Trauma in Pregnancy

Systematic Reviews

www. AJOG.org

OBSTETRICS

Trauma in pregnancy: an updated systematic review
Hector Mendez-Figueroa, MD; Joshua D. Dahlke, MD; Roxanne A. Vrees, MD; Dwight J. Rouse, MD, MSPH

A

lthough its precise incidence is not
known, trauma is estimated to
complicate approximately 1 in 12 pregnancies1 and is the leading nonobstetrical cause of maternal death.2 Trauma has
fetal implications as well, and has been
reported to increase the incidence of
spontaneous abortion (SAB), preterm
premature rupture of membranes, preterm birth (PTB), uterine rupture, cesarean delivery, placental abruption, and
stillbirth.3-7 In a 16-state fetal death certificate study conducted over 3 years, the
rate of fetal death from maternal trauma
was calculated to be 2.3 per 100,000 live
births,8 with placental abruption as a
major contributing factor.9 By one estimate, as many as 1 in 3 pregnant women
admitted to the hospital for trauma will
deliver during her hospitalization.10
Clearly the rate will vary depending on
the criteria used for hospitalizing pregnant women with trauma. While pregnancy per se does not appear to increase
morbidity or mortality due to trauma,
the presence of a gravid uterus does alter
the pattern of injury.9 Although the literature on trauma in pregnancy is quite
extensive, unbiased estimates of the
overall impact of trauma on maternal

From the Divisions of Maternal-Fetal Medicine
(Drs Mendez-Figueroa, Dahlke, and Rouse)
and Emergency Medicine (Dr Vrees),
Department of Obstetrics and Gynecology,
Women and Infants’ Hospital, Warren Alpert
Medical School of Brown University,
Providence, RI.
Received Oct. 26, 2012; revised Jan. 10,
2013; accepted Jan. 14, 2013.
The authors report no conflict of interest.
Reprints: Hector Mendez-Figueroa, MD,
Division of Maternal-Fetal Medicine,
Department of Obstetrics and Gynecology,
Women and Infants’ Hospital, Warren Alpert
Medical School of Brown University, 101 Plain
St., 7th Floor, Providence, RI 02903.
[email protected].
0002-9378/$36.00
© 2013 Mosby, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2013.01.021

We reviewed recent data on the prevalence, risk factors, complications, and management
of trauma during pregnancy. Using the terms “trauma” and “pregnancy” along with specified mechanisms of injury, we queried the PubMed database for studies reported from
Jan. 1, 1990, through May 1, 2012. Studies with the largest number of patients for a given
injury type and that were population-based and/or prospective were included. Case reports
and case series were used only when more robust studies were lacking. A total of 1164
abstracts were reviewed and 225 met criteria for inclusion. Domestic violence/intimate
partner violence and motor vehicle crashes are the predominant causes of reported trauma
during pregnancy. Management of trauma during pregnancy is dictated by its severity and
should be initially geared toward maternal stabilization. Minor trauma can often be safely
evaluated with simple diagnostic modalities. Pregnancy should not lead to underdiagnosis
or undertreatment of trauma due to unfounded fears of fetal effects. More studies are
required to elucidate the safest and most cost-effective strategies for the management of
trauma in pregnancy.
Key words: management, pregnancy, systematic review, trauma

and fetal outcomes are scarce, and the
optimal means of monitoring and treating pregnant women who have suffered
trauma remain uncertain. The purpose
of this report is to present a concise review of the most recent data (since 1990)
on the overall incidence, risk factors,
outcomes, and management approaches
for the many different types of trauma
encountered during pregnancy.

Materials and methods
A systematic review was prepared according to the Quality of Reporting of
Metaanalysis standards. We conducted a
search of the PubMed database (January
1990 through May 2012) using the key
words “trauma” and “pregnancy” along
with key words for mechanism of injury
including “motor vehicle accident/crash,”
“burns,” “falls,” “slips,” “accidental overdose,” “domestic violence,” “suicide,”
“homicide,” “penetrating abdominal
wound,” and “intentional overdose.” To
identify the most appropriate management strategies, the key words “management,” “KB stain,” “ultrasound,” “CT
scan,” “fetal monitoring,” and “perimortem cesarean section” were also utilized in
the search (Table 1). Only English-language publications were included. The size
and quality of the articles reviewed varied

considerably depending on the injury. We
selected studies for this review that included the largest number of patients and
that were population-based and/or prospective. Case reports and case series were
used only when more robust studies were
lacking. We considered all reports concerning trauma in pregnant women regardless of obstetrical (eg, gestational age,
plurality) or demographic (eg, maternal
age, race) characteristics. All publications
meeting inclusion criteria were assessed for
quality by 2 authors (H.M-F., J.D.D.) who
independently abstracted information on
incidence, risk factors, outcomes, monitoring methods, and various treatment
schemes. When available, we recorded incidence rates, relative risk, and 95% confidence intervals (CIs) for adverse outcomes. This systematic review is exempt
from institutional review board approval
because of the nature of the research design
(review article).

Results
We reviewed a total of 1164 abstracts and
included 225 in this review, of which
only 17 had a prospective design (Table
1). Table 2 contains reported (and in
some cases calculated) prevalence rates
for the various mechanisms of trauma.

JULY 2013 American Journal of Obstetrics & Gynecology

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Systematic Reviews

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TABLE 1

Results of search for informative studies
Search criteria

No. of abstracts
reviewed

Abstracts meeting
criteria for inclusion

Retrospective
studies

“Trauma,” “pregnancy,” and “motor vehicle accident/crash”

Prospective
studies

252

36

34

2

76

11

9

2

165

12

11

1

................................................................................................................................................................................................................................................................................................................................................................................

“Trauma,” “pregnancy,” and “falls” and “slips”

................................................................................................................................................................................................................................................................................................................................................................................

“Trauma,” “pregnancy,” and “burns”

................................................................................................................................................................................................................................................................................................................................................................................

“Trauma,” “pregnancy,” and “accidental poisoning”

46

2

1

“Trauma,” “pregnancy,” and “domestic violence” and
“intimate partner violence”

99

93

85

1

“Trauma,” “pregnancy,” and “penetrating trauma”

32

2

2

0

“Trauma,” “pregnancy” and “suicide” and “homicide”

27

13

13

0

“Trauma,” “pregnancy,” and “toxic exposure”

10

3

3

0

“Trauma,” “pregnancy,” and “management”

235

14

12

2

................................................................................................................................................................................................................................................................................................................................................................................

7
1 RCT

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

“Trauma,” “pregnancy,” and “KB stain”

19

6

6

0

“Trauma,” “pregnancy,” and “ultrasound”

81

10

10

0

“Trauma,” “pregnancy,” and “CT scan”

33

3

3

0

“Trauma,” “pregnancy,” and “fetal monitoring”

84

17

16

1

5

3

3

0

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

“Trauma,” “pregnancy,” and “perimortem cesarean section”

................................................................................................................................................................................................................................................................................................................................................................................

Studies were selected for inclusion if they were published from 1990 through present and if, after review of abstract, it was determined that objective of study was to report on outcomes of interest
for this analysis.
CT, computed tomography; KB, Kleihauer-Betke; RCT, randomized controlled trial.
Mendez-Figueroa. Trauma in pregnancy. Am J Obstet Gynecol 2013.

Table 3 presents the characteristics of the
largest trauma studies.
Unintentional trauma accounts for a
large portion of major trauma during

pregnancy,4 the most commonly encountered form of which is motor vehicle crashes (MVC). The overall incidence
rate of MVC during pregnancy has been

estimated at around 207 cases per
100,000 pregnancies.11 It is one of the
leading causes of both maternal and fetal
mortality, with estimated mortality rates

TABLE 2

Estimated incidence/prevalence of injury by type of trauma during pregnancy
Mechanism of injury
Motor vehicle crashes

Estimated incidence/prevalence
in pregnancy
207/100,000 live births11

Study design

Estimated incidence/prevalence
outside of pregnancy

Population-based cohort

1104/100,000 womenc99

Retrospective case-control

3029/100,000 women

................................................................................................................................................................................................................................................................................................................................................................................
24
100

Falls and slips

48.9/100,000 live births

................................................................................................................................................................................................................................................................................................................................................................................
27
27

Burns

0.17/100,000 person-years

Retrospective case-control

2.6/100,000 person-years

................................................................................................................................................................................................................................................................................................................................................................................

Accidental poisoning

N/A

N/A

N/A

Domestic violence

8307/100,000 live births

Review

5239/100,000 women

................................................................................................................................................................................................................................................................................................................................................................................
101
c44
................................................................................................................................................................................................................................................................................................................................................................................
a
61
c102

Suicide

2/100,000 live births

Retrospective cohort

8.8/100,000 population

Homicide

2.9/100,000 live births

Retrospective cohort

2.3/100,000 women

3.27/100,000 live births

N/A

................................................................................................................................................................................................................................................................................................................................................................................
61
100
................................................................................................................................................................................................................................................................................................................................................................................
b
c62
c62

Penetrating trauma

3.4/100,000 women

................................................................................................................................................................................................................................................................................................................................................................................
103
104

Toxic exposure

25.8/100,000 person-years

Retrospective cohort

115.3/100,000 person-years

................................................................................................................................................................................................................................................................................................................................................................................

Literature relating to incidence of burns during pregnancy is limited to most severe cases admitted to burn units and referral centers. Rate for accidental poisoning during pregnancy could not be
calculated from available published literature. Domestic violence incidence includes all forms of partner violence: sexual, physical, and psychological.
N/A, not available.
a

Rates exclude attempted suicides. Attempted suicide rate during pregnancy is approximately 40/100,000 pregnancies65 and during postpartum period is 43.9/100,000 live births66; b Rates include
only causes leading to fatality; c Rates calculated using 2009 US data from Centers for Disease Control and Prevention.

Mendez-Figueroa. Trauma in pregnancy. Am J Obstet Gynecol 2013.

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Systematic Reviews

TABLE 3

Representative studies of trauma organized by year of publication (1990 through 2012)
Authors, location (y)
MVC

Design

Inclusion

Sample size

Primary outcome: results

.......................................................................................................................................................................................................................................................................................................................................................................

Vivian-Taylor et
al,13 Australia
(2012)

Retrospective casecontrol

Hospital admissions after
MVC

2147

Kvarnstrand et al,11
Sweden (2008)

Retrospective casecontrol

National Forensic
Pathology Database

2270

Weiss et al,105 Utah Retrospective cohort
(2008)

State Department of
Health ER records

7350

Incidence of MVC and pregnancy outcomes after MVC: 3.5/1000 maternity admissions,
similar outcomes among MVC and non-MVC

.......................................................................................................................................................................................................................................................................................................................................................................

Maternal and perinatal mortality after MVC: maternal mortality calculated at 1.4/100,000
pregnancies; perinatal mortality calculated at 3.7/100,000 pregnancies

.......................................................................................................................................................................................................................................................................................................................................................................

Most common types of maternal injury and risks associated with adverse birth outcomes:
MVC are most common mechanism of injury; increased risk of preterm labor, placental
abruption, cesarean delivery, and delivery of LBW infant

.......................................................................................................................................................................................................................................................................................................................................................................

El Kady et al,106
California (2006)

Retrospective casecontrol

Fractures from Vital
Statistics Database

3292

Hyde et al,107 Utah
(2003)

Retrospective casecontrol

State Department of
Transportation reports

8938

Association of fractures with adverse maternal/fetal outcomes: increased maternal mortality
and morbidity when delivered during hospitalization, worse outcomes with pelvic fractures

.......................................................................................................................................................................................................................................................................................................................................................................

Likelihood of adverse outcomes after MVC: women in MVC who use seatbelts are not at
significantly increased risk of adverse fetal outcomes than women not in crashesa; lack of
seatbelt use increases risk for LBW infant, excessive maternal bleeding

.......................................................................................................................................................................................................................................................................................................................................................................

Wolf et al,108
Washington (1993)

Retrospective cohort

Police-investigated MVC

2592

Association of seatbelt use on outcome ⬎20 wks’ gestation: no seatbelt use 1.9 times
more likely to have LBW baby and 2.3 times more likely to deliver within 48 hours after
MVC

.......................................................................................................................................................................................................................................................................................................................................................................

Goodwin et al,109
Arizona (1990)

Prospective cohort

Noncatastrophic trauma
during second half of
pregnancy

250

Women who suffered
trauma during pregnancy

85

Association between signs/symptoms and outcomes after MVC: symptoms of contractions,
uterine tenderness, and bleeding after MVC are associated with complications

.......................................................................................................................................................................................................................................................................................................................................................................

Pearlman et al,3
Michigan (1990)

Prospective cohort

Adverse outcomes after trauma: adverse outcomes are not predicted by injury severity; 4
hours of EFM was sensitive but not specific in detecting immediate adverse outcomes

................................................................................................................................................................................................................................................................................................................................................................................

DV/IPV

.......................................................................................................................................................................................................................................................................................................................................................................

Woolhouse et al,57
Australia (2012)

Prospective cohort

Kiely et al,110
Maryland (2010)

RCT

Lutgendorf et al,111
Virginia (2009)

Prospective cohort

Nulliparas 6-24 wks

1305

Measurement of EPDS and Composite Abuse Scale scores: 16% reported depressive
symptoms; 40% also reported DV/IPV

.......................................................................................................................................................................................................................................................................................................................................................................

Self-identified minorities

1044

Efficacy of brief psychobehavioral intervention in reducing IPV recurrence during
pregnancy and postpartum: intervention group less likely to report recurrent IPV

.......................................................................................................................................................................................................................................................................................................................................................................

Prenatal care in Naval
Hospital

1162

Prevalence of current or past DV using Abuse Assessment Screen: current or past abuse
prevalence 15.4%; increased abuse during pregnancy in unwed women and those with
positive family history of abuse

.......................................................................................................................................................................................................................................................................................................................................................................

Rodrigues et al,52
Portugal (2008)

Prospective cohort

Silverman et al,112
United States
(2006)

Retrospective casecontrol

Survey after hospital
deliveries

2660

Assess relationship of abuse with preterm labor: abuse during pregnancy associated with
increased risk of PTB

.......................................................................................................................................................................................................................................................................................................................................................................

PRAMS

118,579

Association of IPV with maternal and neonatal morbidity: IPV prior to and during pregnancy
increases risk for multiple adverse outcomes

................................................................................................................................................................................................................................................................................................................................................................................

Other forms of trauma

.......................................................................................................................................................................................................................................................................................................................................................................

Vladutiu et al,25
North Carolina
(2010)

Prospective cohort

Dunning et al,23
Ohio (2010)

Retrospective cohort

Petrone et al,59
California (2011)

Retrospective casecontrol

Questionnaire about
frequency and duration
of physical activity

1469

Survey after delivery
within 2 months

3997

Injuries from physical activity and exercise: injuries rate of 3.2/1000 physical activity hours
and 4.1/1000 exercise hours

.......................................................................................................................................................................................................................................................................................................................................................................

Rate, risk factors, and characteristics of falls: falls reported in 27%; age 20-24 y with 2fold increase in falls; most falls occurred indoors, involved stairs, ⬎3 feet

.......................................................................................................................................................................................................................................................................................................................................................................

Trauma admissions

291 blunt,
30 penetrating
trauma

Mechanism of injury, injury severity score, abdominal Abbreviated Injury Scale, gestational
age, maternal and fetal mortality: penetrating trauma had higher maternal mortality, fetal
mortality, and maternal morbidity

.......................................................................................................................................................................................................................................................................................................................................................................

Palladino et al,61
United States
(2011)

Retrospective casecontrol

McClure et al,103
California (2011)

Retrospective casecontrol

National Violent Death
Reporting System

94 suicides,
Deaths attributable to homicide or suicide: pregnancy-associated suicide 2.0/100,000 live
139 homicides births, homicide 2.9/100,000 live births; 54% of suicides and 45% of homicides
associated with IPV

.......................................................................................................................................................................................................................................................................................................................................................................

Discharges for
intentional poisoning

430

Birth outcomes after intentional acute overdose during pregnancy: incidence rate of 25.87/
100,000 person years, greatest in first weeks of gestation; PTB, LBW, congenital heart
disease increased

.......................................................................................................................................................................................................................................................................................................................................................................

Gandhi et al,65
California (2006)

Retrospective casecontrol

Vital statistics discharge
database

2132
attempted
suicides

Risks for and outcomes after attempted suicide; substance abuse was best identifier of
women at risk; increased risk of premature labor, cesarean delivery, need for transfusion,
increased respiratory distress syndrome, and LBW

1044

Outcomes associated with self-poisoning: self- poisoning associated with 44.4% live born
birth rate, unknown teratogenic effect

.......................................................................................................................................................................................................................................................................................................................................................................

Czeizel et al,113
Hungary (1999)

Retrospective cohort

Admissions after selfpoisoning

................................................................................................................................................................................................................................................................................................................................................................................

DV, domestic violence; EFM, external fetal monitoring; EPDS, Edinburgh Postnatal Depression Scale; ER, emergency room; IPV, intimate partner violence; LBW, low birthweight; MVC, motor vehicle
crashes; PRAMS, Pregnancy Risks Assessment Monitoring System; PTB, preterm birth; RCT, randomized controlled trial.
a

Presumably because most MVC are minor and do not result in severe maternal morbidity.

Mendez-Figueroa. Trauma in pregnancy. Am J Obstet Gynecol 2013.

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of 1.4 per 100,000 and 3.7 per 100,000
pregnancies, respectively.11 Of pregnant
women involved in a MVC, 87% receive
some sort of medical care12 and 0.61
pregnancy admissions per 1000 live
births can be attributed to MVC.7 The
majority of these admissions occur ⬎20
weeks’ gestation.13 The major risk factor
for adverse outcomes during MVC is improper seat belt use: in both front and
rear collisions, the impact with the steering wheel can be avoided with proper
belt use.14 Unfortunately, in one study,
only half of patients report having received counseling regarding seatbelt use
from their prenatal care provider.15 The
use of intoxicants has also been reported
as a major risk factor for MVC during
pregnancy; 37 of 85 pregnant patients
(43.5%) evaluated following an MVC at
a major trauma center tested positive for
some intoxicant,16 while another study
reported that alcohol was implicated in
45%.17 As a comparison, in one comprehensive report, 41% of fatal MVC (comprised predominantly of nonpregnant
victims) were alcohol-related.18
The major obstetrical concern with
MVC is the strain placed on the uterus,
which may result in placental abruption.
There are 2 major mechanisms of uteroplacental interface failure that have been
described in the literature: shear force
(strain) failure and tensile failure (“contrecoup” mechanism). The impact of an
MVC can generate substantial forward
displacement of the uterus. This motion
builds both negative pressure and a
“contrecoup” effect, 2 mechanisms that
along with maternal body folding over
the abdomen are enough to markedly increase intraabdominal pressure19 and result in forces powerful enough to cause
placental shearing and subsequent abruption.20 However, among severely injured women, placental abruption occurs in as many as 40% of cases.21
Although women in severe MVC are at
higher risk for pregnancy complications,
the greater burden of MVC morbidity in
pregnancy may be borne by women in
minor MVC, as they predominate. Not
surprisingly, pregnant women involved
in MVC appear to be at increased risk for
cesarean delivery,7 but the risk of PTB
and perinatal death seem to increase only

if delivery occurs immediately after
MVC,13 which is fortunately uncommon
with an estimated rate of 0.4% ⬍20
weeks and 3.5% thereafter.20 This increased risk of perinatal death associated
with immediate delivery likely reflects
the severity of trauma, ie, delivery should
never be delayed if clinically warranted
in the hopes of improved outcomes.
Literature pertaining to slips and falls
during pregnancy is limited. It is known
that increased joint laxity and weight
gain can affect gait and predispose pregnant women to slips and to falls.22 Dynamic postural stability decreases with
pregnancy, especially during the third trimester, as evidenced by decline in initial
sway, total sway, and sway velocity, all
measures of stability in response to postural perturbations.22 Approximately 1 in
4 pregnant women will fall at least once
while pregnant.23 A population-based
study found that 79% of hospitalized
women after a fall were in their third trimester; among such women, fracture of
the lower extremity was the most commonly associated injury.24 The majority
of falls occur indoors and 39% involve
falling from stairs.23 In one of the largest
studies to date, Vladutiu et al25 prospectively evaluated ⬎1400 pregnant women
using a structured questionnaire administered at 17-22 weeks and again at 27-30
weeks, and found an overall injury incidence of 4.1 cases per 1000 exercise
hours; the majority of these injuries were
attributed to falls. Dunning et al26 reported that 6.3% of all employed pregnant workers fell at work; major risk factors included walking on slippery floors,
hurrying, or carrying heavy objects.
Schiff,24 in an analysis of hospitalized
pregnant patients admitted after a fall,
reported a 4.4-fold increase in preterm
labor (95% CI, 3.4 –5.7), an 8-fold increase in placental abruption (95% CI,
4.3–15.0), a 2.1-fold increase in fetal distress (95% CI, 1.6 –2.8), and a 2.9-fold
increase in fetal hypoxia (95% CI, 1.3–
6.5) when compared to a randomly selected control group.24
Information on burns in pregnancy is
limited to case reports and case series.
They suggest that the impact of burns depends greatly on the burn depth and the
total body surface area affected; as the

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total body surface area involved exceeds
40%, the mortality rate for both mother
and fetus approaches 100%27 with sepsis
being a major contributor.28 Reports
from major burn referral centers have
shown that maternal and fetal mortality
are significantly increased in cases where
smoke inhalation has occurred.29 Maternal age and trimester of pregnancy of
the burn do not appear to affect maternal or fetal outcome and pregnancy
does not appear to independently alter
maternal survival after severe burns.30
Burns during the first trimester have
been associated with SAB; some authors have speculated that ensuing septicemia after a severe burn may be the
predisposing factor to fetal loss.31 The
majority of these losses will occur
within 10 days of sustaining the burn.28
Thermal injury also appears to increase
the risk of PTB, although this observation is based on a small retrospective
study of 30 patients.32
Reports on electrocution during pregnancy is sparse. Among 15 cases of severe
electrocution during pregnancy, fetal
mortality was 73%,33 although these case
reports may represent a biased sample.
In a prospective study that included 31
pregnant women who sustained minor
electrical shock, mainly from home appliances, no differences were noted in
mode of delivery, birthweight, or gestational age at delivery when compared to
controls.34
Literature on poisoning during pregnancy relates mostly to intentional poisoning and/or suicide attempts. Accidental poisoning is not as widely
reported and its actual incidence unclear. In a study of ⬎400 maternal
deaths, only one was attributed to accidental poisoning.35 Isolated case reports
describe accidental overdose of medications in a hospital setting.36,37
Intentional trauma during pregnancy
accounts for significant maternal-fetal
morbidity, increasing the risk of PTB by
2.7-fold (95% CI, 1.3–5.7) and of low
birthweight by 5.3-fold (95% CI, 3.9 –
7.3).38 The most common form of intentional trauma is domestic violence (DV)
or intimate partner violence (IPV). The
prevalence of DV/IPV across various populations has been evaluated extensively

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with ⬎60 studies from ⬎20 countries reporting a frequency during pregnancy
ranging from 1-57%,39-43 consistent with a
22.1% rate reported in the general female
population.44 One explanation for this
wide range is the inclusion of emotional,
verbal, and/or physical violence within
the definition of DV/IPV in some studies. Risk factors associated with DV/IPV
during pregnancy are broad and include
maternal or intimate partner substance
abuse, low maternal educational level,
low socioeconomic status, unintended
pregnancy, history of DV prior to pregnancy, history of witnessed violence as a
child by mother or intimate partner, and
unmarried status.45-49 Adverse pregnancy outcomes associated with DV/IPV
include increased rate of SAB,50 neonatal
intensive care unit admissions,51 PTB,52
and low birthweight.52-54 Both retrospective and prospective studies have reported a strong association between peripartum depression and DV/IPV.55-58
In a prospective cohort of 13,617 maternal fetal dyads followed up for 42
months, Flach et al56 noted an association between antenatal DV and maternal
antenatal (odds ratio, 4.02; 95% CI, 3.4 –
4.8) and postnatal (odds ratio, 1.29; 95%
CI, 1.02–1.63) depressive symptoms.
There are no prospective studies or
randomized controlled trials evaluating
penetrating trauma in pregnancy and we
identified only 2 retrospective analyses.59,60 In the larger one, comprising 321
patients, penetrating trauma accounted
for 9% of all pregnant trauma admissions. Of those, 73% were handgun-,
23% knife-, and 4% shotgun-related.59
Penetrating trauma in pregnancy is associated with increased fetal mortality (as
high as 73%), increased hospital stay,
and complications such as ileus when
compared to blunt trauma.59 Awwad et
al60 reviewed their experience of selective
laparotomy in 14 penetrating trauma
cases in pregnancy over a 16-year period
during the civil war in Lebanon. In their
cohort, fetal mortality occurred in 50%
and maternal mortality was noted in 2
cases (14.3%).
In a multistate sample from the National Violent Death Reporting System
from 2003 through 2007, Palladino et
al61 estimated the rates of suicide and ho-

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micide in pregnancy were about 2.0/
100,000 and 2.9/100,000 live births, respectively. In the general population, the
respective rates have been estimated at
5.27/100,000 and 12.43/100,000.62 Suicide accounts for approximately 20% of
postpartum maternal deaths.63 Interestingly, pregnancy may be protective in
those women who are otherwise at high
risk for suicide or homicide. In a retrospective analysis of vital statistics records
in North Carolina from 2004 through
2006, Samandari et al64 found the suicide
rate to be 27% lower in a pregnant cohort
and 54% lower in a postpartum cohort
compared to a nonpregnant cohort. Homicide rates were similarly 73% lower in
the pregnant cohort and 50% lower in
the postpartum cohort. Substance abuse
appears to be the best identifier for detecting women at risk for suicide.65 Another major risk factor for attempting
suicide, especially during the postpartum period, is fetal or infant death; Schiff
and Grossman66 reported a case-control
study of 520 suicide attempts (63% poisoning) and found a 3.1-fold increase in
the risk of suicide attempt when fetal or
infant death had occurred. Suicide and
homicide during pregnancy are often
associated with DV/IPV. Similarly,
DV/IPV may be a contributing factor
in up to 54% of cases of suicide among
pregnant women.61,67 Cheng and
Horon68 estimated that 54.5% of pregnancy-associated homicides in Maryland from 2003 through 2008 were
committed by a current or former
partner, while others have reported
rates ranging from 45-74%.67 Unsuccessful suicide attempts have also been
associated with adverse pregnancy outcomes. In a review of 2132 suicide
attempts in California from 1991
through 1999, women who attempted
suicide but were unsuccessful had increased risk of premature labor, cesarean delivery, need for transfusion, increased respiratory distress syndrome,
and low birthweight.65 Suicide attempt
by intentional self-poisoning clearly
affects both fetus and mother69-71; maternal death occurs in 1.8% of cases after suicide attempts by ingestion of
medication.71

Management of trauma during
pregnancy
When caring for the pregnant patient
who has suffered trauma, the primary
management goal is to stabilize the condition of the mother, as fetal outcomes
are directly correlated with early and aggressive maternal resuscitation.72 According to the National Center for Injury Prevention and Control, pregnant women
⬎20 weeks’ gestation should be transported to a center that is: (1) capable of
undertaking a timely and thorough
trauma evaluation; and (2) adept at
management of life-threatening injuries.73 However, whether such transport
is safe and feasible will vary depending
on the individual circumstances of a
given case. The initial maternal evaluation (primary survey) should follow
nonpregnant guidelines and include a
full trauma history and vital signs assessment as well as displacement of the
gravid uterus to one side. Cardiac arrest,
loss of an airway, blood pressure ⬍80/40
mm Hg, pulse ⬍50 or ⬎140 bpm, respiratory rate ⬍10 or ⬎24 breaths per minute, or a fetal rate ⬍110 or ⬎160 bpm
should immediately alert the physician
of probable catastrophic trauma requiring immediate stabilization and initiation of advanced cardiac life support74 as
well as advanced trauma life support.75
Intravenous access should be secured
and targeted laboratory tests ordered
(Figure). In cases of severe hemorrhage,
transfusion of fresh frozen plasma, platelets, and packed red blood cells at 1:1:1
ratio lowers the rate of coagulopathy and
may improve survival.76 Medical antishock trousers have been used for the
prehospital management of trauma patients but they in fact may delay transportation to hospital and worsen outcomes of penetrating trauma to the
thorax and abdomen.77 However, such
trousers may have a role in severe postpartum obstetrical hemorrhage.78,79
When possible, joint evaluation of the
patient by both the trauma and obstetrical team should be undertaken. This assessment should include an evaluation of
the cervical spine, as manipulation with
cervical spinal fracture may result in paralysis. The ideal imaging modality dur-

JULY 2013 American Journal of Obstetrics & Gynecology

5

Systematic Reviews

Obstetrics

www.AJOG.org

FIGURE

Management algorithm for trauma in pregnancy
Assess Maternal Status
- Cardiac arrest
- Unresponsive
- Loss of airway/respiratory arrest
- BP <80/40 mm Hg or HR <50 or >140 bpm
- If fetus viable, FHR <110 or >160 bpm
PRESENT

ABSENT

Advanced life support
Airway/Cervical spine control
Breathing
Circulation
Disability
Exposure
Consultation with trauma team; notify NICU
Supplemental O2
Displace uterus to left if GA >20 weeks
IV Access (2 peripheral lines)
Labs: CBC, Coagulation profile, type &
screen; KB if Rh (-), type & cross
Viable fetus: continuous FHR monitoring
Previable fetus: FHR via Doppler
Tocometer if concern for abruption

Maternal injury greater than minor
bruising, lacerations or contusions
PRESENT

Consider trauma team consultation
IV Access
Labs: CBC, Coagulation profile, type & screen;
KB if Rh (-)
Viable fetus: fetal monitoring for 4 hours –
Ctxs <6/hour consider discharge
Ctxs ≥6/hour consider admission
Previable fetus: FHR via Doppler
Tocometer if concern for abruption

ABSENT

Brief fetal assessment
No lab evaluation required
No radiologic imaging
required
Patient counseling on
signs/symptoms abruption

Once the patient is stable
Fetal Ultrasound +/- Biophysical Profile
Consider other labs - chemistries, urinalysis, urine toxicology screen
Radiologic assessment /Peritoneal lavage/ F.A.S.T. U/S Imaging (if indicated)

MVA
Determine
whether
patient was
wearing
seatbelt

Slips/Falls
Assess for
abdominal
trauma and
extremities for
fractures/
ligament damage

Burns
Aggressive
fluid
resuscitation
Consider
delivery if
burn area
>50%

DV/IPV
Assess for
depression
and suicide
risk

Penetrating trauma
Level of entry
determines affected
organ; gravid uterus
may protect from
visceral injury

Toxic exposure
Agent and GA at
exposure guides
maternal therapy and
counseling

Proposed algorithm for evaluation and management of trauma in pregnancy.
BP, blood pressure; CBC, complete blood cell count; Ctxs, contractions; DV, domestic violence; FAST, focused assessment with
sonography for trauma; FHR, fetal heart rate; GA, gestational age; HR, heart rate; IPV, intimate partner violence; ISS, Injury Severity Score;
IV, intravenous; KB, Kleihauer-Betke; MVA, motor vehicle accident; NICU, neonatal intensive care unit; O2, oxygen; U/S, ultrasound.
Mendez-Figueroa. Trauma in pregnancy. Am J Obstet Gynecol 2013.

ing pregnancy for this evaluation has not
been determined, but computed tomography (CT) appears to have higher sensitivity
than plain film x-ray outside of pregnancy.80 Direct cervical spine trauma
makes securing an airway more difficult
and may necessitate fiberoptic bronchoscopy,81 and pregnancy in general is associated with a higher risk of aspiration and
failed endotracheal intubation, arguing for
the availability of personnel skilled in difficult intubation.82
Minor trauma during pregnancy (ie,
nothing more than minor bruising, lacerations, or contusions) requires only
limited evaluation. In a prospective trial
of 317 patients with minor trauma, placental abruption occurred in only 1 case
and was not predicted by conventional
testing including tocodynamometry, complete blood cell count, coagulation profile,
6

Kleihauer-Betke (KB) testing, or bedside
ultrasound.83 This led the authors to conclude that minor trauma can be appropriately evaluated with limited radiologic,
laboratory, and fetal assessment.83
Management of penetrating injuries
will depend largely on the entrance location of the wound and the gestational
age. Visceral injuries are less likely when
the entry site is anterior and below the
uterine fundus.60 If a thoracostomy tube
is required in a pregnancy, some have
recommended that it be placed at least 1
or 2 intercostal spaces above the usual
landmark of the fifth intercostal space to
avoid inadvertent abdominal insertion.72 Pelvic fractures per se are not an
indication for cesarean delivery. Most
women can safely attempt vaginal birth
following a pelvic fracture, even those
that occur during the third trimester.84

American Journal of Obstetrics & Gynecology JULY 2013

Peritoneal lavage can be performed during pregnancy. An open technique is recommended after placement of a nasogastric tube and a Foley catheter.85 Since
pregnancy-specific criteria have not
been reported, nonpregnant parameters
(ie, cell and red blood cell count, amylase
concentration) for a positive peritoneal
lavage should be used.85 When treating
pregnant burn victims, aggressive fluid
resuscitation, respiratory support, and
initial wound care become priorities
with the ultimate goal of transport to a
tertiary care facility. Some authors have
advocated for delivery of all fetuses in the
second and third trimester if the mother
has sustained burns of ⬎50% total surface area because of the associated high
mortality rate.86 Direct inhalation injury
can result in significant airway compromise with subsequent hypoxia and should
arouse suspicion for carbon monoxide
poisoning (Figure).
Diagnostic radiologic imaging in pregnant trauma patients should be undertaken if clinically indicated and not be
withheld or delayed because of unfounded fears of fetal effects. The 3 modalities most studied in pregnancy include ultrasound, CT, and magnetic
nuclear imaging. Because of the long acquisition time and difficulty in monitoring a critically ill patient while obtaining
imaging, magnetic nuclear imaging is
utilized substantially less in acute trauma
management.87
In the pregnant trauma patient, ultrasound is often easily accessible in an
emergency department and can provide
crucial information such as gestational
age, placental location, fetal presentation, and viability. Ultrasound has been
proposed as a method of diagnosing placental abruption, although this method
has proven to be unreliable in establishing this diagnosis; in one study sensitivity was only 24%.88 Focused assessment
with sonography for trauma is a safe and
efficient method for detecting intraperitoneal free fluid and intraabdominal injuries. This targeted ultrasound assesses
4 areas for evidence of free fluid: the subxiphoid; the right upper quadrant; the
left upper quadrant; and the suprapubic
area. In a large retrospective cohort of
⬎2300 ultrasound examinations, the

www.AJOG.org
sensitivity and specificity for the detection of free fluid and/or intraabdominal
injury in pregnant (n ⫽ 328) and nonpregnant trauma patients were similar
(61% sensitivity and 94% specificity in
pregnant, vs 71% sensitivity and 97%
specificity in nonpregnant women).89
Abdominal helical CT allows the evaluation of multiple organ systems in stable
patients. A known drawback of CT scan
is the fetal radiation exposure of up to 3.5
rads (0.035 Gy) per study90 and this risk
must be weighed against the potential for
identifying life-threatening injuries afforded by this powerful imaging modality. Importantly, radiation doses ⬍5 rads
(0.05 Gy) are not associated with an increased risk of anomalies, pregnancy
loss, or growth restriction.90
In catastrophic trauma or when maternal injury is present, a complete blood
cell count, coagulation profile, KB test,
and type and screen should be obtained.
In Rh-negative mothers, the KB test also
allows for calculation of the total required dose of Rh immune globulin: 1
vial of 300 ␮g protects against 30 mL of
fetal blood (15 mL of fetal red blood
cells).91 When minor trauma is present,
however, these tests do not appear to be
predictive of fetal outcomes.5,83 The KB
test is used in many institutions as a routine component of trauma evaluation.
However, the KB test is insensitive and
poorly predictive of adverse perinatal
outcomes,92 PTB,5 placental abruption,
or fetal distress93 in minor trauma or in
trauma with absent maternal injury.
When the fetus is deemed viable, continuous fetal monitoring should be initiated as soon as possible, as long as it does
not interfere with essential maternal diagnostic tests or therapy. If the mother’s
condition precludes safe emergent cesarean, continuous monitoring is of limited
value. The ideal duration for monitoring
has not been established with recommendations ranging from 4-48 hours94;
the American Congress of Obstetricians
and Gynecologists recommends a minimum of 2-6 hours of monitoring posttrauma.91 A prospective study evaluating
85 women found fetal monitoring for 4
hours to be sensitive but nonspecific for
detecting immediate adverse perinatal
outcomes.3 Although placental abrup-

Obstetrics
tion has been reported to occur up to 24
hours after a traumatic insult,72 it has not
been reported when ⬍1 contraction is
present in any 10-minute interval over a
4-hour period.95 Thus, fetal monitoring
can be discontinued after 4 hours if uterine contractions occur less frequently
than every 10 minutes, the fetal heart
tracing is reassuring, and there is no maternal abdominal pain or vaginal bleeding.
Since placental perfusion and oxygenation
depends on maternal cardiopulmonary
function, fetal monitoring should continue in cases of adult respiratory distress syndrome, continuous lung injury,
or trauma causing maternal cardiac arrhythmia (Table 4).
Perimortem cesarean section, defined
as a cesarean section performed in the
face of maternal cardiac arrest, can be
life-saving for both mother and fetus. In
a multicenter retrospective cohort study
of 114,952 trauma admissions including
441 pregnant women, 32 emergency cesarean sections had a reported 45% fetal
and 75% maternal survival.96 Survival of
both is dependent on multiple factors including the interval between maternal
cardiac arrest and delivery, the underlying etiology of the arrest, where the arrest
takes place, and the expertise of the team
attending to the mother.97 Based on experimental data and case reports, cesarean delivery may be appropriate in the
setting of imminent maternal death or
after 4 minutes of properly performed
cardiopulmonary resuscitation that has
failed to revive the mother, as both infant
and maternal survival are increased when
cesarean delivery is initiated within 4 minutes of maternal cardiac arrest.96,98 Although delivery should ideally occur
within 4 minutes of failed maternal revival, this standard can rarely be met in
actual practice even in ideal situations.
Notably, resuscitation efforts may improve following delivery as a result of diminished aortocaval compression and
improved volume return to the heart.98
Anecdotally, reports of women undergoing cardiopulmonary resuscitation suggest the possibility of improvement in
maternal condition following cesarean
delivery. However, no evidence exists
that cesarean delivery in this setting ac-

Systematic Reviews
TABLE 4

Considerations specific to
management of pregnant
women with trauma
●

●
●

●

●
●

●

●
●

●

●
●

Pregnancy should not lead to
underdiagnosis or undertreatment of
trauma due to the fears of adverse fetal
effects
When possible, uterus should be
displaced to one side laterally
When fetus is deemed viable,
continuous fetal monitoring should be
initiated as soon as possible
Simultaneous (not sequential)
evaluation by trauma and obstetrical
teams may be indicated
Personnel trained in difficult intubation
should be readily available
Penetrating injuries are more likely to
affect the fetus, especially those
anterior and below uterine fundus
If a thoracostomy tube is indicated, it
should be placed 1-2 intercostal spaces
above usual fifth intercostal space
landmark to avoid abdominal
placement
Pelvic fractures do not necessarily
preclude vaginal delivery
If peritoneal lavage is indicated, an
open technique is preferred as is
placement of a Foley catheter and
nasogastric tube
In second- and third-trimester burn
victims, delivery should be considered
if affected total affected body surface
area is ⬎50%
Focused assessment with sonography
for trauma is reliable during pregnancy
Perimortem cesarean section may be
appropriate in setting of imminent
maternal death or after 4 min of
properly performed but unsuccessful
cardiopulmonary resuscitation

...........................................................................................................

Mendez-Figueroa. Trauma in pregnancy. Am J
Obstet Gynecol 2013.

tually improves rates of maternal survival for any specific condition.

Comment
In this systematic review, we evaluated recent data concerning trauma in pregnancy.
We note that the available literature is
characterized by several limitations. The
majority of the studies are retrospective,
and the outcomes reported vary widely. In
many of the studies, ascertainment bias is a
concern, as only the most severe cases of
trauma may have been identified. Studies
that rely on hospitalized trauma patients
may not give an accurate picture of trauma

JULY 2013 American Journal of Obstetrics & Gynecology

7

Systematic Reviews
across gestation, as gravidas suffering
trauma when the fetus is viable are probably more likely to be hospitalized. Studies
based on administrative data are subject to
inaccurate coding. In some studies, control
patients were not matched to cases on the
basis of relevant characteristics.
With the above limitations in mind,
our review leads to the following conclusions. The major determinant of obstetrical outcomes after trauma is the severity of injury. DV/IPV and MVC are the
most common mechanisms of traumatic
injury during pregnancy and substance
abuse is a common accompaniment to
these forms of trauma. In most cases,
management of the pregnant trauma patient should be dictated by the status of
the mother. Major trauma causing maternal instability should be initially managed using advanced cardiac life support/advanced trauma life support
guidelines and, depending on the nature
of the injuries, may require a multidisciplinary approach involving prehospital
care, emergency room providers, obstetricians, and a trauma team to achieve
the best outcomes. Once the maternal
status has stabilized, an improvement in
fetal status often follows. Minor trauma
(associated with only minor bruising,
lacerations, or contusions) can be assessed with limited radiologic, laboratory, and fetal evaluation. More prospective studies are needed to define the
optimal approach to the evaluation and
treatment of pregnant women who suff
fer trauma.
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