Treating orthopaedic trauma during pregnancy - most testing and treatments safe for fetuses and mothers

Pregnant women who suffer orthopaedic trauma should be diagnosed and stabilized in the same manner as any other patient, according to research published in the March 2006 issue of the Journal of the American Academy of Orthopaedic Surgeons.

The extensive review of current data on orthopaedic trauma and pregnancy revealed that techniques used in diagnosis and stabilization -- including x-ray examinations of the abdomen -- pose little to no risk to a fetus provided proper precautions are taken, and that stabilizing the mother quickly provides the optimal probability of a good outcome for the infant.

Trauma affects up to 8 percent of pregnancies and is a leading cause of death among pregnant patients in the U.S. All females of childbearing age who are involved in a physically traumatic event should be required to take a pregnancy test as part of the standard emergency room evaluation, as the research recommended. If the patient is pregnant, once she is stabilized, a fetal assessment, perhaps including an ultrasound, and a pelvic examination should then be conducted.

"Because orthopaedic trauma is relatively common in pregnant women, it is critical for them to understand the importance of taking precautions, such as wearing seat belts," said Kyle R. Flik, MD, lead author of the paper and orthopaedic surgeon at Northeast Orthopaedics, LLP, in Albany, NY. "But if a pregnant woman does suffer trauma, she can feel safe in knowing that initial tests performed to diagnose and stabilize her condition should not harm the fetus."

Physicians do not need to refrain from standard emergency room diagnostic testing because the patient is pregnant. Common diagnostic tests used in orthopaedic trauma that do not pose serious risk to a fetus include standard X-rays, magnetic resonance imaging (MRI), and ultrasounds; most computerized tomography (CT) scans are also safe. Nonetheless, all radiographs should be performed in such a way as to minimize the amount of exposure to the fetus; placing a lead apron over the patient's abdominal and pelvic area can provide additional protection. Emergency orthopaedic surgery can also be safely performed on most pregnant patients.

Of course, the need for diagnostic tests should be weighed against the type and severity of injury suspected. For example, more discretion can be exercised with fractures from minor falls, which can occur as a result of the weight gain and diminished sense of balance that occur in pregnancy, than with potentially life-threatening injuries, such as those that might be suffered in an automobile collision.

Additionally, there are some precautions orthopaedic surgeons and other physicians must take with pregnant patients, because of anatomical and physiological changes in pregnant women. For example, a traumatic level of blood loss might not be immediately apparent. While the patient's arterial pressure often remains stable due to the increase in blood volume during pregnancy, uterine blood flow may still be hindered. Also, certain drugs that affect blood coagulation, or clotting, are not recommended for most pregnant women.

Dr. Flik stressed that patients in later stages of pregnancy should not be placed flat on their backs -- even for surgery -- because the weight of the uterus can compress the vena cava, or the large vein that collects blood from all parts of the body and returns it to the heart.

"Orthopaedic surgeons can avoid this concern by using left lateral decubitus positioning -- tilting the patient slightly to the left -- because this minimizes pressure on the vena cava," Dr. Flik explained. "If surgery and other extensive treatment for an orthopaedic injury in a pregnant patient are required, an experienced multidisciplinary team -- consisting of an orthopaedic surgeon working with an obstetrician, perinatologist, anesthesiologist, radiologist and nursing staff -- will optimize the treatment of both the patient and the fetus."

http://www.aaos.org