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Trauma in Pregnancy: Causes and Types
Nicole Cimino-Fiallos, MD, FAAEM | March 17, 2021
| Contributor Information
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Image from Wikimedia Commons/US Centers for Disease Control and Prevention (CDC)/Jim Gathany.
Trauma in Pregnancy: Causes and Types
Nicole Cimino-Fiallos, MD, FAAEM | March 17, 2021 | Contributor Information
The above ultrasonographic image reveals a 4-month-old fetus.
Trauma is the most common nonobstetric cause of maternal death,[1,2] and it occurs in 1 in 12 of all pregnancies.[1-3] Pregnant trauma victims experience nearly twice the rate of death compared with their nonpregnant counterparts.[4]
Fetal loss occurs in 40-50% of life-threatening traumas and in 1-5% of minor traumas experienced during pregnancy.[5] As will be discussed, maternal death and placental abruption are the most common causes of fetal death after maternal trauma.[2,6] There is also an increased risk of spontaneous abortion, preterm rupture of membranes, uterine rupture, and stillbirth.[6]
Trauma in Pregnancy: Causes and Types
Nicole Cimino-Fiallos, MD, FAAEM | March 17, 2021 | Contributor Information
The above table lists risk factors that predispose pregnant women to trauma.[4,6]
Image from Ahmadi A, Fakheri T, Amini-Saman J, et al. J Inj Violence Res. 2011;3(1):55-9. [Open access.] PMID: 21483215, PMCID: PMC3134918.
Trauma in Pregnancy: Causes and Types
Nicole Cimino-Fiallos, MD, FAAEM | March 17, 2021 | Contributor Information
Common Causes of Trauma in Pregnancy
The image shows irrigation-debridement of the perineal area in a 28-year-old woman at 16 weeks' gestation after she suffered motor vehicle injuries to the vaginal region and rectal area. 1 = inguinal ligament; 2 = the suction; 3 = labium minus; 4 = bulbospongiosus muscle; 5 = adductor longus; 6 = Foley catheter.
Motor vehicle accidents
Motor vehicle accidents (MVAs) are the leading cause of trauma during pregnancy (48%) and result in 82% of fetal deaths.[2]
Falls
Gravid women have a significantly higher risk of falling, likely due to an increase in joint laxity, as well as weight gain.[6,7] About 25-27% of women experience a fall during their pregnancy.[2,6]
Image from Flickr/Hannah Rosen.
Trauma in Pregnancy: Causes and Types
Nicole Cimino-Fiallos, MD, FAAEM | March 17, 2021 | Contributor Information
Domestic violence/intimate partner violence
The most common form of intentional trauma in pregnant women is domestic violence (DV) or intimate partner violence (IPV).[2,6] Of all trauma cases involving pregnant patients, DV accounts for an estimated 6-25%.[2,6] IPC disproportionately affects teen mothers and women of lower socioeconomic status.[8] Thus, healthcare providers must vigilantly screen for DV/IPV despite time constraints and fear of jeopardizing the clinician-patient relationship.[2]
Trauma in Pregnancy: Causes and Types
Nicole Cimino-Fiallos, MD, FAAEM | March 17, 2021 | Contributor Information
Signs of DV or IPV and complications from such trauma are listed in the table above.[2,6]
Image courtesy of Nicole Cimino-Fiallos, MD, FAAEM.
Trauma in Pregnancy: Causes and Types
Nicole Cimino-Fiallos, MD, FAAEM | March 17, 2021 | Contributor Information
Trauma Injury Patterns and Complications in Pregnant Women
The radiograph reveals distal displaced oblique tibia and fibula fractures after a fall in a pregnant patient.
Pregnant women experience unique injury patterns following trauma. Lower-extremity fractures are the most common injuries resulting from maternal trauma.[6] Clinicians should also have a high index of suspicion for bladder injuries following trauma in a gravid patient, as the bladder moves during pregnancy and is not well protected by the pelvis.
The pelvic joints become more flexible during pregnancy; thus, the mother is at greater risk for pelvic fractures and for more significant bleeding from the pelvic venous plexus than a nonpregnant patient would be.[9]
Adapted image from Wikimedia Commons/Patrick J Lynch.
Trauma in Pregnancy: Causes and Types
Nicole Cimino-Fiallos, MD, FAAEM | March 17, 2021 | Contributor Information
Gastrointestinal injuries are less common following blunt abdominal trauma during pregnancy, because the uterus absorbs much of the traumatic force, but hepatic, splenic, and retroperitoneal injuries can still occur.
Pregnant women do not have a higher incidence of hemothoraces and pneumothoraces than nongravid women; however, if these conditions are present, the gravid patient has less reserve to combat their effects. Thoracostomy insertion remains the treatment of choice for these disorders, but the thoracostomy tube should be placed 1-2 intercostal spaces higher than usual (shown).[3]
(1) Illustration of placental abruption courtesy of Bruce Blaus, Blausen gallery 2014, via Wikimedia Commons; (2) ultrasonogram from Honda M, Matsunaga S, Era S, Takai Y, Baba K, Seki H. J Med Case Rep. 2014;8:461. [Open access.] PMID: 25532532, PMCID: PMC4307188.
Trauma in Pregnancy: Causes and Types
Nicole Cimino-Fiallos, MD, FAAEM | March 17, 2021 | Contributor Information
Abruptio placentae
Placental abruption is a complication of abdominal trauma in pregnancy in which the placenta separates from the uterine lining. The ultrasonogram demonstrates placental abruption in a 37-year-old woman at 40 weeks' and 3 days' gestation that resulted in intrauterine fetal demise. A retroplacental hematoma (A) can be seen. B indicates the placenta.
Placental abruption may present as abdominal or pelvic pain, with or without vaginal bleeding. Shock may accompany severe hemorrhage. Management includes hemodynamic and respiratory support, close fetal monitoring, and, potentially, delivery of the fetus.[10]
Placental abruption is a major contributing factor to fetal demise following maternal trauma.[6,11]
Image from Koregol MC, Bellad MB, Nilgar BR, Metgud MC, Durdi G. J Med Case Rep. 2010;4:160. [Open access.] PMID: 20507601, PMCID: PMC2886082.
Trauma in Pregnancy: Causes and Types
Nicole Cimino-Fiallos, MD, FAAEM | March 17, 2021 | Contributor Information
Uterine rupture
Uterine rupture is a rare but potentially catastrophic complication of blunt and penetrating abdominal trauma in which all the uterine layers are disrupted; results include hemorrhage, nonreassuring fetal status, fetal demise, shock, and potential maternal death.[12] Unfortunately, this condition may be difficult to appreciate clinically owing to the initial signs/symptoms being typically nonspecific.[12] Therefore, imaging with fetal monitoring should be considered in all patients with a concerning mechanism of injury.
Management includes emergent cesarean delivery and uterine repair or hysterectomy (shown).[12]
Images from Jiang Q, Yang L, Ashley C, Medlin EE, Kushner DM, Zheng Y. BMC Womens Health. 2015;15:1. [Open access.] PMID: 25608736, PMCID: PMC4310148.
Trauma in Pregnancy: Causes and Types
Nicole Cimino-Fiallos, MD, FAAEM | March 17, 2021 | Contributor Information
The laparoscopic images display a uterine rupture that was disguised by urinary retention after an induced abortion in a 31-year-old woman at 16 weeks' gestation. The patient had a history of a previous cesarean section (a known risk factor for uterine rupture[12]). The left image reveals a 1.5-cm anterior wall uterine rupture along the previous cesarean section scar. After removal of the omentum majus (right image), a patch of placenta can be seen adhering to the rupture and lower uterine segment.
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Contributor Information
Author
Nicole Cimino-Fiallos, MD, FAAEM
Emergency Medicine Specialist, US Acute Care Solutions;
Assistant Medical Director, Emergency Department
Meritus Medical Center
Hagerstown, MD
Disclosure: Nicole Cimino-Fiallos, MD, FAAEM, has disclosed no relevant financial relationships.
Editor
Olivia Wong, DO
Section Editor
Medscape Drugs & Diseases
New York, New York
Disclosure: Olivia Wong, DO, has disclosed no relevant financial relationships.
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References
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Murphy NJ, Quinlan JD. Trauma in pregnancy: assessment, management, and prevention. Am Fam Physician. 2014 Nov 15;90(10):717-22. PMID: 25403036
Jain V, Chari R, Maslovitz S, et al, for the Maternal Fetal Medicine Committee. Guidelines for the management of a pregnant trauma patient. J Obstet Gynaecol Can. 2015 Jun;37(6):553-74. PMID: 26334607
Deshpande NA, Kucirka LM, Smith RN, Oxford CM. Pregnant trauma victims experience nearly 2-fold higher mortality compared to their nonpregnant counterparts. Am J Obstet Gynecol. 2017 Nov;217(5):590.e1-590.e9. PMID: 28844826
Raptis CA, Mellnick VM, Raptis DA, et al. Imaging of trauma in the pregnant patient. Radiographics. 2014 May-Jun;34(3):748-63. PMID: 24819793
Mendez-Figueroa H, Dahlke JD, Vrees RA, Rouse DJ. Trauma in pregnancy: an updated systematic review. Am J Obstet Gynecol. 2013 Jul;209(1):1-10. PMID: 23333541
Brewin D, Naninni A. Women's perspectives on falls and fall prevention during pregnancy. MCN Am J Matern Child Nurs. 2014 Sep-Oct;39(5):300-5.
Chisholm CA, Bullock L, Ferguson JEJ 2nd. Intimate partner violence and pregnancy: epidemiology and impact. Am J Obstet Gynecol. 2017 Aug;217(2):141-4. PMID: 28551446
Puri A, Khadem P, Ahmed S, Yadav P, Al-Dulaimy K. Imaging of trauma in a pregnant patient. Semin Ultrasound CT MR. 2012 Feb;33(1):37-45. PMID: 22264901
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