Archives of Academic Emergency Medicine. 2022; 10(1): e39 REV I EW ART I C L E Orthopedic Trauma During Pregnancy; a Narrative Review Meisam Jafari Kafiabadi1,2, Amir Sabaghzadeh1, Seyyed Saeed Khabiri1, Mehrdad Sadighi1, Amir Mehrvar2, Farsad Biglari1∗, Adel Ebrahimpour1,3 1. Department of Orthopedics Surgery, Shohada-e Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2. Department of Orthopedics Surgery, Taleghani Hospital Research Development Committee, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 3. Physiotherapy Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Received: March 2022; Accepted: April 2022; Published online: 18 May 2022 Abstract: Introduction: Blunt traumas, like road accidents and falls, are common causes of injuries to pregnant women, and the major risk factors are young age and low socioeconomic level. Due to physiological and anatomical changes specific to pregnancy, such as changes in blood pressure and hemoglobin drop, trauma management involves certain complexities. Physical trauma is estimated to cause at least 1 complication in every 12 pregnan- cies. This study aims to evaluate orthopedic trauma during pregnancy and appreciate the different approaches to circumvent the resultant challenges. Methods: We reviewed 55 articles, published on orthopedic trauma during pregnancy between 2011 and 2021. The articles were identified by searching PubMed, google-scholar, Scopus, and Science-Direct. We utilized the search terms: fall in pregnancy, traumas in pregnancy, motor vehi- cle accident/crash in pregnancy, blunt trauma in pregnancy, pregnant trauma patient, penetrating injury dur- ing pregnancy, assault, interpersonal violence in pregnancy, and mortality and pregnancy. Results: According to available reports, after stabilizing the pregnant patient, diagnostic procedures, including radiography, and even gadolinium-based techniques when needed, can be performed to examine extensive trauma. In contrast to elective orthopedic surgery, emergency orthopedic surgeries, including reduction of open fractures, should be performed promptly. Conclusion: Based on our investigation, pregnant women with orthopedic injuries that are severe, or even seemingly less severe, experience significantly increased adverse pregnancy outcomes, which include preterm birth, placental abruption, poor infant condition at birth, infant death, and even mater- nal death. Keywords: Orthopedic Procedures; Wounds and Injuries; Pregnancy Cite this article as: Jafari Kafiabadi M, Sabaghzadeh A, Khabiri SS, Sadighi M, Mehrvar M, Biglari F, Ebrahimpour A. Orthopedic Trauma During Pregnancy; a Narrative Review. Arch Acad Emerg Med. 2022; 10(1): e39. https://doi.org/10.22037/aaem.v10i1.1573. 1. Introduction Trauma is referred to as an externally triggered injury and is one of the major non-obstetric reasons leading to death dur- ing pregnancy (1). In orthopedic medicine, trauma or or- thopedic trauma is characterized as a serious injury to the parts of the locomotor or musculoskeletal system (2). Physi- cal trauma is estimated to complicate 1 in every 12 pregnan- cies (3). The most familiar triggers of trauma in pregnancy comprise car accidents, falls, and violent assaults (4). Life- threatening maternal trauma is associated with a 40% to 50% ∗Corresponding Author: Farsad Biglari; Department of Orthopedics Surgery, Shohada-e Tajrish Hospital, Shahrdari Avenue, Tajrish Square, Tehran, Iran. Phone: +989125193843, Email: biglari.farsad@gmail.com, ORCID: http://orcid.org/0000-0003-0586-6236. fetal loss, implying that both mother and fetus are at risk (1). Therefore, caring for the obstetric patient who suffers a trau- matic injury is one of the most challenging scenarios for both nursing and medical staff. Physiological changes in pregnancy might have an enormous effect on diagnosis and treatment. For example, circulating blood volume increases from the 6th week of gestation and peaks at approximately the 32nd week. Hence, during resus- citation, it can take up to 50% more volume to cause changes in hemodynamic status (5). Managing pregnant patients with orthopedic trauma poses challenges that should be carefully considered to protect both the mother and the developing infant. Physiological changes during pregnancy, risk of radiations, and recom- mendations for monitoring should be focused on during the perioperative and intraoperative processes. In this article, This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M. Jafari Kafiabadi et al. 2 we focused on the epidemiology and risk factors of trauma during pregnancy and its management. We reviewed 55 ar- ticles published on orthopedic trauma during pregnancy in English language, between 2011 and 2021. The articles were identified by searching PubMed, google-scholar, Science- Direct, and Scopus. The following keywords were applied: trauma in pregnancy, blunt trauma in pregnancy, penetrat- ing injury during pregnancy, motor vehicle accident/crash in pregnancy, fall in pregnancy, assault, interpersonal violence in pregnancy, pregnant trauma patient, and mortality and pregnancy. 1.1. Epidemiology and risk factors Blunt trauma is the main cause of injuries among pregnant women. In a study conducted in Pakistan in 2019 (6), road traffic accidents (RTA) were the most common mechanism of injury (47.9%), followed by falls (31.3%). In an alterna- tive research carried out in the United Kingdom in 2016, ve- hicular collision and interpersonal violence were increasing causes of injury (7). In an Iranian study in 2012 (8), falling (28.1%) was the most prevalent cause of injury, followed by RTA (21.9%). A study conducted in America in 2011, showed that the prevalence of interpersonal violence (IPV ) during pregnancy spans between 1-20%, with the domestic partner being the abuser in most cases (9). Based on the literature, risk factors for maternal trauma in- clude: young age (<25 y) and low socioeconomic status (10), domestic violence (11), noncompliance with proper seat belt use (12), and minimal or no prenatal care in the first trimester (13). On another note, falls come second among the ma- jor causes of trauma during pregnancy (8). It was reported that women aged 30 years and below have a twofold risk of falling in pregnancy than those more than 30 years of age (14). The increase in lumbar lordosis in pregnancy moves the center of gravity forward and engenders a higher occurrence of falls. Consequently, violent prodigious exertion should be abhorred in late-stage pregnancy (15). Voluntary or aggressive trauma is responsible for almost 16% of traumatic lesions experienced by pregnant women (16). The occurrence of home or intimate partner abuse upsurges during pregnancy and is accumulated in the third trimester (17). Depending on the region or the country, these traumas may vary in their rate. 1.2. Maternal physiologic changes During pregnancy, the body undergoes many physiologi- cal and anatomical changes to adapt to the growing fetus. In the second trimester, blood pressure changes between 5–10mmHg below baseline (18), and pulse increases by 5- 15bpm (19). Hemoglobin concentration in pregnancy could fall by 5g/L due to plasma volume expansion (20), and the blood volume could increase to approximately 6L. Leukocy- tosis and erythrocyte sedimentation rates are unreliable di- agnostic markers in pregnant patients (21). Besides, there is a drop in the lymphocyte count during pregnancy within the first and second trimesters and a rise within the third trimester (22). Clotting factors and fibrinogen levels also in- crease. An increase in the clotting factors and fibrinogen re- sults in a hypercoagulable state that is linked to a high vul- nerability to thromboembolic complications (23). Transient osteoporosis may prevail due to the altered physi- ology of pregnancy (24), increasing a patient’s susceptibility to fractures (25, 26). Significant alterations in the anatomy during pregnancy principally result from the gravid uterus. Hypertrophied pelvic vasculature creates the potential for massive retroperitoneal hemorrhage in the event of a pelvic fracture. Uterine compression on the inferior vena-cava re- sults in potential impairment of cardiac output, dropping to 30% during supine positioning (4). In Table-1 common risks and physiological changes during pregnancy are categorized based on time. 1.3. Evaluation and initial management On presentation to the emergency room, pregnant women with trauma should be stabilized and be assessed based on the severity of the trauma. If the fetus is viable (≥ 23 weeks), fetal heart rate auscultation and fetal monitoring should be performed before obstetrical consultation (15). To assess a pregnant trauma patient, a focused history should be ob- tained clarifying the origin of the injury. Maternal last men- strual period (LMP), fetal movements, uterine contractions, and vaginal bleeding, are additional factors that should be kept in mind (15). This preliminary evaluation should be done within one minute and basic life-saving measures of trauma should be started simultaneously with the initial as- sessment. If conventional uninterrupted fetal observation is inaccessible, sporadic Doppler measurement or bedside ultrasound calculation of a fetal heart rate is an appropri- ate temporary substitute. Maternal status and stability take precedence over the fetal condition. First and foremost, ba- sic life-sustaining measures through rapid assessment of the initial “A-B-Cs” must be performed (27). 1.4. Airway Airway management and intubation in pregnant patients come with more challenges than unpregnant patients. Preg- nant trauma patients with a nonsecure trachea are more vul- nerable to aspirate their gastric contents (15). One maternal trachea investigation performed at 12 and 38 weeks of ges- tation revealed that the percentage of Mallampati class 4 air- ways (having just visible hard palate and no sight of the soft palate or uvula) was elevated by 34% between the two periods (28). In this regard, video laryngoscopy utilization, if acces- sible, is paramount because it allows for the maximization of This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2022; 10(1): e39 first-pass success in these intubations. 1.5. Breathing The marked increase in basal oxygen expenditure and ut- most sensitivity of the fetus to maternal hypoxia indicate that oxygen supplementation through a nasal cannula, mask, or endotracheal tube should be performed for every pregnant trauma patient to sustain the oxygen saturation greater than 95% (15). Considering the shift in the diaphragm due to pregnancy, it may be worthwhile to perform a thoracostomy tube insertion 1 to 2 intercostal spaces above normal when needed (28). 1.6. Circulation In the event of continuous hemodynamic compromise, transfusion of typed and crossed blood is preferred to crystal- loid solutions (29). In an emergency setting, however, type O Rh-negative blood is utilized to prevent Rh sensitization un- less the mother is in an imminent life-threatening situation (29). Precautions must be observed to prevent supine hy- potension post-mid-pregnancy in the injured pregnant pa- tient. This is achievable either by positioning the patient in the left lateral position or by manual uterine displacement, while the traumatized patient is kept in the supine position. In pregnant patients who are not hemodynamically stable, a focused assessment with sonography for trauma (FAST) ex- amination should be performed during the primary survey to assess for possible sources of bleeding. However, FAST can- not detect retroperitoneal hemorrhage, which is more likely in pregnant women because of the increased blood flow to the uterus (28). Any patient with a viable fetus beyond 23 weeks’ gestation should have cardiotocographic monitoring. We might consider emergent cesarean section in seriously ill trauma patients after 24 weeks’ gestation if the fetus shows non-reassuring heart rhythm. 1.7. Laboratory Tests Normally, indicated diagnostic tests are analogous to those of non-pregnant patients. Along with conventional trauma laboratory procedures, a type and screen, coagulation pro- file, fibrinogen, and Kleihauer-Betke (KB) test should be ob- tained. Fetal-maternal hemorrhage can occur in up to 30% of pregnant patients. Hence, the American College of Obste- tricians and Gynecologists (ACOG) guidelines prescribe KB testing for all Rh-negative pregnant trauma patients due to concerns of possible alloimmunization from 4 weeks of preg- nancy (4, 30). White blood count during pregnancy is usu- ally elevated and leukocytosis should be monitored through other clinical tests. D-dimer is often positive during preg- nancy; therefore, it is not recommended to rule-out venous thromboembolism (15). 1.8. Diagnostic Imaging Radiographic studies are recommended in indicated condi- tions and even gadolinium-based contrast agents are used when advantage to the mother overshadows probable fetal risks (15). This is essential to avoid non-obstetrical laparo- tomy given that non-obstetrical laparotomy alone catalyzes a 26% prevalence of preterm labor during the second trimester and an 82% occurrence of preterm labor in the third trimester (31). When life or limb-threatening injuries are suspected, in- dicated imaging should not be postponed or forsaken due to apprehensions regarding fetal radiation (4). The highest ter- atogenicity of ionizing radiation occurs during organogene- sis (5-10 weeks). Above 10 weeks, radiation will most proba- bly impair growth or engender CNS effects instead of terato- genic changes (15). Nonetheless, fetuses are improbably af- fected by radiation beyond 15 weeks of gestation (32). Table- 2 elucidates the fetal radiation dose from standard radiogra- phy and CT examinations. Conventional chest radiographic reports in a pregnant female encompass a widened mediastinum, mild car- diomegaly, elevated diaphragms, and protrusion of the pul- monary vasculature. The pelvic X-ray reveals a widening of the symphysis pubis and sacroiliac joints (33). 83 pregnant and 167 non-pregnant patients were scrutinized in a previous chart review at an urban level 1 trauma center. The average number of initial imaging studies was 4.3 in the pregnant patients versus 6.8 in the non-pregnant group. The study showed that blunt injured pregnant trauma victims got remarkably lesser radiographic images during their consul- tation than their non-pregnant counterparts. However, only 1% of those pregnant patients were diagnosed with a delayed injury (34). When feasible, body CT investigations of pregnant trauma victims should be done with intravenous iodinated contrast. Iodinated contrast implementation enhances the recogni- tion of both maternal and fetal injuries by imparting vascular contrast in organs and opacification of vascular structures, as well as the placenta (31). Intravenous iodinated contrast material (ICM) is designated as a category B drug by the U.S. Food and Drug Administration (FDA). This implies that it has not demonstrated any side effects in neither animal nor hu- man studies. It is more desirable to utilize ICM to acquire a single diagnostic CT study rather than performing a non- enhanced CT study that may be undiagnostic and compels a repeat study. MRI implementation in pregnancy may be beneficial since no fetal-related deleterious consequences have been re- ported following its application. Even though the FDA has not validated the assurance and application of MRI yet, no existing records relating to adverse perinatal outcomes or long-term pediatric outcomes due to the employment of MRI This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M. Jafari Kafiabadi et al. 4 Table 1: Common risks and physiologic changes during pregnancy categorized based on trimesters Trimester Physiologic Changes Risk Factors First - Central nervous system development - Increased white blood cell count - Increased erythrocyte sedimentation rate -Radiosensitive development period -Increased risk of teratogenesis -Hypercoagulable state -Increased risk of abortion with general anesthesia Second - Relatively radio resistant fetal central nervous system - Increased white blood cell count - Increased erythrocyte sedimentation rate -Increased risk of supine aortocaval compression -Hypercoagulable state -Increased risk of abortion with general anesthesia -Increased risk of seat belt-related injury to the fetus Third - Maternal blood volume increased by 40%–50% - Increased white blood cell count - Increased erythrocyte sedimentation rate -Increased risk of supine aortocaval compression -Increased risk of pregnancy-related osteoporosis -Increased risk of seat belt-related injury to the fetus in pregnancy prevail. At present, gadolinium utilization in pregnancy is contentious. In rare cases, contact with gadolin- ium led to both pediatric and adult nephrogenic systemic fi- brotic syndrome in renal insufficient patients (4). Based on the standard procedure, imaging of pregnant trauma patients should replicate those of any other patient undergoing con- ventional radiography, CT, and MR imaging (31). 1.9. Definitive treatment After the initial assessment and once the maternal hemody- namic balance is attained, monitoring the fetus should im- mediately commence. Surgical supervision of a pregnant patient should consume the barest minimum time possible to attenuate periopera- tive difficulties (35). All indicated emergent injuries such as open fractures, life-threatening traumas, or fissures linked to vascular injury should be treated, regardless of the preg- nancy status. Elective orthopedic surgery procedures should be postponed to the postpartum period to avoid injury to the fetus (1). Maternal pelvic fractures are the most common cause of fetal death amongst traumatic injuries (36). When taken in isola- tion, pelvic fractures do not warrant emergency cesarean sec- tion, as delivery through the vagina can be performed safely, even in the third trimester (37). Pelvic fractures present a challenge because of the proximity to the uterus and the pos- sibility of massive uterine hemorrhage and placental abrup- tion (36). If severe bleeding from a uterine region occurs, an emergency hysterectomy should be done (1). In a pregnant trauma patient having a viable fetus, who does not respond to cardiopulmonary resuscitation or has a non- survivable injury, a perimortem cesarean section should be contemplated (4). A perimortem cesarean section should be considered, for maternal and fetal benefits, within 5 minutes of maternal hemodynamic instability with failure of resusci- tation (38). 1.10. Preoperative considerations Pregnant patients are at higher risk of aspiration (39), due to progestin-mediated weakening of the lower esophageal sphincter as well as the mechanical effect of the gravid uterus. The American Society of Anesthesiologists’ guideline recommends that pregnant patients undergoing elective sur- gical operation should not have any clear liquids 2 hours be- fore surgery and no solid food should have been consumed 6 hours to 8 hours before surgery (40). There is a remarkable increase in the risks associated with preterm labor in the perioperative period (41). If preterm birth is envisaged or considered high risk and the fetus is deemed potentially viable, prophylaxis with glucocorticoids should be considered. Physically, curtailing uterine manip- ulation may lessen the risk of uterus contraction and subse- quent preterm labor (41, 42). Due to the pregnancy-induced hypercoagulable state, de- pending on the location of the surgery, lower leg anti- embolism stockings and sequential compression device leg- gings should be applied before induction of anesthesia (43). Tetanus vaccination poses no risk to the pregnant mother or fetus (44). A fully immunized patient who has not received a booster within 5 years should receive 0.5mL of the tetanus toxoid injected intramuscularly. A patient who has not pre- viously received a full course should receive both the tetanus toxoid and passive immunization (1, 44). 1.11. Intraoperative considerations Subordinate to the probable hemodynamic repercussions of vena cava compression from an enlarged uterus, it is recom- mended that pregnant patients be positioned in the left lat- eral decubitus when possible (42). In the case of a left pos- terior wall acetabulum fracture typically approached from a right lateral decubitus position, prone positioning of the pa- tient is also an acceptable alternative with ample padding of the abdomen to protect the gravid uterus (45). Some frac- tures cannot be managed with the patient in the full left lat- eral decubitus position. If the patient has an unstable spine This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 5 Archives of Academic Emergency Medicine. 2022; 10(1): e39 injury or a contraindication to this position, a wedge can be placed under the right side to tilt the spine and displace the uterus laterally (1, 46). Based on the American College of Obstetricians and Gyne- cologists’ release, the decision to use intermittent or contin- uous intraoperative fetal monitoring should be based on the type of surgery, available resources, and gestational age (47). In the first and early second trimester, fetal pulses are typi- cally monitored before and after anesthesia exposure and op- erative intervention, but not during the operation. In the late second and third trimesters, secondary to the viability of the fetus, continuous intraoperative fetal monitoring via trans- abdominal ultrasonography is generally used. If the surgi- cal field involves the abdomen, transvaginal ultrasonography can be used (42). Intraoperative electronic fetal monitoring may be advisable if the conditions below are satisfied (43): • The fetus is alive. • It is physically probable • A health care provider with obstetric privileges is available • The physician obtained informed consent to perform an emergency cesarean delivery. • The type of surgery will allow for safe disruption of the surgery for physicians to carry out an emergency delivery One of the major concerns among patients and physicians when faced with the possibility of surgery during gestation, is what effect the anesthetic and adjuvant drugs will have on the developing fetus. None of the anesthetic agents has yet been acknowledged as a specific teratogen for humans, and anesthesia increases the risk of fetal hypoxia and preterm la- bor. Although the evidence currently remains encouraging, it is most sensible to defer elective surgery, until postpartum. If this is not possible then the first trimester should be avoided (48, 49). The choice of anesthesia depends on maternal indications, the surgical location, and the method of surgery applied (50). Although general anesthesia is considered safe for use during pregnancy, the use of regional or if possible, local anesthesia may minimize fetal drug exposure (1, 50). 1.12. Fracture management The prime objective in fracture fixation should be to apply the fixation procedure that entails the lowest possible radi- ation without endangering fracture care (51). Minimally in- vasive percutaneous plating techniques and intramedullary nails are commonly used in orthopedic surgeries. However, these difficult techniques often require high cumulative ra- diation exposures. When exposure to radiation poses a high risk, open plating techniques that involve minimal irradia- tion should be considered (51). Closed extremity fractures may be managed non-operatively, or treatment can be de- layed until postpartum when appropriate (5). Table 2: Estimated fetal radiation dose from conventional radio- graphic and computed tomography examinations Examination Dose (mGy)* Radiography Cervical spine (AP, lateral) <0.001 Extremities <0.001 Chest (PA, lateral) 0.002 Thoracic spine 0.003 Abdomen (AP) (21-cm patient thickness) 1 Abdomen (AP) (33-cm patient thickness) 3 Lumbar spine (AP, lateral) 1 Computed tomography (CT) scan Head 0 Chest (routine) 0.2 Chest (pulmonary embolism protocol) 0.2 Abdomen 4 Abdomen and pelvis 25 CT angiography of the aorta 34 CT angiography of the coronary arteries 0.1 *: Estimated fetal dose. AP: anterior posterior; PA: posterior anterior Acute pelvic or acetabular injury during pregnancy can put both mother and fetus at increased risk of mortality (36). If a symphyseal rupture is diagnosed clinically or radio- graphically and the patient is hemodynamically unstable, the most important intervention is the control of internal pelvic hemorrhage with provisional closed reduction of the pelvic ring. If closed pelvic fusion and resuscitation of fluid do not reestablish hemodynamic stability, venous plexus bleeding can be repaired through an open laparotomy with retroperi- toneal packing and external fixation. If the hemorrhage source is from the arteries, it may be more favorable to per- form angiography (1, 36). Otherwise, management includes bed rest, traction, and a pelvic sling in most patients and early mobilization with a walker should be attempted. Surgical intervention on frac- tured pelvis is recommended when the patient suffers from an open tear in the pubic symphysis auxiliary to critical vagi- nal rupture, there is diastasis of the symphysis >4 cm, sub- stantial malreduction of the pelvis, diastasis with the pelvic binder in place, or displacement of one or both sacroiliac joints. When prescribed, either peripheral fixation or open reduction and interior fixation should be performed within 3 weeks of injury. Peripheral fixation decreases further damage to the uterine environment and permits the fetus to reach 34 weeks’ gestation. A supra-acetabular fixation approach can allow the patient to sit up and receive proper nursing care (1, 5). The superiority of operative fracture management for frac- tures involving the acetabulum has been well covered, and it is well known that excellent results are lessened in the re- vision or salvage surgery or when operative care is delayed This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M. Jafari Kafiabadi et al. 6 for greater than 3 weeks. With the current evidence suggest- ing that fracture fixation, fluoroscopy, and general anesthesia may be safely delivered to the pregnant patient, open reduc- tion and internal fixation of the acetabulum fracture may be the treatment of choice (52). The occurrence of a pelvic fracture is not an outright indi- cator for avoiding vaginal delivery. If the pelvic architecture is not substantially disrupted, then a vaginal delivery can be safely performed (53). Normal healing takes 8 to 12 weeks af- ter an injury. Thus, if the fracture happened during the early phases of pregnancy, vaginal delivery may be an option. If a pelvic fracture has healed without substantial residual pelvic malunion, and implants are appropriately placed within the bony pelvis, vaginal delivery should be attempted after eval- uating the risk-benefit ratio for both the fetus and mother (1, 51). 1.13. Prevention and outcomes Pregnant trauma patients have a two-fold risk of dying after the trauma as compared to their non-pregnant counterparts. Violent trauma rates tend to increase twice as much due to pregnancy, and mortality rate due to violent trauma is more than 3-fold higher compared to non-violent trauma (11). Indelicate maternal trauma accounts for less than 1% of di- rect fetal injuries. The fetus is cushioned by the shock- absorbing effect provided by the amniotic fluid, uterus, and maternal soft tissues. A majority of fetal injuries happen dur- ing the late third trimester of pregnancy, which is character- ized by shrinking of the uterine wall and thinned amniotic fluid. Placental break-off is a paramount impediment of ma- ternal trauma, existing in 5-50% of manifestations. It is the most common cause of fetal death in cases of blunt trauma. The occurrence of abruption in significant blunt trauma re- sults in fetal death 60% of the time, second only to maternal death (15, 53). Although trauma is often unpreventable, there is significant documentation that seat belt utilization during pregnancy safeguards the mother and fetus (54). As reported by many investigations, the neglect of a seat belt or other restraints increases the risk of both maternal and fetal morbidity and mortality. Pregnant women who neglected the use of a seat belt during an automobile accident were 1.3-fold more likely to deliver an infant with low birth weight, had twice the pos- sibility of experiencing disproportionate maternal hemor- rhage, and were 2.8 times more certain to encounter a fetal death than women who put on a seat belt during an accident (55). In another study of pregnant patients involved in mo- tor vehicle accidents, severe crashes in which the pregnant woman was not wearing a seat belt resulted in adverse out- comes 100% of the time (28). Seatbelt placement is also an is- sue, with nearly 50% of fetal losses associated with improper strap placement (30). In some studies, airbag deployment during automobile acci- dents has been linked with fatal consequences such as uter- ine rupture, placental abruption, and fetal death. However, this probably reflects the magnitude of the force of the injury instead of being the cause. At this point, there are not enough data to make a recommendation about disabling airbags dur- ing pregnancy (15). 2. Conclusion Overall, pregnant women with orthopedic injuries that are severe or even seemingly less severe, experience a significant increase in adverse pregnancy outcomes comprising preterm birth, placental abruption, poor infant condition at birth, in- fant death, and even maternal death. Many non-emergent pregnant orthopedic trauma patients can be managed con- servatively, and delaying surgical treatment until after deliv- ery is often a safe option. Notwithstanding, when medical attention is prompted in certain cases, the orthopedic sur- geon must consider the physiological changes that accom- pany pregnancy and the potential risks to the fetus. Surgical positioning, administering medication, and diagnostic imag- ing are crucial considerations to ensure the best outcomes for both mother and child. 3. Declarations 3.1. Acknowledgments The authors kindly appreciate all staff members of Imam Hossein Hospital who helped us to collect the data and per- form this study. 3.2. Authors’ contributions MJK, AS and SSKH did the Investigation, Validation, Writ- ing - Original Draft. Methodology, Formal analysis, Writ- ing - Review & Editing. MS and AM: Project administration, Resources, Methodology. FB Methodology, Formal analy- sis, Writing - Review & Editing; AE: Conceptualization, Re- sources. 3.3. Funding and supports This study did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 3.4. Conflict of interest The authors affirm that they do not hold any conflict of inter- est either in financial terms or otherwise. 3.5. Ethical Considerations All ethical principles were considered in this article. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 7 Archives of Academic Emergency Medicine. 2022; 10(1): e39 References 1. Tejwani N, Klifto K, Looze C, Klifto CS. Treatment of Preg- nant Patients With Orthopaedic Trauma. J Am Acad Or- thop Surg. 2017;25(5):e90-e101. 2. Pharaon SK, Schoch S, Marchand L, Mirza A, Mayberry J. Orthopaedic traumatology: fundamental principles and current controversies for the acute care surgeon. J Trauma Acute Care Surg. 2018;3(1):e000117. 3. Cannada LK, Pan P, Casey BM, McIntire DD, Shafi S, Leveno KJ. Pregnancy outcomes after orthopedic trauma. J Trauma. 2010;69(3):694-8; discussion 8. 4. Brown S, Mozurkewich E. Trauma during pregnancy. Ob- stet Gynecol Clin North Am. 2013;40(1):47-57. 5. Matthews LJ, McConda DB, Lalli TA, Daffner SD. Or- thostetrics: Management of Orthopedic Conditions in the Pregnant Patient. Orthopedics. 2015;38(10):e874-80. 6. Gillani M, Uddin Saqib S, Martins RS, Zafar H. Trauma in pregnant women: an experience from a level 1 trauma center. J Emerg Pract Trauma. 2020;6(2):87-91. 7. Battaloglu E, McDonnell D, Chu J, Lecky F, Porter K. Epidemiology and outcomes of pregnancy and obstetric complications in trauma in the United Kingdom. Injury. 2016;47(1):184-7. 8. Mesdaghinia E, Sooky Z, Mesdaghinia A. Causes of trauma in pregnant women referred to Shabih- Khani maternity hospital in Kashan. Arch Trauma Res. 2012;1(1):23. 9. Salazar LF, Head S, Crosby RA, DiClemente RJ, Sales JM, Wingood GM, et al. Personal and social influences re- garding oral sex among African American female adoles- cents. J Womens Health. 2011;20(2):161-7. 10. Cheng H-T, Wang Y-C, Lo H-C, Su L-T, Lin C-H, Sung F-C, et al. Trauma during pregnancy: a population- based analysis of maternal outcome. World J Surg. 2012;36(12):2767-75. 11. Deshpande NA, Kucirka LM, Smith RN, Oxford CM. Preg- nant trauma victims experience nearly 2-fold higher mortality compared to their nonpregnant counterparts. Am J Obstet Gyneco. 2017 Nov 1;217(5):590-e1. 12. Lam W, To WW, Ma ES. Seatbelt use by pregnant women: a survey of knowledge and practice in Hong Kong. Hong Kong Med J. 2016;22(5):420-7. 13. Harland KK, Saftlas AF, Yankowitz J, Peek-Asa C. Risk fac- tors for maternal injuries in a population-based sample of pregnant women. J Womens Health. 2014;23(12):1033- 8. 14. Okeke T, Ugwu E, Ikeako L, Adiri C, Ezenyeaku C, Ekwuazi K, et al. Falls among pregnant women in Enugu, South- east Nigeria. Niger J Clin Pract. 2014;17(3):292-5. 15. Jain V, Chari R, Maslovitz S, Farine D, Maternal Fetal Medicine C, Bujold E, et al. Guidelines for the Manage- ment of a Pregnant Trauma Patient. J Obstet Gynaecol Can. 2015;37(6):553-74. 16. Murphy NJ, Quinlan JD. Trauma in pregnancy: as- sessment, management, and prevention. Am Fam Physician.2014;90(10):717-22. 17. Alhusen JL, Ray E, Sharps P, Bullock L. Intimate partner violence during pregnancy: maternal and neonatal out- comes. J Womens Health. 2015;24(1):100-6. 18. Ishikuro M, Obara T, Metoki H, Ohkubo T, Yaegashi N, Kuriyama S, et al. Blood pressure changes during preg- nancy. Hypertens. Res. 2012;35(5):563-4. 19. Sanghavi M, Rutherford JD. Cardiovascular physiology of pregnancy. Circulation. 2014;130(12):1003-8. 20. Churchill D, Nair M, Stanworth SJ, Knight M. The change in haemoglobin concentration between the first and third trimesters of pregnancy: a population study. BMC Pregnancy Childbirth. 2019;19(1):1-6. 21. Amorosa LF, Amorosa JH, Wellman DS, Lorich DG, Helfet DL. Management of pelvic injuries in pregnancy. Orthop Clin. 2013;44(3):301-15. 22. Chandra S, Tripathi AK, Mishra S, Amzarul M, Vaish AK. Physiological changes in hematological param- eters during pregnancy. Indian J Hematol Blood Transfus.2012;28(3):144-6. 23. Lucia A, Dantoni SE. Trauma management of the preg- nant patient. Critical care clinics. 2016;32(1):109-17. 24. Maliha G, Morgan J, Vrahas M. Transient osteoporosis of pregnancy. Injury. 2012;43(8):1237-41. 25. Emami MJ, Abdollahpour HR, Kazemi AR, Vosoughi AR. Bilateral subcapital femoral neck fractures secondary to transient osteoporosis during pregnancy: a case report. J Orthop Surg . 2012;20(2):260-2. 26. Milonas N, Touzopoulos P, Zafeiris CP, Papantoniou N, Koutsoubeli E, Chatzigiannakis A. Bilateral transient os- teoporosis of the knees during pregnancy. A case report and review of the literature. JRPMS. 2018;2:18-21. 27. Swor R, Khan I, Domeier R, Honeycutt L, Chu K, Comp- ton S. CPR training and CPR performance: do CPR- trained bystanders perform CPR?. Acad Emerg Med. 2006 Jun;13(6):596-601. 28. Raja AS, Zabbo CP. Trauma in pregnancy. Emerg Med Clin North Am. 2012;30(4):937-48. 29. Berkowitz RL, Rafferty TD. Invasive hemodynamic mon- itoring in critically ill pregnant patients: role of Swan- Ganz catheterization. Am J Obstet Gynecol . 1980 May 1;137(1):127-34. 30. Sakamoto J, Michels C, Eisfelder B, Joshi N. Trauma in Pregnancy. Emerg Med Clin North Am. 2019;37(2):317- 38. 31. Raptis CA, Mellnick VM, Raptis DA, Kitchin D, Fowler KJ, Lubner M, et al. Imaging of trauma in the pregnant pa- tient. Radiographics. 2014;34(3):748-63. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M. Jafari Kafiabadi et al. 8 32. Marx MV. Baby on board: managing occupational radia- tion exposure during pregnancy. Tech Vasc Interv Radiol. 2018;21(1):32-6. 33. Lowe SA. Diagnostic radiography in pregnancy: risks and reality. Aust N Z J Obstet Gynaecol. 2004 Jun;44(3):191-6. 34. Herfel ES, Hill JH, Lieber M. Radiographic evaluation of the pregnant trauma patient: What are We willing to miss? Eur J Obstet Gynecol Reprod Biol. 2018;228:325-8. 35. Stewart MK, Terhune KP. Management of pregnant pa- tients undergoing general surgical procedures. Surgical Clinics. 2015;95(2):429-42. 36. Yoo BJ. Pelvic trauma and the pregnant patient: a review of physiology, treatment risks, and options. Curr Trauma Rep.2018;4(3):225-32. 37. Petrone P, Jimenez-Morillas P, Axelrad A, Marini CP. Trau- matic injuries to the pregnant patient: a critical literature review. Eur J Trauma Emerg Surg. 2019;45(3):383-92. 38. Kobori S, Toshimitsu M, Nagaoka S, Yaegashi N, Murot- suki J. Utility and limitations of perimortem cesarean section: A nationwide survey in Japan. J Obstet Gynaecol Res. 2019;45(2):325-30. 39. Westerfield KL, Bhavsar AK, Green S. Aspiration pneu- monitis causing respiratory collapse in a pregnant pa- tient not in labor. Obstet Gynecol. 2019;134(4):692-4. 40. Brown BP, Holt R. Palliative Care and the Pregnant Surgi- cal Patient: Epidemiology, Ethics, and Clinical Guidance. Surg Clin North Am. 2019;99(5):941-53. 41. Balinskaite V, Bottle A, Sodhi V, Rivers A, Bennett PR, Brett SJ, et al. The risk of adverse pregnancy outcomes follow- ing nonobstetric surgery during pregnancy: estimates from a retrospective cohort study of 6.5 million pregnan- cies. Ann Surg. 2017;266(2):260-6. 42. Stewart MK, Terhune KP. Management of pregnant pa- tients undergoing general surgical procedures. Surg Clin North Am. 2015;95(2):429-42. 43. Boisseau L. Special Needs Populations: Care of Pregnant Patients Undergoing Nonobstetric Surgery. AORN Jour- nal. 2012;96(6):635-46. 44. Morgan JL, Baggari SR, McIntire DD, Sheffield JS. Preg- nancy outcomes after antepartum tetanus, diphthe- ria, and acellular pertussis vaccination. Obstet Gynecol. 2015;125(6):1433-8. 45. Hill KL, Gross ME, Sutton KM, Mulcahey MK. Evaluation and resuscitation of the pregnant orthopaedic trauma patient: considerations for maternal and fetal outcomes. JBJS reviews. 2019;7(12):e3. 46. Bongetta D, Versace A, De Pirro A, Gemma M, Bernardo L, Cetin I, et al. Positioning issues of spinal surgery during pregnancy. World Neurosurg. 2020;138:53-8. 47. Tolcher MC, Fisher WE, Clark SL. Nonobstetric surgery during pregnancy. Obstet Gynecol. 2018;132(2):395-403. 48. Kamali A, Azadfar R, Pazuki S, Shokrpour M. Compar- ison of dexmedetomidine and fentanyl as an adjuvant to lidocaine % for spinal anesthesia in women candi- date for elective caesarean. Open Access Maced J Medical Sci.2018;6(10):1862. 49. Toledano RdA, Madden HE, Leffert L. Anesthetic Man- agement of Nonobstetric Surgery during Pregnancy. Curr Anesthesiol Rep. 2019;9(1):31-8. 50. Heesen M, Klimek M. Nonobstetric anesthesia during pregnancy. Curr Opin Anaesthesiol. 2016;29(3):297-303. 51. Harold JA, Isaacson E, Palatnik A. Femoral fracture in pregnancy: a case series and review of clinical management. International journal of women’s health. 2019;11:267. 52. Schwartsmann CR, Macedo CAdS, Galia CR, Miranda RH, Spinelli LdF, Ferreira MT. Update on open reduction and internal fixation of unstable pelvic fractures during preg- nancy. Rev Bras Ortop. 2018;53(1):118-24. 53. Ruffolo DC. Trauma care and managing the injured pregnant patient. J Obstet Gynecol Neonatal Nurs. 2009;38(6):704-14. 54. Acar BS, Edwards AM, Aldah M. Correct use of three- point seatbelt by pregnant occupants. Safety. 2018;4(1):1. 55. Luley T, Fitzpatrick CB, Grotegut CA, Hocker MB, Myers ER, Brown HL. Perinatal implications of motor vehicle accident trauma during pregnancy: identifying popula- tions at risk. Am J Obstet Gynecol. 2013;208(6):466 e1-5. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Conclusion Declarations References