Systematic Reviews
org
OBSTETRICS
Trauma in pregnancy: an updated systematic review
Hector Mendez-Figueroa, MD; Joshua D. Dahlke, MD; Roxanne A. Vrees, MD; Dwight J. Rouse, MD, MSPH
A lthough its precise incidence is not
known, trauma is estimated to
complicate approximately 1 in 12 preg-
nancies1 and is the leading nonobstetri-
cal cause of maternal death.2 Trauma has
fetal implications as well, and has been
reported to increase the incidence of
spontaneous abortion (SAB), preterm
premature rupture of membranes, pre-
term birth (PTB), uterine rupture, cesar-
ean delivery, placental abruption, and
stillbirth.3-7 In a 16-state fetal death cer-
tificate study conducted over 3 years, the
rate of fetal death from maternal trauma
was calculated to be 2.3 per 100,000 live
births,8 with placental abruption as a
major contributing factor.9 By one esti-
mate, as many as 1 in 3 pregnant women
admitted to the hospital for trauma will
deliver during her hospitalization.10
Clearly the rate will vary depending on
the criteria used for hospitalizing preg-
nant women with trauma. While preg-
nancy per se does not appear to increase
morbidity or mortality due to trauma,
the presence of a gravid uterus does alter
the pattern of injury.9 Although the lit-
erature on trauma in pregnancy is quite
extensive, unbiased estimates of the
overall impact of trauma on maternal
From the Divisions of Maternal-Fetal Medicine
(Drs Mendez-Figueroa, Dahlke, and Rouse)
and Emergency Medicine (Dr Vrees),
Department of Obstetrics and Gynecology,
Women and Infants’ Hospital, Warren Alpert
Medical School of Brown University,
Providence, RI.
Received Oct. 26, 2012; revised Jan. 10,
2013; accepted Jan. 14, 2013.
The authors report no conflict of interest.
Reprints: Hector Mendez-Figueroa, MD,
Division of Maternal-Fetal Medicine,
Department of Obstetrics and Gynecology,
Women and Infants’ Hospital, Warren Alpert
Medical School of Brown University, 101 Plain
St., 7th Floor, Providence, RI 02903.
HMendezfigueroa@wihri.org.
0002-9378/$36.00
© 2013 Mosby, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2013.01.021
www. AJOG.
We reviewed recent data on the prevalence, risk factors, complications, and management
of trauma during pregnancy. Using the terms “trauma” and “pregnancy” along with spec-
ified mechanisms of injury, we queried the PubMed database for studies reported from
Jan. 1, 1990, through May 1, 2012. Studies with the largest number of patients for a given
injury type and that were population-based and/or prospective were included. Case reports
and case series were used only when more robust studies were lacking. A total of 1164
abstracts were reviewed and 225 met criteria for inclusion. Domestic violence/intimate
partner violence and motor vehicle crashes are the predominant causes of reported trauma
during pregnancy. Management of trauma during pregnancy is dictated by its severity and
should be initially geared toward maternal stabilization. Minor trauma can often be safely
evaluated with simple diagnostic modalities. Pregnancy should not lead to underdiagnosis
or undertreatment of trauma due to unfounded fears of fetal effects. More studies are
required to elucidate the safest and most cost-effective strategies for the management of
trauma in pregnancy.
Key words: management, pregnancy, systematic review, trauma
and fetal outcomes are scarce, and the considerably depending on the injury. We
optimal means of monitoring and treat- selected studies for this review that in-
ing pregnant women who have suffered cluded the largest number of patients and
trauma remain uncertain. The purpose that were population-based and/or pro-
of this report is to present a concise re- spective. Case reports and case series were
view of the most recent data (since 1990) used only when more robust studies were
on the overall incidence, risk factors, lacking. We considered all reports con-
outcomes, and management approaches cerning trauma in pregnant women re-
for the many different types of trauma gardless of obstetrical (eg, gestational age,
encountered during pregnancy. plurality) or demographic (eg, maternal
Materials and methods age, race) characteristics. All publications
A systematic review was prepared ac- meeting inclusion criteria were assessed for
cording to the Quality of Reporting of quality by 2 authors (H.M-F., J.D.D.) who
Metaanalysis standards. We conducted a independently abstracted information on
search of the PubMed database (January incidence, risk factors, outcomes, moni-
toring methods, and various treatment
1990 through May 2012) using the key
words “trauma” and “pregnancy” along schemes. When available, we recorded in-
with key words for mechanism of injury cidence rates, relative risk, and 95% confi-
including “motor vehicle accident/crash,” dence intervals (CIs) for adverse out-
“burns,” “falls,” “slips,” “accidental over- comes. This systematic review is exempt
dose,” “domestic violence,” “suicide,” from institutional review board approval
“homicide,” “penetrating abdominal because of the nature of the research design
wound,” and “intentional overdose.” To (review article).
identify the most appropriate manage-
ment strategies, the key words “manage- Results
ment,” “KB stain,” “ultrasound,” “CT We reviewed a total of 1164 abstracts and
scan,” “fetal monitoring,” and “perimor- included 225 in this review, of which
tem cesarean section” were also utilized in only 17 had a prospective design (Table
the search (Table 1). Only English-lan- 1). Table 2 contains reported (and in
guage publications were included. The size some cases calculated) prevalence rates
and quality of the articles reviewed varied for the various mechanisms of trauma.
JULY 2013 American Journal of Obstetrics & Gynecology 1
Systematic Reviews Obstetrics www.AJOG.org

TABLE 1
Results of search for informative studies
No. of abstracts Abstracts meeting Retrospective Prospective
Search criteria reviewed criteria for inclusion studies studies
“Trauma,” “pregnancy,” and “motor vehicle accident/crash” 252 36 34 2
................................................................................................................................................................................................................................................................................................................................................................................
“Trauma,” “pregnancy,” and “falls” and “slips” 76 11 9 2
................................................................................................................................................................................................................................................................................................................................................................................
“Trauma,” “pregnancy,” and “burns” 165 12 11 1
................................................................................................................................................................................................................................................................................................................................................................................
“Trauma,” “pregnancy,” and “accidental poisoning” 46 2 1 1
................................................................................................................................................................................................................................................................................................................................................................................
“Trauma,” “pregnancy,” and “domestic violence” and 99 93 85 7
“intimate partner violence” 1 RCT
................................................................................................................................................................................................................................................................................................................................................................................
“Trauma,” “pregnancy,” and “penetrating trauma” 32 2 2 0
................................................................................................................................................................................................................................................................................................................................................................................
“Trauma,” “pregnancy” and “suicide” and “homicide” 27 13 13 0
................................................................................................................................................................................................................................................................................................................................................................................
“Trauma,” “pregnancy,” and “toxic exposure” 10 3 3 0
................................................................................................................................................................................................................................................................................................................................................................................
“Trauma,” “pregnancy,” and “management” 235 14 12 2
................................................................................................................................................................................................................................................................................................................................................................................
“Trauma,” “pregnancy,” and “KB stain” 19 6 6 0
................................................................................................................................................................................................................................................................................................................................................................................
“Trauma,” “pregnancy,” and “ultrasound” 81 10 10 0
................................................................................................................................................................................................................................................................................................................................................................................
“Trauma,” “pregnancy,” and “CT scan” 33 3 3 0
................................................................................................................................................................................................................................................................................................................................................................................
“Trauma,” “pregnancy,” and “fetal monitoring” 84 17 16 1
................................................................................................................................................................................................................................................................................................................................................................................
“Trauma,” “pregnancy,” and “perimortem cesarean section” 5 3 3 0
................................................................................................................................................................................................................................................................................................................................................................................
Studies were selected for inclusion if they were published from 1990 through present and if, after review of abstract, it was determined that objective of study was to report on outcomes of interest
for this analysis.
CT, computed tomography; KB, Kleihauer-Betke; RCT, randomized controlled trial.
Mendez-Figueroa. Trauma in pregnancy. Am J Obstet Gynecol 2013.

Table 3 presents the characteristics of the pregnancy,4 the most commonly en- estimated at around 207 cases per
largest trauma studies. countered form of which is motor vehi- 100,000 pregnancies.11 It is one of the
Unintentional trauma accounts for a cle crashes (MVC). The overall incidence leading causes of both maternal and fetal
large portion of major trauma during rate of MVC during pregnancy has been mortality, with estimated mortality rates

TABLE 2
Estimated incidence/prevalence of injury by type of trauma during pregnancy
Estimated incidence/prevalence Estimated incidence/prevalence
Mechanism of injury in pregnancy Study design outside of pregnancy
Motor vehicle crashes 207/100,000 live births11 Population-based cohort 1104/100,000 womenc99
................................................................................................................................................................................................................................................................................................................................................................................
24 100
Falls and slips 48.9/100,000 live births Retrospective case-control 3029/100,000 women
................................................................................................................................................................................................................................................................................................................................................................................
27 27
Burns 0.17/100,000 person-years Retrospective case-control 2.6/100,000 person-years
................................................................................................................................................................................................................................................................................................................................................................................
Accidental poisoning N/A N/A N/A
................................................................................................................................................................................................................................................................................................................................................................................
101 c44
Domestic violence 8307/100,000 live births Review 5239/100,000 women
................................................................................................................................................................................................................................................................................................................................................................................
a 61 c102
Suicide 2/100,000 live births Retrospective cohort 8.8/100,000 population
................................................................................................................................................................................................................................................................................................................................................................................
61 100
Homicide 2.9/100,000 live births Retrospective cohort 2.3/100,000 women
................................................................................................................................................................................................................................................................................................................................................................................
b c62 c62
Penetrating trauma 3.27/100,000 live births N/A 3.4/100,000 women
................................................................................................................................................................................................................................................................................................................................................................................
103 104
Toxic exposure 25.8/100,000 person-years Retrospective cohort 115.3/100,000 person-years
................................................................................................................................................................................................................................................................................................................................................................................
Literature relating to incidence of burns during pregnancy is limited to most severe cases admitted to burn units and referral centers. Rate for accidental poisoning during pregnancy could not be
calculated from available published literature. Domestic violence incidence includes all forms of partner violence: sexual, physical, and psychological.
N/A, not available.
a
Rates exclude attempted suicides. Attempted suicide rate during pregnancy is approximately 40/100,000 pregnancies65 and during postpartum period is 43.9/100,000 live births66; b Rates include
only causes leading to fatality; c Rates calculated using 2009 US data from Centers for Disease Control and Prevention.
Mendez-Figueroa. Trauma in pregnancy. Am J Obstet Gynecol 2013.

2 American Journal of Obstetrics & Gynecology JULY 2013

www.AJOG.org Obstetrics Systematic Reviews

TABLE 3
Representative studies of trauma organized by year of publication (1990 through 2012)
Authors, location (y) Design Inclusion Sample size Primary outcome: results
MVC
.......................................................................................................................................................................................................................................................................................................................................................................
Vivian-Taylor et Retrospective case- Hospital admissions after 2147 Incidence of MVC and pregnancy outcomes after MVC: 3.5/1000 maternity admissions,
al,13 Australia control MVC similar outcomes among MVC and non-MVC
(2012)
.......................................................................................................................................................................................................................................................................................................................................................................
Kvarnstrand et al,11 Retrospective case- National Forensic 2270 Maternal and perinatal mortality after MVC: maternal mortality calculated at 1.4/100,000
Sweden (2008) control Pathology Database pregnancies; perinatal mortality calculated at 3.7/100,000 pregnancies
.......................................................................................................................................................................................................................................................................................................................................................................
Weiss et al,105 Utah Retrospective cohort State Department of 7350 Most common types of maternal injury and risks associated with adverse birth outcomes:
(2008) Health ER records MVC are most common mechanism of injury; increased risk of preterm labor, placental
abruption, cesarean delivery, and delivery of LBW infant
.......................................................................................................................................................................................................................................................................................................................................................................
El Kady et al,106 Retrospective case- Fractures from Vital 3292 Association of fractures with adverse maternal/fetal outcomes: increased maternal mortality
California (2006) control Statistics Database and morbidity when delivered during hospitalization, worse outcomes with pelvic fractures
.......................................................................................................................................................................................................................................................................................................................................................................
Hyde et al,107 Utah Retrospective case- State Department of 8938 Likelihood of adverse outcomes after MVC: women in MVC who use seatbelts are not at
(2003) control Transportation reports significantly increased risk of adverse fetal outcomes than women not in crashesa; lack of
seatbelt use increases risk for LBW infant, excessive maternal bleeding
.......................................................................................................................................................................................................................................................................................................................................................................
Wolf et al,108 Retrospective cohort Police-investigated MVC 2592 Association of seatbelt use on outcome ⬎20 wks’ gestation: no seatbelt use 1.9 times
Washington (1993) more likely to have LBW baby and 2.3 times more likely to deliver within 48 hours after
MVC
.......................................................................................................................................................................................................................................................................................................................................................................
Goodwin et al,109 Prospective cohort Noncatastrophic trauma 250 Association between signs/symptoms and outcomes after MVC: symptoms of contractions,
Arizona (1990) during second half of uterine tenderness, and bleeding after MVC are associated with complications
pregnancy
.......................................................................................................................................................................................................................................................................................................................................................................
Pearlman et al,3 Prospective cohort Women who suffered 85 Adverse outcomes after trauma: adverse outcomes are not predicted by injury severity; 4
Michigan (1990) trauma during pregnancy hours of EFM was sensitive but not specific in detecting immediate adverse outcomes
................................................................................................................................................................................................................................................................................................................................................................................
DV/IPV
.......................................................................................................................................................................................................................................................................................................................................................................
Woolhouse et al,57 Prospective cohort Nulliparas 6-24 wks 1305 Measurement of EPDS and Composite Abuse Scale scores: 16% reported depressive
Australia (2012) symptoms; 40% also reported DV/IPV
.......................................................................................................................................................................................................................................................................................................................................................................
Kiely et al,110 RCT Self-identified minorities 1044 Efficacy of brief psychobehavioral intervention in reducing IPV recurrence during
Maryland (2010) pregnancy and postpartum: intervention group less likely to report recurrent IPV
.......................................................................................................................................................................................................................................................................................................................................................................
Lutgendorf et al,111 Prospective cohort Prenatal care in Naval 1162 Prevalence of current or past DV using Abuse Assessment Screen: current or past abuse
Virginia (2009) Hospital prevalence 15.4%; increased abuse during pregnancy in unwed women and those with
positive family history of abuse
.......................................................................................................................................................................................................................................................................................................................................................................
Rodrigues et al,52 Prospective cohort Survey after hospital 2660 Assess relationship of abuse with preterm labor: abuse during pregnancy associated with
Portugal (2008) deliveries increased risk of PTB
.......................................................................................................................................................................................................................................................................................................................................................................
Silverman et al,112 Retrospective case- PRAMS 118,579 Association of IPV with maternal and neonatal morbidity: IPV prior to and during pregnancy
United States control increases risk for multiple adverse outcomes
(2006)
................................................................................................................................................................................................................................................................................................................................................................................
Other forms of trauma
.......................................................................................................................................................................................................................................................................................................................................................................
Vladutiu et al,25 Prospective cohort Questionnaire about 1469 Injuries from physical activity and exercise: injuries rate of 3.2/1000 physical activity hours
North Carolina frequency and duration and 4.1/1000 exercise hours
(2010) of physical activity
.......................................................................................................................................................................................................................................................................................................................................................................
Dunning et al,23 Retrospective cohort Survey after delivery 3997 Rate, risk factors, and characteristics of falls: falls reported in 27%; age 20-24 y with 2-
Ohio (2010) within 2 months fold increase in falls; most falls occurred indoors, involved stairs, ⬎3 feet
.......................................................................................................................................................................................................................................................................................................................................................................
Petrone et al,59 Retrospective case- Trauma admissions 291 blunt, Mechanism of injury, injury severity score, abdominal Abbreviated Injury Scale, gestational
California (2011) control 30 penetrating age, maternal and fetal mortality: penetrating trauma had higher maternal mortality, fetal
trauma mortality, and maternal morbidity
.......................................................................................................................................................................................................................................................................................................................................................................
Palladino et al,61 Retrospective case- National Violent Death 94 suicides, Deaths attributable to homicide or suicide: pregnancy-associated suicide 2.0/100,000 live
United States control Reporting System 139 homicides births, homicide 2.9/100,000 live births; 54% of suicides and 45% of homicides
(2011) associated with IPV
.......................................................................................................................................................................................................................................................................................................................................................................
McClure et al,103 Retrospective case- Discharges for 430 Birth outcomes after intentional acute overdose during pregnancy: incidence rate of 25.87/
California (2011) control intentional poisoning 100,000 person years, greatest in first weeks of gestation; PTB, LBW, congenital heart
disease increased
.......................................................................................................................................................................................................................................................................................................................................................................
Gandhi et al,65 Retrospective case- Vital statistics discharge 2132 Risks for and outcomes after attempted suicide; substance abuse was best identifier of
California (2006) control database attempted women at risk; increased risk of premature labor, cesarean delivery, need for transfusion,
suicides increased respiratory distress syndrome, and LBW
.......................................................................................................................................................................................................................................................................................................................................................................
Czeizel et al,113 Retrospective cohort Admissions after self- 1044 Outcomes associated with self-poisoning: self- poisoning associated with 44.4% live born
Hungary (1999) poisoning birth rate, unknown teratogenic effect
................................................................................................................................................................................................................................................................................................................................................................................
DV, domestic violence; EFM, external fetal monitoring; EPDS, Edinburgh Postnatal Depression Scale; ER, emergency room; IPV, intimate partner violence; LBW, low birthweight; MVC, motor vehicle
crashes; PRAMS, Pregnancy Risks Assessment Monitoring System; PTB, preterm birth; RCT, randomized controlled trial.
a
Presumably because most MVC are minor and do not result in severe maternal morbidity.
Mendez-Figueroa. Trauma in pregnancy. Am J Obstet Gynecol 2013.

JULY 2013 American Journal of Obstetrics & Gynecology 3

Systematic Reviews
of 1.4 per 100,000 and 3.7 per 100,000
pregnancies, respectively.11 Of pregnant
women involved in a MVC, 87% receive
some sort of medical care12 and 0.61
pregnancy admissions per 1000 live
births can be attributed to MVC.7 The
majority of these admissions occur ⬎20
weeks’ gestation.13 The major risk factor
for adverse outcomes during MVC is im-
proper seat belt use: in both front and
rear collisions, the impact with the steer-
ing wheel can be avoided with proper
belt use.14 Unfortunately, in one study,
only half of patients report having re-
ceived counseling regarding seatbelt use
from their prenatal care provider.15 The
use of intoxicants has also been reported
as a major risk factor for MVC during
pregnancy; 37 of 85 pregnant patients
(43.5%) evaluated following an MVC at
a major trauma center tested positive for
some intoxicant,16 while another study
reported that alcohol was implicated in
45%.17 As a comparison, in one compre-
hensive report, 41% of fatal MVC (com-
prised predominantly of nonpregnant
victims) were alcohol-related.18
The major obstetrical concern with
MVC is the strain placed on the uterus,
which may result in placental abruption.
There are 2 major mechanisms of utero-
placental interface failure that have been
described in the literature: shear force
(strain) failure and tensile failure (“con-
trecoup” mechanism). The impact of an
MVC can generate substantial forward
displacement of the uterus. This motion
builds both negative pressure and a
“contrecoup” effect, 2 mechanisms that
along with maternal body folding over
the abdomen are enough to markedly in-
crease intraabdominal pressure19 and re-
sult in forces powerful enough to cause
placental shearing and subsequent ab-
ruption.20 However, among severely in-
jured women, placental abruption oc-
curs in as many as 40% of cases.21
Although women in severe MVC are at
higher risk for pregnancy complications,
the greater burden of MVC morbidity in
pregnancy may be borne by women in
minor MVC, as they predominate. Not
surprisingly, pregnant women involved
in MVC appear to be at increased risk for
cesarean delivery,7 but the risk of PTB
and perinatal death seem to increase only
4 American Journal of Obstetrics & Gynecology JULY 2013
Obstetrics
if delivery occurs immediately after
MVC,13 which is fortunately uncommon
with an estimated rate of 0.4% ⬍20
weeks and 3.5% thereafter.20 This in-
creased risk of perinatal death associated
with immediate delivery likely reflects
the severity of trauma, ie, delivery should
never be delayed if clinically warranted
in the hopes of improved outcomes.
Literature pertaining to slips and falls
during pregnancy is limited. It is known
that increased joint laxity and weight
gain can affect gait and predispose preg-
nant women to slips and to falls.22 Dy-
namic postural stability decreases with
pregnancy, especially during the third tri-
mester, as evidenced by decline in initial
sway, total sway, and sway velocity, all
measures of stability in response to pos-
tural perturbations.22 Approximately 1 in
4 pregnant women will fall at least once
while pregnant.23 A population-based
study found that 79% of hospitalized
women after a fall were in their third tri-
mester; among such women, fracture of
the lower extremity was the most com-
monly associated injury.24 The majority
of falls occur indoors and 39% involve
falling from stairs.23 In one of the largest
studies to date, Vladutiu et al25 prospec-
tively evaluated ⬎1400 pregnant women
using a structured questionnaire admin-
istered at 17-22 weeks and again at 27-30
weeks, and found an overall injury inci-
dence of 4.1 cases per 1000 exercise
hours; the majority of these injuries were
attributed to falls. Dunning et al26 re-
ported that 6.3% of all employed preg-
nant workers fell at work; major risk fac-
tors included walking on slippery floors,
hurrying, or carrying heavy objects.
Schiff,24 in an analysis of hospitalized
pregnant patients admitted after a fall,
reported a 4.4-fold increase in preterm
labor (95% CI, 3.4 –5.7), an 8-fold in-
crease in placental abruption (95% CI,
4.3–15.0), a 2.1-fold increase in fetal dis-
tress (95% CI, 1.6 –2.8), and a 2.9-fold
increase in fetal hypoxia (95% CI, 1.3–
6.5) when compared to a randomly se-
lected control group.24
Information on burns in pregnancy is
limited to case reports and case series.
They suggest that the impact of burns de-
pends greatly on the burn depth and the
total body surface area affected; as the
www.AJOG.org
total body surface area involved exceeds
40%, the mortality rate for both mother
and fetus approaches 100%27 with sepsis
being a major contributor.28 Reports
from major burn referral centers have
shown that maternal and fetal mortality
are significantly increased in cases where
smoke inhalation has occurred.29 Mater-
nal age and trimester of pregnancy of
the burn do not appear to affect mater-
nal or fetal outcome and pregnancy
does not appear to independently alter
maternal survival after severe burns.30
Burns during the first trimester have
been associated with SAB; some au-
thors have speculated that ensuing sep-
ticemia after a severe burn may be the
predisposing factor to fetal loss.31 The
majority of these losses will occur
within 10 days of sustaining the burn.28
Thermal injury also appears to increase
the risk of PTB, although this observa-
tion is based on a small retrospective
study of 30 patients.32
Reports on electrocution during preg-
nancy is sparse. Among 15 cases of severe
electrocution during pregnancy, fetal
mortality was 73%,33 although these case
reports may represent a biased sample.
In a prospective study that included 31
pregnant women who sustained minor
electrical shock, mainly from home ap-
pliances, no differences were noted in
mode of delivery, birthweight, or gesta-
tional age at delivery when compared to
controls.34
Literature on poisoning during preg-
nancy relates mostly to intentional poi-
soning and/or suicide attempts. Acci-
dental poisoning is not as widely
reported and its actual incidence un-
clear. In a study of ⬎400 maternal
deaths, only one was attributed to acci-
dental poisoning.35 Isolated case reports
describe accidental overdose of medica-
tions in a hospital setting.36,37
Intentional trauma during pregnancy
accounts for significant maternal-fetal
morbidity, increasing the risk of PTB by
2.7-fold (95% CI, 1.3–5.7) and of low
birthweight by 5.3-fold (95% CI, 3.9 –
7.3).38 The most common form of inten-
tional trauma is domestic violence (DV)
or intimate partner violence (IPV). The
prevalence of DV/IPV across various pop-
ulations has been evaluated extensively
www.AJOG.org
with ⬎60 studies from ⬎20 countries re-
porting a frequency during pregnancy
ranging from 1-57%,39-43 consistent with a
22.1% rate reported in the general female
population.44 One explanation for this
wide range is the inclusion of emotional,
verbal, and/or physical violence within
the definition of DV/IPV in some stud-
ies. Risk factors associated with DV/IPV
during pregnancy are broad and include
maternal or intimate partner substance
abuse, low maternal educational level,
low socioeconomic status, unintended
pregnancy, history of DV prior to preg-
nancy, history of witnessed violence as a
child by mother or intimate partner, and
unmarried status.45-49 Adverse preg-
nancy outcomes associated with DV/IPV
include increased rate of SAB,50 neonatal
intensive care unit admissions,51 PTB,52
and low birthweight.52-54 Both retro-
spective and prospective studies have re-
ported a strong association between pe-
ripartum depression and DV/IPV.55-58
In a prospective cohort of 13,617 mater-
nal fetal dyads followed up for 42
months, Flach et al56 noted an associa-
tion between antenatal DV and maternal
antenatal (odds ratio, 4.02; 95% CI, 3.4 –
4.8) and postnatal (odds ratio, 1.29; 95%
CI, 1.02–1.63) depressive symptoms.
There are no prospective studies or
randomized controlled trials evaluating
penetrating trauma in pregnancy and we
identified only 2 retrospective analy-
ses.59,60 In the larger one, comprising 321
patients, penetrating trauma accounted
for 9% of all pregnant trauma admis-
sions. Of those, 73% were handgun-,
23% knife-, and 4% shotgun-related.59
Penetrating trauma in pregnancy is asso-
ciated with increased fetal mortality (as
high as 73%), increased hospital stay,
and complications such as ileus when
compared to blunt trauma.59 Awwad et
al60 reviewed their experience of selective
laparotomy in 14 penetrating trauma
cases in pregnancy over a 16-year period
during the civil war in Lebanon. In their
cohort, fetal mortality occurred in 50%
and maternal mortality was noted in 2
cases (14.3%).
In a multistate sample from the Na-
tional Violent Death Reporting System
from 2003 through 2007, Palladino et
al61 estimated the rates of suicide and ho-
Obstetrics
micide in pregnancy were about 2.0/
100,000 and 2.9/100,000 live births, re-
spectively. In the general population, the
respective rates have been estimated at
5.27/100,000 and 12.43/100,000.62 Sui-
cide accounts for approximately 20% of
postpartum maternal deaths.63 Interest-
ingly, pregnancy may be protective in
those women who are otherwise at high
risk for suicide or homicide. In a retro-
spective analysis of vital statistics records
in North Carolina from 2004 through
2006, Samandari et al64 found the suicide
rate to be 27% lower in a pregnant cohort
and 54% lower in a postpartum cohort
compared to a nonpregnant cohort. Ho-
micide rates were similarly 73% lower in
the pregnant cohort and 50% lower in
the postpartum cohort. Substance abuse
appears to be the best identifier for de-
tecting women at risk for suicide.65 An-
other major risk factor for attempting
suicide, especially during the postpar-
tum period, is fetal or infant death; Schiff
and Grossman66 reported a case-control
study of 520 suicide attempts (63% poi-
soning) and found a 3.1-fold increase in
the risk of suicide attempt when fetal or
infant death had occurred. Suicide and
homicide during pregnancy are often
associated with DV/IPV. Similarly,
DV/IPV may be a contributing factor
in up to 54% of cases of suicide among
pregnant women.61,67 Cheng and
Horon68 estimated that 54.5% of preg-
nancy-associated homicides in Mary-
land from 2003 through 2008 were
committed by a current or former
partner, while others have reported
rates ranging from 45-74%.67 Unsuc-
cessful suicide attempts have also been
associated with adverse pregnancy out-
comes. In a review of 2132 suicide
attempts in California from 1991
through 1999, women who attempted
suicide but were unsuccessful had in-
creased risk of premature labor, cesar-
ean delivery, need for transfusion, in-
creased respiratory distress syndrome,
and low birthweight.65 Suicide attempt
by intentional self-poisoning clearly
affects both fetus and mother69-71; ma-
ternal death occurs in 1.8% of cases af-
ter suicide attempts by ingestion of
medication.71
JULY 2013 American Journal of Obstetrics & Gynecology
Systematic Reviews
Management of trauma during
pregnancy
When caring for the pregnant patient
who has suffered trauma, the primary
management goal is to stabilize the con-
dition of the mother, as fetal outcomes
are directly correlated with early and ag-
gressive maternal resuscitation.72 Accord-
ing to the National Center for Injury Pre-
vention and Control, pregnant women
⬎20 weeks’ gestation should be trans-
ported to a center that is: (1) capable of
undertaking a timely and thorough
trauma evaluation; and (2) adept at
management of life-threatening inju-
ries.73 However, whether such transport
is safe and feasible will vary depending
on the individual circumstances of a
given case. The initial maternal evalua-
tion (primary survey) should follow
nonpregnant guidelines and include a
full trauma history and vital signs assess-
ment as well as displacement of the
gravid uterus to one side. Cardiac arrest,
loss of an airway, blood pressure ⬍80/40
mm Hg, pulse ⬍50 or ⬎140 bpm, respi-
ratory rate ⬍10 or ⬎24 breaths per min-
ute, or a fetal rate ⬍110 or ⬎160 bpm
should immediately alert the physician
of probable catastrophic trauma requir-
ing immediate stabilization and initia-
tion of advanced cardiac life support74 as
well as advanced trauma life support.75
Intravenous access should be secured
and targeted laboratory tests ordered
(Figure). In cases of severe hemorrhage,
transfusion of fresh frozen plasma, plate-
lets, and packed red blood cells at 1:1:1
ratio lowers the rate of coagulopathy and
may improve survival.76 Medical anti-
shock trousers have been used for the
prehospital management of trauma pa-
tients but they in fact may delay trans-
portation to hospital and worsen out-
comes of penetrating trauma to the
thorax and abdomen.77 However, such
trousers may have a role in severe post-
partum obstetrical hemorrhage.78,79
When possible, joint evaluation of the
patient by both the trauma and obstetri-
cal team should be undertaken. This as-
sessment should include an evaluation of
the cervical spine, as manipulation with
cervical spinal fracture may result in pa-
ralysis. The ideal imaging modality dur-
5
Systematic Reviews Obstetrics www.AJOG.org

Peritoneal lavage can be performed dur-

FIGURE
ing pregnancy. An open technique is rec-
Management algorithm for trauma in pregnancy ommended after placement of a naso-
Assess Maternal Status gastric tube and a Foley catheter.85 Since
- Cardiac arrest
- Unresponsive pregnancy-specific criteria have not
- Loss of airway/respiratory arrest
- BP <80/40 mm Hg or HR <50 or >140 bpm been reported, nonpregnant parameters
- If fetus viable, FHR <110 or >160 bpm
(ie, cell and red blood cell count, amylase
PRESENT ABSENT
concentration) for a positive peritoneal
Advanced life support Maternal injury greater than minor lavage should be used.85 When treating
Airway/Cervical spine control bruising, lacerations or contusions
pregnant burn victims, aggressive fluid
Breathing
Circulation PRESENT ABSENT resuscitation, respiratory support, and
Disability
Exposure initial wound care become priorities
Consultation with trauma team; notify NICU
Supplemental O2 Consider trauma team consultation Brief fetal assessment with the ultimate goal of transport to a
Displace uterus to left if GA >20 weeks IV Access No lab evaluation required
IV Access (2 peripheral lines) Labs: CBC, Coagulation profile, type & screen; No radiologic imaging
tertiary care facility. Some authors have
Labs: CBC, Coagulation profile, type & KB if Rh (-)
screen; KB if Rh (-), type & cross Viable fetus: fetal monitoring for 4 hours –
required
Patient counseling on
advocated for delivery of all fetuses in the
Viable fetus: continuous FHR monitoring
Previable fetus: FHR via Doppler
Ctxs <6/hour consider discharge
Ctxs ≥6/hour consider admission
signs/symptoms abruption second and third trimester if the mother
Tocometer if concern for abruption Previable fetus: FHR via Doppler
Tocometer if concern for abruption
has sustained burns of ⬎50% total sur-
face area because of the associated high
mortality rate.86 Direct inhalation injury
can result in significant airway compro-
Once the patient is stable
Fetal Ultrasound +/- Biophysical Profile
mise with subsequent hypoxia and should
Consider other labs - chemistries, urinalysis, urine toxicology screen
Radiologic assessment /Peritoneal lavage/ F.A.S.T. U/S Imaging (if indicated)
arouse suspicion for carbon monoxide
poisoning (Figure).
Diagnostic radiologic imaging in preg-
MVA Slips/Falls Burns DV/IPV Penetrating trauma Toxic exposure
Determine Assess for Aggressive Assess for Level of entry Agent and GA at nant trauma patients should be under-
whether exposure guides
patient was
abdominal
trauma and
fluid
resuscitation
depression
and suicide
determines affected
organ; gravid uterus maternal therapy and
taken if clinically indicated and not be
wearing
seatbelt
extremities for
fractures/
Consider
delivery if
risk may protect from
visceral injury
counseling withheld or delayed because of un-
ligament damage burn area
>50%
founded fears of fetal effects. The 3 mo-
dalities most studied in pregnancy in-
Proposed algorithm for evaluation and management of trauma in pregnancy. clude ultrasound, CT, and magnetic
BP, blood pressure; CBC, complete blood cell count; Ctxs, contractions; DV, domestic violence; FAST, focused assessment with
sonography for trauma; FHR, fetal heart rate; GA, gestational age; HR, heart rate; IPV, intimate partner violence; ISS, Injury Severity Score;
nuclear imaging. Because of the long ac-
IV, intravenous; KB, Kleihauer-Betke; MVA, motor vehicle accident; NICU, neonatal intensive care unit; O2, oxygen; U/S, ultrasound. quisition time and difficulty in monitor-
Mendez-Figueroa. Trauma in pregnancy. Am J Obstet Gynecol 2013. ing a critically ill patient while obtaining
imaging, magnetic nuclear imaging is
utilized substantially less in acute trauma
ing pregnancy for this evaluation has not Kleihauer-Betke (KB) testing, or bedside management.87
been determined, but computed tomogra- ultrasound.83 This led the authors to con- In the pregnant trauma patient, ultra-
phy (CT) appears to have higher sensitivity clude that minor trauma can be appropri- sound is often easily accessible in an
than plain film x-ray outside of preg- ately evaluated with limited radiologic, emergency department and can provide
nancy.80 Direct cervical spine trauma laboratory, and fetal assessment.83 crucial information such as gestational
makes securing an airway more difficult Management of penetrating injuries age, placental location, fetal presenta-
and may necessitate fiberoptic bronchos- will depend largely on the entrance loca- tion, and viability. Ultrasound has been
copy,81 and pregnancy in general is associ- tion of the wound and the gestational proposed as a method of diagnosing pla-
ated with a higher risk of aspiration and age. Visceral injuries are less likely when cental abruption, although this method
failed endotracheal intubation, arguing for the entry site is anterior and below the has proven to be unreliable in establish-
the availability of personnel skilled in diffi- uterine fundus.60 If a thoracostomy tube ing this diagnosis; in one study sensitiv-
cult intubation.82 is required in a pregnancy, some have ity was only 24%.88 Focused assessment
Minor trauma during pregnancy (ie, recommended that it be placed at least 1 with sonography for trauma is a safe and
nothing more than minor bruising, lac- or 2 intercostal spaces above the usual efficient method for detecting intraperi-
erations, or contusions) requires only landmark of the fifth intercostal space to toneal free fluid and intraabdominal in-
limited evaluation. In a prospective trial avoid inadvertent abdominal inser- juries. This targeted ultrasound assesses
of 317 patients with minor trauma, pla- tion.72 Pelvic fractures per se are not an 4 areas for evidence of free fluid: the sub-
cental abruption occurred in only 1 case indication for cesarean delivery. Most xiphoid; the right upper quadrant; the
and was not predicted by conventional women can safely attempt vaginal birth left upper quadrant; and the suprapubic
testing including tocodynamometry, com- following a pelvic fracture, even those area. In a large retrospective cohort of
plete blood cell count, coagulation profile, that occur during the third trimester.84 ⬎2300 ultrasound examinations, the

6 American Journal of Obstetrics & Gynecology JULY 2013

www.AJOG.org
sensitivity and specificity for the detec-
tion of free fluid and/or intraabdominal
injury in pregnant (n ⫽ 328) and non-
pregnant trauma patients were similar
(61% sensitivity and 94% specificity in
pregnant, vs 71% sensitivity and 97%
specificity in nonpregnant women).89
Abdominal helical CT allows the evalua-
tion of multiple organ systems in stable
patients. A known drawback of CT scan
is the fetal radiation exposure of up to 3.5
rads (0.035 Gy) per study90 and this risk
must be weighed against the potential for
identifying life-threatening injuries af-
forded by this powerful imaging modal-
ity. Importantly, radiation doses ⬍5 rads
(0.05 Gy) are not associated with an in-
creased risk of anomalies, pregnancy
loss, or growth restriction.90
In catastrophic trauma or when ma-
ternal injury is present, a complete blood
cell count, coagulation profile, KB test,
and type and screen should be obtained.
In Rh-negative mothers, the KB test also
allows for calculation of the total re-
quired dose of Rh immune globulin: 1
vial of 300 ␮g protects against 30 mL of
fetal blood (15 mL of fetal red blood
cells).91 When minor trauma is present,
however, these tests do not appear to be
predictive of fetal outcomes.5,83 The KB
test is used in many institutions as a rou-
tine component of trauma evaluation.
However, the KB test is insensitive and
poorly predictive of adverse perinatal
outcomes,92 PTB,5 placental abruption,
or fetal distress93 in minor trauma or in
trauma with absent maternal injury.
When the fetus is deemed viable, con-
tinuous fetal monitoring should be initi-
ated as soon as possible, as long as it does
not interfere with essential maternal di-
agnostic tests or therapy. If the mother’s
condition precludes safe emergent cesar-
ean, continuous monitoring is of limited
value. The ideal duration for monitoring
has not been established with recom-
mendations ranging from 4-48 hours94;
the American Congress of Obstetricians
and Gynecologists recommends a mini-
mum of 2-6 hours of monitoring post-
trauma.91 A prospective study evaluating
85 women found fetal monitoring for 4
hours to be sensitive but nonspecific for
detecting immediate adverse perinatal
outcomes.3 Although placental abrup-
Obstetrics
tion has been reported to occur up to 24
hours after a traumatic insult,72 it has not
been reported when ⬍1 contraction is
present in any 10-minute interval over a
4-hour period.95 Thus, fetal monitoring
can be discontinued after 4 hours if uter-
ine contractions occur less frequently
than every 10 minutes, the fetal heart
tracing is reassuring, and there is no ma-
ternal abdominal pain or vaginal bleeding.
Since placental perfusion and oxygenation
depends on maternal cardiopulmonary
function, fetal monitoring should con-
tinue in cases of adult respiratory dis-
tress syndrome, continuous lung injury,
or trauma causing maternal cardiac ar-
rhythmia (Table 4).
Perimortem cesarean section, defined
as a cesarean section performed in the
face of maternal cardiac arrest, can be
life-saving for both mother and fetus. In
a multicenter retrospective cohort study
of 114,952 trauma admissions including
441 pregnant women, 32 emergency ce-
sarean sections had a reported 45% fetal
and 75% maternal survival.96 Survival of
both is dependent on multiple factors in-
cluding the interval between maternal
cardiac arrest and delivery, the underly-
ing etiology of the arrest, where the arrest
takes place, and the expertise of the team
attending to the mother.97 Based on ex-
perimental data and case reports, cesar-
ean delivery may be appropriate in the
setting of imminent maternal death or
after 4 minutes of properly performed
cardiopulmonary resuscitation that has
failed to revive the mother, as both infant
and maternal survival are increased when
cesarean delivery is initiated within 4 min-
utes of maternal cardiac arrest.96,98 Al-
though delivery should ideally occur
within 4 minutes of failed maternal re-
vival, this standard can rarely be met in
actual practice even in ideal situations.
Notably, resuscitation efforts may im-
prove following delivery as a result of di-
minished aortocaval compression and
improved volume return to the heart.98
Anecdotally, reports of women undergo-
ing cardiopulmonary resuscitation sug-
gest the possibility of improvement in
maternal condition following cesarean
delivery. However, no evidence exists
that cesarean delivery in this setting ac-
JULY 2013 American Journal of Obstetrics & Gynecology
Systematic Reviews
TABLE 4
Considerations specific to
management of pregnant
women with trauma
● Pregnancy should not lead to
underdiagnosis or undertreatment of
trauma due to the fears of adverse fetal
effects
● When possible, uterus should be
displaced to one side laterally
● When fetus is deemed viable,
continuous fetal monitoring should be
initiated as soon as possible
● Simultaneous (not sequential)
evaluation by trauma and obstetrical
teams may be indicated
● Personnel trained in difficult intubation
should be readily available
● Penetrating injuries are more likely to
affect the fetus, especially those
anterior and below uterine fundus
● If a thoracostomy tube is indicated, it
should be placed 1-2 intercostal spaces
above usual fifth intercostal space
landmark to avoid abdominal
placement
Pelvic fractures do not necessarily
●
preclude vaginal delivery
● If peritoneal lavage is indicated, an
open technique is preferred as is
placement of a Foley catheter and
nasogastric tube
● In second- and third-trimester burn
victims, delivery should be considered
if affected total affected body surface
area is ⬎50%
● Focused assessment with sonography
for trauma is reliable during pregnancy
● Perimortem cesarean section may be
appropriate in setting of imminent
maternal death or after 4 min of
properly performed but unsuccessful
cardiopulmonary resuscitation
...........................................................................................................
Mendez-Figueroa. Trauma in pregnancy. Am J
Obstet Gynecol 2013.
tually improves rates of maternal sur-
vival for any specific condition.
Comment
In this systematic review, we evaluated re-
cent data concerning trauma in pregnancy.
We note that the available literature is
characterized by several limitations. The
majority of the studies are retrospective,
and the outcomes reported vary widely. In
many of the studies, ascertainment bias is a
concern, as only the most severe cases of
trauma may have been identified. Studies
that rely on hospitalized trauma patients
may not give an accurate picture of trauma
7
Systematic Reviews Obstetrics
across gestation, as gravidas suffering 6. El-Kady D, Gilbert WM, Anderson J, Dan-
trauma when the fetus is viable are proba- ielsen B, Towner D, Smith LH. Trauma during
pregnancy: an analysis of maternal and fetal
bly more likely to be hospitalized. Studies outcomes in a large population. Am J Obstet
based on administrative data are subject to Gynecol 2004;190:1661-8.
inaccurate coding. In some studies, control 7. Schiff MA, Holt VL. Pregnancy outcomes fol-
patients were not matched to cases on the lowing hospitalization for motor vehicle crashes
basis of relevant characteristics. in Washington state from 1989 to 2001. Am J
Epidemiol 2005;161:503-10.
With the above limitations in mind, 8. Weiss HB, Songer TJ, Fabio A. Fetal deaths
our review leads to the following conclu- related to maternal injury. JAMA 2001;286:
sions. The major determinant of obstet- 1863-8.
rical outcomes after trauma is the sever- 9. Shah KH, Simons RK, Holbrook T, Fortlage
D, Winchell RJ, Hoyt DB. Trauma in pregnancy:
ity of injury. DV/IPV and MVC are the
maternal and fetal outcomes. J Trauma 1998;
most common mechanisms of traumatic 45:83-6.
injury during pregnancy and substance 10. Kuo C, Jamieson DJ, McPheeters ML,
abuse is a common accompaniment to Meikle SF, Posner SF. Injury hospitalizations of
these forms of trauma. In most cases, pregnant women in the United States, 2002.
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management of the pregnant trauma pa-
11. Kvarnstrand L, Milsom I, Lekander T, Druid
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port/advanced trauma life support
12. Whitehead NS. Prenatal counseling on seat
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