Advertisement

Fracture Management in the Pregnant Patient

  • Erich SorantinEmail author
  • Nima Heidari
  • Karin Pichler
  • Annelie-Martina Weinberg

Abstract

Trauma in pregnancy is an uncommon but challenging problem. There are two patients involved, the mother and the foetus. The best management for the foetus is delivered through appropriate management of the mother. The alterations of the maternal anatomy and physiology must be taken into account. Signs of foetal distress may be the initial indication of maternal blood loss and compromise. Life-saving intervention and investigations should be carried out without compromise. Detailed knowledge of the cumulative dose received by the patient is essential for all decisions in management. There is little exposure of the foetus in limb radiographs.

Fractures should be treated much in the same way as in the non-pregnant patient. Use of minimally invasive techniques of fracture reduction and fixation or other techniques dependent on intraoperative imaging is not advocated in the pregnant patient. The management of the pregnant trauma patients requires the early involvement of trauma surgeon, obstetrician and radiologist.

Keywords

Pregnant Patient Nephrogenic Systemic Fibrosis Placenta Previa Placental Abruption Gravid Uterus 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    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(6):1661–8.PubMedCrossRefGoogle Scholar
  2. 2.
    Esposito TJ. Trauma during pregnancy. Emerg Med Clin North Am. 1994;12(1):167–99.PubMedGoogle Scholar
  3. 3.
    Rosenfeld JA. Abdominal trauma in pregnancy. When is fetal monitoring necessary? Postgrad Med. 1990;88(6):89–91, 94.PubMedCrossRefGoogle Scholar
  4. 4.
    Vaizey CJ, Jacobson MJ, Cross FW. Trauma in pregnancy. Br J Surg. 1994;81(10):1406–15.PubMedCrossRefGoogle Scholar
  5. 5.
    Lavin Jr JP, Polsky SS. Abdominal trauma during pregnancy. Clin Perinatol. 1983;10(2):423–38.PubMedGoogle Scholar
  6. 6.
    Connolly AM, Katz VL, Bash KL, McMahon MJ, Hansen WF. Trauma and pregnancy. Am J Perinatol. 1997;14(6):331–6.PubMedCrossRefGoogle Scholar
  7. 7.
    Shah AJ, Kilcline BA. Trauma in pregnancy. Emerg Med Clin North Am. 2003;21(3):615–29.PubMedCrossRefGoogle Scholar
  8. 8.
    Shah KH, Simons RK, Holbrook T, Fortlage D, Winchell RJ, Hoyt DB. Trauma in pregnancy: maternal and fetal outcomes. J Trauma. 1998;45(1):83–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Chang J, Berg CJ, Saltzman LE, Herndon J. Homicide: a leading cause of injury deaths among pregnant and postpartum women in the United States, 1991–1999. Am J Public Health. 2005;95(3):471–7.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Theodorou DA, Velmahos GC, Souter I, Chan LS, Vassiliu P, Tatevossian R, Murray JA, Demetriades D. Fetal death after trauma in pregnancy. Am Surg. 2000;66(9):809–12.PubMedGoogle Scholar
  11. 11.
    Hill CC. Trauma in the obstetrical patient. Womens Health (Lond Engl). 2009;5(3):269–83.CrossRefGoogle Scholar
  12. 12.
    Ikossi DG, Lazar AA, Morabito D, Fildes J, Knudson MM. Profile of mothers at risk: an analysis of injury and pregnancy loss in 1,195 trauma patients. J Am Coll Surg. 2005;200(1):49–56.PubMedCrossRefGoogle Scholar
  13. 13.
    Aynaci O, Kerimoglu S, Ozturk C, Saracoglu M. Bilateral non-traumatic acetabular and femoral neck fractures due to pregnancy-associated osteoporosis. Arch Orthop Trauma Surg. 2008;128(3):313–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Willis-Owen CA, Daurka JS, Chen A, Lewis A. Bilateral femoral neck fractures due to transient osteoporosis of pregnancy: a case report. Cases J. 2008;1(1):120.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Muench MV, Canterino JC. Trauma in pregnancy. Obstet Gynecol Clin North Am. 2007;34(3):555–83, xiii.PubMedCrossRefGoogle Scholar
  16. 16.
    Tsuei BJ. Assessment of the pregnant trauma patient. Injury. 2006;37(5):367–73.PubMedCrossRefGoogle Scholar
  17. 17.
    Greiss Jr FC. Uterine vascular response to hemorrhage during pregnancy, with observations on therapy. Obstet Gynecol. 1966;27(4):549–54.PubMedCrossRefGoogle Scholar
  18. 18.
    Jouppila R, Jouppila P, Hollmen A. Laryngeal oedema as an obstetric anaesthesia complication: case reports. Acta Anaesthesiol Scand. 1980;24(2):97–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Kuczkowski KM, Reisner LS, Benumof JL. Airway problems and new solutions for the obstetric patient. J Clin Anesth. 2003;15(7):552–63.PubMedCrossRefGoogle Scholar
  20. 20.
    Vanner RG. Mechanisms of regurgitation and its prevention with cricoid pressure. Int J Obstet Anesth. 1993;2(4):207–15.PubMedCrossRefGoogle Scholar
  21. 21.
    Pape HC, Pohlemann T, Gansslen A, Simon R, Koch C, Tscherne H. Pelvic fractures in pregnant multiple trauma patients. J Orthop Trauma. 2000;14(4):238–44.PubMedCrossRefGoogle Scholar
  22. 22.
    Petrone P, Asensio JA. Trauma in pregnancy: assessment and treatment. Scand J Surg. 2006;95(1):4–10.PubMedCrossRefGoogle Scholar
  23. 23.
    Hirsh HL. Routine pregnancy testing: is it a standard of care? South Med J. 1980;73(10):1365–6.PubMedCrossRefGoogle Scholar
  24. 24.
    Chames MC, Pearlman MD. Trauma during pregnancy: outcomes and clinical management. Clin Obstet Gynecol. 2008;51(2):398–408.PubMedCrossRefGoogle Scholar
  25. 25.
    Sperry JL, Casey BM, McIntire DD, Minei JP, Gentilello LM, Shafi S. Long-term fetal outcomes in pregnant trauma patients. Am J Surg. 2006;192(6):715–21.PubMedCrossRefGoogle Scholar
  26. 26.
    Eager R, Sutton J, Spedding R, Wallis R. Use of anti-D immunoglobulin in maternal trauma. Emerg Med J. 2003;20(5):498.PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    Huggon AM, Watson DP. Use of anti-D in an accident and emergency department. Arch Emerg Med. 1993;10(4):306–9.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Weinberg L. Use of anti-D immunoglobulin in the treatment of threatened miscarriage in the accident and emergency department. Emerg Med J. 2001;18(6):444–7.PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    Flik K, Kloen P, Toro JB, Urmey W, Nijhuis JG, Helfet DL. Orthopaedic trauma in the pregnant patient. J Am Acad Orthop Surg. 2006;14(3):175–82.PubMedCrossRefGoogle Scholar
  30. 30.
    Lowe SA. Diagnostic radiography in pregnancy: risks and reality. Aust N Z J Obstet Gynaecol. 2004;44(3):191–6.PubMedCrossRefGoogle Scholar
  31. 31.
    Mattox KL, Goetzl L. Trauma in pregnancy. Crit Care Med. 2005;33(10 Suppl):S385–9.PubMedCrossRefGoogle Scholar
  32. 32.
    Patel SJ, Reede DL, Katz DS, Subramaniam R, Amorosa JK. Imaging the pregnant patient for nonobstetric conditions: algorithms and radiation dose considerations. Radiographics. 2007;27(6):1705–22.PubMedCrossRefGoogle Scholar
  33. 33.
    Sardanelli F, Hunink MG, Gilbert FJ, Di LG, Krestin GP. Evidence-based radiology: why and how? Eur Radiol. 2010;20(1):1–15.PubMedCrossRefGoogle Scholar
  34. 34.
    Wikipedia. Strahlungswichtungsfaktor. http://de.wikipedia.org/wiki/Strahlenwichtungsfaktor. 2010. 14-3-2010. Ref Type: Online Source
  35. 35.
    Wikipedia. Effektive Dosis. http://de.wikipedia.org/wiki/Effektive_Dosis. 2010. 13-4-2010. Ref Type: Online Source
  36. 36.
    Committee to Assess Health Risks from Exposure to Low Levels of Ionizing Radiation N R C. Health risks from exposure to low levels of ionizing radiation: BEIR VII Phase 2. 2006. Online resource - http://www.cirms.org/pdf/NAS%20BEIR%20VII%20Low%20Dose%20Exposure%20-%202006.pdf.
  37. 37.
    Shannoun F, Blettner M, Schmidberger H, Zeeb H. Radiation protection in diagnostic radiology. Dtsch Arztebl Int. 2008;105(3):41–6.PubMedPubMedCentralGoogle Scholar
  38. 38.
    The United States Nuclear Regulatory Commission. Lethal dose (LD). http://www.nrc.gov/reading-rm/basic-ref/glossary/lethal-dose-ld html [serial online] 2010; [cited 2010 Apr 27].
  39. 39.
    Dierker J, Eschner W, Gosch D, et al. Pränatale Strahlenexposition aus medizinischer Indikation. Deutsche Gesellschaft für Medizinische Physik; 2002. Online Resource: http://www.dgmp.de/media/document/205/bericht7-neuauflage2002.pdf.
  40. 40.
    Wikipedia. Strahlenbelastung. http://de.wikipedia.org/wiki/Strahlenbelastung. 2010. 14-3-2010. Ref Type: Online Source
  41. 41.
    Ma OJ, Mateer JR, Ogata M, Kefer MP, Wittmann D, Aprahamian C. Prospective analysis of a rapid trauma ultrasound examination performed by emergency physicians. J Trauma. 1995;38(6):879–85.PubMedCrossRefGoogle Scholar
  42. 42.
    Sorantin E, Weissensteiner S, Hasenburger G, Riccabona M. CT in children – dose protection and general considerations when planning a CT in a child. Eur J Radiol. [Internet]. 2012 [cited 16 Apr 2012]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22227258.
  43. 43.
    Matthews S. Short communication: imaging pulmonary embolism in pregnancy: what is the most appropriate imaging protocol? Br J Radiol. [Internet]. 2006;79(941):441–4 [cited 30 Dec 2013]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16632627.
  44. 44.
    Baysinger CL. Imaging during pregnancy. Anesth Analg. [Internet]. 2010;110(3):863–7 [cited 30 Dec 2013]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20185662.
  45. 45.
    Topatan B, Basaran A. Imaging during pregnancy: computed tomography pulmonary angiography versus ventilation perfusion scintigraphy. Anesth Analg. [Internet]. 2011;112(2):483–4 [cited 14 Dec 2013]. author reply 484–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21257704.
  46. 46.
    Lee CH, Goo JM, Ye HJ, Ye S-J, Park CM, Chun EJ, et al. Radiation dose modulation techniques in the multidetector CT era: from basics to practice. Radiographics [Internet]. 2008;28(5):1451–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18794318.
  47. 47.
    Funama Y, Taguchi K, Utsunomiya D, Oda S, Yanaga Y, Yamashita Y, et al. Combination of a low-tube-voltage technique with hybrid iterative reconstruction (iDose) algorithm at coronary computed tomographic angiography. J Comput Assist Tomogr. [Internet]. 2011;35(4):480–5 [cited 28 Dec 2013]. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3151159&tool=pmcentrez&rendertype=abstract.
  48. 48.
    Kihara S, Murazaki H, Hatemura M, Sakumura H, Morisaki T, Funama Y. Radiation reduction and image quality improvement with iterative reconstruction at multidetector-row computed tomography. Nihon Hoshasen Gijutsu Gakkai Zasshi [Internet]. 2011;67(11):1426–32 [cited 28 Dec 2013]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22104234.
  49. 49.
    Kazakauskaite E, Husmann L, Stehli J, Fuchs T, Fiechter M, Klaeser B, et al. Image quality in low-dose coronary computed tomography angiography with a new high-definition CT scanner. Int J Cardiovasc Imaging [Internet]. 2013;29(2):471–7 [cited 28 Dec 2013]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22825255.
  50. 50.
    Hou Y, Liu X, Xv S, Guo W, Guo Q. Comparisons of image quality and radiation dose between iterative reconstruction and filtered back projection reconstruction algorithms in 256-MDCT coronary angiography. AJR Am J Roentgenol. [Internet]. 2012;199(3):588–94. [cited 28 Dec 2013]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22915398.
  51. 51.
    Fuchs TA, Fiechter M, Gebhard C, Stehli J, Ghadri JR, Kazakauskaite E, et al. CT coronary angiography: impact of adapted statistical iterative reconstruction (ASIR) on coronary stenosis and plaque composition analysis. Int J Cardiovasc Imaging [Internet]. 2013;29(3):719–24 [cited 28 Dec 2013]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23053859.
  52. 52.
    Sinitsyn VE, Glazkova MA, Mershina EA, Arkhipova IM. Possibilities of decreasing radiation load during MSRT coronarography: using adaptive statistic iterative reconstruction. Angiol Sosud Khir. [Internet]. 2012;18(3):44–9 [cited 28 Dec 2013]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23059606
  53. 53.
    Nakaura T, Kidoh M, Sakaino N, Utsunomiya D, Oda S, Kawahara T, et al. Low contrast- and low radiation dose protocol for cardiac CT of thin adults at 256-row CT: usefulness of low tube voltage scans and the hybrid iterative reconstruction algorithm. Int J Cardiovasc Imaging [Internet]. 2013;29(4):913–23 [cited 28 Dec 2013]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23160977.
  54. 54.
    Geyer LL, Körner M, Hempel R, Deak Z, Mueck FG, Linsenmaier U, et al. Evaluation of a dedicated MDCT protocol using iterative image reconstruction after cervical spine trauma. Clin Radiol. [Internet]. 2013;68(7):e391–6 [cited 28 Dec 2013]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23537577.
  55. 55.
    Laqmani A, Buhk JH, Henes FO, Klink T, Sehner S, von Schultzendorff HC, et al. Impact of a 4th generation iterative reconstruction technique on image quality in low-dose computed tomography of the chest in immunocompromised patients. Rofo [Internet]. 2013;185(8):749–57 [cited 28 Dec 2013]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23749649.
  56. 56.
    Sorantin E, Riccabona M, Stücklschweiger G, Guss H, Fotter R. Experience with volumetric (320 rows) pediatric CT. Eur J Radiol. [Internet]. 2012 [cited 16 Apr 2012]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22227261.
  57. 57.
    Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol. 2001;176(2):289–96.PubMedCrossRefGoogle Scholar
  58. 58.
    European Society of Urogenital Radiology. Guidelines of the European Society of Urogenital Radiology. Guidelines of the European Society of Urogenital Radiology [serial online] 2010; [cited 2010 Apr 27]. Online resource: http://www.esur.org/guidelines/.
  59. 59.
    Brodsky JB, Cohen EN, Brown Jr BW, Wu ML, Whitcher C. Surgery during pregnancy and fetal outcome. Am J Obstet Gynecol. 1980;138(8):1165–7.PubMedCrossRefGoogle Scholar
  60. 60.
    Steinberg ES, Santos AC. Surgical anesthesia during pregnancy. Int Anesthesiol Clin. 1990;28(1):58–66.PubMedCrossRefGoogle Scholar
  61. 61.
    Mazze RI, Kallen B. Reproductive outcome after anesthesia and operation during pregnancy: a registry study of 5405 cases. Am J Obstet Gynecol. 1989;161(5):1178–85.PubMedCrossRefGoogle Scholar
  62. 62.
    Kallen B, Mazze RI. Neural tube defects and first trimester operations. Teratology. 1990;41(6):717–20.PubMedCrossRefGoogle Scholar
  63. 63.
    Meroz Y, Elchalal U, Ginosar Y. Initial trauma management in advanced pregnancy. Anesthesiol Clin. 2007;25(1):117–29, x.PubMedCrossRefGoogle Scholar
  64. 64.
    Cook PT. The influence on foetal outcome of maternal carbon dioxide tension at caesarean section under general anaesthesia. Anaesth Intensive Care. 1984;12(4):296–302.PubMedGoogle Scholar
  65. 65.
    Visser W, Wallenburg HC. Central hemodynamic observations in untreated preeclamptic patients. Hypertension. 1991;17(6 Pt 2):1072–7.PubMedCrossRefGoogle Scholar
  66. 66.
    Wallenburg HC. Invasive hemodynamic monitoring in pregnancy. Eur J Obstet Gynecol Reprod Biol. 1991;42(Suppl):S45–51.PubMedGoogle Scholar
  67. 67.
    Schueler BA, Vrieze TJ, Bjarnason H, Stanson AW. An investigation of operator exposure in interventional radiology. Radiographics. 2006;26(5):1533–41.PubMedCrossRefGoogle Scholar
  68. 68.
    Timberlake GA, McSwain Jr NE. Trauma in pregnancy. A 10-year perspective. Am Surg. 1989;55(3):151–3.PubMedGoogle Scholar
  69. 69.
    James AH, Tapson VF, Goldhaber SZ. Thrombosis during pregnancy and the postpartum period. Am J Obstet Gynecol. 2005;193(1):216–9.PubMedCrossRefGoogle Scholar
  70. 70.
    Gates S, Brocklehurst P, Davis L J. Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period. Cochrane Database Syst Rev. 2002;(2):CD001689.Google Scholar
  71. 71.
    Jacobsen AF, Skjeldestad FE, Sandset PM. Ante- and postnatal risk factors of venous thrombosis: a hospital-based case–control study. J Thromb Haemost. 2008;6(6):905–12.PubMedCrossRefGoogle Scholar
  72. 72.
    James AH, Jamison MG, Brancazio LR, Myers ER. Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality. Am J Obstet Gynecol. 2006;194(5):1311–5.PubMedCrossRefGoogle Scholar
  73. 73.
    Andersen AS, Berthelsen JG, Bergholt T. Venous thromboembolism in pregnancy: prophylaxis and treatment with low molecular weight heparin. Acta Obstet Gynecol Scand. 2010;89(1):15–21.PubMedCrossRefGoogle Scholar
  74. 74.
    Dunlop DJ, McCahill JP, Blakemore ME. Internal fixation of an acetabular fracture during pregnancy. Injury. 1997;28(7):481–2.PubMedCrossRefGoogle Scholar
  75. 75.
    Leggon RE, Wood GC, Indeck MC. Pelvic fractures in pregnancy: factors influencing maternal and fetal outcomes. J Trauma. 2002;53(4):796–804.PubMedCrossRefGoogle Scholar
  76. 76.
    Loegters T, Briem D, Gatzka C, Linhart W, Begemann PG, Rueger JM, Windolf J. Treatment of unstable fractures of the pelvic ring in pregnancy. Arch Orthop Trauma Surg. 2005;125(3):204–8.PubMedCrossRefGoogle Scholar
  77. 77.
    Yosipovitch Z, Goldberg I, Ventura E, Neri A. Open reduction of acetabular fracture in pregnancy. A case report. Clin Orthop Relat Res. 1992;282:229–32.Google Scholar
  78. 78.
    Prokop A, Swol-Ben J, Helling HJ, Neuhaus W, Rehm KE. Trauma in the last trimester of pregnancy. Unfallchirurg. 1996;99(6):450–3.PubMedGoogle Scholar
  79. 79.
    Weiss HB, Songer TJ, Fabio A. Fetal deaths related to maternal injury. JAMA. 2001;286(15):1863–8.PubMedCrossRefGoogle Scholar
  80. 80.
    Esposito TJ, Gens DR, Smith LG, Scorpio R, Buchman T. Trauma during pregnancy. A review of 79 cases. Arch Surg. 1991;126(9):1073–8.PubMedCrossRefGoogle Scholar
  81. 81.
    Rogers FB, Rozycki GS, Osler TM, Shackford SR, Jalbert J, Kirton O, Scalea T, Morris J, Ross S, Cipolle M, Fildes J, Cogbill T, Bergstein J, Clark D, Frankel H, Bell R, Gens D, Cullinane D, Kauder D, Bynoe RP. A multi-institutional study of factors associated with fetal death in injured pregnant patients. Arch Surg. 1999;134(11):1274–7.PubMedCrossRefGoogle Scholar
  82. 82.
    Scorpio RJ, Esposito TJ, Smith LG, Gens DR. Blunt trauma during pregnancy: factors affecting fetal outcome. J Trauma. 1992;32(2):213–6.PubMedCrossRefGoogle Scholar
  83. 83.
    Kissinger DP, Rozycki GS, Morris Jr JA, Knudson MM, Copes WS, Bass SM, Yates HK, Champion HR. Trauma in pregnancy. Predicting pregnancy outcome. Arch Surg. 1991;126(9):1079–86.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Erich Sorantin
    • 1
    Email author
  • Nima Heidari
    • 2
  • Karin Pichler
    • 3
    • 4
  • Annelie-Martina Weinberg
    • 5
  1. 1.Department of RadiologyMedical University of GrazGrazAustria
  2. 2.Centre for OrthopaedicsRoyal London Hospital, Barts Health NHS TrustLondon, EnglandUK
  3. 3.Department of Orthopedic SurgeryMedical University of GrazGrazAustria
  4. 4.Department of Orthopedic SurgeryMedical University of InnsbruckInnsbruckAustria
  5. 5.Department of Orthopedic SurgeryMedical University of GrazGrazAustria

Personalised recommendations