a b s t r a c t

Background: After a traumatic injury, the provision of appropriate, timely care to pregnant women jury is crucial for the health of both the mother and fetus. The aim of this study was to identify risk factors predicting post- traumatic obstetric complications in pregnant women who presented to the emergency department (ED) with traumatic injuries.

Methods: We conducted a retrospective cohort study of pregnant women aged 18 y and older who were admitted to the trauma unit of our ED between 2017 and 2020. The data collected included maternal demographics, trauma mechanism, and pregnancy outcome. The patients were divided into two subgroups according to the presence or absence of trauma-related complications, and clinical features were compared between the two groups.

Results: In total, 241 pregnant trauma patients were included in the study. The mean maternal age was 26.1 +- 4.4 y, and the mean gestational age the time of the trauma was 28.4 +- 6.8 wk. In the study, 17.8% (43/241) of patients experienced obstetric-related complications within the first 24 h post-trauma. The risk factors associated with obstetric complications were aged older than 35 y (odds ratio [OR] = 5.31,95% confidence interval [CI]: 1.77-15.96, p = 0.003), Third trimester trauma (OR = 2.41,95% CI:1.14-5.12, p = 0.021), and abnormal obstetric ultrasonography (OR = 6.25,95% CI:2.03-19.22, p = 0.001).

Conclusion: Among pregnant patients who present to the ED after a traumatic injury, advanced maternal age, trauma in the third trimester, and abnormal obstetric ultrasonography findings should alert physicians to the possibility of post-traumatic complications (within the first 24 h after trauma) and the need for close monitoring.

(C) 2021

1. Introduction

Traumatic injuries during pregnancy threaten the health of both the mother and fetus [1]. Approximately 7% of pregnancies are complicated by traumatic injuries [2]. Anatomical and physiological changes that occur during pregnancy complicate the evaluation and management of pregnant women who present to the emergency department (ED) with traumatic injuries. The majority of traumatic injuries that occur during pregnancy are minor and do not result in adverse obstetric outcomes [3]. However, traumatic injuries in pregnancy can lead to obstetric complications, such as spontaneous abortion, fetal or neo- natal death, retroplacental hematomas, Uterine rupture, placental abruption, and preterm delivery [3,4]. Guidelines regarding the man- agement of traumatic injuries in pregnant patients do not differenti- ate between minor and major traumas [5,6]. Irrespective of the

* Corresponding author at: Aksaray Universitesi Egitim ve Arastirma Hastanesi, Yeni Sanayi Mahallesi, 68200 Merkez/Aksaray, Turkey.

E-mail address: [email protected] (Z.S. Sert).

nature of the trauma (i.e., major or minor), the guidelines of the Royal College of Obstetricians and Gynecologists on the management of obstetric trauma recommend that maternal vital signs should first be stabilized and that the fetal condition should then be monitored [5]. Likewise, the guidelines of Advanced Trauma Life Support do not take the nature of the trauma into account, recommending a pri- mary survey and resuscitation of the mother first, followed by an assessment of the fetus and then a secondary survey of the mother [6].

Management of traumas that occur during pregnancy requires a Multidisciplinary team approach. A better understanding of ob- stetric risks posed by traumatic injuries during pregnancy and identification of clinical difficulties faced by clinicians would sig- nificantly contribute to patient management and monitoring in the ED. To protect the health of the mother and fetus after a trau- matic injury, it is vital to detect obstetric problems early and to implement appropriate interventions as quickly as possible. The aim of this study was to determine the risk factors predicting post-traumatic obstetric complications in pregnant women who presented to the ED with traumatic injuries.

https://doi.org/10.1016/j.ajem.2021.02.056

0735-6757/(C) 2021

1. Material and methods
   1. Study design

This retrospective cohort study was conducted in the ED of a university-affiliated training hospital. Approximately 300,000 patients are admitted to the ED of this hospital each year, and 10% of this popu- lation consists of adult trauma patients. All pregnant patients who pres- ent to the trauma unit in our hospital are seen by an obstetrician. Pregnant patients are initially stabilized in the trauma unit and then evaluated and monitored by both the trauma unit and the ED. This study was approved by the local ethics committee (No.: 2020/09-17).

• 1. Study population

The study population consisted of pregnant women aged 18 y and older who were admitted to the trauma unit of our ED between January 2017 and January 2020. Cases were identified using the electronic med- ical database of our hospital’s trauma unit and obstetric department. In the patients who presented to the ED with trauma-related injuries, the prospectively recorded data included the vital signs of the patient at the time of admission to the ED, pregnancy status at the time of the trauma, Injury Severity Score (ISS), trauma mechanism, and trauma site. The case presentations were classified using the International Classification of Disease-10 Coding system.

Pregnant patients with major and minor traumatic injuries and an ISS score of >0 were included in the study. Pregnant patients with trau- matic injuries who had incomplete records or who were transferred to another hospital for any reason were excluded, in addition to those younger than 18 y.

• 1. Data collection

Based on inclusion and exclusion criteria, patient selection was done by 2 investigators independently, and they resolved disputes through discussion (ZSS and ETS). A random sample of 10% of patients was checked for accuracy by a third investigator (KK). Based on the random check, the data was considered to be accurate and it was determined by the investigators that a second check was not needed for the remainder of the data. In all pregnant patients who presented to the ED with trau- matic injuries, data were obtained on the patient’s age, gestational week, gravidity, parity, history of singleton or multiple births, and his- tory of diseases, as well as the trauma mechanism/site and the ISS.

In patients who experienced complications, the types of complica- tions and perinatal outcomes were recorded. Obstetric ultrasonography findings (i.e., retroplacental clots, placental location, amniotic fluid index, fetal position, and fetal vitality) were also recorded, and elec- tronic fetal heart rate monitoring and uterine tocodynamometry data were collected.

• 1. Patient assessment and monitoring

All the patients were assessed using a standard protocol. After an ini- tial physical examination, obstetric ultrasound and laboratory tests were conducted. Laboratory tests included the complete blood count, blood chemistries, coagulation profile and blood type analysis. Irrespec- tive of the nature of the trauma (major or minor), all the patients underwent 4 h of continuous cardiotocography. If contractions or other abnormal signs were detected, the monitoring time was further extended. All the women were admitted for 24-h observation, regard- less of the results of the Primary evaluation at admission. The length of hospitalization was extended in cases of uterine contractions, abnor- mal fetal heart rate monitoring, and clinical evidence of preterm labor or placental abruption.

The patients were divided into two subgroups according to the pres- ence or absence of trauma-related complications that developed within

24 h from the time of the first presentation to the ED, and clinical features between the two groups were compared. A flowchart of the pa- tient selection in the study cohort is presented in Fig. 1.

• 1. Definitions

The patients were grouped according to the severity of the trauma. For clinical use and in accordance to other studies, an ISS of 9 or higher was considered severe (1,3). Abnormal uterine activity after 20 wk. of gestation was defined as the occurrence of more than four uterine con- tractions in a 1-h monitoring period. Fetal ultrasound abnormalities were defined as oligohydramnios, retroplacental or subchorionic hem- orrhages, spontaneous abortion, suspected (partial) placental abrup- tion, and an abnormal Gestational sac.

• 1. Outcome measures

The primary outcome was the occurrence of post-traumatic ob- stetric complications within the first 24 h after admission to the ED. Trauma-related complications included delivery secondary to trauma, spontaneous abortion, premature rupture of membranes, delivery before 37 wk. of gestation, an emergency cesarean section due to unreliable fetal heart tracings, retroplacental hematomas, pla- cental abruption, uterine rupture, fetal distress, fetal or neonatal death, and maternal death. The secondary outcome was the associa- tion between the clinical features at the time of admission to the ED and post-trauma obstetric complications.

• 1. Statistical analysis

All statistical data were analyzed using SPSS for Windows, version

17.0 (SPSS Inc., Chicago, IL, USA) software. Descriptive data are pre- sented as numbers (n), frequencies (%), and mean and standard devia- tions. Pearson’s chi-square or Fisher’s test was used for comparison of categorical variables. To test the normality of the distribution of contin- uous variables, the Kolmogorov-Smirnov test was used. The student’s t-test was used to compare normally distributed data, and the Mann- Whitney U test was used to compare non-normally distributed data. Univariate and multivariate logistic regression analyses were performed to determine the potential relationship between obstetric complications and clinical variables. Only variables with a p value of <0.1 in the univar- iate logistic regression analysis were included in a multivariate logistic regression analysis. Odds ratios (ORs) and their 95% confidence inter- vals (CIs) were calculated to estimate the relationship between inde- pendent determinants of obstetric complications. In the multivariate logistic regression analysis and other tests, a value of p < 0.05 was con- sidered statistically significant.

1. Results

In total, 241 pregnant trauma patients were included in the study. The mean maternal age was 26.1 +- 4.4 y, and the mean week of gesta- tion at the time of the trauma was 28.4 +- 6.8 wk. In terms of parity, al- most half (46.5%) the patients had given birth previously (parity: 1). Of the patients, 90/37.3% were in the first trimester, 62/25.7% were in the second trimester, and 88/36.5% were in the third trimester. In 45.2% of cases, a motor vehicle collision was the cause of the trauma. The demo- graphic and clinical characteristics of the cases are presented in Table 1. The most common complaint after the trauma was abdominal pain (22.4%). The median ISS score of those who developed complications within the 24 h after admission to the ED was 3 (ISS: 3-9). Among those with an ISS of >=9, 27.9% (n = 12) of patients experienced obstetric-related complications.

In the study, 17.8% (43/241) of patients experienced complications within the first 24 h after the trauma. There were no cases of Maternal mortality. The complications that developed due to the traumatic

Fig. 1. Flow chart of study Selection process.

injuries are summarized in Table 2. The most common complication was an emergency cesarean section (23.2%). Table 3 provides informa- tion on the results of the univariate and multiple logistic regression analyses, which were performed to determine the risk factors that in- creased the likelihood of post-traumatic obstetric complications. In the regression analysis, age > 35 y (OR = 5.31, 95% CI: 1.77-15.96, p = 0.003), third trimester trauma (OR = 2.41, 95% CI: 1.14-5.12, p = 0.021), and abnormal obstetric ultrasonography findings (OR = 6.25, 95% CI: 2.03-19.22, p = 0.001) at the time of admission to the ED in- creased the probability of post-traumatic complications within the first 24 h after admission.

1. Discussion

Providing appropriate, timely care after a trauma is crucial for the health of both the mother and fetus. In our study, 43 (17.8%) pregnant trauma patients developed obstetric complications. In our study popu- lation, based on a comparison of the cases who experienced adverse outcomes after a traumatic injury versus those who did not, the follow- ing factors were associated with adverse maternal and Fetal outcomes within the first 24 h after admission to the ED: maternal age, gestational age at delivery, and obstetric ultrasonography findings.

According to previous hospital-based studies, the rate of Fetal loss

after maternal trauma varied between 4.7% and 19.1% [7,8]. In one ret- rospective study that evaluated 1195 pregnant trauma patients, the ma- ternal mortality rate was 1.4%, and the fetal loss rate was 5.5% [9]. In another retrospective cohort study on 411 pregnant patients hospital- ized after blunt trauma, the most common post-traumatic obstetric complications in the ED were preterm delivery and placental abruption. In the same study, independent risk factors for such complications in- cluded severe trauma, multiple pregnancies, Vaginal bleeding, and uter- ine contractions [10]. In our study, trauma in the third trimester, advanced gestational age, and abnormal obstetric ultrasonography find- ings at the time of admission to the ED were predictors of adverse ob- stetric outcomes after traumatic injuries. In addition, we detected a high rate of post-traumatic obstetric complications.

Previous studies reported that traumatic injuries during pregnancy were associated with an increased risk of spontaneous abortion, placen- tal abruption, premature rupture of membranes, preterm delivery, uter- ine rupture, and stillbirths, regardless of the severity of the trauma [3,4]. Although some studies reported that minor traumas appeared to be associated with fetal mortality [11,12], others reported that close follow-up was unnecessary in cases of minor traumas [13]. In a study on pregnant women who experienced traumatic injuries, El-Kady et al. [3] reported a relationship between the severity of the trauma and the risk of complications. In a prospective study on 317 pregnant women with minor traumatic injuries, Cahill et al. [13] found that the incidence of adverse maternal and Fetal outcomes due to trauma was low.

Studies aimed at estimating the value of the ISS in predicting adverse obstetric maternal and fetal outcomes in patients with major or minor injuries have reported conflicting results [3,4,9]. According to El-Kady et al. [3], a high ISS was unable to predict adverse obstetric outcomes. In some studies, a high ISS was not a good predictor of adverse obstetric outcomes [3,4]. In our study, trauma-related complications were highly dependent on gestational age and less dependent on the type, mecha- nism, or severity of the trauma. In addition, a high ISS was not an inde- pendent predictor of adverse obstetric outcomes, similar to the results of previous studies [3,4].

Earlier studies reported that in pregnant women who presented with major traumatic injuries, a traffic accident was the most common injury mechanism, whereas a fall was the most common injury mecha- nism in those who presented with minor traumas [14,15]. In terms of those patients who presented after a fall, those with major trauma to the abdominal region and a high ISS had a significantly high risk of ma- ternal morbidity and fetal mortality [16,17]. Curet et al. [18] found that major traumas (i.e., ISS >= 9), such as those encountered in vehicle- pedestrian collisions, motorcycle crashes, and crashes where the driver was not wearing a seat belt, were associated with an increased risk of placental abruption and fetal death, as well as maternal shock and death. Our results confirmed that motor vehicle accidents were associ- ated with serious maternal and Fetal complications. In terms of the loca- tion of the injury, although an abdominal site of injury was associated

Table 1

Demographic and obstetric characteristics of the study population.

Table 2

The type and rate of complications following trauma in the study population.

Parameters Complications

Yes No p-value

Pregnancy complication during the first 24 h of trauma admission

Number of cases^a

N (%)

	(n = 43)		(n = 198)		Delivery <37 wks Emergency CS	8(18.6%) 10(23.2%)
Age	28.8 +- 4.9		25.5 +- 4.4	<0.001	Delivery secondary to trauma	7(16.3%)
Age > 35 years	8(18.6%)		10(5.1%)	0.006	Uterine rupture	1(2.3%)
Glasgow Coma Scale	15(14-15)		15(14-15)	0.055	Placental abruption	2(4.7%)
Systolic blood pressure (mmHg)	123(112-136)		124(110-141)	0.346	Premature rupture of membrane	4(9.3%)
Diastolic blood pressure (mmHg)	86 (80-95)		85(81-95)	0.433	Spontaneous abortion	3(7.0%)
Heart rate (per minute)	94(82-111)		92(80-107)	0.351	Fetal or neonatal death	2(4.7%)
Body mass index(kg/cm2)	23(22-26)		25(22-27)	0.384	Retroplacental hematoma	2(4.7%)
Parity				0.285	Fetal distress	10(23.2%)
Nulliparous	4(9.3%)		37(18.7%)		Maternal death	0

CS: cesarean section.

1	25(58.1%)	87(43.9%)
2	10(23.3%)	53(26.8%)
3+	4(9.3%)	21(10.6%)
estational age at injury First trimester 11(25.6%) 79(39.9%) 0.079
Second trimester	7(16.3%)	55(27.8%)	0.118
Third trimester	25(58.1%)	63(31.8%)	0.001
omplaints Uterine contractions 7(16.3%) 18(9.1%) 0.161
Vaginal bleeding	14(32.6%)	21(10.6%)	<0.001
Reduced fetal movements	4(9.3%)	17(8.6%)	0.774
Abdominal pain	12(27.9%)	42(21.2%)	0.340
resence of risk factor History of a cesarean delivery 6(14.0%) 34(17.2%) 0.607

^a Some women experienced more than one complication, so the total of all complica-

G tions exceeded the number of women who experienced complications (N = 43).

C

Table 3

Univariate and multivariate analysis of predictive factors for complications.

Variables Univariate logistic

P regression

Multivariate logistic regression

Platelets (x10⁹/L) 249.8 +- 65.7 237.4 +- 64.1 0.63

Hypertension	0	3(1.5%)	0.553		OR	95% CI	p value		OR	95% CI	p value
Smoking	2(4.7%)	8(4.0%)	0.856	Age >35 years	4.29	1.58-11.64	0.004		5.31	1.77-15.96	0.003
Diabetes (pregestational and	2(4.7%)	15(7.6%)	0.386	Third trimester trauma	2.97	1.51-5.84	0.002		2.41	1.14-5.12	0.021
gestational)				Vaginal bleeding	3.65	1.65-8.06	0.001		2.43	0.94-6.23	0.064
Laboratory findings				ISS>=9	2.25	1.04-4.89	0.039		2.09	0.82-5.29	0.119
Hemoglobin (g/dL)	11.3 +- 2.1	11.5 +- 3.2	0.85	Abdominal trauma	2.07	1.05-4.06	0.033		1.86	0.84-4.13	0.123

INR > 1.5 0 0 N/A

Fibrinogen <200 mg/dL 0 3(1.5%) 0.553

ISS	3(3-9)	4(2-8)	0.376
ISS >= 16	7(16.3%)	9(4.5%)	0.012
Category of ISS (%)			0.036
ISS <9	31(72.1%)	169(85.4%)
ISS >=9	12(27.9%)	29(14.6%)
Mechanism of injury			0.676
Fall	14(32.6%)	68(34.3%)
Motor vehicle crash	18(41.9%)	91(46.0%)
Assault	6(14.0%)	27(13.6%)
Other	5(11.6%)	12(6.1%)
Main trauma location			0.003
Head and neck	0	45(22.7%)
Thorax and back	11(25.6%)	34(17.2%)
Abdomen	26(60.5%)	84(42.4%)
Pelvis	6(14.0%)	35(17.7%)
Abnormal obstetric ultrasounda	10(23.3%)	7(3.5%)	<0.001
Abnormal cardiofoetal rhythm	5(11.6%)	8(4.0%)	0.061

Data are presented as mean +- STD,Median and 25-75 percentiles or N (%), INR: Interna- tional Normalised Ratio, ISS: Injury Severity Score. Bold text indicates a statistically signif- icant difference with a p-value less than 0.05.

^a Fetal ultrasound abnormalities include oligohydramnios(n = 6), retroplacental or subchorionic hemorrhage (n = 4), spontaneous abortion (n = 3), suspected (partial) abruption(n = 2), abnormal gestational sac (n = 2).

with obstetric-related complications in the univariate analysis, it was not independently associated with complications in the multivariate analysis.

• 1. Limitations

This study has some limitations. First, the retrospective nature of the study limited the data to those routinely collected from trauma patients who presented to the ED. The exclusion of trauma patients with incom- plete data on obstetric outcomes was a substantial limitation. The retro- spective study design may also have been subject to selection bias, as

ISS: Injury Severity Score. Bold text indicates a statistically significant difference with a p-value less than 0.05.

this study included only pregnant trauma patients admitted to the ED. Second, this was a single-center study. Third, the patients were identi- fied using the hospital’s electronic medical database. This database does not take account of pregnant patients with traumatic injuries who died at the scene and were therefore not taken to the hospital. Fourth, because our sample size is relatively small and confidence inter- vals are large, the generalizability of our results is limited. Different sam- ple sizes can provide different confidence intervals and thus different results regarding statistical significance. Further studies involving mul- tiple centers are needed to validate our results.

1. Conclusion

Pregnant women who experience major or minor traumatic injuries and are admitted to the hospital should be monitored closely through- out the remainder of their pregnancy. Among such patients, there is a risk for adverse Pregnancy outcomes among women of advanced ma- ternal age, women in the third trimester, and women with abnormal obstetric ultrasonography findings. The presence of these risk factors should alert physicians to the possibility of post-traumatic complica- tions within the first 24 h after admission. The results of the present study can help identify pregnant women who require obstetric consul- tation and close monitoring after traumatic injuries, even in the absence of apparent post-traumatic complications at the time of presentation to the ED.

Ethical approval

This study was approved by the ethics committee of the Aksaray University Faculty of Medicine (approval no. 2020/09-17).

Consent for publication

All authors have read and approved the final version of this manu- script and have consented for publication.

Financial disclosure

The authors declared that this study has received no financial support.

Declaration of Competing Interest

All authors report no conflict of interest.

Acknowledgements

The authors thank all the participants in this study.

References

1. Van der Knoop BJ, Zonnenberg IA, Otten VM, Van Weissenbruch MM, De Vries JIP. Trauma in pregnancy, obstetrical outcome in a tertiary centre in the Netherlands. J Matern Fetal Neonatal Med. 2018;31(3):339-46.
2. Mendez-Figueroa H, Dahlke JD, Vrees RA, Rouse DJ. Trauma in pregnancy: an up- dated systematic review. Am J Obstet Gynecol. 2013;209(1):1-10.
3. Kady DE, 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.
4. Schiff MA, Holt VL. The injury severity score in pregnant trauma patients: predicting placental abruption and fetal death. J Trauma. 2002;53(5):946-9.
5. Managing obstetric emergencies and trauma2nd ed.. London: RCOG Press; 2016.
6. Galvagno SM, Nahmias JT, Young DA. Advanced trauma life support (R) update 2019: management and applications for adults and special populations. Anesthesiol Clin. 2019;37(1):13-32.
7. Aboutanos MB, Aboutanos SZ, Dompkowski D, Duane TM, Malhotra AK, Ivatury RR. Significance of motor vehicle crashes and pelvic injury on fetal mortality: a five-year institutional review. J Trauma. 2008;65(3):616-20.
8. Greene W, Robinson L, Rizzo AG, Sakran J, Hendershot K, Moore A, et al. Pregnancy is not a sufficient indicator for trauma team activation. J Trauma. 2007;63(3):550-4 [discussion 554-5].
9. 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.
10. Melamed N, Aviram A, Silver M, Peled Y, Wiznitzer A, Glezerman M, et al. Pregnancy course and outcome following blunt trauma. J Matern Fetal Neonatal Med. 2012;25 (9):1612-7.
11. Schiff MA. Pregnancy outcomes following hospitalisation for a fall in Washington state from 1987 to 2004. BJOG. 2008;115(13):1648-54.
12. Schiff MA, Holt VL, Daling JR. Maternal and infant outcomes after injury during preg- nancy in Washington state from 1989 to 1997. J Trauma. 2002;53(5):939-45.
13. Cahill AG, Bastek JA, Stamilio DM, Odibo AO, Stevens E, Macones GA. Minor trauma in pregnancy - Is the evaluation unwarranted? Am J Obstet Gynecol. 2008;198(2): 208 e1-5.
14. Kuo C, Jamieson DJ, McPheeters ML, Meikle SF, Posner SF. Injury hospitalizations of pregnant women in the United States, 2002. Am J Obstet Gynecol. 2007;196(2): 161 e1-6.
15. Chames MC, Pearlman MD. Trauma during pregnancy; outcomes and clinical man- agement. Clin Obstet Gynecol. 2008;51(2):398-408.
16. Battaloglu E, McDonnell D, Chu J, Lecky F, Porter K. Epidemiology and outcomes of pregnancy and obstetric complications in trauma in the United Kingdom. Injury. 2016;47(1):184-7.
17. Petrone P, Talving P, Browder T, Teixeira PG, Fisher O, Lozornio A, et al. Abdominal injuries in pregnancy: a 155-month study at two level 1 trauma centers. Injury. 2011;42(1):47-9.
18. Curet MJ, Schermer CR, Demarest GB, Bieneik III EJ, Curet LB. Predictors of outcome in trauma during pregnancy: identification of patients who can be monitored for less than 6 hours. J Trauma. 2000;49(1):18-24 [discussion 24-5].