Why is gestational age of importance in maternal physical trauma?
Direct trauma to the abdomen below twelve weeks of gestation is unlikely to directly affect the pregnancy, because the uterus is still entirely in the pelvic cavity up to that stage.
Trauma sustained in the early second trimester up to about twenty-four weeks may lead to miscarriage; or if it is 24 weeks or beyond, it can cause preterm labour, depending on severity. The eventual consequence is pregnancy loss because most severely premature babies are lost, even if born alive.
Penetrating trauma sustained in the latter phase of pregnancy (third trimester) has a 40-70 per cent chance of leading to fetal loss. Indirect trauma leading to preterm labour has a less adverse outcome.
Psychological "fallout" from trauma has been mentioned as a factor in the likely outcome. What does this mean?
Researchers have repeatedly observed that there is no consistent relationship between the severity of the physical injury and fetal outcome in trauma during pregnancy. This is particularly observed when trauma was a result of inter-personal violence usually involving a husband or boyfriend.
It has been observed that in some cases where the maternal injury severity score was 0 (i.e. virtually no physical injury), the woman went on to lose the pregnancy. It is believed that the weight of mental and psychological distress resulting from the assault leads to this outcome. This is why it is important to ensure that all victims of assault are given not only the medical treatment for the physical injury (if there), but psychological support as well.
Results of trauma in pregnancy
If trauma sustained in pregnancy leads to heavy blood loss, does this put the pregnancy at a particularly increased risk?
Yes. When there is severe haemorrhage as a result of an injury to any part of the body, the body does not classify the pregnant uterus as a vital organ. If you are going into shock as a result of haemorrhage, blood will be diverted from your uterus to organs such as your heart, lungs and brain. If you think about it, this is logical. What is the point of ensuring fetal survival, if the mother is going to be killed in the process?
Prolonged shock from severe haemorrhage will almost inevitably lead to fetal loss.
What is the best position for a bleeding pregnant woman who has sustained trauma?
Place her on her left side and avoid putting her in a supine (lying on her back) position. This will allow adequate blood to continue flowing to the fetus. It will also prevent increased bleeding from injured lower limbs, a feature associated with a supine position.
Is caesarean section on the cards for a woman presenting with an injury?
Very much so, but this will depend on a few factors. As a rule, caesarean section will only be considered where fetal viability outside the womb is a realistic prospect.
Caesarean section will be considered in cases of:
fetal distress that cannot be relieved otherwise
penetrating injury to the uterus, putting maternal or fetal life at risk
some forms of spinal injury
a need for extensive treatment to the mother in the abdominal area where the pregnant uterus may be in the way.
Is fetal death an indication for caesarean section?
No. The exception, which is quite uncommon, is where this measure is deemed an essential part of treatment for the injured mother.
If abdominal surgery was performed late in pregnancy but the uterus was left untouched, will this mean an inevitable caesarean delivery?
Not at all. The mother may be anxious that her abdominal scar is still too fresh and therefore not strong enough to withstand the rigours of labour. This is not so and even a two week old scar can and will withstand labour.