Pelvic fractures during pregnancy is a partial and complete violation of the integrity of the bone components of the pelvic ring caused by exposure to excessive mechanical loads. It is manifested by local pain at the site of injury, swelling, hematoma, limited movement, in severe injuries — confusion or loss of consciousness, increasing signs of shock. It is diagnosed using pelvic MRI, pelviography. To stabilize the condition of the pregnant woman, infusion, analgesic, tocolytic therapy is prescribed, after which conservative or operative reposition of fragments is performed.
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In recent decades, there has been a steady increase in the level of injuries in industrialized countries, including in pregnant women. According to the observations of specialists in the field of obstetrics, up to 7% of women receive different types of fractures during gestation. Traumatism is one of the leading non–maternal causes of maternal mortality – more than 18% of deaths of pregnant women are caused by trauma and its complications. One of the most severe traumatic disorders during pregnancy, leading to blood loss, shock, and fetal loss, are pelvic bone fractures, especially if they are combined with damage to internal organs and other parts of the musculoskeletal system.
The integrity of the bone elements of the pelvic ring is partially or completely violated under the influence of loads, the strength of which exceeds the strength of the bone tissue. Usually, pelvic damage is the result of strong compressive or shock effects, less often — altered bone architectonics with a decrease in strength characteristics. According to the observations of traumatologists, fractures during pregnancy lead to:
- Injuries. In 53-56% of patients, pelvic bone damage is caused by road accidents: direct impact with protruding parts, hitting a pedestrian, compression by structural elements of a car when crushed in an accident, discarding the victim. Fractures also occur when a pregnant woman falls from a height, gunshot wounds. Injuries are often combined or combined.
- Pathological childbirth. The passage of the fetus through the birth canal is accompanied by significant pressing and bursting loads on the pelvic bones. The probability of fracture of the coccyx or pubic bones increases with prolonged labor in women in labor with a clinically or anatomically narrow pelvis, emergency application of obstetric forceps, vacuum extraction of the fetus, extraction of the child by the pelvic end, performing fruit-destroying operations.
- Diseases of the pelvic bones. The resistance of the pelvic bones to stress decreases when they are destroyed due to pathological processes: bone tuberculosis, osteodystrophy, malignant tumors, osteomyelitis, tertiary syphilis, osteoporosis of various genesis. Pathological fractures that occur with minor impacts and caused by the restructuring of the bone structure are extremely rare in pregnant women.
An additional factor that increases the risk of pelvic fractures during pregnancy and slows down the restoration of damaged bone tissue is physiological calcium deficiency, which is intensively consumed during the formation of the musculoskeletal system of the fetus. Hypocalcemia is more pronounced with a lack of natural insolation, a diet low in calcium and vitamin D, smoking, consumption of large amounts of strong tea, coffee, caffeinated tonics.
The effect on the pelvic ring bones of a load exceeding the strength limit of bone tissue causes linear or comminuted destruction of the mineral part and rupture of collagen fibers. With complete fractures, the fragments are displaced due to the reflex contraction of the muscles attached to them. The destruction of the bone leads to the formation of a hematoma with closed fractures and the onset of difficult-to-stop external bleeding with open ones. Massive blood loss can provoke the development of shock. In the area of damage, a protective inflammatory reaction occurs with edema, migration of leukocytes, deposition of fibrin.
Under the action of osteoclasts, autolysis of the destroyed bone occurs, then the cells of the cambium of the periosteum, spongy substance, bone marrow and vascular adventitia begin to actively multiply. In place of the fallen fibrin filaments, a protein matrix of cartilage is formed with its subsequent mineralization and replacement with strong bone tissue. The formed corn undergoes structural restructuring: first, the blood supply is resumed, a compact substance is formed from the bone beams, then the microarchitectonics of the bone is rebuilt taking into account the lines of the force load, the periosteum is formed.
The main criteria for systematization of pelvic fractures during pregnancy are the degree and nature of injuries, their localization, the time from the onset of injury, the presence of complications. This approach allows you to standardize the pregnancy support plan for different types of injuries. Taking into account the integrity of the skin, there are closed fractures without destroying the skin and open fractures with damage to soft tissues, communication with the environment. Pelvic fractures during pregnancy can be isolated, combined (with damage to the pelvic organs), multiple (combined with fractures in other anatomical areas), uncomplicated and complicated. To predict the outcome of pregnancy and develop obstetric tactics, it is important to determine how the fracture affected the integrity of the pelvic ring. Based on this criterion , there are:
- Marginal fractures. Damaged parts of the bones that do not form the pelvic ring: sciatic tubercles, iliac wing, coccyx, part of the sacrum under sacroiliac amphiarthrosis, awns. In the absence of other injuries, it is considered the easiest variant of pelvic injuries. Continuation of gestation is possible with the provision of a protective regime, competent reposition and dynamic monitoring of the pregnant woman. Taking into account the patient’s condition, natural delivery is permissible.
- Fractures without breaking the continuity of the pelvis. The bones that directly form the pelvic ring are damaged — the sciatic, branches of the pubic bone. The strength of the pelvis is reduced, but since both parts remain connected to the sacrum both directly and through the other half, the support is preserved. In the absence of other injuries, pregnancy can be prolonged, with stable fractures without displacement, natural childbirth is possible.
- Fractures with a violation of the continuity of the pelvis. Each of the halves of the pelvic ring due to injury has a one-way connection with the sacrum, which significantly worsens the support of the pelvis. Due to the mobility of the fragments, the risk of injury to the tissues of the birth canal and adjacent organs increases. In case of unstable fractures and displacement of fragments, a caesarean section is performed. Identification of a threat to the life of the mother or fetus serves as a basis for early delivery.
When deciding on the possibility of prolongation of pregnancy and the option of its completion, the period of traumatic illness is taken into account. Specialists in the field of traumatology and orthopedics distinguish an acute reaction to a fracture (up to 2 days), early manifestations (up to 2 weeks), late manifestations (more than 2 weeks), a rehabilitation period (until full recovery). The shorter the period of time has passed after a pelvic fracture, the more often, when indications for termination of pregnancy or reaching the due date, surgical delivery is performed.
The clinical picture of pelvic fractures during pregnancy is represented by local symptoms, altered gait or characteristic posture, general clinical and concomitant disorders. Local symptoms are intense pain in the affected area, pubis, perineum, which usually increases with foot movements, pressure, palpation. There is a deformity of the pelvis, swelling, visible bruising. In the presence of movable fragments, bone crepitation is detected. Disorders of motor activity and external signs are determined by the location and features of the fracture.
In case of traumatic separation of the anteroposterior spine of the iliac bone, the leg on the side of the lesion is visually shortened due to the displacement of the fragment. To reduce soreness, pregnant women with a damaged sciatic and upper branch of the pubic bone take the “frog pose”, when the posterior semicircle breaks, they lie down on the healthy side. In patients with a damaged acetabulum, mobility in the hip joint is limited, with a combination of fracture and dislocation, the large trochanter is displaced, the leg is in a forced position.
Pronounced common symptoms with pain and hemorrhagic shock are detected in 30% of isolated pelvic fractures and in all patients with multiple, combined, combined injuries. With severe injuries, the skin becomes pale, covered with sticky sweat, the pulse quickens, deafness, confusion or loss of consciousness is noted. In 10-20% of pregnant women, pelvic fractures are combined with damage to the urinary organs. Such injuries are characterized by a delay in urination, the presence of blood impurities in the urine, complaints of pain in the urethra.
In 37% of pregnant women, the normal course of gestation is disrupted by an acute reaction to injury, in 25% — in the rehabilitation period. In 34.2% of cases, there is a threat of spontaneous termination of pregnancy or miscarriage, in 13.2% — premature birth. More than 40% of patients have childbirth with complications. Since a pelvic fracture is often combined with a blunt abdominal injury, premature detachment of the placenta with the development of DIC syndrome, rupture of the uterus, the occurrence of intra-abdominal bleeding is possible. In the late stages of gestation, with tight fixation of the fetal head, the probability of fractures of the bones of the skull and limbs of the child increases.
The level of perinatal mortality due to direct fetal TBI, shock in a pregnant woman, placental abruption ranges from 35 to 55.3%, depending on the severity of fractures. Injuries with rupture of the dilated veins of the cervix and massive hemorrhages in the parametrium or abdominal cavity are particularly dangerous for a woman. Long-term consequences of fractures of the pelvic ring bones are contractures, neuropathies, pelvic deformities, asthenia, subdepressive disorders.
Obstetric complications are noted in patients who have suffered a fracture not only during the current gestation, but also in the past. With long-term post-traumatic changes, the threat of spontaneous miscarriages and premature birth reaches 45%. In 55% of cases, childbirth is complicated by untimely discharge of amniotic fluid, increasing fetal hypoxia, coagulopathic postpartum bleeding, injuries of the cervix, vagina, perineum. After childbirth, 45% of patients have uterine subinvolution, endometritis and other purulent-inflammatory processes develop.
A certain difficulty in detecting of pelvic fractures during pregnancy is the limited use of the most informative radiation research methods that pose a potential threat to fetal development. Taking into account the requirements of the Ministry of Health USA, pelvic radiography is allowed only after the 20th week of pregnancy, except for situations when a decision is made to terminate gestation or provide urgent care. In such cases, maximum protection of the child from radiating influences is required. To confirm the diagnosis and detect possible complications, methods such as:
- MRI of pelvic bones. During magnetic resonance imaging, the fetus does not experience radiation load. In the first trimester of pregnancy, the study is limited. MRI allows you to accurately visualize even small cracks and dislocations of damaged pelvic bones, to determine the degree of traumatic destruction of bone tissue.
- Ultrasound of the uterus and fetus. Due to the high risk of losing a child, ultrasound screening is a mandatory study for pelvic injuries. Ultrasound is used to assess the condition of the fetus, placenta, and the integrity of the uterine wall. To detect possible violations of transplacental hemodynamics, the examination is supplemented with Dopplerography of uteroplacental blood flow.
- The content of chorionic gonadotropin. Determination of the hCG level in dynamics provides high-quality monitoring of the course of pregnancy and is used when choosing the optimal management tactics of the patient. A decrease in the indicator indicates the occurrence of a threat of miscarriage, stillbirth.
In the presence of signs of shock, ongoing bleeding, suspected placental abruption, the state of the hemostasis system is assessed without fail. In order to exclude a threat to the child, CTG, phonocardiography, and fetal MRI are additionally performed to identify possible bone injuries and intracranial hemorrhages. If internal organ damage is suspected, culdoscopy, diagnostic laparoscopy, and cystoscopy are performed. Differential diagnosis is performed with closed abdominal injuries without a pelvic fracture. In addition to the obstetrician-gynecologist and traumatologist, the patient is examined by an abdominal surgeon, neurologist, urologist.
Treatment of pelvic fractures during pregnancy
Patients with a damaged pelvic ring are recommended to be hospitalized in a multidisciplinary hospital to provide obstetric and gynecological, traumatological, neonatological care. In the acute period, it is important to stabilize the condition of the pregnant woman, ensure the reposition of fragments, and prevent complications of gestation. When drawing up a treatment plan, the traumatologist takes into account the duration of pregnancy, the nature of the injuries, the degree of displacement of bone fragments. From the moment of hospitalization in the hospital, the woman is prescribed intensive drug therapy:
- Painkillers. For analgesia, drugs that are safe for the fetus are used. With moderate pain, nonsteroidal anti-inflammatory drugs are used, with intense pain, intra-phase blockades with local anesthetics are possible. The appointment of narcotic analgesics is justified with an increase in signs of traumatic shock.
- Infusion therapy. The introduction of crystalloid and colloidal solutions is aimed at replenishing the volume of circulating blood, stabilizing hemodynamics, improving rheological parameters, restoring microcirculation. When hemostasis indicators deteriorate, anticoagulants, protease inhibitors are administered to the pregnant woman, freshly frozen plasma is transfused.
- Tocolytics. Means that relax the uterine muscles are usually used when there is a threat of interruption of gestation against the background of marginal and stable fractures. According to experts, tocolytic therapy is carried out in about 20-22% of patients. In severe trauma, the effect of tocolytics on hemodynamic parameters is taken into account.
In case of stable fractures, absence of displacement or slight displacement, conservative management of the patient is indicated. The choice of the method of reposition is determined by the localization and features of the damage. With stable isolated and marginal fractures, the woman is fixed in a hammock or on a shield. It is possible to use popliteal rollers, Beler tires. Skeletal traction, external or internal surgical fixation is recommended for pregnant women with unstable fractures. Gestation is not considered a contraindication for performing surgery. Interventions with minimal radiation control are preferred. With a satisfactory condition of the mother and fetus, gestation in some cases can be prolonged for several weeks and completed on time by natural childbirth.
Early delivery according to vital indications (with placental abruption, uterine injury, unstable fractures of the pelvic ring, severe polytrauma, terminal condition of the pregnant woman, signs of increasing fetal hypoxia) is carried out from the 28th week of the gestational period with fetal viability. In urgent situations, cesarean section is usually performed, delivery through the birth canal is possible only with marginal or stable fractures with unbiased fragments. In order to save the child from the death of a pregnant woman, a post-mortem caesarean section is performed. Pelvic injuries suffered before pregnancy do not serve as an absolute indication for surgical delivery, which is performed in 61-64% of patients with post-traumatic pelvis.
Prognosis and prevention
The outcome of gestation in pelvic trauma is determined by the severity of the injuries. The prognosis is often serious, especially in pregnant women with polytrauma, in which maternal and perinatal mortality rates reach 18.2% and 55.3%, respectively, severe disability is observed, reproductive functions are impaired. Preventive measures are aimed at preventing possible injuries, including compliance with traffic rules at pedestrian crossings, when driving a car, refusal to perform professional and household duties with work at height, wearing comfortable shoes with low stable heels, safe behavior in public places.