more than 5700 female sexual assault victims in Dallas County and reported that 2 percent were pregnant. Associated physical trauma is common (Sugar, 2004). From a forensic standpoint, the evidence collection protocol is not altered (Linden, 2011).
In addition to attention to physical injuries, exposure to sexually transmitted diseases must be considered. The CDC (2015) recommends antimicrobial prophylaxis against gonorrhea, chlamydial infection, bacterial vaginosis, and trichomoniasis (Table 47-7). If the woman is not pregnant, another very important aspect is emergency contraception, as recommended by the American College of Obstetricians and Gynecologists (2016; 2017a) and discussed in Chapter 38 (Emergency Contraception).
TABLE 47-7Guidelines for Prophylaxis against Sexually Transmitted Disease in Pregnant Victims of Sexual Assault ||Download (.pdf) TABLE 47-7 Guidelines for Prophylaxis against Sexually Transmitted Disease in Pregnant Victims of Sexual Assault
|Prophylaxis Against ||Regimen ||Alternative |
|Neisseria gonorrhoeae ||Ceftriaxone 250 mg IM single dose plus |
Azithromycin 1 g orally single dose
|Cefixime 400 mg orally single dose plus |
Azithromycin 1 g orally single dose
|Chlamydia trachomatis ||Azithromycin 1 g orally single dosea |
Amoxicillin 500 mg orally three times daily for 7 days
|Erythromycin-base 500 mg orally four times daily for 7 days |
Levofloxacin 500 mg orally once daily for 7 daysb
Ofloxacin 300 mg orally twice daily for 7 daysb
|Bacterial vaginosis ||Metronidazole 500 mg orally twice daily for 7 days |
Metronidazole gel 0.75%, one full applicator (5 g) intravaginally once daily for 5 days
Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days
|Tinidazole 2 g orally once daily for 2 daysb |
Tinidazole 1 g orally daily for 5 days
Clindamycin 300 mg orally twice daily for 7 days
Clindamycin ovules 100 mg intravaginally at bedtime for 3 days
|Trichomonas vaginalis ||Metronidazole 2 g orally single dose |
Tinidazole 2 g orally single doseb
|Metronidazole 500 mg orally twice daily for 7 days |
|Hepatitis B (HBV) ||If not previously vaccinated, give first dose HBV vaccine, repeat at 1–2 and 4–6 months || |
|HIV ||Consider retroviral prophylaxis if risk for HIV exposure is high || |
Finally, the importance of psychological counseling for the rape victim and her family cannot be overemphasized. A 30- to 35-percent lifetime risk each for posttraumatic stress disorder, major depression, and suicide contemplation follows sexual assault (Linden, 2011).
At least 3 percent of pregnant women are involved in motor vehicle accidents each year in the United States. Using data from PRAMS, Sirin and colleagues (2007) estimated that 92,500 gravidas are injured annually. Motor-vehicle crashes are the most common causes of serious, life-threatening, or fatal blunt trauma during pregnancy (Brown, 2013a; Mendez-Figueroa, 2013, 2016; Vladutiu, 2013). Mattox and Goetzl (2005) report these accidents to be the leading cause of traumatic fetal deaths as well. This was also true from our experiences from Parkland Hospital (Hawkins, 2007). Traffic crashes are most frequent in the second trimester (Redelmeier, 2014). As with all motor vehicle crashes, alcohol use is often associated. But sadly, as many as half of accidents occur without seat-belt use, and many of these deaths would likely be preventable by the three-point restraints shown in Figure 47-8 (Luley, 2013; Schuster, 2016). Seat belts prevent contact with the steering wheel, and they reduce abdominal impact pressure (Motozawa, 2010).
Illustration showing correct use of three-point automobile restraint. The upper belt is above the uterus, and the lower belt fits snugly across the upper thighs and well below the uterus.
Original concerns regarding injuries caused by airbag deployment have been somewhat allayed (Luley, 2013; Matsushita, 2014). One study included 30 such women from 20 to 37 weeks’ gestation whose airbag deployed in accidents with a median speed of 35 mph (Metz, 2006). A third did not use seat belts, and there was one fetal death from the single case of placental abruption. In a retrospective cohort study that included 2207 pregnant women in crashes with airbag deployment, perinatal outcomes were not clinically different from 1141 controls without airbags (Schiff, 2010). Importantly, 96 percent of both groups used seat belts. Thus, it appears that injuries with airbag deployment are related to the severity of the crash (Mendez-Figueroa, 2016).
Some other common causes of blunt trauma are falls and aggravated assaults. In the California review reported by El Kady and associates (2005), intentionally inflicted injuries were present in approximately a third of pregnant women who were hospitalized for trauma. Less common are blast or crush injury (Sela, 2008). With blunt trauma, intraabdominal injuries can be serious. Even so, bowel injuries are less frequent because of the protective effect of a large uterus. Still, diaphragmatic, splenic, liver, and kidney damage may also be sustained. Particularly worrisome is the specter of amnionic-fluid embolism, which has been reported with even mild trauma (Ellingsen, 2007; Pluymakers, 2007). Retroperitoneal hemorrhage is possibly more common than in nonpregnant women (Takehana, 2011).
Orthopedic injuries are also encountered with some regularity (Desai, 2007). From the Parkland Hospital trauma unit, 6 percent of 1682 pregnant women evaluated had orthopedic injuries. This subset was also at increased risk for placental abruption, preterm delivery, and perinatal mortality. In a review of 101 pelvic fractures during pregnancy, there was a 9-percent maternal and 35-percent fetal mortality rate (Leggon, 2002). In another study of pelvic and acetabular fractures during 15 pregnancies, there was one maternal death, and four of 16 fetuses died (Almog, 2007). Finally, head trauma and neurosurgical care raise unique issues (Qaiser, 2007).
Perinatal death rates increase with the severity of maternal injuries. Fetal death is more likely with direct fetoplacental injury, maternal shock, pelvic fracture, maternal head injury, or hypoxia (Ikossi, 2005; Pearlman, 2008). Motor vehicle accidents caused 82 percent of fetal deaths from trauma. Death was caused by placental injury in half and by uterine rupture in 4 percent (Weiss, 2001).
Although uncommon, fetal skull and brain injuries are more likely if the head is engaged and the maternal pelvis is fractured (Palmer, 1994). Conversely, fetal head injuries, presumably from a contrecoup effect, may be sustained in unengaged vertex or nonvertex presentations. Fetal skull fractures are rare and best seen using CT imaging (Sadro, 2012). One example is Figure 46-4. Other sequelae include intracranial hemorrhage (Gherman, 2014; Green-Thompson, 2005). A newborn with paraplegia and contractures associated with a motor vehicle accident sustained several months before birth was described by Weyerts and colleagues (1992). Other injuries have included fetal decapitation or incomplete midabdominal fetal transection at midpregnancy (Rowe, 1996; Weir, 2008).
Catastrophic events that occur with blunt trauma include placental injuries—abruption or placental tears (Fig. 47-9). Placental separation from trauma is likely caused by deformation of the elastic myometrium around the relatively inelastic placenta (Crosby, 1968). This may result from a deceleration injury as the large uterus meets the immovable steering wheel or seat belt. Some degree of abruption complicates 1 to 6 percent of minor injuries and up to 50 percent of major injuries (Pearlman, 1990; Schiff, 2002). Abruption was found to be more likely if vehicle speed exceeded 30 mph (Reis, 2000).
Mechanism of placental tear or “fracture” caused by a deformation-reformation injury. Placental abruption is seen as blood collecting in the retroplacental space. Inset. From here, blood can be forced into placental bed venules and enter maternal circulation. Such fetomaternal hemorrhage may be identified with Kleihauer-Betke testing.
Clinical findings with traumatic abruption may be similar to those for spontaneous placental abruption (Chap. 41, Frequency). Kettel and coworkers (1988) emphasized that traumatic abruption may be occult and unaccompanied by uterine pain, tenderness, or bleeding. In our experiences with 13 such women at Parkland Hospital, 11 had uterine tenderness, but only five had vaginal bleeding. Because traumatic abruption is more likely to be concealed and generate higher intrauterine pressures, associated coagulopathy is more likely than with nontraumatic abruption (Cunningham, 2015). Partial separation may also generate uterine activity, which is described more fully in Thermal Injury. Other features are evidence of fetal compromise such as fetal tachycardia, sinusoidal pattern, late decelerations, acidosis, and fetal death.
If the abdominal force associated with trauma is considerable, then the placenta can be torn or “fractured” (see Fig. 47-9). If so, then life-threatening fetal hemorrhage may be encountered either into the amnionic sac or by fetomaternal hemorrhage (Pritchard, 1991). The tear is linear or stellate and is caused by rapid deformation and reformation (Fig. 47-10). Especially if there is ABO compatibility, fetomaternal hemorrhage is quantified using a Kleihauer-Betke stain of maternal blood. A small amount of fetal-maternal bleeding has been described in up to a third of trauma cases, and in 90 percent of these, the volume is <15 mL (Goodwin, 1990; Pearlman, 1990). Parenthetically, nontraumatic placental abruption is much less often associated with significant fetomaternal hemorrhage because only minimal fetal blood enters into the intervillous space. With traumatic abruption, however, massive fetomaternal hemorrhage may follow. In one study, the risk of associated uterine contractions and preterm labor was a 20-fold if there was evidence for a fetomaternal bleed (Muench, 2004). With severe fetal bleeding, long-term adverse neurological outcomes are frequent (Kadooka, 2014).
A. Partial placental abruption in which the adherent blood clot has been removed. Note the laceration of the placenta (arrow), which caused fetal death from massive fetomaternal hemorrhage. B. Kleihauer–Betke stain of a peripheral smear of maternal blood. The dark cells that constituted 4.5 percent of red blood cells are fetal in origin, whereas the empty cells are maternal.
Blunt trauma leads to uterine rupture in <1 percent of severe cases (American College of Obstetricians and Gynecologists, 2017b). Rupture is more likely in a previously scarred uterus and is usually associated with a direct impact of substantial force. Decelerative forces following a 25-mph collision can generate up to 500 mm Hg of intrauterine pressure in a properly restrained woman (Crosby, 1968). Clinical findings may be identical to those for placental abruption with an intact uterus, and maternal and fetal deterioration are soon inevitable. Pearlman and Cunningham (1996) described uterine fundal “blowout” with fetal decapitation in a 20-week pregnancy following a high-speed collision. Similarly, Weir and colleagues (2008) described supracervical uterine avulsion and fetal transection at 22 weeks. CT scanning may be useful to diagnose uterine rupture with a dead fetus or placental separation (Kopelman, 2013; Manriquez, 2010; Sadro, 2012).
In a study of 321 pregnant women with abdominal trauma, Petrone (2011) reported a 9-percent incidence of penetrating injuries. Of these, 77 percent were gunshot wounds and 23 percent were stab wounds. The incidence of maternal visceral injury with penetrating trauma is only 15 to 40 percent compared with 80 to 90 percent in nonpregnant individuals (Stone, 1999). When the uterus sustains penetrating wounds, the fetus is more likely than the mother to be seriously injured. Indeed, although the fetus sustains injury in two thirds of cases with penetrating uterine injuries, maternal visceral injuries are seen in only 20 percent. Still, their seriousness is underscored in that maternal-fetal mortality rates are significantly higher than those seen with blunt abdominal injuries in pregnancy. Specifically, maternal mortality rates were 7 versus 2 percent, and fetal mortality rates were 73 versus 10 percent, respectively.
Maternal and fetal outcomes are directly related to the severity of injury. That said, commonly used methods of severity scoring do not take into account significant morbidity and mortality rates related to placental abruption and thus to pregnancy outcomes. In a study of 582 pregnant women hospitalized for injuries, the injury severity score did not accurately predict adverse pregnancy outcomes (Schiff, 2005). Importantly, relatively minor injuries were associated with preterm labor and placental abruption. Others have reached similar conclusions (Biester, 1997; Ikossi, 2005). In a study of 317 women at 24 weeks’ gestation or more who had “minor trauma,” 14 percent had clinically significant uterine contractions requiring extended fetal evaluation past 4 hours (Cahill, 2008).
With few exceptions, treatment priorities in injured pregnant women are multidisciplinary (Barraco, 2010; Mendez-Figueroa, 2016). Primary goals are evaluation and stabilization of maternal injuries. Attention to fetal assessment during the acute evaluation may divert attention from life-threatening maternal injuries (American College of Obstetricians and Gynecologists, 2017b; Brown, 2009). Basic rules of resuscitation include ventilation, arrest of hemorrhage, and treatment of hypovolemia with crystalloid and blood products. After midpregnancy, the large uterus is positioned off the great vessels to diminish its effect on vessel compression and cardiac output (Nelson, 2015).
Following emergency resuscitation, evaluation is continued for fractures, internal injuries, bleeding sites, and placental, uterine, and fetal trauma. Radiography is not proscribed, but special attention is given each indication. Not surprisingly, one report observed that pregnant trauma victims had less radiation exposure than nonpregnant controls (Ylagan, 2008). Some advocate screening abdominal sonography followed by CT scanning for positive sonographic findings (Brown, 2005; Saphier, 2014). Procedures used include the FAST scan—focused assessment with sonography for trauma. This examination is a 5-minute, four- to six-view imaging study that evaluates perihepatic, perisplenic, pelvic, and pericardial views (Mendez-Figueroa, 2016). In general, if fluid is seen in any of these views, then the volume is >500 mL (Fig. 47-11). Importantly, this amount has not been corroborated for pregnancy. In some cases, open peritoneal lavage may be informative (Tsuei, 2006).
Fast scan. Upper quadrant scan shows anechoic free fluid (asterisk) between the liver edge (arrow) and kidney (Morison pouch). The patient had 2500 mL of blood in the peritoneal cavity. (From Mendez-Figueroa H, Rouse DJ: Trauma in pregnancy. In Yeomans ER, Hoffman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap’s Operative Obstetrics 3rd ed, New York McGraw-Hill Education, 2016, In press.)
Penetrating injuries in most cases must be evaluated using radiography. Because clinical response to peritoneal irritation is blunted during pregnancy, an aggressive approach to exploratory laparotomy is pursued. Whereas exploration is mandatory for abdominal gunshot wounds, some clinicians advocate close observation for selected stab wounds. Diagnostic laparoscopy has also been used (Chap. 46, Medications and Surgeries).
The necessity for cesarean delivery depends on several factors. Laparotomy itself is not an indication for hysterotomy. Some considerations include gestational age, fetal condition, extent of uterine injury, and whether the large uterus hinders adequate management of other intraabdominal injuries (Tsuei, 2006).
Because fetal well-being may reflect the status of the mother, fetal monitoring is another “vital sign” that helps evaluate the extent of maternal injuries. Even if the mother is stable, electronic monitoring may suggest placental abruption. In a study by Pearlman and coworkers (1990), no woman had an abruption if uterine contractions were less often than every 10 minutes within the 4 hours after trauma was sustained. Almost 20 percent of women who had contractions more frequently than every 10 minutes in the first 4 hours had an associated placental abruption. In these cases, abnormal tracings were common and included fetal tachycardia and late decelerations. Conversely, no adverse outcomes were reported in women who had normal monitor tracings (Connolly, 1997). Importantly, if tocolytics are used for these contractions, they may obfuscate findings, and we do not recommend them.
Because placental abruption usually develops early following trauma, fetal monitoring is begun as soon as the mother is stable. The ideal duration of posttrauma monitoring is not precisely known. From data cited above, observation for 4 hours is reasonable with a normal tracing and no other sentinel findings such as contractions, uterine tenderness, or bleeding. Certainly, monitoring should be continued as long as there are uterine contractions, nonreassuring fetal heart patterns, vaginal bleeding, uterine tenderness or irritability, serious maternal injury, or ruptured membranes (American College of Obstetricians and Gynecologists, 2017b). In rare cases, placental abruption has developed days after trauma (Higgins, 1984).
It is unclear whether routine use of the Kleihauer-Betke or an equivalent test in pregnant trauma victims might modify adverse outcomes associated with fetal anemia, cardiac arrhythmias, and death (Pak, 1998). In a retrospective review of 125 pregnant women with blunt injuries, the Kleihauer-Betke test was judged to be of little value during acute trauma management (Towery, 1993). Others have reached similar conclusions, although a positive test with fetal cells of 0.1 percent was predictive of uterine contractions or preterm labor (Connolly, 1997; Muench, 2003, 2004).
For the woman who is D-negative, administration of anti-D immunoglobulin should be considered. This may be omitted if a test for fetal bleeding is negative. Even with anti-D immunoglobulin, alloimmunization may still develop if the fetal-maternal hemorrhage exceeds 15 mL of fetal cells (Chap. 15, Fetomaternal Hemorrhage).
For the pregnant trauma patient, confirmation of current tetanus immunization status is pertinent. When indicated, a dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) is preferred for its neonatal pertussis immunity benefits (Chap. 9, Automobile and Air Travel).