CC

A 22-year-old multiparous G3P2002 (this is the patient’s third pregnancy: two children were born at term, zero children were born premature, zero were abortions or miscarriages, and two living children) who is currently 39 weeks and 4 days pregnant presents to the emergency department (ED) after sustaining a gunshot wound to the face. The oral and maxillofacial surgery (OMFS) team is consulted for evaluation and management of facial injuries.

HPI

The 22-year-old female presents with right-sided facial pain and swelling after being shot by an unknown person. She is currently hemostatic and stable but reports dysphagia (difficulty swallowing) and odynophagia (painful swallowing). Her airway appears patent, but she elicits difficulty breathing and appears to be struggling with increased intraoral secretions. She is followed by her obstetrician regularly and states that her pregnancy is progressing without complications. Her previous two pregnancies have resulted in spontaneous vaginal deliveries at full term. She currently denies any loss of fluid or vaginal bleeding (a sign that amniotic fluid may be leaking from ruptured membrane) or pelvic cramping (cramping described by pregnant patients may actually be contractions). Her current pregnancy is complicated by obesity, gestational hypertension, and gestational thrombocytopenia.

PMHX/PDHX/medications/allergies/SH/FH

The patient has obesity, gestational hypertension, and gestational thrombocytopenia.

POBHx

This is the patient’s third pregnancy. Her previous two pregnancies resulted in spontaneous vaginal deliveries at full term. She currently is at high risk because of morbid obesity, gestational hypertension, and gestational thrombocytopenia.

Maternal obesity increases the risk for gestational diabetes, pre-eclampsia, cesarean delivery, infectious morbidity, and thromboembolism, especially in the postoperative period. Because of the increased risk of venous thromboembolism in obese pregnant patients, ambulation, compression devices, and subcutaneous heparin should be considered.

Hypertension during pregnancy is classified as chronic hypertension, gestational hypertension, or pre-eclampsia. This is typically classified clinically based on the onset of hypertension. Chronic hypertension is present before 20 weeks of gestation, and gestational hypertension begins after 20 weeks of gestation.

Gestational hypertension is defined as a systolic blood pressure of 140 mm Hg or greater but less than 160 mm Hg or a diastolic blood pressure of 90 mm Hg or greater but less than 110 mm Hg. These pressures must also be observed on at least two occasions 4 hours apart but no more than 7 days apart. Pre-eclampsia is gestational hypertension plus proteinuria or the presence of symptoms consistent with pre-eclampsia.

Proteinuria may be present before pregnancy or newly diagnosed during pregnancy. Proteinuria is diagnosed when greater than 0.3 g is detected in a 24-hour urine collection or a P/C (protein/creatinine) ratio is greater than 0.3. If a 24-hour urine protein or P/C ratio is not possible, proteinuria can be defined as a dipstick measurement of at least 1+ on two occasions.

Examination

Vital signs: The patient’s blood pressure was 127/80 mm Hg, heart rate was 103 to 110 bpm (tachycardic), and respirations were 18 breaths per minute. The patient is afebrile with a temperature of 97.6°F.

General: Obese (body mass index, 34), mild distress.

Maxillofacial: The patient has right-sided facial edema and ecchymosis surrounding what appears to be the projectile entry site. The entry wound is hemostatic. The patient’s intraoral examination is limited because of pain. The tongue is edematous with lacerations associated with both the posterior right and left sides. The maxillary right alveolar segment is mobile with associated edematous gingiva tissue and multiple fractured teeth. The maxilla and mandible appear stable. The oropharynx is not clearly visible because of limited mouth opening. The floor of mouth is soft and nonelevated (rules out floor-of-mouth expansile hematoma). The patient appears to be in mild distress with minor difficulty tolerating secretions.

Cardiovascular: The patient is mildly tachycardic, which is likely attributable to pain.

Abdominal: Examination reveals a gravid uterus (pregnant uterus). The fundal height is appropriate for gestational age, and the abdomen is soft, nontender, and nondistended. Fetus presentation is cephalic. Fetal heart rate (FHR) is in the 130s.

Extremities: Extremities are nontender with 1+ pitting edema at the ankles bilaterally (common during pregnancy) and 2+ equal pulses. She is negative for Homan’s sign (calf pain upon dorsiflexion of the foot, suggestive of deep vein thrombosis).

Imaging

Despite the potential theoretical effects of radiation exposure to the fetus, all necessary plain film and computed tomography (CT) studies for diagnosing and managing facial trauma can be safely performed as needed. The radiation exposure to the developing fetus is minimal, especially when imaging the head and neck, and is further reduced by using shielding devices. Nonionization techniques, such as ultrasound scans and magnetic resonance imaging (MRI) of the head and neck, are also considered safe during pregnancy and can aid in imaging soft tissue pathology.

Computed tomography is the initial diagnostic study of choice for this patient because of facial trauma, the patient’s difficult intraoral examination, and possible airway compromise. The CT scan will help visualize facial fractures, broken teeth, foreign bodies, and airway deviation. The use of CT with intravenous (IV) contrast material is generally considered safe during pregnancy; however, special attention must be paid to the gestational age of the fetus as well as the dose and type of radiation being performed. The safe threshold for a fetus is 50 mGy. CT imaging of the maternal abdomen and pelvis can potentially deliver radiation doses that approach this safety threshold, but those of the face are well below the threshold. Changes in variables such as slice thickness, number of cuts, and helical movements can also affect the amount of ionizing radiation used regarding IV contrast. The main concern with the iodinated contrast is depression of the fetal thyroid function. After the fetus is 12 weeks old, they are producing thyroxine under the influence of thyroid-stimulating hormone. IV iodinated contrast can cross the placenta and depress fetal thyroid function. This depression in fetal thyroid function is only observed with ionic contrast agents and not nonionic contrast.

Regarding gadolinium contrast with MRI, the US Food and Drug Administration gives these agents a risk of “C,” which states the “risk cannot be ruled out.” The routine use of gadolinium is not recommended because of its long half-life and its ability to accumulate in amnionic fluid.

In this patient, the CT scan of the face showed multiple fractured teeth, an alveolar fracture of the maxilla, and a foreign body within the left side floor of the mouth.

Labs

A basic metabolic panel and complete blood count with platelets are the baseline studies.

The patient’s hemoglobin and hematocrit were 10.8 g/dL and 32.6% on admission, respectively. Platelets were 126,000 platelets per microliter. White blood cell count was 12,300 white blood cells per microliter.

Anemia is common in pregnancy and is classified as a hemoglobin below 11 g/dL in developed countries. This is due to the hemodilution from greater increases in blood volume compared with the red blood cell mass. The circulatory volumes can increase by 50% during pregnancy. Other causes of anemia in pregnancy include iron-deficiency anemia and folate deficiency. This patient’s hemoglobin is 10.8 g/dL, making her slightly anemic.

Thrombocytopenia is also quite common during pregnancy and is generally not concerning until platelets drop below 100,000 platelets per microliter. Gestational thrombocytopenia is the most common cause of thrombocytopenia in pregnancy, which typically occurs in the third trimester. The platelet count usually does not drop below 70,000 platelets per microliter. These patients typically are asymptomatic and have never had a history of thrombocytopenia. This patient is stable with platelets at 126,000 platelets per microliter, making her at low risk for complications.

Assessment

A 22-year-old G3P2002 at 39 weeks + 4 days of gestation presents with a gunshot wound to the face resulting in a right-sided facial laceration, maxillary alveolar fracture, multiple fractured teeth, and tongue lacerations complicated by a pregnancy with gestational hypertension, gestation thrombocytopenia, and obesity.

Treatment

The ideal time to perform elective or semi-elective oral and maxillofacial surgical procedures is postpartum; otherwise, the early second trimester is considered the safest period for performing nonelective surgery that cannot wait until after pregnancy. Urgent or emergent surgery should not be delayed at any gestation of pregnancy. Local anesthesia is the preferred method for simple procedures that can be performed in an office setting. (There are no contraindications to vasoconstrictors, but aspiration to avoid intravascular injection is important.) If the need arises, IV sedation and general anesthesia (in a hospital setting, when appropriate) can be safely performed without significant risk to the mother or fetus in an uncomplicated pregnancy.

There should be a low threshold for hospital admission of the pregnant patient who has sustained trauma. Dehydration, bleeding, inability to tolerate oral intake, and potential airway compromise are all indications for hospital admission.

When a pregnant patient presents to the ED with trauma, evaluation should be a multidisciplinary approach. All pregnant women who sustained serious injuries are first to be evaluated in the ED with the goal of maternal well-being. After the mother is stabilized, the obstetric team should provide complete physical and obstetric assessment. This is often done simultaneously while the mother is being evaluated. Depending on the facility, stable trauma patients who are beyond 23 weeks of gestation should be admitted to labor and delivery for observation and monitoring. Placental abruption (premature separation of the placenta before delivery) is the most frequent cause of fetal death in trauma. Fetal and uterine contraction monitoring is considered the most sensitive for detecting placental abruption. FHR is important to monitor in case of maternal hemorrhagic shock or hypotension. Frequent uterine contractions provide the most reliable warning signs of placental abruption or preterm labor. Uterine contractions that occur less frequently than every 15 minutes over a 4-hour period of observation are an indication that placental abruption is unlikely to occur. If the fetus is beyond 23 to 24 weeks of gestation, the recommended minimal time of monitoring is at least 4 hours.

Fluid resuscitation, fetal monitoring, nutritional support, and pain management are important in obstetric patients. Caution should be exercised to avoid excessive fluid overload that can lead to pulmonary edema.

Intravenous antibiotics should be initiated if indicated. (The penicillin and cephalosporin families are considered safe first-line antibiotics during pregnancy.) Pain management should be initiated as well with the goal for the patient to tolerate oral medications if the patient does not have NPO (nothing by mouth) status. Acetaminophen is the analgesic of choice during pregnancy and can be used during any trimester when indicated. Aspirin or nonsteroidal antiinflammatory drugs should not be used regularly as analgesic or antiinflammatory doses in the last third of pregnancy. When needed, orally administered hydrocodone, oxycodone, or codeine with acetaminophen combinations are all considered safe during pregnancy for necessary pain control as well as IV morphine and hydromorphone. Prolonged exposure may cause newborns to present with symptoms of withdrawal.

The current patient was admitted by the obstetric team, and OMFS was consulted for facial injuries. The patient was admitted with plans for primary cesarean delivery followed by management of facial injuries by OMFS under general anesthesia.

The pelvic examination showed effacement of 50%, dilation of 1, and –3 station. There was abundant fetal movement on ultrasound examination with an estimated fetal weight of 7 lb, 1 oz.

Fetal heart tracing showed heart rate in the 130s with moderate variability and positive acceleration but no decelerations. The tocodynamometer monitoring showed irregular uterine irritability with contractions every 4 to 6 minutes.

Because of near-term pregnancy and concern for airway compromise, the patient was taken to the operating room for primary cesarean delivery followed by examination under anesthesia with washout, debridement, and closure of facial wounds by OMFS. In the operating room, the patient was placed in the supine position and then placed under general anesthesia, and the airway was secured via a nasal endotracheal tube. She was then placed in a left lateral tilt (left lateral tilt of 15–30 degrees displaces the uterus off the aorta and inferior vena cava [IVC] and prevents supine hypotensive syndrome caused by compression of the great vessels) and prepped and draped in a sterile fashion. The obstetric team completed a successful uncomplicated delivery of the infant.

After delivery of the infant, the OMFS team completed an examination under anesthesia with extraction of indicated teeth, closure of intraoral lacerations, and removal of the foreign body. The patient’s airway was deemed stable and was extubated without difficulty. The infant was taken to the neonatal intensive care unit for observation, and the patient was discharged on postoperative day 3 after she was tolerating oral intake, reported positive urinary output, was ambulating, and had minimal discomfort. At discharge, the patient was hemostatic intraorally and had significantly improved facial and intraoral edema.

Complications

Many things must be considered to help reduce the risk of complications when presented with an obstetric patient with oral and maxillofacial trauma. Proper resuscitation efforts to help stabilize the mother must be addressed accordingly to help reduce possible complications in the mother and fetus. All elective surgical procedures should be avoided during pregnancy, but necessary surgical interventions should not be delayed. If general anesthesia is needed, surgery should be performed in a setting where an obstetrician is available for consultation and where anesthesiologists are familiar with the physiologic changes associated with pregnancy. A collaborative, multidisciplinary approach involving obstetricians, anesthesiologists, and oral and maxillofacial surgeons provides the most appropriate management and treatment plan for pregnant patients. If surgery is necessary, one must consider a few of the complications that increase in obstetrics patient and oral and maxillofacial trauma, including intubation difficulty and increased aspiration risk.

Because of the decreased functional residual capacity in pregnancy, obstetric patients are more likely to become hypoxemic. This is important to consider in this patient population with facial injuries who might develop difficulty breathing sooner than nonpregnant patients. This makes supplemental oxygenation and preoxygenation before intubation even more important. Not only does facial trauma increase the risk of difficulty intubation, but it is also important to remember that airway patency can decrease because of edema during labor. Studies have shown a significant increase in Mallampati score with a decrease in oral volume and pharyngeal areas when comparing prelabor and postlabor airway examinations. Not only are obstetric patients at risk for difficult intubation, but aspiration is also a serious possible fatal complication of general anesthesia after the patient is extubated. The enlarged uterus causes an increase in intraabdominal pressure, causing an increased incidence of esophageal reflux. Progesterone levels are also increased, which affects smooth muscle, further delaying gastric emptying and relaxing the gastroesophageal sphincter. To help reduce the risk of aspiration, a clear antacid should be given before surgery. If a patient has additional risk factors such as a difficult airway, obesity, diabetes, or recent ingestion of food, one should consider giving H2 receptor blocking agents and metoclopramide.

Discussion

With every trauma patient, the initial evaluation should start with airway, breathing, and circulation. For female trauma patients, one should always consider the possibility of pregnancy. The approach to a pregnant trauma patient should be a multidisciplinary approach with initial stabilization of the mother being the priority.

When approaching a pregnant patient with oral and maxillofacial injuries, one should be aware of potential complications that are increased because of the current pregnancy. Pregnant patients have a decreased ability to maintain a patent airway for proper ventilation, which could lead to fetal distress. This may result in maternal hyperventilation and alkalosis, which can reduce uterine blood, further inducing fetal distress. The anatomic airway in pregnancy is more edematous and friable, which could lead to a difficult intubation. One should have a lower threshold for advanced airway management because of a difficult airway and lower maternal oxygen reserve. After it is decided to intubate the patient, it is important to properly position the mother in a left lateral tilt to help displace the uterus off the IVC so one can help maintain proper vascular preload. Anesthesia is many times induced with a rapid sequence intubation to help reduce aspiration. To further help decrease the risk of aspiration, one should maintain cricoid pressure during intubation. Even if intubation is not indicated, supplemental oxygen should be provided to the obstetric patient because of the reduction in oxygen reserve that can result in inadequate respiratory compensation causing maternal hypoxia. After airway and breathing are stabilized, proper circulation should be maintained with IV fluids. Lower extremity IV placement should be avoided because of vascular congestion and IVC compression by the uterus. Signs of hypovolemia such as tachycardia, hypotension, and abnormal FHC should be detected early to initiate timely resuscitation.