INTRODUCTION

Management of trauma in pregnant women has always been a challenging task. The incidence of trauma during pregnancy is approximately 7%, with a higher incidence observed at advanced gestational age. Motor vehicle accidents (MVCs) are currently the leading cause of maternal trauma, accounting for up to 55% of all cases, followed by falls, assaults, and burns [1,2].

Placental abruption is a severe traumatic event that can occur during pregnancy. It occurs in 1% of all pregnancies and is one of the most frequent causes of perinatal and maternal morbidity [3,4]. Although painful vaginal bleeding is a typical symptom of abruption, in placental abruption with trauma, only regular uterine contractions are observed without significant vaginal bleeding [1]. Therefore, the Eastern Association for the Surgery of Trauma (EAST) practice guidelines recommend that all pregnant women with trauma at >20 weeks of gestation should undergo cardiotocographic monitoring for at least 6 hours, and physicians should consider obstetric consultation in all cases of trauma in pregnant patients [5].

Although the initial management priorities for injured pregnant women are the same as those for nonpregnant patients, physicians should keep in mind that there are two patients: the fetus and the mother. Here, we report the case of a 35-year-old woman with placental abruption following an MVC, with an atypical clinical presentation at the time of initial resuscitation.

CASE REPORT

A 35-year-old gravida 2 para 1 patient with chronic hypertension presented to the trauma center at 34 weeks and 2 days gestation complaining of chest and facial pain following an MVC 3 hours earlier. The patient was a driver wearing a seat belt, and a frontal airbag deployed at the time of the accident. The patient’s vehicle collided with the rear of the forward vehicle due to a sudden stop, and the speed of the patient’s vehicle at the time of the collision was unknown. The EMS evaluated the patient at the scene of the accident and transported her to the nearest obstetrics and gynecology hospital. Cardiotocography and ultrasonography performed at the hospital revealed no abnormal fetal findings. However, an obstetrician recommended that the patient be transferred to a level I trauma center for evaluation of her chest pain, and thus she was transferred to our trauma center.

Upon arrival at the trauma center, the patient was immediately assessed by the trauma team. Her blood pressure was 181/111 mmHg, heart rate was 102 beats per minute (bpm), and respiratory rate was 25 breaths per minute, with an oxygen saturation of 99% on room air. Physical examination revealed a gravid abdomen with a definite seat belt sign (Fig. 1) and no tenderness on palpation of the lower abdomen. The patient complained of chest and facial pain but did not have abdominal discomfort.

A Focused Assessment with Sonography for Trauma (FAST) showed no evidence of free fluid in the abdomen or pelvis, was negative for pericardial effusion, and showed normal lung sliding in both sides of the chest. Chest and facial computed tomography scans were performed to evaluate the presence of injury, and nasal bone fracture and minimal pulmonary contusions were diagnosed. An initial laboratory workup revealed maternal blood type A+, leukocytosis of 20.2×10³/μL (normal range, 3.4×10³/μL–10.6×10³/μL), and a normal international normalized ratio of 1.04.

The patient was subsequently admitted to the trauma intensive care unit for observation, and an obstetrician was consulted. Two hours after admission, the patient was sent to the delivery unit for obstetric examination and fetal monitoring, where she started to complain of worsening abdominal pain and vaginal discharge. Formal ultrasonography revealed no definite signs of placental abruption, whereas the fetal heart rate averaged 176 bpm. Vaginal examination revealed a closed cervix with pooling of amniotic fluid and no active bleeding. The amniotic fluid index was calculated as 3.39 cm, which implied premature rupture of membranes (Fig. 2). In fetal cardiotocography, regular uterine contractions were observed, whereas fetal tachycardia (baseline, 170 bpm) and minimal variability were noted (Fig. 3). A single dose of hydralazine 5 mg was administered intravenously because of persistent hypertension (185/117 mmHg). A subsequent hemoglobin level 2 hours later had dropped from 12.7 to 10.7 g/dL. On the first hospital day, she underwent a cesarean section, and the placenta revealed approximately 20% abruption. The estimated blood loss was 1,000 mL. The newborn at birth weighed 2,280 g, and the Apgar scores were 3 at 1 minute and 5 at 5 minutes.

Ethics statement

This study was reviewed and approved by the Institutional Review Board and Human Research Protection Center of Ajou University Hospital (No. AJOUIRB-EX-2024-355). The requirement for informed consent was waived, as all data were anonymized to protect the patient’s right to privacy.

DISCUSSION

Although trauma is the leading cause of nonobstetric maternal death, the management of trauma in pregnant women is challenging for trauma providers because of the altered physiology and anatomical relationships. Despite the physiological and anatomical differences, initial treatment strategies for injured pregnant patients remain identical to those for nonpregnant patients. Optimal initial resuscitation for the mother can establish the utmost treatment for the fetus. As gestational age advances, the incidence of trauma during pregnancy increases. Placental abruption is one of the leading causes of maternal morbidity and perinatal mortality, which occurs in half of major trauma cases. These cases are without significant vaginal bleeding but can be accompanied by regular uterine contractions [3,5,6]. The leading cause of placental abruption is not clear; however, numerous risk factors have been identified such as maternal hypertension, premature rupture of membranes, oligohydramnios, or trauma [7]. About 6% of all trauma cases are associated with placental abruption; however, placental abruption is difficult to predict based on the severity of injury [8].

Placental injury is directly associated with placental abruption. In contrast to the placenta, the uterus can change shape in response to forces on the abdomen due to its higher elasticity. Therefore, a shearing force can partially or completely disrupt the attachment between the placenta and decidua, and massive abruption can result in maternal morbidity and fetal death due to the loss of placental function [4,7]. Placental abruption is clinically diagnosed and should be suspected when a patient presents with vaginal bleeding or abdominal pain after trauma. Although ultrasonography is widely used in the initial evaluation of the fetus, its sensitivity for detecting placental abruption is only 24%, and false-negative findings of >50% have been reported. Although ultrasonography is insensitive to placental abruption, echogenic amniotic fluid and retroplacental hemorrhage are signs of abruption [9]. In this case, the diagnosis of placental abruption was not established through ultrasonography. Therefore, physicians should understand the importance of meticulous observation and continuous monitoring of both fetal and maternal conditions in the management of injured pregnant patients.

The optimal length of fetal monitoring following trauma is not clear, though the EAST guidelines recommend a minimum of 6 hours of cardiotocographic monitoring for pregnant women at >20 weeks of gestation [5]. Placental abruption mostly occurs within 4 to 9 hours after a traumatic event, with almost all cases occurring within 24 hours of injury. Even with minor trauma, abruption can occur, and it is important to maintain a high level of suspicion to detect the abruption. Therefore, in pregnant trauma patients with risk factors for adverse fetal outcomes, monitoring may be necessary for at least 24 hours [10,11]. Patients with abnormal cardiotocographic monitoring, significant vaginal bleeding, unstable vital signs, and abnormal findings on physical examination, including seat belt signs or abdominal tenderness, should be managed by trauma and obstetric teams with close monitoring.

ARTICLE INFORMATION

Author contributions

Conceptualization: DC; Investigation: JK, SK, DK; Methodology: JK; Visualization: SK, DK; Writing–original draft: JK; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Images of the patient upon arrival. (A) Clinical image showing abdominal seat belt sign (diagonal abrasions are present along the course of the three-point seat belt). (B) A right flank abrasion and bruise on the patient who was seated on the driver’s side.

Fig. 2.

Ultrasound scan images. (A) The amniotic fluid index (AFI) was estimated at 3.39 cm, which indicates oligohydramnios. (B) The cervix length of the patient was 4.78 cm, which is in the normal range. (C) Ultrasound detected fetal heart rate was 176 beats per minute, which indicates fetal tachycardia. (D) Ultrasound scan confirmed non-heteroechogenic placenta.

Fig. 3.

Fetal tachycardia (baseline, 170 beats per minute) and minimal variability were noted, whereas regular uterine contractions were observed.

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Figure & Data

References

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