Penetrating Abdominal Trauma

Penetrating abdominal trauma can be very challenging to manage in pregnancy. Penetration of the uterus is often devastating for the fetus, and the associated mortality is high. Small caliber bullets rarely penetrate through the posterior wall of the uterus, so in one sense, the pregnant uterus provides a protective barrier to the mother.¹⁰ In the second and third trimester of pregnancy, the bowel is displaced superiorly by the gravid uterus which changes the typical pattern of injury during this stage of pregnancy. Injuries of the bowel occur less commonly with lower abdominal wounds but are more likely with upper abdominal wounds. Amniocentesis may be considered to assess uterine penetration. Many patients with penetrating injuries to the uterus require an emergency cesarean section if the fetus is viable.

Pelvic Fractures

The management of pelvic fractures during pregnancy deserves special mention. Because a large amount of force is required to fracture the pelvic ring, pelvic fractures are a marker of severe trauma. Given the proximity to the pregnant uterus, the fetus is particularly vulnerable to injury in even minor pelvic fractures.²³ A prospective registry of pregnant patients with fractures included 151 patients with pelvic fractures and found these patients to be at particular risk for placental abruptions, need for blood transfusion, and maternal and fetal death.⁸ Because of venous engorgement in the pelvis during pregnancy, blood loss can be particularly severe. Angiography and embolization of bleeding vessels have not been well studied. Orthopedic fixation can be performed on pregnant patients similar to non-pregnant patients.²³

Intimate Partner Violence

It is well established that intimate partner violence (IPV) increases during pregnancy.²⁴ The first episode of violence may occur during the pregnancy, or the violence may escalate in a relationship already characterized by violence. In a classic article on the subject, MacFarlane reported a prevalence of physical or sexual abuse of 17% in a cohort of 691 pregnant patients, using a 3-question screening tool. The abuse was recurrent in 60% of the patients. The author reports that pregnant patients who were victims of interpersonal violence were unlikely to seek prenatal care until the third trimester, when injuries to the abdomen are more common.²⁵ In a cohort of 1203 patients presenting for prenatal care, 20.6% of teens and 14.2% of adult women reported abuse during the pregnancy. These women were more at risk for delivering low birth weight babies.²⁶ Victims of IPV frequently use the emergency department for treatment of their injuries, and it is critical that the physician inquire about this possibility especially when the patient has injuries suspicious for IPV. The American College of Obstetrics and Gynecology recommends the universal screening of pregnant patients for IPV, and emergency departments should have programs in place to provide appropriate resources for referral of these patients.²

 

<< Previous | Topic Table of Contents | Next >>