Abstract
Introduction
Trauma during pregnancy is the leading cause of non-obstetric maternal death and complicates
up to 5%-7% of pregnancies. This systematic review without meta-analysis explores
the current literature regarding the assessment and management of pregnant trauma
patients to provide evidence-based recommendations to guide the general surgeon regarding
the prognostic value of laboratory testing including Kleihauer-Betke testing, duration
of maternal and fetal monitoring, the use of tranexamic acid, the safety of radiographic
studies, and the utility of perimortem cesarean section to improve maternal and fetal
mortality.
Materials and methods
A systematic search of MEDLINE (Ovid), the Cochrane Library (Wiley), and Embase (Elsevier)
was performed. The reference lists of included studies were reviewed for relevant
citations.
Results
Of the 45 studies included in this review, there was reasonable evidence to suggest
that the minimally injured pregnant trauma patient should be observed for a minimum
of 4 h, CT scans to rule out traumatic injury are necessary and safe, perimortem cesarean
sections should be performed as soon as maternal cardiac arrest occurs.
Conclusions
We recommend delivery by perimortem cesarean section as soon as possible after maternal
cardiac arrest, to provide TXA to the hemorrhaging pregnant trauma patient, to obtain
trauma CT scans as indicated, and to observe the injured pregnant patient for a minimum
of at least 4 h. Additional high-quality studies focusing on the prognostic potential
of KB tests and other laboratory studies are needed.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Surgical ResearchAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Predictors of fetal outcome in pregnant trauma patients: a five-year institutional review.Am Surg. 2007; 73: 824-827
- Predictors of fetal mortality in pregnant trauma patients.J Trauma Inj Infect Crit Care. 1997; 42: 782-785
- Trauma in pregnancy.Mayo Clin Proc. 2000; 75: 1243-1248
- Maternal death in the emergency department from trauma.Arch Gynecol Obstet. 2012; 288: 507-512
- Trauma during pregnancy: a population-based analysis of maternal outcome.World J Surg. 2012; 36: 2767-2775
- Trauma and pregnancy.Am J Perinatology. 1997; 14: 331-336
- Predictors of outcome in trauma during pregnancy: identification of patients who can be monitored for less than 6 hours.J Trauma Inj Infect Crit Care. 2000; 49: 18-24
- Trauma during pregnancy. A review of 79 cases.Arch Surg. 1991; 126: 1073-1078
- Blunt traumatic injury during pregnancy: a descriptive analysis from a level 1 trauma center.Eur J Trauma Emerg Surg. 2018; 45: 393-401
- Pregnant trauma victims experience nearly 2-fold higher mortality compared to their nonpregnant counterparts.Am J Obstet Gynecol. 2017; 217: 590.e1-590.e9
- Pregnant trauma patients may be at increased risk of mortality compared to nonpregnant women of reproductive age: trends and outcomes over 10 years at a level I trauma center.Women’s health. 2019; 16: 1-6
- Practice management guidelines for the diagnosis and management of injury in the pregnant patient: the EAST practice management guidelines work group.J Trauma. 2010; 69: 211-214
- Guidelines for the management of a pregnant trauma patient.J Obstet Gynaecol Can. 2019; 37: 553-574
- The Oxford levels of evidence 2.Oxford Centre for Evidence-Based Medicine, Oxford, England2011
- High-velocity penetrating wounds of the gravid uterus: review of 16 years of civil war.Obstet Gynecol. 1994; 83: 259-264
- Abdominal injuries in pregnancy: a 155-month study at two level 1 trauma centers.Injury. 2011; 42: 47-49
- Motor vehicle crashes in pregnancy: maternal and fetal outcomes.J Trauma acute Care Surg. 2021; 90: 861-865
- Motor vehicle collision-related accidents in pregnancy.J Obstet Gynaecol Res. 2015; 41: 1370-1376
- Significance of motor vehicle crashes and pelvic injury on fetal mortality: a five-year institutional review.J Trauma Inj Infect Crit Care. 2008; 65: 616-620
- Management of trauma during pregnancy.ANZ J Surg. 2004; 74: 125-128
- Trauma in pregnant women: analysis of maternal and fetal mortality.Injury. 1999; 30: 239-243
- Minor trauma in pregnancy--is the evaluation unwarranted?.Am J Obstet Gynecol. 2008; 198: 208.e1-208.e5
- Blunt abdominal trauma: are there any predictive factors for abruptio placentae or maternal-fetal distress?.Am J Obstet Gynecol. 1993; 169: 1054-1059
- Kleihauer-betke testing is important in all cases of maternal trauma.J Trauma. 2004; 57: 1094-1098
- Trauma during pregnancy: an analysis of maternal and fetal outcomes in a large population.Am J Obstet Gynecol. 2004; 190: 1661-1668
- Trauma in pregnancy. Predicting pregnancy outcome.Arch Surg. 1991; 126: 1079-1086
- Trauma in pregnancy: an updated systematic review.Am J Obstet Gynecol. 2013; 209: 1-10
- Trauma in pregnancy: maternal and fetal outcomes.J Trauma Inj Infect Crit Care. 1998; 45: 83-86
- A prospective controlled study of outcome after trauma during PRegnancy.Am J Obstet Gynecol. 1990; 162: 1502-1507
- The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care.J Trauma. 1974; 14: 187-196
- Maternal and neonatal outcomes of assaults during pregnancy.Obstet Gynecol. 2005; 105: 357-363
- Association of maternal fractures with adverse perinatal outcomes.Am J Obstet Gynecol. 2006; 195: 711-716
- A multi-institutional study of factors associated with fetal death in injured pregnant patients.Arch Surg. 1999; 134: 1274-1277
- Long-term fetal outcomes in pregnant trauma patients.Am J Surg. 2006; 192: 715-721
- Guidance for evaluation and management of blunt abdominal trauma in pregnancy.Obstet Gynecol. 2019; 134: 1343-1357
- Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial.Lancet (london, england). 2017; 389: 2105-2116
- Post-partum haemorrhage and tranexamic acid: a global issue.Br J Haematol. 2018; 180: 799-807
- Does tranexamic acid prevent postpartum haemorrhage? A systematic review of randomised controlled trials.BJOG An Int J Obstet Gynaecol. 2016; 123: 1745-1752
- Treatment with tranexamic acid during pregnancy, and the risk of thrombo-embolic complications.Thromb Haemost. 1993; 70: 238-240
- Antifibrinolytic therapy with tranexamic acid in pregnancy and postpartum.Expert Opin Pharmacother. 2011; 12: 503-516
- Antifibrinolytic drugs for treating primary postpartum haemorrhage.Cochrane Database Syst Rev. 2018; 2: CD012964
- The incidence of venous thromboembolic events in trauma patients after tranexamic acid administration: an EAST multicenter study.Blood Coagul Fibrinolysis. 2012; 32: 37-43
- ACOG committee opinion No. 723: guidelines for diagnostic imaging during pregnancy and lactation.Obstet Gynecol. 2019; 133: 186
- Quality initiatives: guidelines for use of medical imaging during pregnancy and lactation.Radiographics. 2012; 32: 897-911
- Radiation exposure and pregnancy: when should we be concerned?.Radiographics. 2007; 27: 909-917
- Saving lives and changing family histories: appropriate counseling of pregnant women and men and women of reproductive age, concerning the risk of diagnostic radiation exposures during and before pregnancy.Am J Obstet Gynecol. 2009; 200: 4-24
- ACR–SPR practice parameter for imaging pregnant or potentially pregnant adolescents and women with ionizing radiation.(Available at:)https://www.acr.org/-/media/acr/files/practice-parameters/pregnant-pts.pdfDate accessed: May 8, 2021
- Imaging in pregnant patients: examination appropriateness.Radiographics. 2010; 30: 1215-1229
- Screening helical CT for evaluation of blunt traumatic injury in the pregnant patient.Radiographics. 1999; 19: S243-S255
- The CAPS Study: incidence, management and outcomes of cardiac arrest in pregnancy in the UK: a prospective, descriptive study.BJOG An Int J Obstet Gynaecol. 2016; 124: 1374-1381
- Cardiac arrest in pregnancy: increasing use of perimortem caesarean section due to emergency skills training?.BJOG. 2009; 117: 282-287
- Management of cardiac arrest in pregnancy: a systematic review.Resuscitation. 2011; 82: 801-809
- Perimortem cesarean delivery: were our assumptions correct?.Am J Obstet Gynecol. 2005; 192: 1916-1920
- Maternal cardiac arrest in The Netherlands: a nationwide surveillance study.Eur J Obstet Gynecol Reprod Biol. 2019; 237: 145-150
- Advanced trauma life support. 10 ed. American College of Surgeons, Chicago, IL2018
- Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial.Lancet. 2010; 376: 23-32
Article info
Publication history
Published online: January 21, 2023
Accepted:
November 16,
2022
Received in revised form:
November 15,
2022
Received:
May 5,
2022
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
