Accidental trauma complicating pregnancy and delivery

Accidental trauma complicating pregnancy and delivery ISADORE DAVID New

DYER, L.

Orleans,

M.D.

BARCLAY,

M.D.

Louisiana

I T I s a recognized fact that pregnant women, because of the awkwardness which they encounter as the weight of the pregnancy develops, are prone to be unstable in their footing and are subject to frequent falls. In addition to this hazard they find it difficult to protect themselves in a fall or other accident. The pregnant uterus, particularly at term, is the most prominent area of the lower half of the individual. It becomes vulnerable, thereby, and may be the recipient of gunshot wounds, stab wounds, blows, or any other conceivable type of trauma. This discussion will concern itself with the more serious types of trauma in pregnancy which have occurred in our area for the past 25 years. This has included fractures to the extremities and bony pelvis, intra-abdominal injury to viscera and, specifically, to the uterus, as well as injury to the fetus. Review

of the

ence was made to 6 cases gathered from colleagues, to which he added 2 personal cases. Meyer and Cummins”” reported one case in 1941; Voegelin and McCalP renewed interest in the subject by reporting 3 personal cases in 1944, and Mulla4” reported an additional 3 cases in 1957. Nolan and Conwellbs in 1930 found that 50 per cent of pelvic fractures occurred in women in contrast to 10 per cent reported in 1923.47 Women also accounted for 60 per cent of nonindustrial fractures in a series of pelvic fractures reported by Eliason and Johnson19 in 1937. They considered the female pelvis to be more fragile than the male pelvis, and thereby broken with less force. Fractures of the pelvis are usually caused by severe injury, which formerly was encountered only in heavy industry. However, with the increasing number of auto accidents the incidence of pelvic fracture has increased accordingly. The victim may be struck as a or as a passenger be thrown pedestrian, from a car, or receive a crushing injury. A rear seat passenger may be forcibly thrown against the side of the car. Mulla reported due to auto accidents, 3 pelvic fractures, associated with pregnancy; one victim was a driver, one a passenger next to the driver, and the third a pedestrian standing on the highway. Occasionally, however, only a minor fall may cause pelvic fracture. Eliason and Johnson lg classify pelvic fracture into four groups: fracture of the pelvic ring, fracture of individual pelvic bones, fracture of the acetabulum, and the double vertical fracture of Malgaigne. The latter

literature

Pelvic fracture. Schuman54 introduced the subject of pelvic fracture in relation to pregnancy to the obstetric literature in 1932. He noted the significant increase in the number of pelvic fractures in women with the advent of the automobiIe. Refer-

From the Department Gynecology, Tulane of Medicine.

of Obstetrics and University School

Presented at the Seventy-second Annual Meeting of the American Association of Obstetricians and Gynecologists, Hot Springs, Virginia, Sept. 7-9, 1961. 907

908

Dyer

and

Barclay

tracture refers to breakage of the pelvic ring anteriorly and posteriorly on the same side. Eighty per cent of the patients in this series revealed more than one fracture line, and in 20 per cent bilateral involvement. With only one fracture line of the pelvic ring the ligamentous attachments of the sacroiliac ligaments must be injured to allow bend in the ring. The most common fractures are through the anterior one half of the pelvic ring, usually the horizontal rami of the pubis. Fracture of the sacrococcygeal joint with ankylosis and encroachment on the capacity of the pelvic outlet may be a specific pelvic bone fracture of great significance to the obstetrician.31 Pregnant women have a predisposition to pelvic pain which YoungGT calls “pelvic arthropathy of pregnancy.” Pregnancy is associated with relaxation of the pubic bones which begins in early pregnancy, reaches a maximum at 7 months, and returns to normal within 6 months post parturn.*? The sacroiliac joints are probably similarly affected. The principal symptoms are pain and tenderness in the pubic and sacroiliac joints which may have a spontaneous onset or appear to be precipitated by minor trauma. Mild cases have been relieved by several days bed rest followed by restricted activity and a girdle for support. Some patients required complete bed rest and, occasionally, treatment similar to that for pelvic fracture. Nolan and Cornwel14’ reported a mortality of 16 per cent: however. Eliason and .JohnsonXg reported only 5 deaths in 60 acute cases of pelvic fracture. Death is usually the result of associated head, chest. or abdominal injury. Blunt abdominal trauma with rupture of viscera, commonly the urinary tract, or retroperitoneal hemorrhage required immediate operative attention. The obstetrician may encounter an acute pelvic fracture in the pregnant patient, or pregnancy subsequent to an old, healed fracture. McCarty and RisIey36 reported rupture of a 3 month gravid uterus by blunt trauma associated with severe pelvic fracture

\u.

Apil 1, 1Y62 J. Obat. & Gynec.

Irom an auto accident. .t’hey could find no report of a similar case. Meyer and (:urnrnins”* reported a patient struck by an automobile and severely injured in the first trimester of pregnancy. Despite this severe trauma the pregnancy continued to term and resolved with a normal spontaneous delivery. Four other cases of pelvic fracture occurring from 6 months to term gestation had no effect on the fetus,4Gr G’ and all were dclivered vaginally from 7 days to 2 months subsequent to trauma. Voegelin and McCall”” concluded that operative delivery after pelvic fracture should be the exception rather than the rule. It must be remembered also that fracture may occur in a small pelvis and have no etiological relationship to subsequent dystocia. Lateral crushing fractures tend to disturb the pelvic inlet and displaced fractures of the descending rami may encroach upon the pelvic outlet. Separation or displacement of fractures around the symphysis jeopardizes the urethra or bladder when the presenting part descends during labor. Displacement of the coccyx with ankylosis of the sacrococcy
Accidental

Beattie and Daly4 in 1960, one by Geggiez4 in 1961, and two by Bochner8 in 1961. Bost,l” in 1940, recommended cesarean section or hysterotomy whenever the uterus was involved, and this was re-emphasized by Echerling and Teaffls in 1950. However, Kobak and Hurwitz33 recommended that the uterus not be disturbed unless abruption was considered or a viable fetus compromised. An unharmed or dead fetus was left for vaginal delivery. Hysterectomy was necessary in 4 reported cases. Three maternal deaths from abdominal gunshot wounds have been reported, and all occurred prior to 1921.33 This is in contrast to the 27.15 per cent mortality reported by Boyd,ll in 1951, in a review of abdominal gunshot wounds unassociated with pregnancy. This is probably related to the fact that only 10 reported cases of abdominal gunshot wounds involving the uterus have been associated with other visceral injury.33 Boyd’s mortality increased from 17 per cent for a single viscus injury to 34.7 per cent for multiple viscus injuries. The uterine bulk undoubtedly protected the remaining abdominal viscera from injury. Stab wounds of the pregnant uterus are considerably more rare than gunshot wounds. We have found 4 reported cases: one each by Guadagnini,G” in 1930, Badie and Charlton,3 1940, Wright and associates,65 1954, and Bochner,’ 1961. The 4 reported cases were not associated with viscus damage other than the uterus, and in none was the uterine cavity penetrated. All were treated by simple repair of the laceration, with subsequent vaginal delivery of a normal infant. Blunt abdominal trauma. Griswold and Collier?* have recently reviewed blunt abdominal trauma and summarized the literature. They found that visceral injury from nonpenetrating abdominal trauma has increased progressively with the incidence of traffic accidents. Automobile accidents are responsible for about 50 per cent of nonpenetrating abdominal wounds and the remainder are the result of falls, fights, and other mishaps. The trauma is usually very

trauma

complicating

pregnancy

909

severe and is associated with multiple additional injuries. Fitzgerald, Crawford, and reported extraabdominal injuries DeBakey” in 70 per cent of those admitted to the hospital alive and in 90 per cent of those dead on arrival. FarreY classified closed abdominal injuries into three groups: ( 1) hemorrhage from laceration of solid viscera or vascular channels, (2) peritonitis from hollow viscus perforation, and (3) injuries to the abdominal wall, mesentery, or diaphragm. Griswold and Collierz8 summarized the frequency of visceral injury as follows: spleen 26.2 ptr cent, kidney 24.2 per cent, intestines 16.2 per cent, liver 15.6 per cent, abdominal wall 3.6 per cent, retroperitoneal hematoma 2.7 per cent, mesentery 2.5 per cent, pancreas 4 per cent, and diaphragm 1.1 per cent. The theories for the mechanism of visceral injury from blunt trauma are principally speculative rather than proved by experimentation. Pemberthyso considered the rate of application of force as an important factor in determining the extent and type of injury since a slowly applied force is less likely to injure mobile viscera than is a sudden localized blow. Also, a relaxed abdominal wall offers less resistance and protection. Despite the fact that the hollow viscera occupy a greater area of the abdominal cavity, they apparently have been less frequently injured because of their greater mobility and collapsible walls. Splenic injury is the most common complication of blunt abdominal trauma. Zabinski and Harkinse8 classified splenic injury according to the etiological factor and previous condition of the spleen. They classified splenic rupture as spontaneous or traumatic rupture of a normal or diseased spleen. with further subdivisions into acute or delayed rupture. Approximately two thirds of splenic trauma was associated with additional injury, the most frequent being chest injury, fracture of the extremities, and head injuries, in that order. 6o About 14 to 33 per cent of splenic ruptures were of the delayed variety. Approximately 50 per cent of drlayed ruptures occurred in less than one

910

Dyer

and

April

Barclay .\rrl.

week and 75 per cent in less than 2 weeks. Delayed periods of from 6 months38 to 2 years have been reported.Gs The only acceptable treatment for splenic rupture was operation, and the over-all mortality for acute and delayed rupture was about 20 per cent.z8 Mortality was principally dependent upon associated injury and promptness of surgical intervention. SparkmanSG reviewed rupture of the spleen in pregnancy, found 42 cases, and added an additional 2 cases. He tabulated all reported cases in chart form and related 16 cases to trauma of varying severity. The type of trauma varied from overstretching to more severe injury from a direct blow over the spleen, a fall, or auto accident. Four cases were classified as delayed hemorrhage, that is, with a latent period of greater than 48 hours after suspected trauma or initial symptoms, and the longest delay was 10 days. Rupture usually occurred in multiparous women, 3 were reported in primiparas, and 29 were in the third trimester. The predisposing factor of splenic disease was present in 6 cases, and toxemia present in 4 cases. The remaining cases revealed no apparent predisposing factor, and the coexistence of pregnancy. As compared to diseases associated with ruptured spleen, pregnancy was second only to malaria in frequency of recorded cases. It was postulated that the hypervolemia of pregnancy predisposed to splenic rupture as well as rupture of vascular anomalies, such as aneurysms. Treatment consisted generally of splenectomy with cesarean section, if necessary, for exposure. Maternal mortality was 8 per cent with splenectomy, with an over-all mortality of 26 per cent during the past 30 years. Fetal survival was good with prompt diagnosis and splenectomy. Untreated incomplete rupture of the spleen may occasionally result in a traumatic cyst. FowleP considered approximately one fourth of a series of splenic cysts to be the result of old trauma. Traumatic rupture of the liver is a catastrophic event with a mortality of approximately 67 per cent, which has not improved

J

Ohst.

1, 1962 & Gynec.

with the availability of surgical facilities and improved surgical technique. Glen’” stated, “One-third will die at the site of injury, one-third will die within six hours, and one-third will survive.” Hemorrhage has been controlled by clamping the aorta or compression of the hepatic vessels, hemostasis by gauze packing or suture. Two reviews of spontaneous rupture (JI the liver during pregnancy have recently appeared, and each has presented an additional case.45. 6X There are 22 cases of ruptured liver during pregnancy in the literature, of which several were associated with questionably significant trauma. A predisposing factor was considered to he toxemia of pregnancy which was present in all but 2 cases. All cases occurred during the last half of pregnancy or durin,g the postpartum period. Only 7 patients survived, each ha\:inc received prompt surgical treatment. WC have found no reports of pregnancy associated with traumatic rupture of the pancreas, urinary system, gastrointestinal tract, or extrahepatic biliary tract. However, one case of maternal death from nontraumatic rupture of the common bile duct,’ and one case of spontaneous perforation of a diseased gall bladder have been reported.“” Uterine rupture from blunt abdominal trauma is a rarity, We are aware of 51 reported cases. Lazard and Kliman34 reviewed the literature to 1936. found 41 cases, and added one case. Nine subsequently reported cases have come to our attention.14s 17, ?O. 3’i. ::7. 44. ;l,Y.37, 64 Few ruptures occurred before the fundus emerged from its inaccessible position in the true pelvis. McCarty and Risley3B reported rupture of a 3 month pregnant uterus, which to our knowledge is the earliest reported case. Their patient sustained a 4 cm. rent in the anterior uterine wall at the junction of the lower uterine segment in association with multiple pelvic and long bone fractures in an auto accident. No other evidence of intraabdominal injury was noted and the uterine laceration was sutured. The rlterus had been ruptured by a sudden and apparently insignificant blow, as in

Accidental

a stair injury or by severe and prolonged compression. Snidow’s” patient, at 6 months’ gestation, tripped while ascending steps and suffered an apparent insignificant injury. However, laparotomy 10 hours later for signs of peritoneal irritation revealed a longitudinal rent in the midline posterior surface of the uterus. was struck by a bus CoLltt’s14 patient wheel, and the fetus extruded into the thigh above the deep fascia. Woodhull’s patient, at 30 weeks’ gestation, was thrown from an automobile and the auto fell across the dorsal surface of her flexed thighs, forcing the fetus through the posterior wall of the uterus into the peritoneal cavity. The latter 2 cases demonstrated the effects of extreme but less transient application of force to the uterus. Pressure applied to the uterus is distributed equally in all directions by the amniotic fluid with rupture at the weakest point which was most commonly the posterior wall of the fundus. One might expect the placental site to be the weakest area and most common point of rupture, but this was not the case. Several records revealed postpartum endometritis or intrauterine instrumentation with previous pregnancies. The diagnosis was usually unsuspected and incidentally discovered at the time of abdominal exploration for shock from intraabdominal hemorrhage. Other visceral injury was rarely encountered. Treatment was equally distributed between uterine repair and hysterectomy. Undoubtedly the most bizarre cause of rupture of the pregnant uterus was reviewed by Obstetrical and Gynecological Survey, from the Journal of The Indonesian Medical Associatiox2 The patient, at approximately 7 months’ gestation, was struck above the umbilicus by a bolt of lightning, producing a 10 cm. rent in the anterior surface of the uterus. The uterine wound was excised and closed after delivery of a stillborn infant. The diaphragm and abdominal wall serve as boundaries to the abdominal cavity. The abdominal wall receives the initial impact with blunt abdominal trauma and is often

trauma

complicating

pregnancy

911

injured. The diaphragm is less commonly involved. Rupture of the diaphragm has been reported to be of traumatic origin in 41.7 per cent of cases.3o Forty-eight per cent of the traumatic group were from blunt trauma. The most frequently associated visceral injury was rupture of the sp1een.l’ The association of diaphragmatic hernia and pregnancy has received extensive review in the recent literature.l”, “2 43, 59 All cases reported have been of the paraesophageal variety, with no indication of a traumatic origin. Pregnancy has been recognized as a predisposing factor for epigastric vessel rupture and hematoma formation. This has been related to distortion and stretching of the rectus muscle and vascular channels with repeated pregnanciesG1 TeskeG1 reviewed 100 cases of rectus abdominis hematoma collected from 1900 to 1946 and found 22 associated with pregnancy. Sixteen cases occurred during late pregnancy, 3 during labor, and 3 in the immediate puerperium. Lucas and Baker35 reviewed 38 cases associated with pregnancy. The major precipitating factors were chronic cough in 18. labor strain in 6, and falls in 2. The typical patient was an older multipara. The onset was usually abrupt, with localized tenderness over the hematoma. Ninety per cent occurred unilaterally in the caudal half of the rectus muscle. Treatment consisted of surgical exploration, ligation of bleeding points, if found, and closure with or without a drain. One death occurred among the 10 last reported cases.35p 53 Prenatal fetal injury. Prenatal fetal injury has been infrequently reported in the medical literature. We have found 2 cases. Pikes1 reported an in utero depressed fracture of the fetal skull. His patient, one day post term, fell forward while ascending a stairway and struck her abdomen on the sharp stair edge. The injury appeared inconsequential and pregnancy proceeded to an uneventful spontaneous vaginal deiivery (vertex presentation) 13 days later. Immediately at delivery a 3.5 by 5 cm. depression

912

Dyer

i; I -

and

Barclay

J, P.

J.B.

B. B.

D.T.

I.M.

A. K.

M.H.

R. 0.

J. B.

L. G.

I. s.

M.P.

M.L.

J.A

15

16

17

18

19

20

21

22

23

24

25

"6

27

28

w

W

L'4

'7

N

N

'2

18

M

19

w

28

N

w

34

26

w

36

M

N

19

23

N

N

21

18

M

35

(J

2

0

0

2

1

38

37

36

34

30

30

19

27

27

26

26

25

25

22

.4utomobile

Automobile

Automobile

Automobile

.4utomobile

Automobile

Automobile

Automobile

Automobile

Automobile

Automobile

Automobile

Automobile

.\utomobile

contusions

contusions, wheel injury

and

inferior

rami rami,

sealed

concealed

separation

by dome

abruption,

contusions

Separation

of symphysis

Fx right superior and inferior rami, separated left sacroiliac joint, separated symphysis. hematoma lower 5’3 right rectus muscle

Subdural hematoma, Fx pelvis, unspecified, Fx right clavicle and ribs one and 2, laceration liver, partial abruption

Fx left superior symphysis

and inferior

rami,

Fx ribs 6,

inferior

Fx ribs,

of

cerebral concusseventh nerve palsy

abdominal

right diaphragm, Fx ribs 2-7, right

Fx superior

Rupture liver,

Abdominal steering

and

rami

wall

and fibula,

hemorrhage, skull Fx,

tibia

concussion,

Subarachnoid sion, basilar Cerebral

and inferior

abdominal

Fx left femur,

simple Fx superior Fx wing left ilium

Simple Fx right 7, and 8

Bilateral simple

Fx left superior

Severe

Fx right humerus, Fx maxilla

cast.

days

0

+

rest traction

bed

Vaginal,

14 days later

Rx bed rest, labor

Postmortem cesarean section

Vaginal,

term

sec-

term

term

term

Vaginal,

Vaginal,

38

Vaginal, weeks

Cesarean tion

stillbirth;

term

Vaginal,

Abortion 10 days after accident

term

Vaginal,

term

term

Vaginal, Vaginal,

term

term

Vaginal,

Vaginal,

-___.-

Labor 12 hrs. after admission; fetal skull fracture

Died on admission; maternal death

Rx

0

Postmortem cesarean section

Rx

Final diagnosis postpartum. Surgical repair 0

0

FHT not heard 5 days after accident. Neg. fetal ECG, uterus decreased in size, stillborn

three

+

bleeding accident

Vaginal after

hospitalization

reduction

rest

Rx

cast

+

bed

traction

body

1 month

Open

Rx

Rx

Symptomatic

.4rm

0

0

0

0

0

0

‘0 w

8 3 3 2 n f. 2

2

3

M. P.

D. C.

D.F.

A. B.

E.R.

R. W.

w.

L. 0.

D. S.

M.M

R. F.

G.S.

29

30

31

32

33

34

35

36

37

38

39

40

P.

Initials

I-Cont’d

No.

Table

23

28

18

30

25

22

19

24

37

38

20

18

Age

N

N

N

N

W

N

N

N

w

N

N

W

Race

8

1

7

2

1

33

29

29

28

26

4

1

20

4

11

8

4

1

4

Frll

on abdomen

Fall from 2nd floor

Step from curb

Fall

Fall

Fall, striking vulva

Fall from house roof

Fall

Fall

Fall

Automobile

Automobile

38

39

Etiology

mgnancy

5

3

0

Parity

of

Weeks

sustained

laceration vein

upper

medial

maleolus

tibia

and

on

right

left

,\bdominal

Fx

Separation

Fx

wall

superior

sprain

and soreness

Lumbosacral

contusion

ramus

symphysis.

patella

and

abdo-

Severed left Achilles tendon at 26 weeks. Repeat fall and severence of tendon at 34 weeks

at introitus

‘/3 right

hematoma

and ulna

Fx distal

3 x 3 cm. vagina right

Fx left radius

Comminuted fibula

Fx right

Fell down steps and refractured left tibia fibula fractured t months previously

tibia and fibula, ruptured uterine

of knee, ecchymosis men over uterine fundus

Fx left femur, right face,

Laceration

Trauma

Ice

0

.-.

Internal

0

Bed

Bed

0

0

Unable

rest

rest

Removal

0 0

Sutured Cast

0

leg cast

to walk

2 weeks

of fragments

fixation

long

leg cast

pack

Traction.

Internal fixation, vaginal bleeding day after accident

+

0

Long

no FHT, stillborn.

0

in labor, in shock, death

Admitted expired maternal

hemor-

+

intracranial

Stillborn, rhage

Remarks

+

Pregnancy terminated

Vaginal,

T’aqinal.

\‘aginal,

\‘a,ginal.

Vaginal,

Vaginal,

Vaginal.

Vaginal,

\‘a,qinal

Vaginal

Delivery

~___

term

term

term

term

term

term

term

term

2

2 n m

7

,om

‘0 h

E.S.

M.W.

C.J.

E. M.

M.H.

J. M.

F. H.

E. C.

V. B.

L. K.

S.R.

L. C.

I,. D.

41

42

43

-14

45

46

47

48

49

50

51

52

53

18

35

19

21

20

19

27

14

2%

28

28

30

26

N

w

W

w

N

w

N

N

N

N

N

N

N

1

6

0

0

3

0

0

0

2

4

1

3

3

36

36

35

3%

37

32

27

27

40

14

37

35

34

stab

stab

Beaten, stabbed

Beaten

Beaten

Gunshot

Gunshot

Gunshot

Gunshot

Gunshot

Knife

Knife

Fall in sitting position

Fall

Fall, struck abdomen

strain

of symphysis

of symphysis.

unable

to walk

left thigh above inguinal into anterior aspect of

wound

of right

Supraclavicular subsequent

surgical expIoration; A-V fistula

to stand ; severe

laceration;

and to left of of uterus only

leg and abdomen

contusion, loss

unable

wound, subclavian

Struck in low back, abdominal pain

Cerebral concussion, 300-500 C.C. blood

Projectile entered below umbilicus; penetration

Shotgun

left

left border of rectus muscle, exit at border: abdominal cavity not entered

entered and horn

wall, 9 cm. to left uterus penetrated

Projectile entered abdomen just below umbilicus; perforation of right common iliac artery and vein

Entered medial

Projectile ligament uterine

2 cm. laceration abdominal of umbilicus; no FHT; to left of round ligament

Stab wound left suprapubic area, perforation of uterine fundus, laceration and evisceration of ileum

Lumbosacral

Separation

Separation

0

0

0

+

+

+

0

+

partially

for

hysterectomy,

exploration

in placenta

Surgical

exploration

; obser-

Repair of lacerations vation Observation

wound projectile

still-

of wound

; uterine stillborn, abdomen

Exploration sutured; in fetal

Pellets

Subtotal born

Surgical

in fetal

severed

hemostasis

Hysterotomy, bullet foot, stillborn

Stillborn, cord

+

rest

rest

rest

Hvsterotomy

Bed

Bed

Bed

+

0

0

0

sec-

sec-

term

Vaginal.

Vaginal.

Vaginal.

term

term

term

Vaginal, 21 hours postoperative

Cesarcan tion

Cesarean tion

Vaginal,

Hysterectomy

Cesarean tion

sec-

term

\‘aginal.

Hysterectomy

term

1.aginal,

‘0

u 2 CQ 2 2 Y

0” 3 73 _.

i

=r 9

916

Dyer

and

Barclay

of the right frontal bone was noted and a depressed skull fracture was confirmed by x-ray. No neurological involvement was present. Surgical elevation 3 days later revealed evidence of an old fracture consistent with trauma from the previous fall. It was speculated that the fetal head, in the right occipitoanterior position, had been compressed between the sacral promontory and the stair edge. A case of more extensive fetal trauma associated with traumatic rupture of the uterus was reported by Elias.‘O The patient sustained a massive laceration of the abdominal wall, with a complete tear across the uterus at the junction of the upper and lower segments, with extrusion of the fetus and placenta into the peritoneal cavity. The fetus sustained a fragmented fracture of the fifth cervical vertebra with fracture and dislocation of the cervical spine. She survived with subtotal hysterectomy. Materials

The patients described in this study were admitted to Charity Hospitals of Louisiana or treated as private patients. The exact number of pregnant women sustaining severe injury is difficult fo determine. Often women were admitted to the emergency room of the Orthopedic or General Surgery Service and the obstetrician consulted only if a complication of pregnancy were present. The number of maternal deaths, however. is accurately recorded. To our knowl-

Table II. Auto Total

accidents

Major

fractures”

vehicle

30

Extremities

12 12

Pelvis Skull Other complicatiom Shock Concussion

1

Severe contusions Internal lacerations _.__-

‘Fetal

skull

fracture

accidents

3 3 3 5 ..~~~~~_~~. .

1.

edge, none of these cases have been previously reported (Table I). Auto vehicle accidents accounted for 30 instances of severe maternal trauma (Table II) . Twenty-three patients sustained fractures of which 12 involved the pelvis. These typically involved the pubic rami, with or withof the out comminution, and disruption symphysis pubis with accompanying disruption of the sacroiliac joint. Twelve patients sustained extremity fractures and one a basilar skull fracture. Several patients had a combination of fractures. In addition to fractures, auto vehicle accidents were responsible for the following injuries: 5 internal lacerations, 3 shock, 3 contusions, and 3 cerebral concussions. Internal lacerations will be referred to under blunt trauma. The treatment of fractures was not altered by the presence of a pregnancy. In several instances multiple surgical procedures were necessary to complete orthopedic treatment. It was often important to immobilize some patients with traction or casts. If a

Volulne

83

Number

i

hody

cast

indicated nancy

Accidental

was

it

to accommodate tumor. In one

produced

a

utero,

necessary,

fracture

described

adjusted

the growing patient the of

in

was

the

the

complicating

pregnancy

917

as preginjury

fetal

skull

following

trauma

in

case

his-

tory. Mrs. M. L., aged 22, gravida iv, para iii, was admitted to the hospital at 8:lO P.M. on Dec. 25, 1949, at approximately term gestation. She had been involved in an automobile accident 5 hours previously and complained of severe pain over the lower abdomen, symphysis, pubic rami, and lower back. The fetal head was at the pelvic inlet in a left occipitotransverse position and the fetal heart tones were normal. X-ray study of the pelvis revealed comminuted fractures involving the pubic rami on the right, with marked and left sacroiliac dislocation displacement, (Figs. 1 and 2). Labor commenced 11 hours following admission and cesarean section was elected because of the instability of the recent pelvic fracture. Hemorrhage into the lower third of the right rectus muscle was the only other associated injury. The 8 pound, 3 ounce infant was normal except for a depressed fracture in the right occipital bone approximately 3 cm. in diameter, which was confirmed by x-ray film (Fig. 3). Delivery 2 years subsequently was by cesarean section because of the presence of a uterine scar and not pelvic deformity. An

additional

utero

as

was

incidence

a result

made

of

an

fetal

injury

of Alexandria,

fracture

of

occipital

bone

in

fetus.

in

accident

to us by Dr. Rodney

available

Masterson

of

automobile

Fig. 3. Depressed

G.

Louisiana.

This patient, an 18-year-old primigravida, near term, was involved in an automobile accident on Aug. 22, 1950. While she was driving, her vehicle was struck on the driver’s side and she was thrown against the dashboard in a doubled-up position. No fetal movement was felt subsequently, and fetal heart tones disappeared within 2 hours of admission. No serious maternal trauma was present. A stillborn infant was delivered the following day, and autopsy examination revealed intracranial hemorrhage felt to be the cause of intrapartum death. Auto for

deaths ated

vehicle

2 maternal resulted

with

accidents and

7 fetal

in

abortions,

maternal

death

were deaths.

responsible Three

2 were

near

term,

fetal associ-

Fig. 4. Postmortem

and 2

jectile

in abdomen

view of infant and peritonitis.

showing

pro-

918

Dyer

and

Barclay

were from in utero injury. One abortion O( curred 6 weeks after trauma and is ~)rot’ably unrelated. Penetrating wounds Penetrating wounds were observed in 7 patients 5 due to gunshot and 2 to knife stab wounds. A gunshot wound involved the abdominal wall alone in one patient, and the uterus in 4, of which 3 uteri were gravid. The projectile was received by the fetus in 2 instances producing fetal death in both. and by the placenta in one instance. The 3 gunshot wounds involving the pregnant uterus are summarized : Case 1. Mrs. L. I(., aged 21, near term, was accidentally shot in the midabdomcn on Oct. 21, 1930, when a 38 caliber p&o1 fell to the floor. On admission she was not acutely ill; fetal hrart tones were not heard. The gunshot wound was to the left and slightly below the level of the

umbilicus. Fig.

5.

Anteroposterior

view

showing

shotgun

pellets.

X-ray

anterior

wall

domen

X-ray.

in

placenta

visualized

by

revealed

of the uterus, which

Spontaneous labor mission with delivery study revealed the

Fig. 6. One of pellets

examination

a term

fetus presenting as a vertex in the left occipitotransverse position, and the projectile was seen lodged in the area of the fetal abdomen. Surgical exploration 2 hours after admission revealed only a bleeding puncture wound in the

was sutured.

ensued 12 hours after adof a stillborn fetus. X-ray projectile in the fetal ab-

(Fig. 4). Autopsy

demonstrated

that the

bullet had pierced the liver, spleen, and botvel and there was evidence of peritonitis. Subsequent pregnancies and vaginal delivery were uneventful. Case 2. Mrs. V. B., 20 years of age, gravida iv, para iii, at term, was admitted on May 2, 1960, having been accidentally shot with a shotgun. The last 2 pregnancies had been terminatecl by cesarean section. Fetal heart tones were prccent. Gunshot wounds were present in the right leg and abdomen. S-ray study revealed thr presence of two pellets in the area of the fetus and uterus (Fig. 5). A normal term infant was delivered by cesarean section, and the only intra-abdominal injury found was a 1.5 cm. rent in the midportion of the anterior surface of the fundus. The missing pellets were found by x-ray embedded in the placenta (Fig. 6). Case 3. Mrs. J. M., aged 14, gravida i, para 0, was admitted on Aug. 19, 1954, at 27 weeks’ gestation, having received a gunshot wound of the thigh. The projectile entered the abdomen

Accidental

above the inguinal vessels, penetrated the anterior aspect of the left uterine horn, and lodged in the fetal foot. No fetal heart tones were heard. At laparotomy uterine hemostasis could not be obtained and therefore a hysterotomy was necessary, with delivery of a stillborn infant. Three subsequent pregnancies have been terminated by cesarean section. Case 4. Mrs. E. C., aged 19, at approximately :{2 weeks’ gestation, was shot in the abdomen by a 22 caliber rifle. The projectile entered just below the umbilicus and was identified by x-ray examination to be lodged in the area of the right fourth lumbar vertebra (Fig. 7). She was in shock on admission, and no fetal heart tones were audible. Surgical exploration revealed the abdomen to be filled with blood, and the uterus demonstrated an entrance and exit wound on the upper right anterior and posterior surfaces, h classical cesarean section and subtotal hysterecio.my was performed for hemostasis, and a stillborn infant was delivered. Examination of the right posterior pelvic floor revealed a retroperitoneal hematoma produced by a perforation of the right common iliac artery and vein. The vessels were repaired; however, the bullet could not be removed. The hospital course was prolonged and complicated by ileus and by thrombophlebitis of the right leg.

trauma

complicating

pregnancy

919

the abdomen 9 cm. to the left of the umbilicus. A stillborn infant was delivered by cesarean section, the knife having severed the fetal cord. The second patient was stabbed in the left lower quadrant at 14 weeks’ gestation. Evisceration of the small bowel and intraperitoneal bleeding resulted. The small bowel laceration was sutured, and hysterotomy was necessary to obtain uterine hemostasis. All penetrating wounds of the gravid uterus, either by gunshot or knife stab, interrupted pregnancy. Four patients were de-

The following case illustrates a complication of pregnancy and delivery due to a gunshot wound which had occurred some time previous to pregnancy: Mrs. C. F., aged 32, was admitted on April 2, 1959, in early labor, with a transverse lie. X-ray examination confirmed the unusual fetal position, and also demonstrated a projectile lodged in the true pelvis on the left (Fig. 8). At age 13 the gunshot had entered the right hip, traversed the pelvis, and lodged on the left side of the pelvic inlet. At cesarean section the bladder and lower uterine segment were found to form a 7 cm. cystic mass. In addition, massive adhesions obscured all but the anterior surface of the uterine fundus, which necessitated a high transverse incision for delivery of a normal infant. Although the initial surgical records were unavailable, it would appear that the previous gunshot wound had perforated the bladder and lower uterine segment. Knife stab wounds of the uterus were observed in two patients. In the first case the wound occurred at term. The knife entered

Fig. 7. Projectile

lodged in iliac fossa.

livered by cesarean section or hysterotomy, and one vaginally following laparotomy and hemostasis after a gunshot wound. Falls severe enough to require hospitalization were observed in 13 patients. Injuries included separation of the symphysis pubis in 3, lumbosacral strain, vulvar hematoma, Achilles tendon laceration, and a fall on the abdomen in one each. Six falls produced fractures of the lower extremities in 4, one of an upper extremity, and one of the pelvis. This type trauma produced no interruption of pregnancy. Seuere beatings in the clientele seen at charity hospitals is not uncommon. Three

920

Dyer

and

Barclay

injuries of this type are cited as having been extensive. The first patient sustained a cerebral concussion with multiple lacerations and an approximate 300 to 500 C.C. blood loss. The second patient received multiple first blows to the lower abdomen which required 8 days’ hospitalization. The third beating included a stab wound to the superclaviculal

area which required surgical exploration : however, an arterial venous aneurysm developed subsequently and was repaired after a normal vaginal delivery. None of these patients sllffered fetal injury or premature termination of pregnancy. Blunt abdominal trauma produced the most serious injuries and was responsible fol 2 of the maternal deaths. Two patients suffered placental separation, and one each sustained rupture of the diaphragm, rupture of the liver, rupture of the gastrocolic ligament and spleen, rupture of the uterine vein, and rupture of the urinary bladder. There was no instance in which the uterus was ruptured. Severe blunt abdominal trauma is psemplificd by the following case : Mrs. 73. J., aged 34, gravida

Fig. 8. Projectile due to anatomic vious trauma.

and abnormal attitude chanse in uterus caused

of fetus by prr-

iv, para iv, was

admitted on Oct. 8, 1955, at 30 weeks’ gestation, after an automobile accident. Her principal complaint was pain in the lower posterior right chest, and x-ray examination revealed a displaced fracture of the second through seventh ribs; however, there was no evidence of pneumothorax. There was no evident intra-abdominal injury, and fetal heart tones were normal. Repeat x-rays on November 28 were compatible with a diaphragmatic hernia secondary to trauma ;Fig. 9j. However, this was asymptomatic. Thr progress of pregnancy was satisfactory, and a normal vaginal delivery occurred on Dec. 6,

1955. Five months later a large diaphragmatic hernia was present on x-ray and a 12 by 14 by 10 cm. rent in the right diaphragm was repaired (Fig. IO). A large portion of the liver had herniated into thr pleural cavity and adhered to the defect. No suhsrquent pregnancies have occurred. This patient obviously sItstained tremendous blunt abdominal trauma without disturbance of prcgnanc-y.

Fig. 9. hernia.

Elevation

of

right

diaphragm

suggesting

Rupture of the liver and rupture of a ltterine vein each accounted for a maternal death. The patient with a ruptured liver also had a partial placental separation in addition. She died on admission. The patirnt with a ruptured uterine vein was in\rolved in an automobile accident at 39 weeks’ ,gestation and was admitted in labor with nnlltiple fractures, lacerations, and in

Accidental

shock. A stillborn infant was delivered per vaginam; however, the patient died 36 hours later as a result of hemorrhagic shock. Another patient received a steering wheel injury to the lower chest and upper abdomen at approximately 18 to 20 weeks’ gestation. She was admitted in shock with evidence of intra-abdominal bleeding, The gastrocolic ligament was found avulsed near the pylorus in addition to avulsion of the r,ight gastroepiploic artery and incomplete rupture of the spleen. Bleeding points were ligated and the spleen was removed. This pregnancy proceeded uneventfully. One patient sustained a laceration of the bladder with extravasation of urine in association with multiple pelvic fractures from an automobile accident at 16 weeks’ gestation. The bladder laceration was repaired surgically, and the pelvic fracture was treated by traction. The pregnancy was unaffected and a cesarean section at term was elected because of residual deformity of the pelvis and previous bladder injury. Blunt abdominal trauma? therefore, was responsible for 2 maternal and 3 fetal deaths. Comment Except for direct penetrating wounds of the gravid uterus, pelvic fracture produces the most concern to the obstetrician. However, as a rule, pregnancy is unaffected by severe pelvic fractures. We have reviewed 13 cases of pelvic fracture during pregnancy and only 3 resulted in interruption of pregnancy (Table III). Of those unaffected, 2 were delivered by cesarean section at term because of residual pelvic deformity and instability and previous bladder injury in one. Pregnancy was interrupted in 3 patients. One of these died and a postmortem cesarean section was unsuccessful. The second patient was injured at 37 weeks’ gestation. and labor ensued 12 hours after admission and necessitated abdominal drlivery because of pelvic deformit),. The third patient had XII abortion a~ 15 weeks’ gestation, which was 6 weeks srrhsequent to injury and probably unrelated. Pelvic fracture prior to pregnancy may

trauma

Fig. 10. Postpartum matic hernia.

complicating

pregnancy

921

evidence of large diaphrag-

Fig. 11. Old pelvic injury contracting bi-ischial diameter to 8 cm.

midplane

alter the mode of delivery. The cases of 22 patients who sustained fracture prior to pregnancy were reviewed. Only 8 required abdominal delivery, 2 of which were for indications unrelated to the previous pelvic fracture.

922

Dyer

Table

and

III.

Barclay

Pelvic

fractures

Occurrence in pl-egnancy Pregnancy unaffected Term vaginal deIivery Term abdominal delivery Pregnancy interrupted Premature vagina1 delivery Term abdominal delivery Maternal deaths “Sk

weks

13 IO

titular, to the bladder. A residual displacemerit of the pubic bony complex could endanger the bladder if compressed by the presenting

8 :! 3 I* I 1

latm

tion,

Table

IV Trauma to fetur Skull fracture cerebral hrmorrhage Severance of umbilical Gunshot wound Trauma

to

Gunshot Abruptio

I 1* 1” 2*

cord

placenta

1 2*

placenta?

Two examples proach to delivery reported :

of the conservative after pelvic fracture

apare

Case 1. Mrs. K. H. fell and suffered a pelvic fracture at age 20 and was first seen for pregnancy at age 29. X-ray examination of the pelvis revealed evidence of old, healed fractures of the rami of the left pubis with shortening of the superior ramus and reduction of the bi-ischial diameter to 8 cm., with a midplane volume capacity of 240 ml. (Fig. 11). Progress of labor, however, was uneventful with delivery of a normal 6 pound, 12 ounce infant. Vaginal dclivery was facilitated by the presence of a generous posterior half of the pelvis. Case 2. Mrs. S. B., 21 years of age, gravida i. para Y), was admitted in labor on March 17. 1960, having received no prenatal care. In November, 1956, she had sustained a fracture

dislocation

of the right

hip with

part.

Injury to the sacrococcygeal joint, with or without fracture of the coccyx, is one of the most common injuries to the female pelvis. Whenever a coccyx is found to be ankylosed and fixed with an acute angulathe

anterior

posterior

diameter

of

the

pelvic outlet may be compromised. Vaginal delivery may necessitate refracture of the coccyx and predispose to postpartum coccyaIgia which often is refractory to treatmcnt. A simple outlet forceps delivery over a markedly angulated and firmly ankylosed coccyx may produce a depressed fracture of the fetal skull as depicted in Fig. 14. One patient sustained similar injury to 2 infants delivered in successive pregnancies. We have considered, on rare occasions, delivery by the abdominal route as one of preference. Abdominal injury which involves the abdominal viscera, uterus, or its appendages, warrants immediate investigation. The surgical approach, particularly in penetrating abdominal trauma, should not be altered by the presence of a gravid uterus. The uterus, presenting the most prominent target,

will

be involved

more

often

in

pene-

trating wounds than will the relatively wrllprotected intestinal tract or other abdominal

comminution

of the acetabulum, separation of the symphysis pubis, dislocation of the right sacroiliac joint, and prroneal nerve palsy on the right (Fig. 12). Internal fixation was accnmplished; however, she did not return for ftlrthcr treatment linti admirtrd in labor (Fin. 13). She was delivered of :I normal 8 pound. L’ ~IIIICC infant unrv~~ntfully.

,411 additional irldicatiorl for abdominal delivery after pehic fracture would be previous injury to the urinary tract and, in par-

Fig. 12. Initial and

sacroiliac

injury junction.

to hip

joint,

pubic

rami,

Accidental

viscera. In this investigation this was the rule in third trimester injuries. The intestine and uterus were perforated by a knife in one woman, at 14 weeks’ gestation. The uterus need not be disturbed during surgical exploration for internal abdominal trauma unless necessary for adequate exposure or the presence of direct uterine in,juries. Regardless of gestational age, the fetus need not be removed unless uterine damage is extensive, or in an attempt to sal\‘age a living, viable fetus which may be compromised by direct or placental damage. Experience has proved that a woman. even at term, may undergo laparotomy and be delivered vaginally without incident 72 hours later.

Fig. over

trauma

14. Depressed fixed, angulated

complicating

pregnancy

frontal bone due maternal coccyx.

923

to delivery

at Tulane, and reported 214 cases of abruptio placentae occurring in 39,076 deliveries, In this group there were no instances of traumatic separation of the placenta. In the present report, 2 traumatic abruptions were found; one at autopsy and not responsible for the maternal death, and the second, because of its many unusual aspects, is hereb) presented :

Fig. 13. Pregnancy evidence.

at term

with

pinned

femur

in

The safety of the fetus appears enhanced by its intrauterine environment and disturbed only by extreme compression, or if injured directly by penetrating wounds of the uterine cavity. This security of the fetus is demonstrated by the fact that there were only 2 instances of fetal damage as a result of blunt trauma which resulted in one case each of depressed skull fracture and cerebral hemorrhage (Table IV) Abruptio placentae. Traumatic abruptio placentae should occur more often than it is obser\red. Dyer and McCaughey” teLiewed a 10 year experience, 1946 to 1955,

Mrs. 0. O., 36 years of age, gravida iv, para iii, at 27 weeks’ gestation, was involved in an automobile accident and was struck in the ahdomen by the steering wheel. Fetal movement was not felt subsequently, and the following evening and the next day small blood clots were passed. Examination revealed multiple bruises of the abdomen; no fetal heart tones were heard, and a fetal electrocardiogram on two occasions was negative for the fetal complex. The uterus regressed in size, and x-ray signs of fetal death developed; however, there was no evidence of a bleeding diathesis. Nine weeks after injury a stillborn infant in breech presentation was delivered spontaneously. The placenta measured 15 cm. in diameter and was markedly fibrotic-. There was a craterlike appearance of the central area approximately 0.5 cm. thick, and the nlargin at the edge of the crater was about I CIII. thick and L cm. wide. This was considered to represent a concealed abruption which had 0~ curred at the time of the accident, with fet‘ll clemise. No other cause of fetal death was fotmtl on necropsy.

924

Dyer

and

Barclay

.\rn. J. Ohst. & Gynec.

Mortality

There were 3 maternal deaths, both occasioned by auto vehicle accidents. The first patieht sustained a subdural hematoma, fractured pelvis, lacerated liver, and partial abruptio placentae at 36 weeks’ gestation. She died on admission, and postpartum cesarean section was unsuccessful. The second patient died from hemorrhagic shock 36 hours after admission, associated with multiple fractures, including the femur, facial lacerations, and a ruptured uterine vein. A term stillborn infant was delivered vaginally 4 hours after admission. Only the second patient was compromised by the presence of a pregnancy: however, the ruptured uterine vein was not the primary source of blood loss. Six previable and 6 viable fetuses died. Deaths of the previable fetuses were due to a fall in one case, to auto vehicle accidents in 3, to a stab wound in 1, and to a gunshot wound in 1. The stab wound and gunshot wound of the uterus each injured the uterus to such an extent that hysterotomy was necessary to obtain hemostasis. The faI1 and auto accidents eventuated in spontaneous abortions, of which 2 were early abortions. In one of the auto vehicle accidents the pregnancy terminated 6 weeks later, and there is a question as to whether or not the accident was the precipitating factor. It would appear from this limited fetal loss that the unripe cervix in the early months

Table

V. Mortality Maternal (auto vehicle) Fetal Previable Gunshot Fall Auto++ Stab Total \‘iablr Gunshot Auto+ Stab Total II~..

“Onr iTwo

6 weeks maternal

later. deaths.

2 1 1 3 1 s 2 3 1 6

of pregnancy will not readily yield to the emotional or physical impact of severe injury. There were 6 deaths of viable fetuses. Three were the result of penetrating wounds of the uterus with gunshot injury to the fetus in 2 instances and severance of the fetal cord by a knife in the third instance. Auto accidents resulted in the deaths of 3 infants; 2 were due to maternal death and one was due to traumatic ahruptio placentae. Fetal and placental injury are summarized in Table V. Legal

considerations

Despite the infrequency of prenatal fetal injury reported in the medical literature, numerous cases of alleged fetal damage have been presented to the courts. Belli ’ and Harthe’Q have reviewed the subject of liability for prenatal injury. Until about 1924 the precedent of the Honorable Justice Holmes established in 1884 prevailed. He ruled that a prenatal injury affords no action in damage in favor of the child. The child in utero was considered by him to be a part of the mother, rather than residing with the mother as a separate individual. However, civil and criminal laws recognized a child conceived but unborn as a human being. Property rights of an unborn child could not be ignored and the rights of inheritance considered the child a person from the timr of conception. In 1924 a lower Pennsylvania court allowed recovery for prenatal injuries I‘?‘sulting in severe deformity. The weight of authority has steadily shifted to recognition of the rights of a conceived but unborn child. Recent court decisions are listed bv BeW ’ and HartheTZg the latter in table form. Several more recent cases have also heen reviewed and compiled hy the Bureau ol’ Legal Medicine and Legislation of the American Medical Association.3Y* x Further medicolegal aspects of trauma in pregnancy and labor have been explored by Dyer”” and is presented as reference to thr legal profession.

Accidental

Summary 1. Fifty-three instances of trauma in pregnancy and 23 of preconceptional trauma have been presented. 2. There were 30 auto vehicle accidents, 5 penetrating wounds of the uterus (3 gunshot and 2 knife), 13 falls, and 3 severe beatings in pregnancy. 3. The effect of pelvic fracture on pregnancy and delivery was reviewed. Thirteen pelvic fractures occurred during pregnancy and 22 prior to pregnancy. 4. Six penetrating wounds of the gravid uterus were studied. One gunshot wound of the uterus which occurred prior to pregnancy was reported. 5. Blunt abdominal trauma produced rupture of abdominal viscera in 5 women and placental separation in 2. No ruptured uteri were observed from blunt trauma. 6. Fetal trauma was observed in 5 patients, and placental injury in 3.

REFERENCES

1.

Abital, M. M.: AM. J. OBST. & GYNEC. 76: 599, 1958. 2. Abstract: Obst. & Gynec. Surv. 15: 335, 1960. 3. Badie, P. D., and Charlton, A.: New York J. Med. 40: 1797, 1940. 4. Beattie, J. E., and Daly, R. F.: AM. J. OBST. &c GYNEC. 80: 772. 1960. 5. Belli, Melvin M.: Modern Trials, Indianapolis. 1956, The Bobbs-Merrill Company, Inc., vol. 1, p. 254. 6. Belli, Melvin M.: Supplement to Modern Trials, 1958. 7. Black,. W. T.: Memphis M. J. 14: 198, 1939. 8. Bochner. K.: Obst. & Gvnec. 17: 520. 1961. 9. Bollinger, J, A., and Fdwler, E. F.: Am. J. Surg. 91: 952, 1956. 10. Bost, T. C.: South. M. J. 34: 1040, 1941. 11. Boyd, F. J.: J. Indiana M. A. 44: 945, 1951. 12. Carlson, R. I., Diveley, W. L., Gobbel, W. G., and Daniel, R. A., Jr.: J. Thoracic Surg. 36: 254, 1958. 13. Carter, J. 3.: j. M. A. Alabama 24: 249, 1955. D.: Proc. Roy. Sot. Med. 29: 308, 14. Coutts, 1936. M.: Gyn&. et obst. 55: 505, 1956. 15. DuPont, 16. Dyer, I. and McCaughey, E. V.: Ahl. J. OBST. & GYNEC. 77: 1176, 1959. N. J.: Obst. & Gynec. Surv. 13: 17. Eastman, 68, 1958.

trauma

complicating

pregnancy

925

7. There were 2 maternal and 12 fetal deaths. 8. Reference is given to the legal aspects of fetal injury in utero. Conchsions The ability of women to withstand trauma is not greatly influenced by pregnancy, which in itself makes them more vulnerable. The pregnant uterus can resist the traumatic initiation of labor unless near term, or severely injured by blunt or penetrating trauma.

We would like to hereby tion to the following who

express our appreciacontributed individual case experiences mentioned in the text: Dr. Ellis Oster, Ellendale, North Dakota, Dr. Rodney G. Masterson, Alexandria, Louisiana, Dr. E. L. King, Dr. James G. Mu& and Dr. Frank G. Nix, of New Orleans, Louisiana.

18.

Echerling, B., and Teaff, R.: J. Obst. & Gvnaec. Brit. Emn 57: 747. 1950. 19. Eliason, E., and johnson, J.: S. Clin. North America 17: 1571, 1937. 20. Elias, M.: Lancet 2: 253, 1950. 21. Farrell, J. J.: J. Florida M. A. 43: 1104, 1957. 22. Fitzgerald, J. B., Crawford, E., DeBakty, M. E.: Am. J. Surg. 10: 22, 1960. 23. Fowler, R. H.: Surg. Gynec. & Obst. 70: 213, 1940. 24. Geggie, N. S.: Canad. M. A. J. 84: 489, 1961. 25. Glenn, F.: Am. J. Surg. 91: 534, 1956. P. S., and Sproul, A. E.: Obst. 8c 26. Grant, Gynec. 16: 740, 1960. 27. Greenhill, J. P.: Obstetrics, ed. 12, Philadelphia, 1960, W. B. Saunders Company. R. A., and Collier, H. S.: Surg. 28. Griswold, Gynec. & Obst. 112: 309, 1961. R. V.: Proceedings of the National 29. Harthe, Association of Claimants Compensation Attorneys, Boston, 1954, p. 239. 30. Hedblom, C. A.: J. A. M. A. 85: 947, 1925. J. C., and Wacks, C.: AM. J. OBST. & 31. Hirst, GYNEC. 7: 199, 1924. E. C.: Surgery 14: 163, 1943. 32. Kelly, A. J., and Hurwitz, C. H.: Obst. 8( 33. Kobak, Gynec. 4: 383, 1954. E. M., and Kliman, F. E.: California 34. Lazard, & West. Med. 45: 482. 1936. W. E., and Biker, W. S.: Ani. J. 35. I&as, OBST. & GYNEC. 76: 1302, 1958.

926

36. 37. 38. 39.

40. 41.

42. ‘43. 44. 45. 46. 47. 48. 49. 50. 51. 52.

Dyer

and

Barclay

McCarty, V., alld Risely, D. R.: J. Internat. Coll. Surgeons 26: 228, 1956. McClure, J. N., Jr.: Surgery 35: 487, 1954. McIndoe, A. H.: Brit. J. Surg. 20: 249, 1932. Medico&al Cases, Abstracts of Court Dcvisions of Medicolesal Interest 1947-1952, Compiled by The B&au of Legal Medicin; and Legislation, American Medical Association. Meyer, H. and Cummins, H.: ‘4~. J. OBST. & GYNEC. 42: 150, 1941. Mikesky, W. E., Howard, J. M., and DeBakey, M. E.: Surg. Gynec. & Obst. 103: 323, 1956. Milloy, F. F., Anson, B. J., and McAfee, D. K.: Sure. Gvnec. & Obst. 110: 293. 1960. Mixson, w‘: T.; and Woloshin, H. J.; Obst. & Gym-c. 8: 249, 1956. Morrison, J. H., and Douglass, L. H.: As*. J. OBST. & GYNEC. 50: 330, 1945. Moss, L. K., and Hudgens, J. C.: Am. Surgeon 26: 763, 1960. Mulla, N.: Aw. J. OBST. & GYNEG. 74: 246, 1957. Nolan, L., and Cornwell, H. E.: Surg. Gynee. & Obst. 56: 522, 1923. Nolan, L., and Cornwell, H. E.: J. A. M. A. 94: 174, 1930. Oster, E.: Personal Communication, Ellendale Clinic, Ellendale, N. D. Pcmberthy, G. C.: Surg. Gynec. & Obst. 94: 626, 1952. Pike, J. B.: Medical Times 86: 869, 1958. Prenatal Injuries: Liability for Injuries Received Prior to Birth, J. A. M. A. 158: 590, 1955.

Ragucci, N.: Arch. ostet. (* ginec. 65: 346. 1960. W.: .4b1. J. 0~s~. & G~.NIx. 23: 5 h. Schuman, 103, 1932. F. A.: AM. J. &ST. & GYNEC. 35: ‘15. Snidow, 751, 1935. R. S.: AM. J. OBST. & GI-YEC. 56. Sparkman, 76: 587, 1958. 57. Staprlton, G.: Brit. M. J. 2: 367, 1937. 58. Stone, W. W., and Douglass, F. M.: .4m. ,J. Surg. 45: 301, 1939. C. G., Atkinson, J. C., Bragdon, 59. Sutherland, B. G., Crow, N. E.. and Brown, W. E.: Obst. & Gynec. 8: 261, 1956. J. II., Self, M. M., and Howard, .J. 60. Terry, M.: Surgery 40: 615, 1956. 61. TeskP, J. M.: Surgery 71: 689, 1946. 62. Voegelin, ‘4. W., and McCall, M. L.. All. J. OBST. 61 GYNEC. 48: 361, 1944. A. B., and Thompson, J, W.: 63. Weingold, AX. J. OBST. 8.z GYNEC. 80: 155. 1960. R. B., and Minot, N. D.: Sur64. Woodhull, wry 12: 615, 1942. 65. Wright, C. H., Posner. A. C., and Gilchrist. J.: A%r. J. OBST. & Gyrec. 67: 1085, 1954. 66. Wright, C. H., Posner, A. C., and Gilchrist, unavailable) .t; r;fyzo, Cj ournal 67. loung. J.. J. Obst. & Gynaec. Brit. Emp. 53.

68. 69.

Zaiinski, E. J., and Harkins, H. N.: .4rch. Surg. 46: 186, 1943. Dyer, I. Section on Labor, Traumatic Medicine and Surgery for the Attorney, London. 1962. Buttrrworth, Inc.. vol. 7. 1430 Tulane Nezc> Orlenns

Ave. 12, Louisiclna

Discussion DR. JOHN E. SAVAGE, Baltimore, Maryland. Among the earliest recorded instances of accidrntal trauma during prrgnancy are the so-called animal horn cesarean sections. According to Young, “The propensity of the bovine race to rip with horns was recognized by Moses 3,500 years ago, and special laws were made to deal with sllch accidents. The earliest known cast‘ occurred in 1647, and Harris (1887) collected 9 rasrs where pregnant women were gored, with subsequent expulsion of a fetus through the wound, pither immediately or after a short intrrval. Gould and Pyle (1897) mention threr others.” Accidents involving the gravid patient vary from a simple fall to a catastropic event. Paradoxically, one uterus may rupture as the result of a seemingly inconsequential force, while another will remain intact following severe CCtcrnal trauma. In 1936, De Lee stated that he could, “. . re-

port numerous cases of premature and precipitate delivery as the result of trauma-automoIjiling, running up and down stairs, striking the belly against objects, surf bathing, horseback riding, even golf and ordinary rail travel and mental shock. . . .” He therefore indicted many activities which many present-day obstetricians believe innocuous, Perhaps in the “Crescent City,“ the birthplace of jazz, the tempo of life is morr predisposing tu trauma than in staid Baltimore. In the period 1950 to 1960 in Baltimore there were no maternal deaths ascribed to causes which would rrflect the occurrence of an injury during pregnancy; and from 1955 to 1960 there were only 11 stillbirths (7.6 per 100,000 births) due to trauma to the mother during pregnancy. We would be interested to know the incidence of suppurative peritonitis in those patients of the authors’ series with penetrating wounds of the abdomen. Also, we would like to know what

Accidental

the authors’ experience has been to trauma as an etiological factor labor.

with regard in premature

trauma

complicotmg

pregnancy

927

was riding, the woman being 25 weeks pregnant. l’he point of impact was very close to the place where the young woman was sitting and, as x-ray pictures showed, she sustained 4 pelvic fractures low down in the ischium. She did not lose consciousness and there was no vaginal bleeding, either at that time or subsequently. However, movcmcnt was excruciatingly painful and she was hospitalized 2 months because of these fractures. But at 6 months she was able to get along quite well and in a year she had no disability whatsoever. As the result of discussion between the government lawyers and her lawyers,

above that. In any event, these 6 expert witnesses testified that there was no relationship between the accident and the cerebral palsy. Nevertheless, this judge awarded this young couple $260,000, and a little arithmetic would show that at 4 per cent interest this would yield $10,000 a year in perpetuity for the maintenance of this child, a child whose life expectancy must be very short; and in that event the larger part of this huge sum of money would revert to the couple. Can cerebral palsy be caused in this manner? About 14 months ago another couple \\-a~ touring the country in a station wagon. They were in Illinois and the wife, who was 8 weeks’ pregnant, became tired and went to sleep in the back end of the station wagon, with the door to the back completely open. A car going at terrific speed side-swiped this station wagon, turned it over, and she was hurled through the air a distance of about 12 feet and landed in a ditch at the side of the road. She did not lost consciousness. She had no fractures. She had

the Federal government paid her $70,000 because of pain, suffering, hospital bills and so on. Her husband was less severely injured and was hospitalized a week. He received $12,000 from the Federal government. The pregnancy went on and, rightly or wrongly, at term, because of these fractures, a cesarean section was performed. It soon became apparent, as the months went by, that this child was severely damaged. Indeed, when the case was finally brought to court it was apparent that the child was completely deaf, almost entirely blind, could not hold its head up; this was clearly and example of extreme brain damage. The couple brought suit against the Federal government for $900,000. The case was tried in Federal court in Columbia, the judge sitting without a jury. The woman sat with this pathetic child right in the front row before the judge throughout the trial. One expert witness for the plaintiff, we learned later, was a general practitioner who was in practice nearby and was a sort of a chronic expert witness for plaintiffs on almost any kind of case. He testified that in his opinion the accident caused the cerebral palsy. Six expert witnesses for the government from all over the country-one obstetrician, one neurosurgeon, two neurologists, two pediatricians--all testified that in their opinion there was no relationship brtween the accident and the resultant cerebral 1~1s~. S-ray pictures showed these fractures very low down and a small baby’s head 3 or 4 inches

no vaginal bleeding, and 9 months or so later she gave birth to an anencephalic child. This case is now in litigation. The insurance company representing the driver of the car that was going so fast apparently feels that they are going to have to pay something and they have offered a very large sum for settlement, but the plaintiffs think they can get even more if they go to court with the case, and the case will probably come up subsequently. Can anencephalus be caused in this manner? In a certain Midwestern city, a woman who had had 2 previous children weighing about 8 pounds was attended by one of the best younger obstetricians in that city, a Board diplomate, a perfectly qualified young man. The pregnancy went along quite normally. She went a week over the expected date of confinement. She went into normal labor and was delivered with very easy elective outlet forceps. But the child developed cerebral palsy and suit was brought, I believe, for $1,200,000 against this obstetrician. The allegations-incredible to the obstetricians in this audience-were as follows : ( 1) The patient should not have been allowed to go so long over term and cesarean section should have been done a day or two after thtb expected date of confinement, mind you in this utultipara who had had 2 normal deliveries of normal sized babies; (2) x-ray pelvimctry should have been taken, mind you again in this multipara v\;ho had had 2 babies and in this day and

DR. NICHOLSON EASTMAN, Baltimore, Maryland. About 3 years ago in the city of Columbia, South Carolina, a truck owned and operated by the Federal government crashed into an automobile in the back seat of which a young couple

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Dyer

and

Barclay

age when we are trying to curtail x-rays; (3) the forceps operation was brutally performed. It would be an affront to this audience to ask if any such series of events would cause cerebral palsy. I am certainly not going to discuss the possible causal relationship between trauma in pregnancy and cerebral palsy, but I would like to bring this subject to the attention of the Association because it is a growing field of litigation which you, as obstetricians, are very likely to encounter as expert witnesses, or at least your opinion is very likely to be asked. Indeed, it would be my prediction that plaintiff’s lawyers engaged in personal injury work are going to find pretty soon that they could make much more money if, instead of chasing ambulances, they would stand outside a cerebral palsy clinic and when the mothers come out, they would tell the mothers how easy it is for them to pick up a quarter of a million dollars by suing some person or another. At the Johns Hopkins Hospital we have seen in the past 2 decades 17 cases of pregnant women who had fractured pelves. Two of these were fractured during pregnancy. One woman was washing windows and lost her balance and fell out a 6 floor window. The other was in an automobile accident. The other 15 had been fractured prior to the pregnancy under our care. The point I want to make, in confirmation of what Dr. Dyer said, is that in these 17 cases careful x-ray pelvimetry showed distortion of the pelvis of sufficient degree to warrant cesarean section in only one case. So as he indicated, most of these cases of pelvic fracture do very well. DR. J. BAY JACOBS, Washington, D. C. Reference was made to a patient having separation of the pubic bones following a fall. I might say that that is a rather common condition normally. In x-raying pelves over a period of years I found that it was very common to notice separation of the pubic bones in some cases, even as much as % to s/4 inch, and this is often associated with some separation of the sacroiliac joints. Dr. Young, who is an Honorary Fellow of this Association, once wrote an article called “Pubosacroiliac Arthropathy.” Some of these patients have symptoms during the latter months of pregnancy and one can readily realize why; because of the mobility of those joints. The symptoms usually disappear after delivery; but it is a common situation.

April 1, IY6L’ Am. J. Obst. & Gyncc.

I was impressed with the fracture of the child’s skull because of ankylosis of the maternal coccyx. Usually we hear the coccyx snap, but I have never seen a fractured skull a$ a rcsnlt of this condition. I also wanted to stress the in1portanc.e of x-ray pelvimetry in order to determine the architecture of the pelvis or distorsion of the architecture following fractures of the pelvis which, of course, do not always indicate the necessity for cesarean section. DR. HAROLD HENDERSON, Detroit, Michigan. As a consultant for some insurance companies in gynecologic casts, I have been confronted with a number of legal situations that arc rather startling. For instance, a 40-year-old woman with 2 children 19 and 20 years of age, while traveling 300 miles from Detroit had her cat side-swiped. The auto she drove was a Cadillac and damage amounted to $15. She missed a period while on her trip but began to bleed shortly after returning home. A doctor was found who would curette her and who said she was pregnant. Bleeding continued, so a hysterectomy was performed. This insurance company is being asked for something like $25,000. There are many cases of this type that are utterly and completely ridiculous. We must bc very careful in assessing them. Those of us \vho come in contact with such a case have gained great comfort out of what Dr. Dyer has said today. It is very rare that a patient will miscarry as a result of an accident. Trivial accidents brought into medicolcgal courts are receiving verdicts as high as $260,000. We must get together and try to block these actions in our own way.

DR. DYER (Closing). With regard to the relationship of trauma to premature delivery, there were only 5 of 53 patients that were delivered prematurely. When one considers anomalies seen after accidents we would do well to enlist the help of a geneticist and see if there is a genetic background which becomes of importance only bccause there happened to br an accident prcceding delivery. :A patient of mine has had two anencephalic infants, her only children, and since she and her husband have a close family relationship OUT geneticist thinks that there are chances of IWI repeating the process again and again.

Accidental

S-ray evidence of pubic bone separation, parlicularly in very young women, is a point you can use to diagnose pregnancy. However, I should have emphasized that we were referring not only to separation but to displacement producing a considerable amount of pain. So far as

trauma

complicating

the skull fracture is patient, referred to in 2 babies, her first 2 frontal bone injuries maternal coccyx.

pregnancy

concerned, the paper, children, due to

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we have one who has had with identical the angulated