PREGNANCY TRAUMA
Mother
Fetus

SUMMARY: Some maternal injuries during pregnancy are not what they seem, and others are concealed. Whether adverse fetal outcome was Caused by injury during pregnancy may require exhaustive medicolegal analysis.

6-7% of women suffer physical trauma during pregnancy^(1,2).

Because it is by far the commonest variety, minor trauma Causes most pregnancy losses.

MOTHER

Some maternal injuries during pregnancy are not what they seem, and others are concealed.

Many accidental injuries to the pregnant woman are self-evident, but personal injury lawyers should also be aware of the not-so-obvious.

Spousal Abuse

Although the true cause is usually established eventually by treating physicians, litigators should be aware of occult spousal abuse.

Of these, 67% seek medical treatment but only 3% explicitly disclose the abuse to their caregivers.

The commonest area struck is the abdomen.

Spousal assault, which is often repetitive, may Cause fetal loss without evidence of significant maternal injury⁽⁶⁾.

Among women who have suffered abuse before pregnancy, nearly two-thirds report increased frequency of spousal assault during pregnancy.

Rhesus Sensitisation

Leakage of fetal blood across the placenta into the maternal blood-stream (feto-maternal hemorrhage) occurs in 8-30% of cases of pregnancy trauma, depending on severity⁽⁷⁾.

By comparison, such bleeding happens in 2-8% of pregnancies without trauma, and the estimated volume of fetal blood loss is materially greater after trauma.

In Rhesus-negative mothers with a Rhesus-positive fetus, such bleeding can cause maternal injury, or more accurately risk to the next fetus.

If the Rhesus-negative pregnant woman is not administered the appropriate dose of antibody (Rh immune globulin, RhIG) within 72 hours of injury⁽⁸⁾, there is potential risk of hemolytic anemia (blood destruction) and jaundice in a subsequent Rhesus-negative fetus or newborn infant.

FETUS

Figures from 1971 suggest that the reduced use of seat-belts by pregnant women increases mortality if the woman is ejected from the vehicle - to 33% for the mother, 46% for the fetus⁽⁹⁾.

According to a Canadian study, fetal mortality can be as high as 65% after major trauma⁽¹⁰⁾.

Hemorrhage

If the fetus loses blood into the maternal circulation, consequences may range from abnormalities on Continuous Electronic Fetal Monitoring, through anemia to death from exsanguination.

Whether adverse fetal outcome was Caused by injury during pregnancy may require exhaustive medicolegal analysis.

Fetal Loss

A direct blow to the pregnant abdomen is more likely to injure the placenta than the fetus.

Premature separation of the placenta (abruptio placentae) from the uterus occurs in 3-50% of blunt trauma, depending on severity^(7,9,11).

Fetal death occurs in 20-35% of cases.

Brain Damage

As well as causing direct head injury, trauma may result in compromise of the supply of blood and oxygen to the fetal brain, Causing long-term neurological damage⁽¹²⁾.

Premature Labour

Abruptio insufficient to kill may yet require emergency delivery of the immature fetus, or can precipitate immediate or delayed onset of premature labour.

Pregnancy trauma Causes premature labour in up to 11% of cases, preterm delivery in up to 25%⁽⁵⁾.

When premature delivery results in a compromised infant, whether brain damaged or with other permanent disability, delays of days or weeks between trauma and delivery may raise a question of Causation and Liability.

Circumstantial evidence of traumatic Causation of premature labour may be present in the contemporaneous clinical records.

More minor degrees of abruptio can Cause a propensity to delayed onset of premature labour, and diagnostic ultrasound or other evidence of the abruptio such as uterine tenderness may provide the necessary Causal link.

Premature Rupture of Membranes, or minor leaking of liquor, may require the obstetrician to deliver the infant prematurely, or result in delayed premature labour.

Continuing loss of liquor may compromise fetal health and development by the mechanism of liquor deficiency ( oligohydramnios).

Ruptured membranes may, with or without antibiotic treatment, result in infection of the liquor and membranes (chorioamnionitis), itself a precipitant of delayed premature labour.

Deformities

When a pregnancy complicated by an early MVA results in a deformed infant, the question of traumatic Causation may arise.

Otherwise unexplained congenital (at birth) abnormalities and trauma during pregnancy are both relatively common, so it is inevitable that the two will sometimes co-exist.

In most instances a Causal connection cannot be made on balance of probability, but various factors will be weighed in the analysis of the individual case: