Traumatic pelvic ring fracture during pregnancy: a systematic review

Abstract

Purpose: This systematic review aims to investigate the management and outcomes of pelvic ring fractures (PRFs) during pregnancy, emphasizing maternal and fetal mortality rates, mechanisms of injury, and treatment modalities.

Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a comprehensive search of databases from 2000 to 2023, identifying 33 relevant studies. Data extraction included demographics, fracture types, treatment methods, and outcomes. Risk of bias was assessed using the JBI criteria.

Results: Maternal mortality stood at 9.1%, with fetal mortality at 42.4%. Maternal factors impacting mortality included head trauma and hemodynamic instability. Fetal mortality correlated with mechanisms like motor vehicle accidents and maternal vital signs. Surgical and conservative treatments were applied, with a majority of pelvic surgeries performed before delivery. External fixators proved effective in fracture stabilization.

Conclusion: Pelvic ring fractures during pregnancy present significant risks to maternal and fetal health. Early stabilization and vigilant monitoring of maternal vital signs are crucial. Vaginal bleeding/discharge serves as a critical fetal risk indicator. The choice between surgical and conservative treatment minimally influenced outcomes. Multidisciplinary collaboration and tailored interventions are essential in managing these complex cases.

Keywords: external fixators; fetal mortality; fracture types; maternal mortality; pelvic ring fractures; pregnancy; systematic review; treatment.

Figure 1

This flowchart illustrates the systematic literature search process conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) algorithm.

Figure 2

Algorithm for the initial management of pregnant patients with pelvic ring fractures (PRFs) in trauma care. In the context of managing pregnant patients with PRFs, the primary objective during the initial assessment is to conduct a primary survey. The foremost priority is to optimize the maternal hemodynamics and ensure an adequate oxygen supply. The initial approach to fetal well-being involves prioritizing the optimal resuscitation of the pregnant woman. Fetal evaluation should be performed as part of a secondary examination (11, 40). The standard trauma assessment follows the ABCDEs (airway, breathing, circulation, disability or displacement, exposure). Simultaneously, obstetrician providers should perform fetal heart rate (FHR) monitoring, and when gestational age is greater than or equal to 20 weeks, tocometry can also be considered. These evaluations should be conducted without disrupting the ongoing maternal resuscitation, in addition to addressing semi-traumatic and orthopedic considerations (3, 11, 40). If the mother’s condition is stable, the management plan should be coordinated by the obstetrician team based on gestational age and by the orthopedic team based on the type of fracture (3, 11, 40). In cases where the patient’s condition is unstable, adherence to the Advanced Trauma Life Support (ATLS) protocol is essential, along with the application of a pelvic binder and focused assessment with sonography for trauma (FAST) ultrasound. In situations where the fetus is viable, the obstetric team can continue fetal assessment concurrently with the trauma team’s interventions. If the FAST ultrasound yields positive findings or patient unresponsive to resuscitation, immediate transfer to the operating room is imperative, allowing for timely interventions such as laparotomy, pelvic packing, and external fixator placement (3). If the FAST ultrasound results are negative, regardless of pregnancy status, contrast-enhanced pelvic computed tomography (CT) should be performed. This step ensures that in the presence of a substantial hematoma or arterial extravasation, appropriate measures like arterial embolization, laparotomy, pelvic packing, and external fixator application can be promptly initiated (3).