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Shot in the womb
Journal of Pediatric Surgery Case Reports 35 (2018) 4–6
Contents lists available at ScienceDirect
Journal of Pediatric Surgery Case Reports journal homepage: www.elsevier.com/locate/epsc
Shot in the womb a
T b
c
Dylan Hutchison , Neal D. Uitvlugt , Teri L. Crumb , James M. DeCou a b c
b,∗
Michigan State College of Human Medicine, 15 Michigan St. NE, Grand Rapids, MI, 49503, USA Helen DeVos Children's Hospital, Department of Pediatric Surgery, 100 Michigan St. NE, Grand Rapids, MI, 49503, USA Helen DeVos Children's Hospital - Research, 100 Michigan St. NE, Grand Rapids, MI, 49503, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Fetal trauma Penetrating injury Pediatric trauma Gunshot injury
A fetus surviving a prenatal penetrating gunshot injury is rarely encountered. We report the case of a 26-week pregnant mother shot in the abdomen. Her uterine wound was missed at exploration, and when the baby was born 6 weeks later, the bullet was found in the superficial soft tissues of his posterior neck. It was removed without difficulty, and the baby, our youngest trauma patient ever, recovered without sequelae.
1. Introduction
2. Case report
Trauma is a serious factor in causing fetal death and injury [1–3]. No matter the seriousness of the trauma suffered by the mother, the fetus can still be in significant danger [2]. Motor vehicle collisions account for the majority of fetal trauma and therefore are the most studied [1,3,5]. Fetal injury due to penetrating trauma is rarer [5] and therefore is less studied. It is very uncommon for a fetus to survive a direct penetrating gunshot injury [4]. Reported infant mortality data states 40–70% death [6]. The literature shows that in the event of a bullet wound in a pregnant mother, conservative or surgical care can be taken, depending on the situation of the gunshot wound. Conservative treatment should be utilized when there is a previable fetus, a dead fetus, a negative abdominal exam, the entrance wound is below the uterine fundus, or the urinalysis is negative for blood [7–9]. If conservative care is not indicated then surgical intervention should be performed, which has been shown to prevent maternal and fetal death [9]. When dealing with a uterine bullet wound, delivery should be highly considered, even with premature fetuses. In addition to conservative or surgical care, delivery often is the best chance the fetus has at survival, even if it is premature. Presently, premature infants are now better suited for survival because of the recent advances in premature neonatal care [9–11]. Trauma surgery on a newborn less than 24 h old is also quite unusual. This unique case of penetrating fetal trauma with immediate postnatal surgery easily makes this the youngest patient in our pediatric trauma registry.
A 19 year old woman, G1P0, 26 weeks pregnant, presented to the emergency department of our adjacent Level 1 Adult Trauma Center with two bullet wounds. Entrance wounds were noted in her left upper thigh and the left lower quadrant of her abdomen. Obstetrical ultrasound assessment was performed – the fetus was viable with good heart tones and sufficient amniotic fluid. Radiographs of the mother revealed a bullet in the pelvic area (Figs. 1 and 2) and a fragment in the left thigh. Two metal fragments visualized within the pelvis with notation that they possibly were in the uterus and adjacent to the fetal skull. The mother was taken to the operating room for exploratory laparotomy. Fetal heart rate was monitored by high-risk Obstetricians and remained stable throughout the procedure. No significant blood was noted upon entering the abdomen, and very little free fluid was found. The gunshot to the left lower quadrant caused a retroperitoneal hematoma involving the psoas muscle. The hematoma was not expanding and was explored and evacuated. The gravid uterus was evaluated along with the fallopian tubes and ovaries bilaterally. All were free from any damage. Specifically, no entrance wound was noted in the uterus. There was no damage to major vascular structures, small or large intestine, or ureter. The bullet was not located. It was believed to be retroperitoneal and therefore was not removed. The left leg wound was explored and a small piece of shrapnel was removed. Both wounds were irrigated and dressed. Mother and fetus were monitored postoperatively and did well. A post-operative fetal ultrasound showed no evidence of fetal compromise from the abdominal trauma. There was a decrease in amniotic fluid volume (4.89 cm). She went home after a 9day hospitalization.
∗
Corresponding author. Helen DeVos Children's Hospital, Department of Pediatric Surgery, 330 Barclay Avenue, Suite 202, Grand Rapids, MI, 49503, USA. E-mail addresses: [email protected] (D. Hutchison), [email protected] (N.D. Uitvlugt), [email protected] (T.L. Crumb), [email protected] (J.M. DeCou). https://doi.org/10.1016/j.epsc.2018.04.016 Received 25 April 2018; Accepted 28 April 2018 Available online 30 April 2018 2213-5766/ © 2018 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Journal of Pediatric Surgery Case Reports 35 (2018) 4–6
D. Hutchison et al.
Fig. 1. Radiographs of the mother showing projectiles in the pelvis.
Fig. 3. Cervical radiograph of the newborn infant showing a bullet fragment in the soft tissues of the posterior neck.
metallic fragment in the superficial soft tissues (Fig. 3) which came out with a later dressing change. No bony injuries were identified. The baby did very well and was discharged home with his mother on day 2. 3. Discussion This case presents a rare gunshot injury to a fetus followed by an immediate surgical procedure on the newborn baby. The bullet was left in the mother after exploratory surgery did not reveal any injury to the gravid uterus. When the baby was born, the bullet was found protruding from the newborn baby's neck. The bullet was removed without difficulty from the capsule that had formed deep to it. We can learn several lessons from this unique case. First, the bullet wound to the uterus was missed during the mother's exploratory surgery. In this case, the missed uterine bullet wound may have benefitted the fetus, giving him six more weeks of intrauterine growth and development prior to delivery. If the wound had been identified, uterine exploration likely would have led to an extremely premature delivery of the baby at 26 weeks gestation. Secondly, the uterus appears to have protected the fetus from significant injury. Passage of the bullet through the mother's abdominal wall and gravid uterus damped the bullet's kinetic energy, leading to only a superficial injury to the fetus [12]. Thirdly, the unusual capsule deep to the bullet may be an example of fetal wound healing. Unfortunately, this baby was lost to follow-up, so the long term result of the wound could not be evaluated. Lastly, this case demonstrates that fetuses can survive penetrating maternal trauma as long as the mother remains hemodynamically stable, and the uterus, amniotic sac, and placenta remain intact. This case adds some insight into what to do when a pregnant woman presents with a gunshot wound to the abdomen or pelvis. The most important factors are the health and hemodynamic stability of the mother and the viability of the fetus. If the mother and fetus are stable, then finding and removing the bullet may not be as important. This case suggests that as long as the mother and fetus remain stable and the placenta and amniotic sac appear intact, that immediate intrauterine exploration may not always be necessary, even with a known intrauterine projectile.
Fig. 2. Radiographs of the mother showing projectiles in the pelvis.
43 days following the gunshot wounds, the woman experienced premature rupture of membranes. She delivered a 32-1/7 week gestation premature baby boy by vaginal delivery. At the time of delivery, the baby was examined and found to have a foreign body protruding from the posterior aspect of his neck. The object was clearly visible and metallic in nature. It was quite superficial with no evidence of deeper injury. Besides the foreign body, the baby appeared normal. APGARS were 9 at one minute and 9 at 5 min. He moved all four extremities. The surgeon on call for our Level 1 Pediatric Trauma Center was called. Since the foreign body was partially protruding, the surgeon decided to remove it right away. The procedure was performed in the Neonatal ICU. A hemostat was used to carefully remove the foreign body, which appeared to be the bullet that had remained in the mother for 43 days. The area where the bullet was removed appeared to be a walled-off capsule without bleeding or drainage. A gauze dressing was applied, to be changed twice daily. The bullet was saved and was given to police for forensic examination. Follow-up cervical x-rays showed a small
4. Conclusion This prenatal gunshot injury to a fetus led to him becoming the 5
Journal of Pediatric Surgery Case Reports 35 (2018) 4–6
D. Hutchison et al.
Appendix A. Supplementary data
youngest patient in our pediatric trauma registry. Although the penetrating uterine wound was missed at the mother's exploratory surgery, this case demonstrates that as long as the mother and baby are stable and the uterus and its structures remain intact, that the fetus can grow and develop normally and have the bullet removed later.
Supplementary data related to this article can be found at http://dx. doi.org/10.1016/j.epsc.2018.04.016. References
Patient consent [1] Brown HL. Trauma in pregnancy. Obstet Gynecol 2009;114(1):147–60. http://dx. doi.org/10.1097/aog.0b013e3181ab6014. [2] Farmer DL, Adzick NS, Crombleholme WR, Crombleholme TM, Longaker MT, Harrison MR. Fetal trauma: relation to maternal injury. J Pediatr Surg 1990;25(7):711–4. http://dx.doi.org/10.1016/s0022-3468(05)80002-8. [3] Mattox KL, Goetzl L. Trauma in pregnancy. Crit Care Med 2005;33(Supplement). http://dx.doi.org/10.1097/01.ccm.0000182808.99433.55. [4] Pasley JD, Demetriades D. Penetrating fetal trauma with late complications: a case report. J Pediatr Surg 2012;47(9). http://dx.doi.org/10.1016/j.jpedsurg.2012.04. 004. [5] Shah KH, Simons RK, Holbrook T, Fortlage D, Winchell RJ, Hoyt DB. Trauma in pregnancy. J Trauma Inj Infect Crit Care 1998;45(1):83–6. http://dx.doi.org/10. 1097/00005373-199807000-00018. [6] Ward HR, vanDeurzen DF, van Dongen PW. Gunshot uterine rupture: a case report. Eur J Obstet Gynecol Reprod Biol 1998;80(2):279–81. [7] Franger AL, Buchsbaum HJ, Peaceman AM. Abdominal gunshot wounds in pregnancy. Am J Obstet Gynecol 1989;160:1124–8. [8] O’Shaughnessy MJ. Conservative obstetric management of a gunshot wound to the second - trimester gravid uterus. A case report. J Reprod Med 1997;42:606–8. [9] Overstreet K, Mannino FL, Benirschke K. The role of placental pathology in the evaluation of interpersonal violence: a case of abdominal gunshot wound in a 27week gravid uterus. J Perinatol 2002;22(8):675–8. http://dx.doi.org/10.1038/sj.jp. 7210814. [10] Stone IK. Trauma in the obstetric patient. Obstet Gynecol Clin North Am 1999;26:459–67. (viii). [11] Lavin Jr. JP, Polsky SS. Abdominal trauma during pregnancy. Clin Perinatol 1983;10:423–38. [12] Carugno JA, Rodriguez A, Brito J, Cabrera C. Gunshot wound to the gravid uterus with non-lethal fetal injury. J Emerg Med 2008;35(1):43–5. http://dx.doi.org/10. 1016/j.jemermed.2007.06.042.
Consent to publish the case report was not obtained. This report does not contain any personal information that could lead to the identification of the patient. Funding No funding or grant support was received for this scholarly activity. Conflict of interest The following authors have no financial disclosures: DH, NU, TC and JD. Declarations of interest None. Authorship All authors attest that they meet the current ICMJE criteria for Authorship.
6
Contents lists available at ScienceDirect
Journal of Pediatric Surgery Case Reports journal homepage: www.elsevier.com/locate/epsc
Shot in the womb a
T b
c
Dylan Hutchison , Neal D. Uitvlugt , Teri L. Crumb , James M. DeCou a b c
b,∗
Michigan State College of Human Medicine, 15 Michigan St. NE, Grand Rapids, MI, 49503, USA Helen DeVos Children's Hospital, Department of Pediatric Surgery, 100 Michigan St. NE, Grand Rapids, MI, 49503, USA Helen DeVos Children's Hospital - Research, 100 Michigan St. NE, Grand Rapids, MI, 49503, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Fetal trauma Penetrating injury Pediatric trauma Gunshot injury
A fetus surviving a prenatal penetrating gunshot injury is rarely encountered. We report the case of a 26-week pregnant mother shot in the abdomen. Her uterine wound was missed at exploration, and when the baby was born 6 weeks later, the bullet was found in the superficial soft tissues of his posterior neck. It was removed without difficulty, and the baby, our youngest trauma patient ever, recovered without sequelae.
1. Introduction
2. Case report
Trauma is a serious factor in causing fetal death and injury [1–3]. No matter the seriousness of the trauma suffered by the mother, the fetus can still be in significant danger [2]. Motor vehicle collisions account for the majority of fetal trauma and therefore are the most studied [1,3,5]. Fetal injury due to penetrating trauma is rarer [5] and therefore is less studied. It is very uncommon for a fetus to survive a direct penetrating gunshot injury [4]. Reported infant mortality data states 40–70% death [6]. The literature shows that in the event of a bullet wound in a pregnant mother, conservative or surgical care can be taken, depending on the situation of the gunshot wound. Conservative treatment should be utilized when there is a previable fetus, a dead fetus, a negative abdominal exam, the entrance wound is below the uterine fundus, or the urinalysis is negative for blood [7–9]. If conservative care is not indicated then surgical intervention should be performed, which has been shown to prevent maternal and fetal death [9]. When dealing with a uterine bullet wound, delivery should be highly considered, even with premature fetuses. In addition to conservative or surgical care, delivery often is the best chance the fetus has at survival, even if it is premature. Presently, premature infants are now better suited for survival because of the recent advances in premature neonatal care [9–11]. Trauma surgery on a newborn less than 24 h old is also quite unusual. This unique case of penetrating fetal trauma with immediate postnatal surgery easily makes this the youngest patient in our pediatric trauma registry.
A 19 year old woman, G1P0, 26 weeks pregnant, presented to the emergency department of our adjacent Level 1 Adult Trauma Center with two bullet wounds. Entrance wounds were noted in her left upper thigh and the left lower quadrant of her abdomen. Obstetrical ultrasound assessment was performed – the fetus was viable with good heart tones and sufficient amniotic fluid. Radiographs of the mother revealed a bullet in the pelvic area (Figs. 1 and 2) and a fragment in the left thigh. Two metal fragments visualized within the pelvis with notation that they possibly were in the uterus and adjacent to the fetal skull. The mother was taken to the operating room for exploratory laparotomy. Fetal heart rate was monitored by high-risk Obstetricians and remained stable throughout the procedure. No significant blood was noted upon entering the abdomen, and very little free fluid was found. The gunshot to the left lower quadrant caused a retroperitoneal hematoma involving the psoas muscle. The hematoma was not expanding and was explored and evacuated. The gravid uterus was evaluated along with the fallopian tubes and ovaries bilaterally. All were free from any damage. Specifically, no entrance wound was noted in the uterus. There was no damage to major vascular structures, small or large intestine, or ureter. The bullet was not located. It was believed to be retroperitoneal and therefore was not removed. The left leg wound was explored and a small piece of shrapnel was removed. Both wounds were irrigated and dressed. Mother and fetus were monitored postoperatively and did well. A post-operative fetal ultrasound showed no evidence of fetal compromise from the abdominal trauma. There was a decrease in amniotic fluid volume (4.89 cm). She went home after a 9day hospitalization.
∗
Corresponding author. Helen DeVos Children's Hospital, Department of Pediatric Surgery, 330 Barclay Avenue, Suite 202, Grand Rapids, MI, 49503, USA. E-mail addresses: [email protected] (D. Hutchison), [email protected] (N.D. Uitvlugt), [email protected] (T.L. Crumb), [email protected] (J.M. DeCou). https://doi.org/10.1016/j.epsc.2018.04.016 Received 25 April 2018; Accepted 28 April 2018 Available online 30 April 2018 2213-5766/ © 2018 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Journal of Pediatric Surgery Case Reports 35 (2018) 4–6
D. Hutchison et al.
Fig. 1. Radiographs of the mother showing projectiles in the pelvis.
Fig. 3. Cervical radiograph of the newborn infant showing a bullet fragment in the soft tissues of the posterior neck.
metallic fragment in the superficial soft tissues (Fig. 3) which came out with a later dressing change. No bony injuries were identified. The baby did very well and was discharged home with his mother on day 2. 3. Discussion This case presents a rare gunshot injury to a fetus followed by an immediate surgical procedure on the newborn baby. The bullet was left in the mother after exploratory surgery did not reveal any injury to the gravid uterus. When the baby was born, the bullet was found protruding from the newborn baby's neck. The bullet was removed without difficulty from the capsule that had formed deep to it. We can learn several lessons from this unique case. First, the bullet wound to the uterus was missed during the mother's exploratory surgery. In this case, the missed uterine bullet wound may have benefitted the fetus, giving him six more weeks of intrauterine growth and development prior to delivery. If the wound had been identified, uterine exploration likely would have led to an extremely premature delivery of the baby at 26 weeks gestation. Secondly, the uterus appears to have protected the fetus from significant injury. Passage of the bullet through the mother's abdominal wall and gravid uterus damped the bullet's kinetic energy, leading to only a superficial injury to the fetus [12]. Thirdly, the unusual capsule deep to the bullet may be an example of fetal wound healing. Unfortunately, this baby was lost to follow-up, so the long term result of the wound could not be evaluated. Lastly, this case demonstrates that fetuses can survive penetrating maternal trauma as long as the mother remains hemodynamically stable, and the uterus, amniotic sac, and placenta remain intact. This case adds some insight into what to do when a pregnant woman presents with a gunshot wound to the abdomen or pelvis. The most important factors are the health and hemodynamic stability of the mother and the viability of the fetus. If the mother and fetus are stable, then finding and removing the bullet may not be as important. This case suggests that as long as the mother and fetus remain stable and the placenta and amniotic sac appear intact, that immediate intrauterine exploration may not always be necessary, even with a known intrauterine projectile.
Fig. 2. Radiographs of the mother showing projectiles in the pelvis.
43 days following the gunshot wounds, the woman experienced premature rupture of membranes. She delivered a 32-1/7 week gestation premature baby boy by vaginal delivery. At the time of delivery, the baby was examined and found to have a foreign body protruding from the posterior aspect of his neck. The object was clearly visible and metallic in nature. It was quite superficial with no evidence of deeper injury. Besides the foreign body, the baby appeared normal. APGARS were 9 at one minute and 9 at 5 min. He moved all four extremities. The surgeon on call for our Level 1 Pediatric Trauma Center was called. Since the foreign body was partially protruding, the surgeon decided to remove it right away. The procedure was performed in the Neonatal ICU. A hemostat was used to carefully remove the foreign body, which appeared to be the bullet that had remained in the mother for 43 days. The area where the bullet was removed appeared to be a walled-off capsule without bleeding or drainage. A gauze dressing was applied, to be changed twice daily. The bullet was saved and was given to police for forensic examination. Follow-up cervical x-rays showed a small
4. Conclusion This prenatal gunshot injury to a fetus led to him becoming the 5
Journal of Pediatric Surgery Case Reports 35 (2018) 4–6
D. Hutchison et al.
Appendix A. Supplementary data
youngest patient in our pediatric trauma registry. Although the penetrating uterine wound was missed at the mother's exploratory surgery, this case demonstrates that as long as the mother and baby are stable and the uterus and its structures remain intact, that the fetus can grow and develop normally and have the bullet removed later.
Supplementary data related to this article can be found at http://dx. doi.org/10.1016/j.epsc.2018.04.016. References
Patient consent [1] Brown HL. Trauma in pregnancy. Obstet Gynecol 2009;114(1):147–60. http://dx. doi.org/10.1097/aog.0b013e3181ab6014. [2] Farmer DL, Adzick NS, Crombleholme WR, Crombleholme TM, Longaker MT, Harrison MR. Fetal trauma: relation to maternal injury. J Pediatr Surg 1990;25(7):711–4. http://dx.doi.org/10.1016/s0022-3468(05)80002-8. [3] Mattox KL, Goetzl L. Trauma in pregnancy. Crit Care Med 2005;33(Supplement). http://dx.doi.org/10.1097/01.ccm.0000182808.99433.55. [4] Pasley JD, Demetriades D. Penetrating fetal trauma with late complications: a case report. J Pediatr Surg 2012;47(9). http://dx.doi.org/10.1016/j.jpedsurg.2012.04. 004. [5] Shah KH, Simons RK, Holbrook T, Fortlage D, Winchell RJ, Hoyt DB. Trauma in pregnancy. J Trauma Inj Infect Crit Care 1998;45(1):83–6. http://dx.doi.org/10. 1097/00005373-199807000-00018. [6] Ward HR, vanDeurzen DF, van Dongen PW. Gunshot uterine rupture: a case report. Eur J Obstet Gynecol Reprod Biol 1998;80(2):279–81. [7] Franger AL, Buchsbaum HJ, Peaceman AM. Abdominal gunshot wounds in pregnancy. Am J Obstet Gynecol 1989;160:1124–8. [8] O’Shaughnessy MJ. Conservative obstetric management of a gunshot wound to the second - trimester gravid uterus. A case report. J Reprod Med 1997;42:606–8. [9] Overstreet K, Mannino FL, Benirschke K. The role of placental pathology in the evaluation of interpersonal violence: a case of abdominal gunshot wound in a 27week gravid uterus. J Perinatol 2002;22(8):675–8. http://dx.doi.org/10.1038/sj.jp. 7210814. [10] Stone IK. Trauma in the obstetric patient. Obstet Gynecol Clin North Am 1999;26:459–67. (viii). [11] Lavin Jr. JP, Polsky SS. Abdominal trauma during pregnancy. Clin Perinatol 1983;10:423–38. [12] Carugno JA, Rodriguez A, Brito J, Cabrera C. Gunshot wound to the gravid uterus with non-lethal fetal injury. J Emerg Med 2008;35(1):43–5. http://dx.doi.org/10. 1016/j.jemermed.2007.06.042.
Consent to publish the case report was not obtained. This report does not contain any personal information that could lead to the identification of the patient. Funding No funding or grant support was received for this scholarly activity. Conflict of interest The following authors have no financial disclosures: DH, NU, TC and JD. Declarations of interest None. Authorship All authors attest that they meet the current ICMJE criteria for Authorship.
6