Complications of Trauma and Pregnancy

By Steven J. Anglés, Attorney at Law

When a pregnant woman suffers a traumatic injury, medical providers face a host of complex challenges.  On a fundamental level, the difficulties stem from the reality that both mother and fetus must be treated simultaneously.  The challenges continue when one considers that the likelihood of an adverse outcome for the fetus is unpredictable and often, there is no direct correlation between the degree of trauma and the medical outcome.  Additionally, due to the very nature of the pregnancy, a mother’s physiological adaptations may alter her symptom picture and mask maternal and/or fetal injury, particularly when compared to a non pregnant patient. For example, hemodynamic alterations caused by pregnancy, such as increased muscle laxity, cardiac output, or pulmonary alterations of pregnancy, such as reduced lung capacity, can provide the illusion of greater stability relative to the degree of insult in the case of hemorrhagic shock.[1]

Estimates indicate 5%-8% of pregnant women in the United States experience trauma.[2]  While blunt trauma is by far the most common mechanism of maternal injury, 50%-70% of blunt trauma among pregnant patients is attributed to motor vehicle collisions.[3] Motor vehicle collisions are the most common cause of injury related to hospitalizations of pregnant patients.  Moreover, motor vehicle collisions also remain one of the leading causes of both maternal and fetal mortality, with an estimated mortality rate ranging from a 1.4 per 100,000 to 3.7 point seven per 100,000 pregnancies, even though direct fetal injury occurs less than one percent of the time.[4]    Aside from injuries to the pregnant patient herself, the likelihood of miscarriage, early labor, premature rupture of membranes, abruption,[5] and fetal demise are possible medical outcomes for the fetus.  What makes these possibilities more concerning from a preventative basis is that to date, there is no study that has established any relationship with the direction of the impact to a vehicle or the mother’s position within a vehicle, and the degree or nature of injury.[6]

In recent years, several population-based studies have evaluated maternal-fetal outcomes with regard to trauma admissions at emergency rooms. One 2004 study[7]  reviewed all maternal trauma admissions in California hospitals from 1991 to 1999.  This study sought to reveal occurrence rates, outcomes, risk factors, and timing of delivery following trauma. The study revealed that the single largest contributor to fetal and neonatal deaths was a gestational age of less than 28 weeks. Maternal and fetal deaths were found to be highest with injuries to the mother’s pelvis, abdomen, and thorax.  (As the mothers pelvis becomes more lax during the course of her pregnancy, trauma can result in pelvic fractures as one of the more common injuries sustained through blunt trauma. In fact, pelvic fractures and abruption are the most common causes of the loss due to motor vehicle collisions.) [8]

An earlier study conducted in the state of Washington between 1989-1997 reviewed all post-trauma hospital admissions and sought to distinguish patient outcomes between those with major and minor injuries.[9]  (Patients with an Injury Severity Score or ISS[10] greater than 9 were considered to be severely injured.)  The study is noteworthy in that it revealed that women classified as sustaining “minor injuries” nonetheless show an increased risk of abruption, infant hypoxia, and fetal death when compared to uninjured women, thus underscoring the clinical distinction between any degree of traumatic insult and the absence of trauma during pregnancy. This same study later evaluated state wide pregnancy outcomes in 2005.  A majority of the patients were discharged from hospitals undelivered, at 82.9 percent. But, this later component of the Schiff study again revealed that that ISS did not have a correlation with adverse pregnancy outcomes. The study ultimately concluded that women hospitalized after a motor vehicle collision are indeed at an increased risk for adverse pregnancy outcomes regardless of the presence or absence of identifiable physical injuries.

Numerous other clinical studies reveal very similar results.  These studies underscore the importance of a multidisciplinary team approach in treating pregnant trauma patients.  A typical team providing emergency care to a pregnant patient will likely consist of obstetricians, anesthesiologists, surgeons, emergency care providers, and intensive care providers.  The studies also specifically underscore the importance of seatbelt use in pregnancy given the overwhelming prevalence of trauma due to motor vehicle collisions.  Lastly, if discharged undelivered from emergency care, a patient should participate in close patient monitoring, consisting of regular growth examinations and weekly or biweekly antenatal testing.  Bi-weekly testing is strongly encouraged in pregnant women past 36 weeks through time of delivery.[11]

Families who have been injured due to the negligence of others while awaiting the arrival of a child deserve top-tier legal representation to complement top-tier medical care.  Facing the legal uncertainties that arise due to a traumatic injury is often difficult without the assistance of experienced legal counsel. The attorneys at Adler Giersch, PS are committed to providing tough advocacy and compassionate counsel for those that have been impacted by traumatic injuries. Our consultations are complimentary. Simply give us a call.

[1] Oxford C, et al. Trauma in Pregnancy. Clinical Obstetrics and Gynecology, Volume 52, Number 4, 611-629; 2009.

[2] El Kady D, Gilbert WM, Anderson J, et al. Trauma during pregnancy: an analysis of maternal and fetal outcomes in a large population. Am J Obstet Gynecol. 2004;190:1661–1668.

[3] Ikossi DG, Lazar AA, Morabito D, et al. Profile of mothers at risk: an analysis ofinjury and pregnancy loss in 1195 trauma patients. Am Coll Surg. 2005;200:49–56.  Also, Mattox KL, Goetzl L. Trauma in pregnancy.Crit Care Med. 2005;33:385–389.

[4] Mendez-Figueroa H, et al. Trauma in Pregnancy: An Updated Systemic Review. American Journal of Obstetrics and Gynecology 2013; [E-pub ahead of print]

[5] A pregnancy complication where in the placental lining separates from the uterus.

[6] Klinich KD, Rupp JD. Fetal outcomes in motor-vehicle crashes: effects of crash characteristics and maternal restraint. Am J Obstet Gynecol. 2008;198:450e1–450e9.

[7] See El Kady.

[8] See Oxford

[9] Schiff MA, Holt VL, Daling JR. Maternal and infant outcomes after injury during pregnancy in Washington state from 1989 to 1997. J Trauma Inj Infect Crit Care. 2002;53:939–945.

[10] The Injury Severity Score (ISS) is an anatomical scoring system for patients with multiple injuries.  Each injury is scored 1-6 according to its severity in each of the six possible body regions.  A rating of “1” indicates “minor” injury.  To calculate an ISS, the highest severity code for the three most injured body regions are squared, then added together.  Scores range from 1-75.

[11] See Oxford.