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Severe road traffic injuries in the third trimester of pregnancy
376
Injury(1984) 15, 376-378
Printedin Great Britain
Severe road traffic pregnancy
injuries
in the third trimester
of
Olusola 0. A. Oni, E. E. Okpere, 0. Tabowei and E. A. Omu University of Benin and Teaching Hospital, Benin City, Nigeria Summary
We report 9 women in the third trimester of pregnancy who were severely injured in road traffic accidents. There were 3 accelerated labours and half the babies died. Immediate obstetric interference was often impractical and did not improve fetal survival. Noteworthy injuries of the central nervous system were associated with very high fetal mortality. Fractures of the pelvis were not nearly as disastrous as the literature suggests. The first consideration in management should be the well being of the severely injured mother, since the injuries that would kill the fetus are not likely to be amenable to surgery. The only justification for intervention for the sake of the fetus that survives the moment of impact is to salvage it from its dying mother’s body. INTRODUCTION
SEVERELYinjured pregnant women pose peculiar difficulties in management, yet the subject of injury and pregnancy has not been extensively reported in the English literature. An understanding of the relationship between injury and pregnancy is important to the obstetrician in the proper management of the pregnancy and safe conduct of labour, as it is in accurately predicting the possible effects.on future pregnancies. The subject is also important to the accident/orthopaedic surgeon who has to identify any dangers to the mother and her unborn child and modify, where necessary, the manage,ment of the injuries sustained. As the gravid uterus increases in size and occupies a greater proportion of the abdominal cavity it becomes increasingly susceptible to injury; damage may occur to. the uterus (Ojwang et al., 1978), membranes (Buchsbaum, 1968) and/or cord or placenta (Connor and Curran, 1976) and may be severe enough to precipitate labour and/or injure the fetus. Disturbances in maternal homeostasis without obvious maternal injury may also jeopardize the fetus and/or alter the course of pregnancy. ,For example, maternal hypovolaemia increases adrenergic secretion (Greiss, 1966), which in turn leads to peripheral vasoconstriction, decreased uterine blood flow and a drop in fetal tissue PO, (Boba et al., 1966). Placental separation may result from mechanical dislodgement or from uterine compression of the inferior vena cava. As for the mother, the lax abdominal musculature offers poor protection and, therefore, the hyperaemic viscera, especially the uterus, which is superficial may rupture very easily. The physiological upheaval of pregnancy, such as changes in circulatory haemodynamics
(Taylor, 1976), the tendency to hypoproteinaemia (Cauchi, 1981) and increases in the secretion of steroids and other humoral factors (Cauchi, 1981), may delay recovery from shock or hypovolaemia. Thromboembolic phenomena may result from trauma (Sevitt and Gallagher, 1959) as well as from pregnancy itself (Taylor, 1976). CASE SERIES
AND
METHODS
Nine women in the third trimester of pregnancy who sustained very severe injuries as a result of road traffic accidents between January and December 1982 were studied. Severe injuries were defined as those which appeared to threaten the life of the patient and/or the fetus. The following matters were studied: type of accident, pattern of injuries, management and the obstetric performance. RESULTS
Less than 1 per cent of our severely injured patients were pregnant women and this is in accord with published work (DHSS, 1979). The clinical characteristics of our patients are shown in Table I. The ages ranged from 18 to 30 years and parity from 0 to 4; all patients were more than 30 weeks pregnant. Five patients were occupants of vehicles, 2 were pillion riders and 2 were knocked down by motorcycles. The patterns of injury were not peculiar to pregnant women: 3 patients had fractures of the pelvis and 2 fractures of the long bones of the limbs, 3 had serious central nervous system injuries and one patient had a perforating abdominal injury with a ruptured uterus. The management of patients depended on the types of injuries, and pregnancy was allowed to continue unless there was a clear need for obstetric intervention. Six patients had spontaneous vaginal deliveries (SVD) ranging from a few hours to 8 weeks after injury; labour was induced in one case and was followed by vacuum extraction; 2 patients had Caesarean sections (CS) because of respectively perforated abdominal viscera and intrauterine death. There were 4 still births (SB) and 2 babies survived only after several weeks in the special care baby unit (SCBU). DISCUSSION
Certain trends which may be useful in making difficult management decisions are evident from this study. First, of the 5 pregnancies
that terminated
within
1 week of
Oni et al.: Road traffic injuries in pregnancy Table 1. The clinical accidents
data of women
in the third trimester
Case Kinematics
377
Injuries
of pregnancy
Management of injuries
sustaining
no.
Age
1
30
Ejected from vehicle
Fracturedislocation of c7
As for paraplegic
2
26
Vehicle occupant
Fracture of pelvis
Bedrest and analgesics
Toxaemia, unstable lie Wound infection (tetanus)
3
22
Vehicle occupant
Open comminuted fracture of leg, dental
Antibiotics, toilet and open reduction
4
26
Fell off pillion
Fracture of pelvis
Bedrest and analgesics
5
27
Knocked down by motorcycle
Head injury
6
18
Vehicle occupant
7
21
8
9
Pregnant y
-
severe injuries following
Labour SVD 3 days
-
road traffic
Outcome Maternal Fetal Paraplegic
Apgar 3-4 in 1 minute SCBU (F, 2.85 kg)
cs
Apgar 8 (M, 3.5 kg)
6 weeks Uneventful SVD 3 weeks
Died
Apgar 3 SCBU (F. 2.5 kg)
-
SVD 8 weeks
Uneventful
Apgar 8 (F. 3.0kg)
As for head injury
-
SVD 24 hours
Recovered
Fresh SB (M. 3.2 kg)
Head injury
As for head injury
-
SVD 24 hours
Recovered
Fresh SB (M, 2.4 kg)
Fell off pillion
Fracture of pelvis
Tranquillizers
-
SVD 8 weeks
Uneventful
Apgar 7 (F, 2% kg)
30
Knocked down by motorcycle
Fracture of olecranon, absen; fetal movement
POP cast
-
Induction vacuum
Uneventful
Fresh SB (F, 2.9 kg)
18
Vehicle
Perforating abdominal injury, ruptured uterus
Laparotomy
Survived
Fresh SB (M, 25kg)
trauma, only one baby survived and then only after several weeks of special care, while the 3 babies born more than 6 weeks after injury presented no difficulties. It may be inferred, therefore, that the fetus sustains maximal damage at the moment of impact (Connor and Curran, 1976; Ojwang et al., 1978) or shortly afterwards. Thus, early obstetric intervention is unnecessary and may be inimical to the fetus because it does not allow time for re-adjustments to fetal homeostasis. The injuries sustained by a surviving fetus usually do not threaten life (London, 1974); only one baby in our study had any evidence of physical damage. Therefore, the fetus may be more susceptible to secondary effects of maternal injuries such as septicaemia, hypoxia and drugs (Boba et al., 1966; Greiss, 1966) than is often realized. Further, 6 of our patients had spontaneous vaginal deliveries in the supine position and in 3 patients (cases 1, 5 and 6) this occurred while resuscitative efforts were in progress. No objective pressure effects of the gravid uterus on the inferior vena cava (IVC) were observed. Therefore, modification in posture during delivery is unnecessary and is often impracticable in the circumstances. Secondly, although pelvic injuries are potentially the most damaging to both the uterus and the fetus, there was no change in the course of labour and its outcome in
the 3 patients with pelvic fractures, whereas injuries elsewhere in the body were responsible for accelerated labour in 3 patients and also for the high death rate (Allay and Prysor-Jones, 1967). This suggests that the amount of energy transferred to the uterus is substantially reduced if the pelvis is fractured. Pelvic fractures rarely require more than symptomatic treatment and although all severe fractures of the pelvis may deform the birth canal, not all encroach upon it to a serious degree. Deformation of the pelvis matters very little to most women, especially those who have the services of obstetricians. Much of what has to be done to save the life of the injured patient or the fetus or to save both from much morbidity must be done immediately after arrival at hospital. Decisions taken at the time may affect subsequent management. Priorities in treatment are not arbitrary but depend on the imminence and causes of a fatal outcome. Hypoxia must be treated vigorously and predisposing conditions such as a blocked airway must be corrected immediately. The treatment of shock and the control of haemorrhage are of even more importance in pregnancy. Further, pregnancy is associated with decreased gastric motility (Eastman and Hellman, 1966); therefore, it may be advisable to pass a nasogastric tube. A urethral catheter is also recommended. Ambulatory
378
methods are preferable in the management of fractures in pregnancy because pregnancy may delay healing due to interference with calcium metabolism (Buchsbaum, 1968), traction may physically impede the management of labour, and prolonged immobilization in bed may further increase the already high risk of thromboembolism (Sevitt and Gallagher, 1959). Finally, labour can be said to have been truly accelerated in only 3 of the 9 patients (cases 1, 5 and 6); injuries of the central nervous system were responsible in all cases. It is also to be noted that injuries of the central nervous system in pregnancy adversely affect fetal outcome (cases 1,5 and 6); the precise mechanism is unclear but may be humoral. Spinal injuries especially affecting level Ll or above may alter the autonomic and sensory outflow to the uterus. Spinal injuries also pose peculiar problems as to the course of labour since the patient may have in effect what amounts to a spinal shock. In case 1 the cervix was almost fully dilated before the patient was discovered to be in labour.
Injury: the British Journal of Accident
Surgery Vol. 1 ~/NO. 6
Boba A., Linkie D. M. and Plotz E. J. (1966) Effects of vasopressor administration and fluid replacement on foetal bradycardia and hypoxia induced by maternal haemorrhage. Obstet. Gynecol. 27, 408.
Buchsbaum H. J. (1968) Accidental injury complicating pregnancy. Am. J. Obstet. Gynecol. 102, 752. Cauchi M. N. (1981) In: Obstetric and Perinatal immunology. London: Arnold. Connor E. and Curran J.(1976) In utero traumatic intraabdominal deceleration injury to the foetus-a case report. Am. J. Obstet. Gynecol. 125, 576.
of Health and Social Security (1979) Report on Contdential Enquiries into Maternal Deaths in England and Wales 19733197.5. London; HMSO. Eastman N.Y. and Hellman L. L. (1966) In: Williams Obstetrics, 13th ed. New York: ACC. Department
Greiss F. C. (1966) Uterine vascular response to haemorrhage during pregnancy with observations on therapy. Obstet. Gynecol. 27, 549.
London P. S. (1974) Injury and pregnancy. Injury 6, 129. Ojwang S. B., Bennum M. and Musila S. (1978) Uterine rupture due to road traffic accident. East Afr. Med. J. 55, 14. Sevitt S. and Gallagher N. G. (1959) Prevention of venous thrombosis and pulmonary embolism in injured patients. Lancer 2, 98 1.
REFERENCES
Allay R. D. and Prysor-Jones D. (1967) Blunt external abdominal trauma causing foetal death. Am. J. Obstet. and Gynecol. 97, 577.
Taylor E. S. (1976) In: Beck’s Obstetrical Practice and Foetal Medicine, 10th ed. Baltimore; Md.: WWB. Paper accepted 8 September 1983.
Requestsfor reprintsshouldbe addressed to: Mr 0. 0. A. Oni, 18 Ellenborough Place, Roehampton Close, London SW15.
Injury(1984) 15, 376-378
Printedin Great Britain
Severe road traffic pregnancy
injuries
in the third trimester
of
Olusola 0. A. Oni, E. E. Okpere, 0. Tabowei and E. A. Omu University of Benin and Teaching Hospital, Benin City, Nigeria Summary
We report 9 women in the third trimester of pregnancy who were severely injured in road traffic accidents. There were 3 accelerated labours and half the babies died. Immediate obstetric interference was often impractical and did not improve fetal survival. Noteworthy injuries of the central nervous system were associated with very high fetal mortality. Fractures of the pelvis were not nearly as disastrous as the literature suggests. The first consideration in management should be the well being of the severely injured mother, since the injuries that would kill the fetus are not likely to be amenable to surgery. The only justification for intervention for the sake of the fetus that survives the moment of impact is to salvage it from its dying mother’s body. INTRODUCTION
SEVERELYinjured pregnant women pose peculiar difficulties in management, yet the subject of injury and pregnancy has not been extensively reported in the English literature. An understanding of the relationship between injury and pregnancy is important to the obstetrician in the proper management of the pregnancy and safe conduct of labour, as it is in accurately predicting the possible effects.on future pregnancies. The subject is also important to the accident/orthopaedic surgeon who has to identify any dangers to the mother and her unborn child and modify, where necessary, the manage,ment of the injuries sustained. As the gravid uterus increases in size and occupies a greater proportion of the abdominal cavity it becomes increasingly susceptible to injury; damage may occur to. the uterus (Ojwang et al., 1978), membranes (Buchsbaum, 1968) and/or cord or placenta (Connor and Curran, 1976) and may be severe enough to precipitate labour and/or injure the fetus. Disturbances in maternal homeostasis without obvious maternal injury may also jeopardize the fetus and/or alter the course of pregnancy. ,For example, maternal hypovolaemia increases adrenergic secretion (Greiss, 1966), which in turn leads to peripheral vasoconstriction, decreased uterine blood flow and a drop in fetal tissue PO, (Boba et al., 1966). Placental separation may result from mechanical dislodgement or from uterine compression of the inferior vena cava. As for the mother, the lax abdominal musculature offers poor protection and, therefore, the hyperaemic viscera, especially the uterus, which is superficial may rupture very easily. The physiological upheaval of pregnancy, such as changes in circulatory haemodynamics
(Taylor, 1976), the tendency to hypoproteinaemia (Cauchi, 1981) and increases in the secretion of steroids and other humoral factors (Cauchi, 1981), may delay recovery from shock or hypovolaemia. Thromboembolic phenomena may result from trauma (Sevitt and Gallagher, 1959) as well as from pregnancy itself (Taylor, 1976). CASE SERIES
AND
METHODS
Nine women in the third trimester of pregnancy who sustained very severe injuries as a result of road traffic accidents between January and December 1982 were studied. Severe injuries were defined as those which appeared to threaten the life of the patient and/or the fetus. The following matters were studied: type of accident, pattern of injuries, management and the obstetric performance. RESULTS
Less than 1 per cent of our severely injured patients were pregnant women and this is in accord with published work (DHSS, 1979). The clinical characteristics of our patients are shown in Table I. The ages ranged from 18 to 30 years and parity from 0 to 4; all patients were more than 30 weeks pregnant. Five patients were occupants of vehicles, 2 were pillion riders and 2 were knocked down by motorcycles. The patterns of injury were not peculiar to pregnant women: 3 patients had fractures of the pelvis and 2 fractures of the long bones of the limbs, 3 had serious central nervous system injuries and one patient had a perforating abdominal injury with a ruptured uterus. The management of patients depended on the types of injuries, and pregnancy was allowed to continue unless there was a clear need for obstetric intervention. Six patients had spontaneous vaginal deliveries (SVD) ranging from a few hours to 8 weeks after injury; labour was induced in one case and was followed by vacuum extraction; 2 patients had Caesarean sections (CS) because of respectively perforated abdominal viscera and intrauterine death. There were 4 still births (SB) and 2 babies survived only after several weeks in the special care baby unit (SCBU). DISCUSSION
Certain trends which may be useful in making difficult management decisions are evident from this study. First, of the 5 pregnancies
that terminated
within
1 week of
Oni et al.: Road traffic injuries in pregnancy Table 1. The clinical accidents
data of women
in the third trimester
Case Kinematics
377
Injuries
of pregnancy
Management of injuries
sustaining
no.
Age
1
30
Ejected from vehicle
Fracturedislocation of c7
As for paraplegic
2
26
Vehicle occupant
Fracture of pelvis
Bedrest and analgesics
Toxaemia, unstable lie Wound infection (tetanus)
3
22
Vehicle occupant
Open comminuted fracture of leg, dental
Antibiotics, toilet and open reduction
4
26
Fell off pillion
Fracture of pelvis
Bedrest and analgesics
5
27
Knocked down by motorcycle
Head injury
6
18
Vehicle occupant
7
21
8
9
Pregnant y
-
severe injuries following
Labour SVD 3 days
-
road traffic
Outcome Maternal Fetal Paraplegic
Apgar 3-4 in 1 minute SCBU (F, 2.85 kg)
cs
Apgar 8 (M, 3.5 kg)
6 weeks Uneventful SVD 3 weeks
Died
Apgar 3 SCBU (F. 2.5 kg)
-
SVD 8 weeks
Uneventful
Apgar 8 (F. 3.0kg)
As for head injury
-
SVD 24 hours
Recovered
Fresh SB (M. 3.2 kg)
Head injury
As for head injury
-
SVD 24 hours
Recovered
Fresh SB (M, 2.4 kg)
Fell off pillion
Fracture of pelvis
Tranquillizers
-
SVD 8 weeks
Uneventful
Apgar 7 (F, 2% kg)
30
Knocked down by motorcycle
Fracture of olecranon, absen; fetal movement
POP cast
-
Induction vacuum
Uneventful
Fresh SB (F, 2.9 kg)
18
Vehicle
Perforating abdominal injury, ruptured uterus
Laparotomy
Survived
Fresh SB (M, 25kg)
trauma, only one baby survived and then only after several weeks of special care, while the 3 babies born more than 6 weeks after injury presented no difficulties. It may be inferred, therefore, that the fetus sustains maximal damage at the moment of impact (Connor and Curran, 1976; Ojwang et al., 1978) or shortly afterwards. Thus, early obstetric intervention is unnecessary and may be inimical to the fetus because it does not allow time for re-adjustments to fetal homeostasis. The injuries sustained by a surviving fetus usually do not threaten life (London, 1974); only one baby in our study had any evidence of physical damage. Therefore, the fetus may be more susceptible to secondary effects of maternal injuries such as septicaemia, hypoxia and drugs (Boba et al., 1966; Greiss, 1966) than is often realized. Further, 6 of our patients had spontaneous vaginal deliveries in the supine position and in 3 patients (cases 1, 5 and 6) this occurred while resuscitative efforts were in progress. No objective pressure effects of the gravid uterus on the inferior vena cava (IVC) were observed. Therefore, modification in posture during delivery is unnecessary and is often impracticable in the circumstances. Secondly, although pelvic injuries are potentially the most damaging to both the uterus and the fetus, there was no change in the course of labour and its outcome in
the 3 patients with pelvic fractures, whereas injuries elsewhere in the body were responsible for accelerated labour in 3 patients and also for the high death rate (Allay and Prysor-Jones, 1967). This suggests that the amount of energy transferred to the uterus is substantially reduced if the pelvis is fractured. Pelvic fractures rarely require more than symptomatic treatment and although all severe fractures of the pelvis may deform the birth canal, not all encroach upon it to a serious degree. Deformation of the pelvis matters very little to most women, especially those who have the services of obstetricians. Much of what has to be done to save the life of the injured patient or the fetus or to save both from much morbidity must be done immediately after arrival at hospital. Decisions taken at the time may affect subsequent management. Priorities in treatment are not arbitrary but depend on the imminence and causes of a fatal outcome. Hypoxia must be treated vigorously and predisposing conditions such as a blocked airway must be corrected immediately. The treatment of shock and the control of haemorrhage are of even more importance in pregnancy. Further, pregnancy is associated with decreased gastric motility (Eastman and Hellman, 1966); therefore, it may be advisable to pass a nasogastric tube. A urethral catheter is also recommended. Ambulatory
378
methods are preferable in the management of fractures in pregnancy because pregnancy may delay healing due to interference with calcium metabolism (Buchsbaum, 1968), traction may physically impede the management of labour, and prolonged immobilization in bed may further increase the already high risk of thromboembolism (Sevitt and Gallagher, 1959). Finally, labour can be said to have been truly accelerated in only 3 of the 9 patients (cases 1, 5 and 6); injuries of the central nervous system were responsible in all cases. It is also to be noted that injuries of the central nervous system in pregnancy adversely affect fetal outcome (cases 1,5 and 6); the precise mechanism is unclear but may be humoral. Spinal injuries especially affecting level Ll or above may alter the autonomic and sensory outflow to the uterus. Spinal injuries also pose peculiar problems as to the course of labour since the patient may have in effect what amounts to a spinal shock. In case 1 the cervix was almost fully dilated before the patient was discovered to be in labour.
Injury: the British Journal of Accident
Surgery Vol. 1 ~/NO. 6
Boba A., Linkie D. M. and Plotz E. J. (1966) Effects of vasopressor administration and fluid replacement on foetal bradycardia and hypoxia induced by maternal haemorrhage. Obstet. Gynecol. 27, 408.
Buchsbaum H. J. (1968) Accidental injury complicating pregnancy. Am. J. Obstet. Gynecol. 102, 752. Cauchi M. N. (1981) In: Obstetric and Perinatal immunology. London: Arnold. Connor E. and Curran J.(1976) In utero traumatic intraabdominal deceleration injury to the foetus-a case report. Am. J. Obstet. Gynecol. 125, 576.
of Health and Social Security (1979) Report on Contdential Enquiries into Maternal Deaths in England and Wales 19733197.5. London; HMSO. Eastman N.Y. and Hellman L. L. (1966) In: Williams Obstetrics, 13th ed. New York: ACC. Department
Greiss F. C. (1966) Uterine vascular response to haemorrhage during pregnancy with observations on therapy. Obstet. Gynecol. 27, 549.
London P. S. (1974) Injury and pregnancy. Injury 6, 129. Ojwang S. B., Bennum M. and Musila S. (1978) Uterine rupture due to road traffic accident. East Afr. Med. J. 55, 14. Sevitt S. and Gallagher N. G. (1959) Prevention of venous thrombosis and pulmonary embolism in injured patients. Lancer 2, 98 1.
REFERENCES
Allay R. D. and Prysor-Jones D. (1967) Blunt external abdominal trauma causing foetal death. Am. J. Obstet. and Gynecol. 97, 577.
Taylor E. S. (1976) In: Beck’s Obstetrical Practice and Foetal Medicine, 10th ed. Baltimore; Md.: WWB. Paper accepted 8 September 1983.
Requestsfor reprintsshouldbe addressed to: Mr 0. 0. A. Oni, 18 Ellenborough Place, Roehampton Close, London SW15.