# Multiple trauma in pregnant women: injury assessment, fetal radiation exposure and mortality. A multicentre observational study

Paer-Selim Abback, Alison Benchetrit, Nathalie Delhaye, Jean-Luc Daire, Arthur James, Arthur Neuschwander, Mathieu Boutonnet, Fabrice Cook, Hélène Vinour, Jean-Luc Hanouz, et al.

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Paer-Selim Abback, Alison Benchetrit, Nathalie Delhaye, Jean-Luc Daire, Arthur James, et al. Multiple trauma in pregnant women: injury assessment, fetal radiation exposure and mortality. A multicentre observational study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2023, 31 (1), pp.22. 10.1186/s13049-023-01084-y. http://hal-04832687

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# Multiple trauma in pregnant women: injury assessment, fetal radiation exposure and mortality. A multicentre observational study

Paer-Selim Abback¹* ID, Alison Benchetrit², Nathalie Delhaye³, Jean-Luc Daire⁴, Arthur James⁵,
Arthur Neuschwander³, Mathieu Boutonnet⁶, Fabrice Cook⁷, Hélène Vinour⁸, Jean-Luc Hanouz⁹, Jean Cotte¹⁰,
Bruno Pastene¹¹, Viridiana Jouffroy¹², Tobias Gauss¹ and Traumabase Group¹

**Abstract**

**Background** Fetal radiation exposure in pregnant women with trauma is a concern. The purpose of this study was to evaluate fetal radiation exposure with regard to the type of injury assessment performed.

**Methods** It is a multicentre observational study. The cohort study included all pregnant women suspected of severe traumatic injury in the participating centres of a national trauma research network. The primary outcome was the cumulative radiation dose (mGy) received by the fetus with respect to the type of injury assessment initiated by the physician in charge of the pregnant patient. Secondary outcomes were maternal and fetal morbi-mortality, the incidence of haemorrhagic shock and the physicians' imaging assessment with consideration of their medical specialty.

**Results** Fifty-four pregnant women were admitted for potential major trauma between September 2011 and December 2019 in the 21 participating centres. The median gestational age was 22 weeks [12–30]. 78% of women (n=42) underwent WBCT. The remaining patients underwent radiographs, ultrasound or selective CT scans based on clinical examination. The median fetal radiation doses were 38 mGy [23–63] and 0 mGy [0–1]. Maternal mortality (6%) was lower than fetal mortality (17%). Two women (out of 3 maternal deaths) and 7 fetuses (out of 9 fetal deaths) died within the first 24 h following trauma.

**Conclusions** Immediate WBCT for initial injury assessment in pregnant women with trauma was associated with a fetal radiation dose below the 100 mGy threshold. Among the selected population with either a stable status with a moderate and nonthreatening injury pattern or isolated penetrating trauma, a selective strategy seemed safe in experienced centres.

**Keywords** Severe trauma, Pregnancy, Initial assessment after injury, Whole-body computed tomography

Full list of author information is available at the end of the article

<footnote>*Correspondence:
Paer-Selim Abback
paer.abback@gmail.com</footnote>
**Background**

Severe traumatic injuries are a major cause of mortal-
ity, morbidity and handicap worldwide, [1]. The major-
ity of deaths occur within the first 24 h following trauma.
Admission to a designated trauma centre is associated
with a survival benefit, [2]. As a standard of care, the ini-
tial injury assessment strategy involves standard X-rays,
bedside E-FAST (Extended - Focused Assessment with
Sonography for Trauma) and whole-body computed
tomography (WBCT). Although this method is efficient,
it is time-consuming, requires transfer to the radiology
department, may reveal incidental findings unrelated
to the current trauma, and carries the risk of radiation
exposure, [3].

Radiation exposure is of particular concern in pregnant
women since trauma is the leading cause of non-obstetric
death, [4]. One out of twelve pregnant women experi-
ences trauma during her pregnancy, [4]. Most of these
injuries are mild and do not necessitate complex manage-
ment. However, after motor vehicle accidents (MVAs),
falls or domestic violence, the situation may require a
work-up in a trauma centre. Trauma during pregnancy
can result in miscarriage, preterm labour, fetal growth
restriction and in utero fetal death, [5].

Fetal exposure to ionizing radiation remains a serious concern in the assessment of pregnant trauma patients. On the one hand, systematic WBCT with injection of contrast media can be considered the safest strategy to ensure that all important injuries are found; on the other hand, selective CT guided by clinical examination could be the most appropriate way to ensure minimal exposure of the fetus to radiation while providing a sufficient diagnostic evaluation of the mother. Recent evidence suggests that a cumulative radiation dose of less than 100 mGy carries very few risks at any term of pregnancy, [6] [7]. Furthermore, after initial management, some patients will require additional imaging, for example repeat computed tomography (CT) of the head or perioperative x-rays.

In this context, the present study aimed to explore
whether knowledge about pregnancy in trauma is insuf-
ficient even among trauma consultants and to determine
the cumulative fetal radiation dose received during the
initial assessment in a cohort of pregnant women with
trauma. The study group expected the knowledge level to
be insufficient and that regardless of which injury assess-
ment strategy was adopted, the radiation dose would
remain beneath the 100 mGy threshold.

**Methods**

**Study design and patients**

This multicentre, observational, retrospective study was
conducted within the TRAUMABASE network. The
TRAUMABASE network manages a prospective trauma

registry with 21 participating centres across France. All
consecutive pregnant trauma patients admitted to one
of the participating centres were included in the study.
All centres perform a routine pregnancy test on admis-
sion to female patients of reproductive age. Clinical and
epidemiological data were extracted from the registry or
retrieved from the patient's file: age, body mass index,
gestational age (GA), medical history, length of intensive
care unit (ICU) and hospital stay, mechanism and sever-
ity of trauma, prehospital and resuscitation parameters,
biological and radiological data, blood product require-
ment, Simplified Acute Physiology Score II (SAPS II),
Injury Severity Score (ISS), Sequential Organ Failure
Assessment score at 24 h (SOFA score), imaging modali-
ties for injury assessment, in-hospital mortality and
maternal and fetal outcome.

**Online survey**

To assess the potential knowledge gap with regard to the
management of pregnant trauma patients and the risk
benefits of radiation exposure, and to characterize exist-
ing practice patterns and protocols, a sample of radiol-
ogy, obstetric, critical care and emergency physicians
in various level-1 trauma centres in France received an
online survey (Google Docs, see supplementary material
2). The questionnaire explored the initial injury assess-
ment of pregnant patients and how confident partici-
pants felt in this particular context. All participants were
urged to forward the survey questionnaire to their col-
leagues to increase participation (snowballing). All par-
ticipants were summoned twice to respond and forward
the questionnaire.

**Radiation dose calculation**

No predetermined imaging or WBCT protocol was
applied by any participating centre. The team in charge
decided upon the diagnostic strategy and the performed
WBCT protocol. A senior radiophysicist (JLD) ret-
rospectively calculated the cumulative radiation dose
received by the fetus during the initial radiological injury
assessment. Only the radiation dose generated by the ini-
tial WBCT or other selective imaging on admission was
considered for the study. Total irradiation exposure dur-
ing the entire hospital stay was not calculated. The vari-
ables used to calculate the uterine absorbed radiation
dose after CT examinations are CT scan manufacturer
and model; explored organs/regions; number, length and
positioning of scan series (CT protocol); for each series
- tube voltage (kVp), tube current (mAs), pitch, slice
thickness, volume computed tomography dose index
(CTDIvol) and the dose-length product (DLP); number
of detectors and collimation.

The radiation dose was calculated according to these
criteria and the recommendations of the French National
Institute for Radioprotection and Nuclear Safety (IRSN), [8, 9]. The CTDIvol is routinely recorded in a CT dose report. For the exams before 2015, the CTDIvol value was not available. We then used CTexpo software (SAS-CRAD society: Scientific and application-oriented studies and consulting in Radiology; http://www.sascrad.com) to generate an estimation of CTDIvol in these cases. Once the CTDI was known, VirtualDose software (Virtual Phantoms Inc., http://www.virtual-dose.com) was used to estimate the cumulative fetal radiation dose varying by GA with three distinctive anthropomorphic phantoms (3, 6 and 9 months of pregnancy). Monte Carlo simulations allowed us to estimate the dose received by each organ, [10]. The result was considered "Fetus total" (see supplementary material 1).

## Outcomes

The primary endpoint was the cumulative radiation dose (mGy) received by the fetus depending on the imaging strategy during the initial injury appraisal, including WBCT, CT and/or X-rays needed.

Secondary endpoints were (a) the proportion of patients receiving 100 mGy or more, (b) fetal and maternal mortality, (c) the incidence of haemorrhagic shock after trauma, defined as transfusion of 4 units of red blood cells or more within the first six hours of admission, (d) the description of the initial imaging assessment and (e) the level of agreement between participants to the survey with regard to echographic and radiological injury work-up and their medical specialty.

## Statistical analysis

Continuous data are presented as the median and interquartile range (IQR) or mean (Standard deviation) for the Trauma Injury Severity Score TRISS. Categorical data are presented as absolute values and percentages, with 95% Confidence Intervals [CI] for observed and reported rates.

<table><caption>**Table 1** Initial injury assessment according to the medical specialty</caption><thead><tr><td>Specialty</td><td>Number of responders</td><td>Targeted imaging strategy</td><td>WBCT</td></tr></thead><tbody><tr><td>Anesthesiology/Critical care</td><td>46</td><td>14 (30% [17; 43])</td><td>32 (70% [57; 83])</td></tr><tr><td>Obstetric/ Gynaecology</td><td>24</td><td>11 (46% [26; 67])</td><td>13 (54% [34; 74])</td></tr><tr><td>Radiology</td><td>23</td><td>12 (52% [32; 72])</td><td>11 (48%[28; 68])</td></tr><tr><td>Emergency medicine</td><td>31</td><td>9 (29% [13; 45])</td><td>22 (71% [55; 87])</td></tr><tr><td>All disciplines</td><td>124</td><td>46 (37% [28; 45])</td><td>78 (63% [54; 71])</td></tr></tbody></table>

Data are presented as n(%) and 95% Confidence Intervals in the specialty or among all responders.

## Regulatory aspects and data protection and monitoring

This registry obtained approval from the Institutional Review Board (Comité de Protection des Personnes, Paris VI and Clermont-Ferrand), and the study was specifically approved by the Review Board of the French Society of Anesthesiology and Intensive Care (SFAR; reference number IRB 00010254–2020–015). The trauma registry was approved by the Advisory Committee for Information Processing in Health Research (Comité Consultatif Pour le Traitement de l'information en matière de recherche dans le domaine de la santé CCTIRS, 11.305bis) and from the National Data Protection Agency (Commission Nationale de l'Informatique et des Libertés CNIL, 911,461), waiving the need for informed consent. All research was performed in accordance with relevant guidelines and regulations. The registry deploys numerous internal algorithms for data consistency and coherence; professional data monitoring is performed by trained statisticians from the Biostatistics Laboratory of Paris 7 University.

## Results

### Online survey

One hundred and twenty-four physicians responded to the survey. Most of the respondents were senior physicians (n=79, 64%), 36 (29%) were residents and 9 (7%) were interns. Over 50% of them had more than 5 years of experience caring for multiple trauma victims, and 47% declared having already previously taken care of a pregnant patient in a trauma context. When asked about their strategy regarding imaging assessment, 85% [79; 91] would perform E-FAST, 65% [57; 73] would perform WBCT and 37% [38; 45] would perform targeted imaging based on clinical examination. The strategy regarding the specialty of clinicians is presented in Table 1. Only 31% [23; 39] of the participants were aware of the increasing probability of harm to the fetus above a 100 mGy threshold.

### Cohort study

From September 2011 until December 2019, 25 331 patients were admitted to one of the participating centres for major trauma. Among these, 5595 (22%) were women, and 3497 (62%) were 50 years old or younger. Fifty-four (0.2%) of all patients, representing 1.5% of women aged 50 or less, were identified as pregnant in the registry, and 9 of them (17%) were unknown and diagnosed during routine pregnancy testing on admission (Fig. 1).

Patient characteristics at admission are reported in Table 2. The main mechanism of injury was MVA (n=37, 69%) of moderate to high velocity. Five patients (9%) presented with penetrating injury: 4 patients with multiple stab wounds and 1 patient with a gunshot wound to the head after suicide attempt. Ten patients (19%) had
<table><caption>**Table 2** Patient's characteristics</caption><tbody><tr><td><strong>Age, y</strong></td><td>29<br/>[26–34]</td></tr><tr><td><strong>BMI (kg.m<sup>-2</sup>)</strong></td><td>25.3<br/>[23.3–27.3]</td></tr><tr><td><strong>Median gestational age (weeks)</strong></td><td>22<br/>[12–30]</td></tr><tr><td><strong>Mechanism of trauma</strong></td><td></td></tr><tr><td>- MVA</td><td>37 (69%)</td></tr><tr><td>- Gunshot wounds / Stab wounds</td><td>5 (9%)</td></tr><tr><td>- Falls</td><td>12 (22%)</td></tr><tr><td><strong>Severity Scores</strong></td><td></td></tr><tr><td>- SAPS 2</td><td>14 [8–21]</td></tr><tr><td>- ISS</td><td>9 [2–20]</td></tr><tr><td>- ISS > 15</td><td>20 (37%)</td></tr><tr><td>- SOFA at 24 h</td><td>0 [0–3]</td></tr><tr><td><strong>Maternal mortality</strong></td><td>3 (6%)</td></tr><tr><td><strong>Predicted maternal mortality</strong></td><td></td></tr><tr><td>- TRISS (mean(SD)):</td><td>8% (12%)</td></tr><tr><td><strong>Clinical data at first medical evaluation</strong></td><td></td></tr><tr><td>- Cardiac arrest</td><td>2</td></tr><tr><td>- GCS</td><td>15<br/>[14–15]</td></tr><tr><td>- Systolic blood pressure < 90 mmHg</td><td>11 (20%)</td></tr><tr><td>- Heart rate > 120/min</td><td>7 (13%)</td></tr><tr><td>- Vasopressors (adrenaline, noradrenaline)</td><td>8 (15%)</td></tr><tr><td>- Out-of-hospital intubation</td><td>12 (22%)</td></tr><tr><td><strong>Clinical data upon arrival at the hospital</strong></td><td></td></tr><tr><td>- Cardiac arrest</td><td>1</td></tr><tr><td>- Systolic blood pressure < 90 mmHg</td><td>4 (7%)</td></tr><tr><td>- Heart rate > 120/min</td><td>5 (9%)</td></tr><tr><td>- Vasopressors (adrenaline, noradrenaline)</td><td>8 (15%)</td></tr><tr><td>- In-hospital intubation</td><td>0</td></tr><tr><td><strong>Biological data upon arrival at the hospital</strong></td><td></td></tr><tr><td>- lactate (mmol/L)</td><td>1.4 [1–1.9]</td></tr><tr><td>- base excess (mmol/L)</td><td>-4.9<br/>[-6.4–3.5]</td></tr><tr><td><strong>Transfusion (RBC)</strong></td><td></td></tr><tr><td>- pre-hospital</td><td>2</td></tr><tr><td>- in-hospital</td><td>12 (22%)</td></tr><tr><td><strong>Surgery in the first 24 h</strong></td><td>22 (41%)</td></tr><tr><td>- orthopedic surgery</td><td>12</td></tr><tr><td>- exploratory laparotomy</td><td>5</td></tr><tr><td>- maxillofacial surgery</td><td>2</td></tr><tr><td>- emergency cesarean section</td><td>2</td></tr><tr><td>- neurosurgery</td><td>1</td></tr><tr><td><strong>ICU length of stay, d</strong></td><td>2 [1–6]</td></tr><tr><td><strong>Hospital length of stay, d</strong></td><td>6 [2–17]</td></tr></tbody></table>

Data are presented as medians [IQR 25-75, absolute value (percentage %) or mean (standard deviation) for the TRISS.

BMI Body Mass Index, MVA motor Vehicle Accident, SAPS II Simplified Acute Physiology Score II, ISS Injury Severity Score, SOFA Sequential Organ Failure Assessment, GCS Glasgow Coma Score, ICU Intensive Care Unit, RBC Red Blood Cells, TRISS Trauma Injury Severity Score.

a Glasgow coma scale (GCS) less than or equal to 13 on scene, and 12 patients (22%) were intubated on scene. No patient was intubated in the resuscitation room. Twenty out of 54 (37%) presented with a severe traumatic load (ISS > 15). The median GA was 22 weeks [12–30]. A total of 35% were in their first trimester, 33% were in their second trimester, and 29% were in their third trimester. The term of pregnancy was unknown for 2 women.

**Primary outcome**

In 42 of 54 cases (78% [67; 89]), the initial injury appraisal included a WBCT, in 9 of 54 (17% [7; 27]) appraisal consisted of selective imaging guided by clinical evaluation and in 3 of 54 (6% [0; 12]) cases no imaging was performed (Fig. 1). For 7 of 42 patients, imaging files were not retrieved on the server, and in 6 of 42 cases, it was impossible to obtain access to the image files. After exclusion of 16 of 54 cases without image files (13 of 16 were unavailable, 3 of 16 had no imaging), 29 cases with WBCT and nine selective injury assessment cases were analysed. The median fetal radiation dose received by all patients was 23 mGy [0.5–43]. When WBCT was performed, the median fetal radiation dose was 38 mGy [23–63] compared to 0 mGy [0–1] when a clinically guided CT examination was adopted (Table 3).

Among the 29 women assessed by WBCT, two fetuses received a radiation dose above 100 mGy (110.89 mGy and 112.99 mGy, respectively). One of them (GA 18 weeks) was exposed to a radiation dose greater than 100 mGy in the context of repeated abdominal and pelvis imaging with and without arterial and venous phase contrast enhancement. For the second, fetal death was diagnosed before WBCT; concordantly, a higher dose was tolerated in the trauma appraisal of the mother.

Nine patients had a selective imaging strategy. In 3 of 54, the fetus was in the irradiation field, but the clinical assessment alone limited the injury appraisal to a selective strategy with regional CT and/or standard radiographs. This reduced the fetal radiation dose in one patient with multiple abdominal stab wounds to 51 mGy after a trunk-only scan. One patient had a standard pelvic X-ray, which was sufficient to rule out a pelvic fracture (fetal radiation dose < 1 mGy); one patient required two perioperative lumbar radiographs in the operating room after spine surgery (fetal radiation dose < 1 mGy). The initial assessment of this patient consisted of magnetic resonance imaging (MRI). For the 6 remaining patients, the fetus was not exposed to any radiation because it was out of the radiation field.

**Secondary outcomes**

**Maternal mortality**

Three pregnant women died as a consequence of their trauma (6%). One woman died on day one after multiple
<figure><img src="image_3.png" /><figcaption>**Fig. 1** Flow Chart of patients included in the study</figcaption></figure>

<table><caption>**Table 3** Cumulated radiation dose (mGy) received by the fetus according to the type of injury assessment method and the gestational age</caption><thead><tr><th></th><th>WBCT (n = 29)</th><th>Imaging guided by clinical evaluation (n = 9)</th></tr></thead><tbody><tr><td>Median gestational age (weeks)</td><td>23 [12–30]</td><td>14 [14–20]</td></tr><tr><td>Fetal radiation dose (mGy)</td><td>38 [23–63]</td><td>0 [0–1]</td></tr></tbody></table>

Data are presented as medians [IQR 25-75]; WBCT Whole Body Computed Tomography, mGy milliGray

stab wounds to the trunk and initially resuscitated haemorrhagic cardiac arrest on scene. Two other patients succumbed after MVAs at 24 and 30 weeks gestation. One patient was in cardiac arrest on scene and died within a few hours of arrival due to uncontrolled haemorrhagic shock despite resuscitation and damage control laparotomy. The other patient suffered massive craniofacial trauma with severe intracranial hypertension due to brain oedema despite decompressive craniectomy. An emergency caesarean section was performed because of fetal bradycardia.

## Fetal mortality

An obstetric ultrasound was at admission performed to assess fetal vitality in 39 of 54 patients (72%), in the resuscitation room (90%) or in the first 24 h (10%). Five patients were considered too premature in their pregnancy to perform this exam. Nine of 54 fetuses (17%) died: one uterine rupture at 10 weeks, one early traumatic miscarriage following a high velocity MVA, six in utero fetal deaths and one fetus at 38 weeks requiring

emergency caesarean section due to extreme bradycardia (maternal haemorrhagic shock) but was stillborn. Most of them (7 of 9) died upon arrival in the trauma bay as diagnosed by fetal ultrasound.

Two patients underwent therapeutic abortions after the discovery of polymalformative syndromes. The first was diagnosed in the context of trauma, and the second was diagnosed later in pregnancy following fetal irradiation of less than 1 mGy resulting from a clinically guided initial assessment.

## Maternal haemorrhagic shock

Six patients presented with haemorrhagic shock. Four patients required immediate surgery before WBCT. The two remaining patients underwent WBCT first after haemodynamic stabilization. In total, five patients required emergency surgeries: three splenic injuries, four hepatic injuries, one uterine rupture, and two wounds of the digestive tract (caecum and small intestine). One patient needed embolization of the two hypogastric arteries due to active haemorrhage complicating a pelvic fracture after an emergent caesarean section for fetal bradycardia on admission. Among those six patients, one died, while five fetuses did not survive.

## Imaging injury assessment

Among the 48 (89% of all patients) E-FAST exams performed upon arrival in the resuscitation room, 8 (16%) were positive: seven cases of haemoperitoneum, two of haemothorax and one of pneumothorax.

A WBCT was ordered for 42 of 54 patients (78%): 35 were performed immediately after the first clinical
assessment in the resuscitation room, four after fetal
extraction (two emergency caesarean sections with only
one child alive and two intraoperative fetal extractions
for deceased fetuses) and four after emergency surgery
(exploratory laparotomy).

Nine patients (17%) had a clinically guided imaging
strategy. These were haemodynamically stable, with a
negative E-FAST and no clinical signs of severe injury. A
patient who presented with a sensory-motor deficit of the
lower limbs underwent lumbar spine MRI demonstrating
a T12 burst fracture with spinal cord compression. Three
had CT guided with clinical examination (head after gun-
shot, trunk after multiple stab wounds, head and spine
after loss of consciousness and pain). Two patients had
X-rays focused on painful areas (limbs, thorax). Three
patients did not have any imaging other than E-FAST.

Among the 54 included patients, 9 of them were
unknown and diagnosed during routine pregnancy test-
ing on admission. Seven of them had a WBCT while 2
had clinically guided strategy. On the opposite, 7 fetuses
died upon arrival in the trauma bay as diagnosed by fetal
ultrasound, 6 of them having a WBCT. So if we try to cal-
culate a WBCT rate where a viable pregnancy was known
at the time of decision, this would be 29 WBCT with via-
ble fetuses among 38 patients, so a WBCT rate of 76%.

Discussion

This study explored the knowledge level regarding preg-
nancy and trauma, and assessed maternal and fetal radia-
tion exposure [11]. First, there seems to be a considerable
knowledge gap among providers treating these cases.
Second, fetal radiation exposure was considerably higher
with systematic use of WBCT for injury assessment com-
pared to a targeted image protocol based on clinical sus-
picion alone. However, in the vast majority of cases, the
cumulative fetal radiation exposure remained below a
potentially harmful 100 mGy threshold. Fetal mortality in
our cohort was higher than maternal mortality: 17% (9
fetuses) and 6% (3 women), respectively.

A recent French multicentre prospective study, [12]
followed a cohort of 319 pregnant women exposed to an
abdominopelvic scan for various diagnostic purposes and
compared these to a matched nonexposed cohort. In the
exposed cohort, three hundred and twelve fetuses (97.5%)
received a radiation dose below 50 mGy and 99.4% below
100 mGy. There was no significant difference between the
two groups regarding miscarriage, in utero fetal death,
fetal growth restriction or malformations (7.8% vs. 7.2%;
p=0.88). These data suggest that a fetal radiation dose of
less than 100mGy is safe.

The place of WBCT as part of a routine trauma work-
up remains a matter of debate. Several large retrospective
studies with adequate confounder control and adjust-
ment for severity demonstrate a reduction in mortality

with initial and routine use of WBCT, [13–15]. A mul-
ticentre randomized controlled trial did not find any
decrease in mortality when performing WBCT versus a
clinically guided CT examination (16% vs. 16%, p=0.92)
in patients admitted for suspicion of severe traumatic
injuries, [16]. Furthermore, radiation doses were sig-
nificantly higher in the systematic WBCT group than in
patients assessed with a clinically oriented CT scan. (20.9
mSv [20.6–20.9] vs. 20.6 mSv [9.9–22.1]; p<0.0001).
However, despite being significant, this difference is
probably not clinically relevant, particularly consider-
ing a high crossover rate between both groups. Other
authors contend that WBCT detects lesions unrelated
to the current trauma, adding anxiety for the patient and
increasing medical costs (longer hospital stay, comple-
mentary examinations), [17]. However, as Salim demon-
strated in a prospective trial, systematic use of a WBCT
in blunt trauma unveils 20% of injuries otherwise unde-
tected, [18]. This finding is important in particular in
specific patient groups, such as pregnant women, which
are difficult to examine and assess. The difficulties associ-
ated with pregnancy-related anatomical and physiologi-
cal changes can make the clinical examination unreliable
and a WBCT indispensable.

Trauma E-FAST provides crucial information for
prompt decision-making and even more so in pregnant
patients: (1) identification of intraabdominal free fluid
for unstable patients and (2) early diagnosis of absence
of fetal heart activity. Consequently, any injury assess-
ment protocol should associate early E-FAST with quick
obstetric ultrasound. Based on the results, several strate-
gies can be adopted depending on the situation. In sta-
ble patients with a moderate and nonthreatening injury
pattern, a clinically guided imaging strategy associating
E-FAST, X-ray or selective CT, and lower irradiation can
be applied in experienced centres. In the present cohort,
no complications or missed injuries were observed.
This selective imaging strategy could also be sufficient
in unstable patients with isolated penetrating trauma.
However, the results also demonstrate that in most cases,
even with a strategy including a WBCT, the final radia-
tion dose remains below a potentially harmful threshold
of 100 mGy.

The results and the survey underscore considerable
discrepancies in imaging protocols to assess pregnant
trauma patients across different centres resulting in vari-
ous levels of fetal radiation exposure. For example, in
one hospital, 6 of 14 patients were exposed to radiation
during portal acquisition, with exposure equivalent to
three abdominal irradiations, limited to two in all other
centres. In fact, survey results illustrate the knowledge
gap with regard to fetal irradiation and exposure and
exemplify the discrepancies among different specialties.
Radiologists tend to have a higher threshold to perform a WBCT than practitioners in anaesthesia/critical care.

These observations of the cohort study combined with the survey results plead the case for standardized institutional imaging protocols for injury assessment in pregnant patients. The objective of such a protocol is to associate a high level of sensitivity to detect maternal injuries while keeping fetal irradiation as low as possible. As demonstrated by this cohort, the incidence of pregnant major trauma patients was low. This contributes to uncertainty and possibly disagreement between the involved clinicians and heterogeneous practice patterns. Institutional protocols help to reduce uncertainty, conflict and discrepancy. In the development of this imaging protocol, it is important to keep in mind that, as the Royal College of Radiologists describes, “...The health of the mother takes precedence over the health of the fetus and, if appropriate, modification of pathways should be decided by the trauma team leader and consultant radiologist”, [19].

## Limitations

This study is characterized by a few limitations. The cohort appears small but reflects recruitment from a large sample of designated trauma centres across France based on routine and systematic screening. The incidence of pregnant patients admitted for trauma seems indeed low [5]. Due to the retrospective design, this study was not able to determine whether GA influenced the initial strategy. However, we can suppose that not only GA but also fetal status (alive or not) on admission played a role in the assessment strategy. Furthermore, for a few patients admitted prior to 2015, it proved impossible to retrieve detailed imaging reports.

It would be preferable to examine the medium- and long-term evolution of exposed fetuses. Theoretically selective imaging carries the risk of missed injuries, but all patients were observed over a few days in the hospital. Any clinically pertinent injury would have been identified; with regard to the low risk associated with a selective strategy in selected cases, selection bias cannot be excluded. Given the small sample size, the risk of lack of power in detecting infrequent complications is real.

We did not study the possible radiation of secondary exams such as control CT. Without the time constraint of the initial urgent assessment, the relatively nonurgent aspect of these exams allows the adoption of diagnostic strategies to reduce fetal exposure to a minimum.

We decided to estimate the absorbed dose in mGy determined by Monte Carlo simulations and not the effective dose in mSv. To our knowledge, there are unfortunately no official methods to assess the effective dose (mSv). All recommendations about the clinical critical thresholds were made in mGy.

## Conclusion

This multicentre observational study confirms that pregnant women are rarely victims of severe trauma, but the associated morbidity and mortality are substantial. It seems that performing total-body CT scanning immediately on admission is not associated with fetal radiation doses above the recommended threshold of 100 mGy. Furthermore, in experienced centres, among the selected population with either a stable status with a moderate and nonthreatening injury pattern or isolated penetrating trauma, a selective strategy seemed safe. There is a knowledge gap even among experienced clinicians and a need for institutional initial injury assessment protocols.

## Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s13049-023-01084-y.

Supplementary Material 1

Supplementary Material 2

## Acknowledgements

Traumabase Group.

## Authors' contributions

Conceptualization, project administration and Writing (PSA, AB, TG); Resources and validation (ND, AJ, AN, MB, FC, HV, JLH, JC, BP, VJ); Formal analysis (JLD).

## Funding

The authors declare that they have no Fundings for this work.

## Data Availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

## Declarations

### Ethics approval and consent to participate

This registry obtained approval from the Institutional Review Board (Comité de Protection des Personnes, Paris VI and Clermont-Ferrand), and the study was specifically approved by the Review Board of the French Society of Anesthesiology and Intensive Care (SFAR; reference number IRB 00010254 – 2020-015).

### Consent for publication

The trauma registry was approved by the Advisory Committee for Information Processing in Health Research (Comité Consultatif Pour le Traitement de l'information en matière de recherche dans le domaine de la santé CCTIRS, 11.305bis) and from the National Data Protection Agency (Commission Nationale de l'Informatique et des Libertés CNIL, 911461), waiving the need for informed consent.

### Competing interests

The authors declare that they have no competing interests.

### Author details

¹Department of Anesthesiology and Intensive Care, AP-HP.Nord, Beaujon Hospital, DMU PARABOL, 100 boulevard du General Leclerc, Clichy 92110, France

²Department of Anesthesiology, Burn and Critical Care, Saint-Louis-Lariboisière University Hospital, APHP, Paris, France

³Department of Anesthesiology and Critical Care Medicine, Hôpital Européen Georges Pompidou, AP-HP, Paris, France

⁴Radiology department, AP-HP.Nord, Beaujon Hospital, Clichy, France
⁵DMU DREAM, Department of Anesthesiology and critical care, Sorbonne University, AP-HP, Pitié-Salpêtrière Hospital, GRC 29, Paris, France

⁶Department of Anesthesiology and Intensive Care, Percy Military Teaching Hospital, Clamart, France

⁷Service d'Anesthésie et des Réanimations chirurgicales, Hôpitaux Universitaires Henri Mondor, Assistance Publique - Hôpitaux de Paris (APHP), Créteil, France

⁸Department of Anesthesiology and Critical Care, Toulouse University Hospital, University, Toulouse, France

⁹Department of Anesthesiology and Intensive Care, University Hospital of Caen, Caen, France

¹⁰Intensive Care Unit, HIA Sainte Anne, Military Teaching Hospital, Toulon, France

¹¹Department of Anesthesiology and Critical Care, Nord Hospital, Assistance Publique Hôpitaux Universitaires de Marseille, Aix Marseille Université, Marseille, France

¹²Department of Anesthesiology and Intensive Care, AP-HP, Kremlin-Bicêtre Hospital, Kremlin-Bicêtre, France

Received: 10 January 2023 / Accepted: 1 April 2023

Published online: 02 May 2023

## References

1. Evans JA, van Wessem KJP, McDougall D, Lee KA, Lyons T, Balogh ZJ. Epidemiology of traumatic deaths: Comprehensive Population-Based Assessment. World J Surg janv. 2010;34(1):158-63.

2. MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens NB, Frey KP, Egleston BL, Salkever MPP, Scharfstein DS. A national evaluation of the Effect of Trauma-Center Care on Mortality. N Engl J Med. 2006;354:366-78.

3. Brenner DJ, Hall EJ. Computed tomography - an increasing source of Radiation exposure. N Engl J Med. 2007;357:2277-84.

4. Sakamoto J, Michels C, Eisfelder B, Joshi N. Trauma in pregnancy. Emerg Med Clin North Am May. 2019;37(2):317-38.

5. El Kady D, Gilbert WM, Anderson J, Danielsen B, Towner D, Smith LH. Trauma during pregnancy: an analysis of maternal and fetal outcomes in a large population. Am J Obstet Gynecol. 2004;190(1661):8.

6. French National Institute for Radioprotection and Nuclear Safety. Fetal radiation dose estimate. https://www.irsn.fr/FR/prestations_et_formations/Prestations/DosimetrieRadioprotection/Pages/Estimer-dose-uterine-patientenceinte.aspx#.YF79TZNKjDE

7. International Commission on Radiological Protection (ICRP). Pregnancy and medical radiation (ICRP publication 84). Updated 2000. https://www.icrp.org/publication.asp?id=icrp%20publication%2084.

8. Étard C, Aubert B. Analyse des évaluations de dose utérine réalisées par l'IRSN de 2004 à 2008. Radioprotection oct. 2009;44(4):479-93.

9. ICRP. The 2007 recommendations of the International Commission on Radiological Protection. ICRP publication 103. Ann ICRP. 2007;37:2-4.

10. Damilakis J, Tzedakis A, Perisinakis K, Papadakis AE. A method of estimating conceptus doses resulting from multidetector CT examinations during all stages of gestation. Med Phys. 2010;37:6411-20.

11. Raptis CA, Mellnick VM, Raptis DA, Kitchin D, Fowler KJ, Lubner M, Bhalla S, Menias CO. Imaging of Trauma in the pregnant patient. RadioGraphics May. 2014;34(3):748-63.

12. Guilbaud L, Beghin D, Dhombres F, Blondiaux E, Friszer S, Le Ducou H, Elefant E, Jouannic JM. Pregnancy outcome after first trimester exposure to ionizing radiations. Eur J Obstet Gynecol Reprod Biol janv. 2019;232:18-21.

13. Huber-Wagner S, Lefering R, Qvick L-M, Körner M, Kay MV, Pfeifer K-J, Reiser M, Mutschler W, Kanz KG, on behalf of the Working Group on Polytrauma of the German Trauma Society. Effect of whole-body CT during trauma resuscitation on survival: a retrospective. multicentre study. 2009;373:7.

14. Kanz KG, Paul AO, Lefering R, Kay MV, Kreimeier U, Linsenmaier U, Mutschler W, Huber-Wagner S. Trauma Registry of the german Trauma Society. Trauma management incorporating focused assessment with computed tomography in trauma (FACTT) - potential effect on survival. J Trauma Manag Outcomes. 2010 May;10:4-4.

15. Jiang L, Ma Y, Jiang S, Ye L, Zheng Z, Xu Y, Zhang M. Comparison of whole-body computed tomography vs selective radiological imaging on outcomes in major trauma patients: a meta-analysis. Scand J Trauma Resusc Emerg Med. 2014 Sep;2:22:54.

16. Sierink JC, Treskes K, Edwards MJ, Beuker BJ, Den Hartog D, Hohmann J, Dijkgraaf MG, Luitse JS, Beenen LF, Hollmann MW et al.; REACT-2 study group. Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial. Lancet. 2016 Aug 13;388 (10045):673-83.

17. Sierink JC, Saltzherl TP, Wirtz MR, Streekstra GJ, Beenen LF, Goslings JC. Radiation exposure before and after the introduction of a dedicated total-body CT protocol in multi trauma patients. Emerg Radiol. 2013 Dec;20(6):507-12.

18. Salim A, Sangthong B, Martin M, Brown C, Plurad D, Demetriades D. Whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study. Arch Surg. 2006 May;141(5):468-73. discussion 473-5.

19. The Royal College of Radiologists. Standards of practice and guidance for trauma radiology in severely injured patients, Second edition. The Royal College of radiologists, 2015.

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