Trauma during pregnancy in a Nigerian setting: Patterns of presentation and pregnancy outcome.

CONTEXT: Trauma is an important health concern during pregnancy in developing nations though it is under-reported. AIMS: The aim of this study was to determine the patterns of presentation and feto- maternal outcomes of trauma during pregnancy in a Nigerian setting. SETTINGS AND
DESIGN: A hospital-based retrospective analysis of database of entire patient population who presented in Ebonyi State University Teaching Hospital, Abakaliki, with trauma during pregnancy.
MATERIALS AND METHODS: The data on demographics, obstetrics, and injury characteristic in addition to the outcome of all injured pregnant women hospitalized from January 2002 to December 2010 were analyzed. STATISTICAL ANALYSIS: SPSS version 16 and quantitative skills software SISA were used in data analysis.
RESULTS: Trauma-necessitated hospitalization in 12 per 1000 pregnant women admitted in antenatal ward and was a complication of pregnancy in 4.7 per 1000 live birth in the hospital. Physical assault was the predominant causative factor and accounted for 46% of injuries whereas road traffic accident (motorcycle injury related in over 80%) was involved in 30.2% of the patients. The parity of the patients was significantly related to the trimester of pregnancy at the time of injury - 73% of grand-multiparae and about 60% of primigravida involved presented with injury in the 3(rd) and 2(nd) trimester, respectively (P < 0.017). Preterm delivery (7.9%), abruptio placentae (4.8%), and stillbirth (4.8%) were common obstetric complications observed. Maternal mortality of 1.6% and fetal loss of 7.9% were associated with trauma.
CONCLUSIONS: Injury prevention measures during pregnancy deserve a place in any policy response aimed at reducing feto-maternal morbidity and mortality in developing countries.

INTRODUCTION

Morbidity and mortality associated with trauma is a major problem worldwide. Prompt and adequate care of injured patients in developing nations can be quite challenging due to lack of appropriate infrastructure and equipment in hospitals.[1] The care of the injured is even more demanding where two delicate patients, the pregnant mother and her fetus are involved. The anatomical and physiological changes in pregnancy, that can mask or mimic the clinical features of injury and make diagnosis of trauma-related problem difficult, compound the situation.

In developed and high-income nations, trauma complicates 6-7% of all pregnancy.[2] “Maternal injury is also the leading non-obstetric cause of fetal death in developed countries.”[3]

The etiology of trauma varies between and within countries depending on prevailing cultural and geopolitical conditions. The causes of maternal trauma during pregnancy are almost similar to that of the general population. Thus, road traffic accident, falls, physical assault, burns, gunshot, and firearms are common causes of traumatic injury in pregnancy documented in most published studies.[34567] However, pregnant women are more vulnerable to injuries from falls due to gait instability arising from pelvic ligament laxity and altered center of gravity by the gravid uterus.[68]

Non-severe or severe traumatic injury during pregnancy has been associated with increased risk of obstetrics complications such as abortion, premature rupture of membrane, preterm delivery, placental abruptio, uterine rupture, stillbirth, and maternal death.[45]

Therefore, an understanding of the pattern of presentation of maternal trauma and its pregnancy outcome in an environment can facilitate appropriate injury-preventive measures aimed at achieving optimum care.

Although there have been many published reports on trauma in pregnancy only a few of them are from West African countries. Thus, limited data on trauma during pregnancy in the sub-region necessitated this study.

The aim of this study was to determine the pattern of presentation and feto-maternal outcome of trauma during pregnancy in a Nigerian setting.

MATERIALS AND METHODS

Setting

This was a retrospective study of all pregnant women hospitalized for trauma in Ebonyi State University Teaching Hospital (EBSUTH), Abakaliki, within a period of 9 years- January 2002 to December 2010. EBSUTH serves a population of 8 million and is one of the major University teaching hospital in Southeast Nigeria.

Study design and ethics statement

With the permission of the Hospital Ethics and Research Committee, the case notes of these patients served as the source of data. Personal interview via mobile telephone communication (telephone numbers extracted from patients’ case notes) served as an additional source of data on the outcome of pregnancy in some patients who were lost to follow-up after discharge with normal developing pregnancy.

Information such as demographic and obstetric data, etiology and mechanism of injury, trauma score parameters, anatomical site of injury, complications related to trauma, maternal and perinatal outcome were all extracted from the patients’ case notes. In the setting of this study, all injured women presenting to the hospital with a history of missed menstrual period were routinely screened for pregnancy. The ones with documented evidence of pregnancy confirmed by positive serum human chorionic gonadotropin test, physical, and ultrasound examination were included in this study. Thus, this study included those with pregnancy as early as gestational age of 8 weeks.

The injury severity score (ISS) of each of the patient was calculated using the trauma score parameters documented. Patients with ISS of 1-8 were classified as having non-severe injury whereas those with ISS ≥9 were classified as having severe injury. An ISS cut-off point of 9 was used because prior studies have reported its high sensitivity and specificity in predicting fetal death.[910]

A serial coordinated multi-disciplinary team approach involving emergency physicians, obstetricians, surgeons, anesthetists, neonatologists, radiologists, and others as the cases demanded was the modality of care in all the patients. The patients were received in emergency unit of the hospital on arrival.

Maternal stability and survival was a high priority, thus on arrival in emergency room patients were first resuscitated based on Advance Life Trauma Support protocols in addition to deflection of gravid uterus to the left using a wedge. Evaluation for fetal well-being was given due attention as soon as maternal stability was ensured after initial resuscitation. Ultrasonography was used in all cases for evaluation of fetal well being, gestational age, amniotic fluid volume, and placenta location. There was neither cardiotocographic monitoring nor Kleihauser Betke test carried out on any of the patients. Anti-D immunoglobulin was administered to mothers who were Rh D-negative. After initial maternal resuscitation, stabilisation and evaluations in emergency room the patients were admitted into the ward or intensive care unit with the obstetrician leading in the coordinated effort of multiple personnel involved in patients management.

Pregnancy outcome was successful if the infant survived the neonatal period and unsuccessful if spontaneous abortion, stillbirth, fetal death in utero, or neonatal death occurred.

Statistical analysis

Data analysis was carried out with statistical package for social sciences (SPSS) version 16 and quantitative skills software SISA. Frequency tables, cross tabulation, Fisher exact table, and Pearson Chi-square test of significance were used. For all statistical analysis, a P < 0.05 was considered significant.

RESULTS

Within the 9-year study period, 5339 pregnant women were admitted in the antenatal ward and the indication for admission in 63 of them was trauma i.e. 12 in every 1000 pregnant women were admitted into the antenatal ward because of injury. There were 13,500 live births in the hospital within the same period, thus 4.7 per 1000 live births were involved in trauma during pregnancy.

Maternal age was between 15 and 35 years. The mean age was 25.5 ± 5 years. The mean age of the primigravidae, multiparous, and grand-multiparous was 21.3 ± 4.3, 26.4 ± 3.4, and 31.1 ± 3.4 years, respectively.

Fifty-nine (93.7%) patients were married whereas about four (6.3%) of them were single parent.

The highest education attained was primary in 26 (41.3%), secondary in 29 (46.0%), and tertiary in four (6.4%) of the patients. Four patients (6.4%) had no formal education.

Full-time housewives (16 patients) accounted for 25.4% of the women. Farmers, civil servants, and traders each accounted for 11 patients (17.7%) whereas students, tailors, and hairdresser each accounted for 16.1%, 4.2%, and 1.6% of the patients, respectively.

Thirty-eight of these patients (60.3%) booked for antenatal care of the index pregnancy whereas 25 of them (39.7%) were unbooked at the time of admission. There were two cases of multiple pregnancies, one twin gestation, and the other triplets.

Thirty-one (49.2%) patients were multiparae, 21 (33.3%) were primigravidae whereas 11 (17.5%) were grandmultiparae.

Assault accounted for injuries in 29 patients (46%) whereas road traffic accidents and falls accounted for injuries in 19 (30.2%) and nine (14.3%) of patients, respectively, as shown in Table 1. Gunshot injury accounted for injuries in four patients (6.3%), one of them was shot in the abdomen during the 1st trimester of pregnancy whereas the rest were shot in the lower extremities.

Table 1

Etiology of injury by trimester of pregnancy

Interpersonal violence was involved in 72.4% of assault whereas domestic violence was involved in 27.4% of cases. The common mechanisms of injury in the victims of assault were multiple punches to the torso in 19 patients (65.5%), kicks in four patients (13.8%), and a push to the ground in another four patients (13.8%).

Motorcycles were involved in about 83.3% of the road traffic injuries and falls from them or blunt injury to the abdomen by its handlebars during crashes were the most common mechanism of injury observed in 50% of the cases.

Domestic falls accounted for injury in five (55.6%) of the nine patient with falls whereas falls in farm field were involved in four (44.4%) patients.

Majority of the patients (88.7%) sustained blunt injuries. The rest of them had penetrating injuries (8.1%) and burns wound (3.2%). All the penetrating injury was intentional whereas blunt injuries were accidental (50.9%) and intentional (49.1%).

The ISS was within a range of 1-16. The mean and median ISS were 5.2 and 4, respectively.

The mean and median gestational age at the time of injury was 26.1 and 26.5 weeks, respectively. About 57.1% of injuries occurred during the 2nd trimester, 31.7% in the 3rd trimester, and 11.2% in the 1st trimester as shown in Table 2.

Table 2

Parity by trimester of pregnancy during injury

The married patients presented with injuries throughout the trimesters of pregnancy (8.5%, 30.5%, and 61% in 1st, 2nd, and 3rd trimester, respectively) whereas in the single ones injury significantly occurred in the 1st (50%) and 2nd (50%) trimester (P < 0.015). The gestational age at the time of injury was within the range of 12-24 weeks in the single and 6-39 weeks in the married ones.

Road traffic injuries and assaults occurred in all the trimesters whereas falls occurred more often in the 2nd and 3rd trimesters as shown in Table 2. The parity of the patients was significantly related to the trimester of pregnancy at the time of injury (P < 0.01). Eight of the 11 (72.7%) of grand-multiparous sustained injuries in the 3rd trimester whereas about 12 of 21 (57%) of primigravida sustained injuries in 2nd trimester [Table 2].

The time interval between injury and presentation to the hospital was in a range of 30 minutes to 13 days with a mean and median of 26 and 5 h, respectively. 55.5% of victims of assault and 94.4% of the patients with road traffic injuries presented within the first 6 hours of injury whereas 44.4% of those who had accidental falls presented after 72 hours as shown in Table 3.

Table 3

Time interval between injury and hospital presentation by mechanism of injury

There was preterm delivery in five patients (7.9%). Intrauterine fetal death and abruptio placenta were complication in three (4.8%) patients each [Table 4]. Fall was the mechanism of injury observed in the two patients who presented with abruptio placentae and in another (primigravidae who fell down from a tree) patient who presented with uterine rupture as a complication. Five patients had emergency Cesarean section necessitated by fetal distress. There were no peri-mortem Cesarean sections.

Table 4

Obstetric complications related to trauma (N=63)

The pregnancy outcome was successful in 57 patients (90.5%) and unsuccessful in five patients (7.9%) [Table 5]. Spontaneous abortion in two patients (3.2%) and fresh stillbirths in three patients (4.8%) were observed. Severe maternal injury accounted for 80% of fetal loss where as non-severe injury accounted 20% [Table 5]. Traumatic uterine rupture, major burns, and falls in farm field each accounted per one of stillbirth. Sixty percent of fetal loss occurred in the 2nd trimester whereas 40% occurred in the 3rd trimester of pregnancy.

Table 5

Pregnancy outcome by injury severity

There was one case of maternal death (1.6%) from major burns and the pregnancy ended in spontaneous abortion.

DISCUSSION

In developing countries, injury is generally a neglected burden and its associated morbidity and mortality can be a challenging health problem in pregnancy. The result of this study indicates that there were 12 injury hospitalization per 1000 pregnant women admitted in the hospital during the study period. This is significant and implied that trauma is an important health concern in pregnancy in our environment.

The causes and mechanism of injuries in pregnancy are essentially the same, though the proportion of cases attributed to each of them varies from place to place. In Table 1, physical assault was the cause of injury observed in majority and about half of our patients. This is at variance with road traffic injuries and falls reported in many published studies from developed countries as leading causes of trauma during pregnancy.[34671112] The involvement of physical assault in majority of our patients is not surprising because previous studies have reported a high prevalence rate of gender-based violence against pregnant women in another Nigerian setting.[1314] There is evidence in another study that the gravid uterus is frequently the target in torso injuries in victims of assault.[15] Multiple punches in the torso were the mechanism of injury we observed in about 65% of victims of assault. This implied the intent of most physical assaults observed was possibly to inflict both maternal and direct fetal injuries.

The involvement of motorcycle crashes in over 85% of those with road traffic injuries was not surprising as the motorcycle is a common mode of transportation in Nigeria and another study has documented a rising incidence of motorcycle-related injury hospitalization during pregnancy in Calabar, Nigeria.[16]

The occurrence of majority of injuries in 2nd and 3rd trimester correlated with the finding reported by Tinker, et al.[6] in a population-based study on epidemiology of maternal injuries during pregnancy. Most of the injuries involving fall occurred in the 2nd and 3rd trimester whereas most involving assault and road traffic accident occurred throughout pregnancy period. This also correlated the finding reported by Biswas, et al.[8] in a prospective study on trauma in pregnancy.

The women who sustained injuries from falls were more likely to present later than 72 hours (P < 0.000) [Table 3]. The reason for this observation will require another study. Previous study has demonstrated adverse pregnancy outcome after a fall even in the absence of perceived injury.[6] Hence, enlightenment on the importance of early presentation to the hospital in the event of a fall is needed in our environment.

The parity of the patients was significantly related (P < 0.017) to the trimester of pregnancy during injury [Table 2]. Most of the grandmultiparae (72%) presented with injury in the 3rd trimester. Another study is required to determine the factors that make the grandmultiparae more vulnerable to injury in 3rd trimester of pregnancy

It was observed that injury significantly occurred in the single women during the 1st and 2nd trimester and in the married ones throughout the trimester of pregnancy. The exact reason/s for this is not evident and may require further study.

The apprehension-attending trauma in pregnancy often relates to its effect on ongoing pregnancy. A third of all women in this survey suffered such obstetrics complication [Table 4]. The direct impact of offending force on the distended uterus often results in uterine rupture, a complication in 1.6% of women in this study. Other direct effects include detachment of normally sited placenta-abruptio placentae and premature rupture of membrane that occurred in 4.8% of mothers each. In some cases, uterine irritability occurs resulting in abortion or preterm delivery. In this study, two women had abortion and preterm delivery was the commonest obstetric complication recorded. Generally, fetal compromise in cases of trauma result mainly from associated hypoxia, hypotension and preterm delivery. A decrease in maternal packed cell volume (as a result of massive hemorrhage) or 20% decrease in mean blood pressure or oxygen saturation less than 90% result in fetal hypoxia then acidosis and fetal demise.[17] There were three cases of stillbirth in this series. The fetal loss rate of 7.9% observed was toward the range of 4-61% reported in other studies.[3810151819]

There was one maternal death (1.6%) and one near miss (consequent upon uterine rupture with the resulting massive obstetric hemorrhage) recorded. The trauma-associated maternal mortality rate of 1.6% is less than 10% and 25.92% reported by Esposito et al.[3] and Biswas et al.,[8] respectively. The range and mean ISS of the patients studied by Esposito were 1-51 and 14.6, respectively, whereas ours were 1-16 and 5.2. Therefore, the variation in maternal mortality rate may be due to differences in mean injury severity score of patients studied.

The limitations of this study were

It was a retrospective study subject to challenges of incomplete record documentation

It was a single center and hospital-based study, data obtained may not be representative of entire population.

CONCLUSIONS

Trauma during pregnancy is an important cause of peri-natal and maternal morbidity and mortalities in our environment.

Injury prevention based on the observed pattern of presentation deserves a place in any policy response or intervention aimed at reducing feto-maternal morbidity and mortality in the sub-region. Injury prevention measures should include legislation or enforcement of existing laws on gender-based violence, discouraging use of commercial motorcycle, an educational program to provide information to pregnant women about falls emphasizing the need for more precaution in the third trimester and early presentation to the hospital after falls.