Trauma
1. Morton DC. Gynaecological complications of water-skiing. Med J Aust 1970 Jun 20;1(25):1256-7
2. Connolly AM, Katz VL, Bash KL, McMahon MJ, Hansen WF. Trauma and pregnancy. Am J Perinatol 1997 Jul;14(6):331-6. Trauma and/or accidental injury complicates 6-7% of all pregnancies. The management protocols for trauma in pregnancy are based largely on case reports and small series. The purposes of this study were to: describe the demographics of pregnant trauma patients at a tertiary care center and a large community hospital; identify variables predictive of fetal outcome including an examination of Kleihauer-Betke and nonstress testing; and recommend an evaluation and management protocol after trauma based on empirical data rather than anecdotal reports. Data from pregnancies complicated by trauma from July 1987 through October 1993 were retrospectively reviewed. Statistical analysis included Chi-square and Kruskall-Wallis testing. There were 476 medical records available for review. Of the trauma cases, 54.6% were motor vehicle accidents, 22.3% were domestic abuse and assaults, 21.8% were associated with falls, and 1.3% were secondary to burns, puncture wounds, or animal bites. Mean maternal age was 24 years, 49.9% were Caucasian, and 43% were primigravid. Mean gestational age at occurrence of trauma was 25.9 weeks and mean gestational age of delivery was 37.9 weeks. Domestic abuse occurred most frequently before 18 weeks, falls between 20-30 weeks' gestation, and motor vehicle accidents occurred with equal frequency throughout gestation. Uterine contractions occurred in 39.8% of patients and as often as every 1 to 5 min in 18% of patients. Preterm labor occurred in 11.4%, preterm delivery in 25%, and abruptions in 1.58% of the trauma population. Fetal heart rate monitoring was abnormal in 3% of cases. Twenty-seven perinatal deaths were noted and in 14 pregnancies the deaths were related to trauma. Eight of these perinatal deaths were associated with motor vehicle accidents, four with domestic violence, and two with falls. The only preventable perinatal deaths were a twin pregnancy transferred with nonreassuring fetal heart tones. Early warning symptoms of vaginal bleeding, uterine contractions, and/or abdominal and/or uterine tenderness were not predictive of either preterm delivery or adverse pregnancy outcome, sensitivity 52%, specificity 48%. Abnormal monitoring and positive Kleihauer-Betke tests were also not predictive of adverse pregnancy outcome. However, there were no adverse outcomes directly related to trauma when monitoring was normal and early warning symptoms were absent (negative predictive value 100%). Two hundred eighty-nine Kleihauer-Betke tests were performed and only one affected management. Repetitive monitoring over several days did not uncover any patients whose heart rate tracings evolved from normal to abnormal monitoring. Given our findings that prolonged monitoring was not helpful in management of pregnant trauma patients, we support the recommendation that initial external fetal monitoring be performed for 4 hr, and, if reassuring, the patient may be sent home with precautions. We also recommend an Rh-immunoglobulin work-up for all Rh-negative pregnant trauma patients, but do not recommend Kleihauer-Betke testing for Rh-positive women. Given the frequency with which trauma affects pregnancy and the difficulty encountered with identifying variables predictive of pregnancy outcome, there may be great benefits of incorporating trauma prevention into routine prenatal care.
3. ACOG Technical Bulletin #151—Automobile Passenger Restraints for Children and Pregnant Women
4. ACOG Educational Bulletin #251—Obstetric Aspects of Trauma Management
5. Colburn V. Trauma in pregnancy. J Perinat Neonatal Nurs 1999 Dec;13(3):21-32. Of all cases that come to hospital emergency rooms, the traumatized pregnant patient presents one of the most complicated dilemmas because nurses and doctors who commonly treat trauma victims rarely have comparable expertise in the management of pregnancy. Treatment and care of the traumatized pregnant patient are challenging because advanced pregnancy influences the pattern of trauma, alters laboratory values and clinical assessments, and changes hemodynamic parameters. Pregnancy may alter the usual trauma routines, and trauma may affect the outcome of the pregnancy. It is imperative that both the trauma team and perinatal team work collaboratively toward a common goal of resuscitating and stabilizing the pregnant woman without jeopardizing the fetus whenever possible. This article reviews alterations in anatomy and physiology that occur during pregnancy and discusses the impact of decision making by health care practitioners faced with the dilemma of managing trauma during pregnancy.
6. Dobo SM, Johnson VS. Evaluation and care of the pregnant patient with minor trauma. Clinics in Family Practice, Volume 2 • Number 3 • September 2000
7. Henderson SO, Mallon WK. Trauma in pregnancy. Emergency Medicine Clinics of North America, Volume 16 • Number 1 • February 1998. Over the past 60 years, trauma has become the leading cause of morbidity and mortality in the pregnant patient. The emotional and physiological challenges of treating two patients simultaneously adds to an already stressful situation. Resuscitation of the pregnant trauma patient is discussed from the prehospital setting to disposition. Also discussed are non-invasive monitoring tools, such as tocodynanomometry and ultrasonography.
8. Runnebaum IB, Holcberg G, Katz M. Pregnancy outcome after repeated blunt abdominal trauma. Eur J Obstet Gynecol Reprod Biol 1998 Sep;80(1):85-6. During a four-year period, five of 49671 parturients were admitted on a prospective study protocol for repeated direct blunt abdominal trauma due to falls during pregnancy. Preterm contractions were noted in three patients one of which delivered preterm. No delayed abruptio placentae, intrauterine growth restriction or antepartum death were encountered. All patients delivered spontaneously. Repeated blunt abdominal trauma occurs rarely in pregnancy. Routine hospitalised surveillance in the absence of vaginal bleeding or uterine contractions may not be warranted.
9. Huzel PS, Remsburg-Bell EA. Fetal complications related to minor maternal trauma. J Obstet Gynecol Neonatal Nurs 1996 Feb;25(2):121-4. The active lifestyle of pregnant women, in combination with the increased incidence of violence in society, place women at greater risk for accidental injury during pregnancy. This identification of increased risk has altered the health care management of mother and fetus after injury. The health care provider treating this patient population must perform thorough maternal-fetal assessments and be suspicious of fetal compromise, even in the face of maternal stability.
10. Ribe JK, Teggatz JR, Harvey CM. Blows to the maternal abdomen causing fetal demise: report of three cases and a review of the literature. J Forensic Sci 1993 Sep;38(5):1092-6. Traumatic abruption results in 6% of third-trimester gravidas who are hit or kicked in the abdomen during assaults. Three cases are presented in which blows inflicted to the abdomen of pregnant women in their third trimester resulted in the death of the fetus due to abruptio placentae. Two cases were domestic altercations while one was a third-party criminal assault. In all cases the gravida herself escaped significant intra-abdominal injury, and external abdominal findings were minimal. The clinical signs were a history of loss of fetal movements shortly after the assault and loss of fetal heart tones within hours after the assault. One patient had vaginal bleeding; one had uterine contractions. In the cases of domestic abuse, both women initially gave false histories of how the injury occurred.
11. McFarlane J. Battering during pregnancy: tip of an iceberg revealed. Women Health 1989;15(3):69-84. Physical abuse of women is pervasive with one in three women experiencing battering. Battering occurs during pregnancy with women reporting blows to the pregnant abdomen, injuries to the breast and genitals, and sexual assault. A recent study in a large metropolitan area documented one in twelve pregnant women to have been physically battered during the present pregnancy. Among the women battered, 87% had been physically abused prior to pregnancy and 29% reported the abuse increased after becoming pregnant. Health care providers did not assess any of the women for abuse. When pregnancy outcome was analyzed in another study of 589 postpartum women, battered women were four times more likely to deliver a low-birthweight infant. This paper discusses the etiology of battering, prevalence of battering during pregnancy and pregnancy outcomes of battered women. A community-wide primary prevention program is presented that has linked the health care provider with law enforcement and shelters for battered women to interrupt the cycle of violence and promote the health and safety of pregnant women.
12. McFarlane J. Abuse during pregnancy: the horror and the hope. AWHONNS Clin Issues Perinat Womens Health Nurs 1993;4(3):350-62. Physical violence against women is pervasive; and such abuse may begin during pregnancy. This article chronicles the clinical research on battering during pregnancy and focuses on a prospective study of 691 pregnant women; the study documented that one in six women are abused during pregnancy. Ethnic differences in the patterns of abuse are discussed, as are related findings of entry into prenatal care and characteristics of the abuser. Clinical implications are presented, with an emphasis on the usefulness of straightforward assessment with a three-question abuse assessment screen to identify abused women and intervene to prevent abuse during pregnancy.
13. Condon JT. "The battered fetus syndrome". Preliminary data on the incidence of the urge to physically abuse the unborn child. J Nerv Ment Dis 1987 Dec;175(12):722-5. Recently published reports of physical assault by women in late pregnancy upon their unborn children have elicited a response of incredulity in many professionals. This response is identical to that which followed the publication of the first cases of child abuse in the 1960s. The present paper attempts a preliminary exploration of the incidence of the urge to "hurt or punish" the unborn child using a sample of 112 normal pregnant women and their male partners. Eight percent of the women and 4% of the men acknowledged experiencing such an urge. The male partner appeared to be aware of the woman's aggressive feelings toward the fetus and the male's reports tend to validate the female findings. Despite some methodological shortcomings, the findings suggest that the urge to physically assault the fetus is not rare. The need for further investigation of the phenomenon is highlighted, as it may well represent the earliest precursor of later physical child abuse.
14. Schmuel E, Schenker JG. Violence against women: the physician's role. Eur J Obstet Gynecol Reprod Biol 1998 Oct;80(2):239-45. Violence against women is one reflection of the unequal power relationship between men and women in societies. Reflections of this inequality include marriage at a very young age, lack of information or choice about fertility control and forced pregnancy within marriage. The different forms of violence against women are: domestic violence and rape, genital mutilation or, gender-based violence by police and security forces, gender-based violence against women during armed conflict, gender-based violence against women refugees and asylum-seekers, violence associated with prostitution and pornography, violence in the workplace, including sexual harassment. Violence against women is condemned, whether it occurs in a societal setting or a domestic setting. It is not a private or family matter. The FIGO Committee for the Study of Ethical Aspects of Human Reproduction released statements to physicians treating women on this issue. Physicians are ethically obliged to inform themselves about the manifestations of violence and recognize cases, to treat the physical and psychological results of violence, to affirm to their patients that violent acts toward them are not acceptable and to advocate for social infrastructures to provide women the choice of seeking secure refuge and ongoing counselling.
15. Gazamararian JA, Lazorick S, Spitz AM, Ballard TJ, Saltzman LE, Marks JS. Prevalence of violence against pregnant women. JAMA1996;275:1915-1920. OBJECTIVES: To summarize the methods and findings of studies examining the prevalence of violence against pregnant women and to synthesize these findings by comparing study characteristics for studies with similar and dissimilar results. DATA SOURCES: MEDLINE, POPLINE, Psychological Abstracts, and Sociological Abstracts databases were searched for all articles pertaining to violence during pregnancy for the period 1963 through August 1995. STUDY SELECTION: Thirteen studies were selected on the basis of specific criteria: a sample with initially unknown violence status; a clear statement of research question(s), with focus on measuring the prevalence of violence; descriptions of the sample, data source, and data collection methods; and data from the United States or another developed country. DATA EXTRACTION: Relevant data were extracted to compare studies by study description, methods, and results. DATA SYNTHESIS: Evidence from the studies we reviewed indicates that the prevalence of violence during pregnancy ranges from 0.9% to 20.1%. Measures of violence, populations sampled, and study methods varied considerably across studies, and these factors may affect prevalence estimates. Studies that asked about violence more than once during detailed in-person interviews or asked later in pregnancy (during the third trimester) reported higher prevalence rates (7.4%-20.1%). The lowest estimate was reported by women who attended a private clinic and responded to a self-administered questionnaire provided to them by a person who was not a health care provider. CONCLUSIONS: Violence may be a more common problem for pregnant women than some conditions for which they are routinely screened and evaluated. Future research that more accurately measures physical violence during pregnancy would contribute to more effective design and implementation of prevention and intervention strategies.
16. Awwad JT, Azar GB, Seoud MA, Mroueh AM, Karam KS. High-velocity penetrating wounds of the gravid uterus: review of 16 years of civil war. Obstet Gynecol 1994 Feb;83(2):259-64. OBJECTIVE: To evaluate the value of selective laparotomy in pregnant women with penetrating abdominal injuries. METHODS: A retrospective survey was carried out at our center over 16 years of civil war, extending from 1975 to 1991. Fourteen pregnant women had uterine injuries secondary to high-velocity abdominal penetrating trauma. The corresponding management was evaluated carefully with respect to maternal and fetal outcomes. RESULTS: Two maternal deaths occurred, neither resulting solely from intra-abdominal injuries. Visceral injuries were present when the entrance of the missile was in either the upper abdomen or the back. When the entry site was anterior and below the uterine fundus, visceral injuries were absent in all six women upon surgical exploration. Perinatal deaths occurred in half of the cases and were due to maternal shock or uteroplacental or direct fetal injury. Immediate cesarean delivery was performed because of either limited surgical field exposure, fetal injury, or distress. Three patients explored were managed by delaying delivery. All later delivered vaginally with successful fetal outcomes in all three. CONCLUSION: Selective laparotomy may be considered in pregnant women with anterior penetrating abdominal trauma, as the likelihood of intra-abdominal injuries may be predicted based on the location of the penetrating wound.
17. Pierson R, Mihalovits H, Thomas L, Beatty R. Penetrating abdominal wounds in pregnancy. Ann Emerg Med 1986 Oct;15(10):1232-4. Despite the fact that penetrating abdominal wounds in late pregnancy are becoming increasingly common, there are few such reports in the medical literature. We report the case of a Cambodian woman injured in the border fighting between the Vietnamese and Khmer troops in 1980. Our case is unique in that the fetus survived with a relatively minor fragment wound in the leg. To our knowledge, this is the first report of such a case.
18. Carballo M, Simic S, Zeric D. Health in countries torn by conflict: lessons from Sarajevo. Lancet 1996 Sep 28;348(9031):872-4.
19. Lumey LH, Stein AD, Ravelli AC. Timing of prenatal starvation in women and birth weight in their first and second born offspring: the Dutch Famine Birth Cohort study. Eur J Obstet Gynecol Reprod Biol 1995 Jul;61(1):23-30.
20. Stein AD, Lumey LH. The relationship between maternal and offspring birth weights after maternal prenatal famine exposure: the Dutch Famine Birth Cohort Study. Hum Biol 2000 Aug;72(4):641-54. We examined the impact of famine-induced changes in maternal birth weight (MBW) on the association between MBW and offspring birth weight (OBW). Women born before, during, and after the Dutch Famine of 1944-1945 were interviewed at ages 41 to 46 years. Women (n = 582) and their children (n = 1,111) were included in the analysis if both mother and child were singleton and the child was not delivered preterm. Mean birth weight (BW) of women with first-trimester exposure (n = 110) was 154 g higher (p = 0.008), and mean BW of women with third-trimester exposure (n = 138) was 251 g lower (p < 0.001) than mean BW of unexposed women (n = 302). First-born offspring of women with first-trimester exposure were 72 g heavier (95% confidence interval [CI], -57 to 201; p = 0.27), and offspring of women with third-trimester exposure were 43 g lighter (95% CI, -170 to 79; p = 0.47) than offspring of unexposed women. Among unexposed women, each 100 g increase in MBW was associated with 25 g (95% CI, 12 to 37) increase in OBW (adjusted for maternal age, smoking, weight, and height and offspring sex). This association was attenuated in famine-exposed women (first-trimester change in OBW = 20 g per 100 g MBW; 95% CI, -1 to 41; third-trimester change in OBW = 14 g per 100 g MBW; 95% CI, -9 to 37). When MBW and trimester of maternal famine exposure were considered in a joint model, there was no independent effect of trimester of maternal famine exposure on OBW. Associations were less consistent for later-born offspring. We conclude that maternal prenatal famine exposure does not affect the association between maternal and offspring BW. Trimester of exposure was not a determinant of OBW, other than through its effect on MBW. Nevertheless, acute famine may impact on second-generation BW distributions indirectly, through its effect on the distribution of MBW.
21. Krpina V, Zrilic I. Increase in the frequency of premature births in a war affected area. Eur J Obstet Gynecol Reprod Biol 1995 Jan;58(1):87-8
22. Fischman Y. Sexual torture as an instrument of war. Am J Orthopsychiatry 1996 Jan;66(1):161-2
23. Rojnik B, Andolsek-Jeras L, Obersnel-Kveder D. Women in difficult circumstances: war victims and refugees. Int J Gynaecol Obstet 1995 Mar;48(3):311-5. The majority of problems that women are confronting today originate from a lack of respect for human and reproductive rights. Escalating war crises are producing an enormous number of civilian victims, of whom women and children comprise the major part. Rape used as a war tactic in Bosnia has proven to be a very powerful tool. War in Bosnia has provided a tragic incentive to work on strategies and tactics for reaching the victims in such chaotic and unpredictable circumstances.
