In a study of 321 pregnant women with abdominal trauma, Petrone (2011) reported a 9-percent incidence of penetrating injuries. Of these, 77 percent were gunshot wounds and 23 percent were stab wounds. he incidence of maternal visceral injury with penetrating trauma is only 15 to 40 percent compared with 80 to 90 percent in nonpregnant individuals (Stone, 1999). When the uterus sustains penetrating wounds, the fetus is more likely than the mother to be seriously injured. Indeed, although the fetus sustains injury in two thirds of cases with penetrating uterine injuries, maternal visceral injuries are seen in only 20 percent. Still, their seriousness is underscored in that maternal-fetal mortality rates are signiicantly higher than those seen with blunt abdominal injuries in pregnancy. Specifically, maternal mortality rates were 7 versus 2 percent, and fetal mortality rates were 73 versus 10 percent, respectively .
• Management of Trauma
Maternal and fetal outcomes are directly related to the severity of injury. That said, commonly used methods of severity scoring do not take into account significant morbidity and mortality rates related to placental abruption and thus to pregnancy outcomes. In a study of 582 pregnant women hospitalized for injuries, the injury severity score did not accurately predict adverse pregnancy outcomes (Schif, 2005). Importantly, relatively minor injuries were associated with preterm labor and placental abruption. Others have reached similar conclusions (Biester, 1997; Ikossi, 2005). In a study of 317 women at 24 weeks' gestation or more who had "minor trauma," 14 percent had clinically significant urerine contractions requiring extended fetal evaluation past 4 hours (Cahill, 2008).
With few exceptions, treatment priorities in injured pregnant women are multidisciplinary (Barraco, 2010; Mendez-Figueroa, 2016). Primary goals are evaluation and stabilization of maternal injuries. Attention to fetal assessment during the acute evaluation (merican College of Obstetricians and Gynecologists, 2017b;
Brown, 2009). Basic rules of resuscitation include ventilation, arrest of hemorrhage, and treatment of hypovolemia with crys talloid and blood products. After midpregnancy, the large uterus is positioned of the great vessels to diminish its efect on vessel compression and cardiac output (Nelson, 2015).
Following emergency resuscitation, evaluation is continued for fractures, internal injuries, bleeding sites, and placental, uterine, and fetal trauma. Radiography is not proscribed, but special attention is given each indication. Not surprisingly, one report observed that pregnant trauma victims had less radiation exposure than nonpregnant controls (Ylagan, 2008). Some advocate screening abdominal sonography followed by CT scanning for positive sonographic findings (Brown, 2005; Saphier, 2014). Procedures used include the FAST scan ocused 4ssessment with �onography or t.rauma. his examination is ars-minute, four-to six-view imaging study that evaluates perihepatic, perisplenic, pelvic, and pericardial views (MendezFigueroa, 2016). In general, if fluid is seen in any of these views, then the volume is >500 mL (Fig. 47-11). Importantly, this amount has not been corroborated for pregnancy. In some cases, open peritoneal lavage may be informative (Tsuei, 2006).