TRAUMA IN THE OBSTETRIC PATIENT

Trauma is the leading nonobstetric cause of maternal death and occurs in approximately 7% of pregnancies. A review by Connolly and co-workers 6 of pregnancies complicated by trauma from July 1987 through October 1993 at the University of North Carolina Hospitals in Chapel Hill, North Carolina and the Women's Hospital in Greensboro, North Carolina revealed a risk distribution of trauma cases. A total of 54.6% of the incidents were motor vehicle accidents; 22.3% were domestic abuse and assaults; 21.8% were associated with falls; and 1.3% were secondary to burns, puncture wounds, or animal bites. 6 The mean gestational age at the occurrence of trauma was 25.9 weeks and the mean gestational age at delivery 37.9 weeks. Domestic abuse occurred most frequently before 18 weeks. Falls were most common between 20 and 30 weeks of gestation. Motor vehicle accidents occurred with equal frequency throughout pregnancy. Preterm labor occurred in 11.4% of patients and preterm delivery in 25% of patients. Abruptions were noted in 1.58% of the trauma population. There were 27 perinatal deaths in a review of 476 medical records, and, in 14 pregnancies, the deaths were related to the trauma. Eight of the perinatal deaths were associated with motor vehicle accidents, four were associated with domestic violence, and two were associated with falls. A review of the records of the Cook County medical examiner by Fildes and co-workers 10 demonstrated 95 maternal deaths from January 1986 through December 1989. Forty-four of these deaths were caused by trauma. The mechanism of injury in the traumatic deaths included gunshot wounds (22.7%), motor vehicle accidents (20.5%), stab wounds (13.6%), strangulation (13.6%), blunt head injuries (9.1%), burns (6.8%), falls (4.5%), toxic exposure (4.5%), drowning (2.3%), and iatrogenic injury (2.3%). Trauma was found to be the leading cause of maternal death in this review, accounting for 46.3% of maternal deaths. In a review by Ali and co-workers, 1 an effort was made to control for the severity of maternal injury by limiting review to those patients with injury severity scores greater than 12 who were admitted to the University of Toronto Trauma Hospitals. Most reviews of maternal and perinatal mortality as a consequence of trauma examine a wide continuum of injury and do not control for the severity of injury to the mother. In Ali's review of 20 patients, 19 (95%) sustained blunt injury from motor vehicle crashes and one patient (5%) sustained multiple stab wounds. There were 13 fetal deaths (65%), one occurring immediately after delivery. One mother died of severe head, chest, and spleen injuries with multiple fractures, resulting in an injury severity score of 66. Among the fetal death group, eight were delivered by cesarean section between 26 and 38 weeks' gestation because of marked signs of distress as determined by clinical and Doppler fetal monitoring. Five of the 13 fetal deaths were documented in utero and vaginal delivery ensued. These deaths were between 16 and 34 weeks' gestation. There was one cesarean section at 34 weeks in the fetal survival group. Late decelerations after 5 hours of monitoring prompted a cesarean section with survival of the infant. The remaining six surviving fetuses ranged in gestational age from 8 to 38 weeks, and none required emergent delivery.