Trauma is one of the most common reasons for emergency room visits during pregnancy. The exact incidence is unknown, although trauma is estimated to complicate approximately 1 in 12 pregnancies (Hill, 2008). Trauma is also the leading nonobstetric cause of maternal death. In some reports, it accounts for up to 20 percent of all maternal mortalities (Fildes, 1992; Kuhlmann, 1994). As perspective, this represents a larger proportion than the combined mortality rates of several well-known obstetric causes. Of specific events, Figure 17-1 shows the estimated incidences for several types of trauma suffered by gravidas compared with nonpregnant women.
Estimated incidence of injury by type of trauma during pregnancy. Rates are reported per 100,000 live births in pregnancy and per 100,000 women in the nonpregnant cohort. Rates for nonpregnant women were calculated using 2013 U.S. data from the Centers for Disease Control and Prevention Web-based Injury Statistics Query and Reporting System (WISQARS) (2015) when not available from the literature. MVC = motor vehicle crash.
The link between maternal injury and adverse pregnancy outcome is well recognized (Weiss, 2002). Most pregnancy complications directly correlate with the trauma severity, although even minor trauma may be linked to serious obstetric complications. Of sequelae, trauma has been associated with increased incidences of spontaneous abortion, placental abruption, preterm premature rupture of membranes, preterm birth, uterine rupture, cesarean delivery, and stillbirth (Pak, 1998; Pearlman, 1990; Schiff, 2002b, 2005). Specifically, pregnant women admitted for trauma but not delivered face an associated 2.7-fold increased risk of preterm labor, a 1.5-fold increased risk of abruption, and a fourfold increase in the risk of maternal death compared with noninjured controls (El Kady, 2004).
Fetal morbidity and mortality similarly may follow trauma during pregnancy. Each year almost 4000 fetal losses in the United States will result from motor vehicle crashes (El Kady, 2004). In these deaths, placental abruption is a major contributing factor (Shah, 1998). Only approximately 0.4 percent of women will require admission for trauma during pregnancy, but of those who do, almost one third will deliver during their hospitalization (John, 2011; Kuo, 2007). Thus, many of the consequences for these neonates derive from their preterm birth.
Pregnancy per se does not appear to increase the morbidity or mortality rate attributed to trauma. It may even contribute to a lower adjusted mortality rate (Ikossi, 2005; John, 2011). However, the pattern and severity of the injury may be modified by the qualities of the gravid uterus (Shah, 1998).
Management of a gravida and her fetus is complex. Thus, a multidisciplinary approach is often required to address the challenges posed by trauma in pregnancy. Ideally, experts in neonatology, anesthesiology, radiology, labor and critical care nursing, surgery, and obstetrics are available for consultation.
MATERNAL PHYSIOLOGIC CHANGES