Injury and pregnancy

This subject receives very little attention in textbooks and most of the articles in journals report small numbers of injuries of one kind or another. One general review suggests that between 5 and 10 per cent of pregnant women suffer injury, usually with no risk to the pregnancy: for example, the incidence of abortion ascribed to accidental injury is less than 1 in 10,000. Personal and reported experience can be summarized as follows. The baby may be injured during pregnancy or during birth, or may be harmed by the effects or complications of injury to the mother, e.g. Gram-negative septicaemia or hypoxic states. Injuries inflicted on the baby during pregnancy are most often fractures, which affect the skull almost as often as any other bone, and frequently accompany fractures of the mother's pelvis. Gunshot and other penetrating injuries of the child are rare and are not always fatal. Fractures of the maternal pelvis are the most frequent of the major injuries and are serious to viscera and other parts of the body. In some patients deformation of the pelvis can be corrected or prevented by operation, but it is usually best accepted. Rigid internal fixation of fractures of the lower limbs sustained in the later months of pregnancy can make labour much easier for the patient and her attendants. If the effect of injury on pregnancy is usually obvious, the effect of pregnancy on recovery from injury is usually not.     

Obstetric dislocation of the thoracic spine: case report and review of the literature

A fracture dislocation of the upper thoracic spine with spinal cord injury is reported in a neonate. This rare injury is associated with attendant predisposing obstetric circumstances (breech transverse presentations, large baby size) that can alert clinicians of potential problems and aid in the diagnosis of neonatal hypotonia and paralysis.     

Traumatic cervical internal carotid artery occlusion in an infant. Case report

A 10-month-old boy presented with traumatic internal carotid artery (ICA) occlusion caused by blunt injury after falling from a baby carrier attached to a standing bicycle. Physical examination found bruises on the scalp in the right temporal region and the right shoulder, but no wound in the neck. Chest radiography showed a right clavicular fracture. He developed left hemiparesis at 19 hours after the injury. Computed tomography revealed cerebral infarct and angiography showed cervical ICA occlusion. Conservative therapy with hemodilution was given under a diagnosis of cervical ICA occlusion caused by extension and rotational head injury. Traumatic cervical ICA occlusion due to blunt injury is not uncommon in adults, but extremely rare in infants. We would like to emphasize the dangers of leaving a baby unattended in a carrier attached to a standing bicycle.     

Knowledge, beliefs, and practices concerning seat belt use during pregnancy

OBJECTIVE: This study seeks to evaluate the comprehension of and attitudes toward proper restraint use among women attending prenatal care clinics. METHODS: Four-hundred and fifty women were asked to complete a survey during prenatal care visits at county health department clinics; the response rate was 92.0%. Women were asked to provide demographic information and report their frequency and knowledge of proper automobile restraint use. RESULTS: Nearly all subjects (95.4%) either maintained or increased their pre-pregnancy frequency of restraint use. Three-hundred (72.5%) subjects demonstrated that they wore their restraints in the correct location, with women who wore restraints more frequently being more likely to report correct placement. Two-hundred and forty-nine (60.1%) of women reported that restraints would protect their baby if they were involved in a collision, while 48 (11.6%) thought the restraints would cause injury to their baby, and 153 (37.0%) were unsure. Women who reported that restraints would protect them and their baby if involved in a collision were significantly more likely to report always wearing restraints compared with those who were unsure or had negative perceptions of restraints (84.4% vs. 64.6%; p < 0.0001). The most commonly reported reasons for lack of restraint use were lack of comfort (52.8%) and forgetfulness (42.5%). Only 36.9% percent of women reported receiving information regarding restraint use during their current pregnancy. CONCLUSIONS: Many gravid women lack information regarding proper seat belt use and their role in injury prevention. Consequently, the frequency of seat belt use and its correct placement are negatively impacted. Health care workers should take an active role in educating pregnant gravid women about proper restraint use.     

Shaken baby syndrome: an odyssey

Shaken baby syndrome is evaluated in the context of its historical evolution and its veracity in referring to causal injury mechanisms. A rational assessment of the injury causation and consequent pathological states associated with the syndrome is presented. It is now evident that shaken baby syndrome evolved as a result of a faulty application of scientific reasoning and a lack of appreciation of mechanisms of injury. A brief explanation of the commonly understood usage and interface of scientific methodology and reasoning as applied to clinical medicine is given.     

Battered baby with multiple epiphyseal separations: case report and review of literature

Multiple epiphyseal separation in battered baby syndrome is a rare occurrence. We report epiphyseal separations of proximal tibia and distal humerus along with femoral shaft fracture in a child of two and half years of age. In the course of clinical, laboratory, and radiological examinations, the child was diagnosed to be a case of battered baby syndrome. The child was treated and isolated from the mother, who was the culprit for battering the child. We believe, in any epiphyseal injury below 3 years of age, particularly when the distal humerus physis is involved, diagnosis of child abuse should be considered as an etiology.     

Multiple chronic subdural hematoma in shaken-baby syndrome

We described a case of shaken-baby syndrome with multiple chronic subdural hematomas. A 10-month-old male baby was admitted to our hospital because of loss of consciousness and convulsions. CT scan revealed an acute subarachnoid hemorrhage extending into the interhemispheric fissure and supracerebellar space. The patient was treated conservatively, and discharged from the hospitaL Two months after ictus, a baby was admitted to our hospital with general fatigue. CT scan demonstrated multiple chronic subdural hematomas. Burr hole irrigation and drainage brought about complete disappearance of these lesions. Retrospectively, it was found that these multiple subdural hematomas were due to shaken-baby syndrome. Shaken-baby syndrome is a form of child abuse that can cause significant head injury, and subdural hematoma is the most common manifestation. It is well known that the outcome of shaken-baby syndrome is generally not good. It is important to suspect shaken-baby syndrome when a chronic subdural hematoma is seen in a baby.     

Laparoscopic Aortic Injury Leading to Delayed Aortoenteric Fistula: An Alternative Technique for Repair

Complications of laparoscopic procedures occur in up to 10% of cases. The most lethal complication relates to injury of major retroperitoneal vascular structures. A case of aortoenteric fistula referred to the vascular surgical service 1 month following emergency repair of laparoscopic aortic injury is presented. A technique utilizing a saphenous vein panel graft for distal aortic repair is described. Review of reported cases demonstrates that major retroperitoneal vascular injury during laparoscopy is rare, with a reported incidence of 3 to 10/10,000 procedures, and a mortality of up to 20%. Simple suture repair is the usual form of treatment, but specialized techniques are occasionally required.     

Burn injury in the aged patient

It is a tragedy when an aged patient dies after sustaining a minor burn. Although many reported series illustrate the poor prognosis of burn injury in the elderly, the number of patients studied is often small. In a 10-year-period, 276 patients aged over 60 years were admitted to the Wessex Regional Burn Centre following acute burn injury. These patients represented 16 per cent of all acute burn admissions, and were studied in a retrospective review. Various data on mortality and burn size incidence are presented for this traditionally regarded high risk group.     

Bilateral simultaneous fracture of the femoral neck following electrical shock

Simultaneous, bilateral fracture of the neck of the femur is rare; the number of reported cases does not exceed 10. Those fractures which occur as a result of electric shock, whether accidental or controlled, i.e. electroconvulsive therapy (ECT), account for almost 50 per cent of reported cases, while violent injury and epilepsy account for the remainder.This study combines a report of 1 case of bilateral fracture of the neck of the femur due to accidental electric shock with a review of the literature to discover the frequency of these fractures.     

Type IV jejunal atresia with an unusual variation of enteric duplication: report of a case

We report a rare case of type IV jejunal atresia with enteric duplication and multiple diverticuli, found in a 3-day-old baby girl. To our knowledge, this association has never been reported before.     

Emergency cricothyrotomy in infants--evaluation of a novel device in an animal model

Background: According to different algorithms of airway management, emergency cricothyrotomy is the final step in managing an otherwise not accessible airway. As an alternative to an open surgical procedure, minimally invasive approaches exist. Quicktrach baby? is a commercially available set for a minimal invasive cricothyrotomy in infants. The set consists of a plastic cannula over a metal needle for direct placement in the trachea. So far, this device has not been evaluated for its intended use. Objectives: We hypothesize that Quicktrach baby? allows the establishment of an emergency airway. The aim was to prove that the device is easy to handle and the cricothyrotomy fast to perform. Methods: After approval of the local ethics committee, the study was performed on the cadavers of 10 adult rabbits. Cricothyrotomy was performed with Quicktrach baby?. Successful placement, performance time, and complication rate were documented. Possible ventilation with a breathing bag was evaluated. Data are reported as mean and interquartile range. Results: Successful placement of Quicktrach baby? was possible in all attempts. The placement took 31 [23–43] s. In two cases, a fracture of the cricoid’s cartilage was seen. In one animal, damage to the posterior wall mucosa was observed. In all cases, sufficient ventilation was possible. Conclusions: Quicktrach? baby proved to be a reliable technique. In the animal model, it is easy and fast to perform. Only a few minor complications occurred. Sufficient ventilation was possible in all attempts.     

Anesthesia in Beckwith-Wiedemann syndrome

Anesthetic management of a 3-month-old boy with Beckwith-Wiedemann syndrome for bronchoscopy is reported. Management may be complicated by a difficult airway, congenital heart disease, and hypoglycemia. We did not have difficulty in airway management either with tracheal intubation or rigid bronchoscopy, but we could not extubate the baby because of tracheomalacia.     

Neonatal separation of distal humeral epiphysis during Caesarean section: a case report

We report a rare injury of distal humeral epiphyseal separation in a newborn during a Caesarean section. The diagnosis was made using magnetic resonance imaging. Emergency Caesarean deliveries with considerable traction applied to extract the baby can be the risk factor of such an injury.     

ISCHAEMIC PRECONDITIONING OF THE LIVER: A PRELIMINARY STUDY

Background: A phenomenon of ‘preconditioning’ exists for the heart, but has not been described for the liver. This study was undertaken to determine whether a brief episode of ischaemia (3 or 5 min) followed by a short reperfusion time (5 or 10 min) would precondition the liver to reduce subsequent injury from prolonged ischaemia (30 to 90 min). Methods: Male Wistar rats were allocated into five control (no preconditioning) and five preconditioned groups, each having a liver resection. The preconditioning times were 3 rnin ischaemia followed by 5 rnin reperfusion with a prolonged ischaemia of 60 or 90 min for the first two groups, and 5 min ischaemia followed by 10 rnin reperfusion with prolonged ischaemia times of 30 or 45 min for the other three groups. Results: Of rats resected with 3–5–60 rnin time sequence designed to assess survival, 9/10 died. However 9/10 died also in the matching control group with 60 rnin ischaemia. With a 5–10–45 rnin sequence, 9/10 survived more than 24 h in the preconditioned group and 1/10 in the non-preconditioned controls. With a 5–10–30+ sequence designed to measure liver function tests, the prothrombin time was significantly improved; bilirubin, serum alkaline phosphatase and the alanine aminotransferase improved but these did not reach significance. Conclusion: A brief episode of ischaemia followed by an episode of reperfusion before a prolonged period of ischaemia ameliorated the effects of ischaemia-reperfusion injury in a rat liver resection model. If hepatic preconditioning is confirmed in humans, ischaemic preconditioning will have an important role for all liver surgery.     

Seat belt injury of the breast—a case report

A case is reported of a breast injury sustained as a result of wearing a seat belt. A possible mechanism for this particular injury is proposed.     

The shaken baby syndrome. A clinical, pathological, and biomechanical study

Because a history of shaking is often lacking in the so-called "shaken baby syndrome," diagnosis is usually based on a constellation of clinical and radiographic findings. Forty-eight cases of infants and young children with this diagnosis seen between 1978 and 1985 at the Children's Hospital of Philadelphia were reviewed. All patients had a presenting history thought to be suspicious for child abuse, and either retinal hemorrhages with subdural or subarachnoid hemorrhages or a computerized tomography scan showing subdural or subarachnoid hemorrhages with interhemispheric blood. The physical examination and presence of associated trauma were analyzed; autopsy findings for the 13 fatalities were reviewed. All fatal cases had signs of blunt impact to the head, although in more than half of them these findings were noted only at autopsy. All deaths were associated with uncontrollably increased intracranial pressure. Models of 1-month-old infants with various neck and skull parameters were instrumented with accelerometers and shaken and impacted against padded or unpadded surfaces. Angular accelerations for shakes were smaller than those for impacts by a factor of 50. All shakes fell below injury thresholds established for subhuman primates scaled for the same brain mass, while impacts spanned concussion, subdural hematoma, and diffuse axonal injury ranges. It was concluded that severe head injuries commonly diagnosed as shaking injuries require impact to occur and that shaking alone in an otherwise normal baby is unlikely to cause the shaken baby syndrome.     

The Effects of Hypertonic Saline on Spinal Cord Blood Flow Following Compression Injury

Summary  7.5% hypertonic saline was administered following spinal cord injury to test its effect on spinal cord blood flow. Four different groups of rats underwent 10 minutes of spinal cord compression (45g) at the C3 to C5 levels. A fifth group was not injured, but received hypertonic saline (5 ml/kg) at 5, 15 and 60 minutes following injury. Somatosensory evoked potentials and spinal cord blood flow were measured prior to and for 4 hours following the injury. The administration of hypertonic saline caused a significant increase in flow when administered 5 minutes following injury. Topical nitroprusside administration did not cause any increase in spinal cord blood flow during this time period. Hypertonic saline administration at the later time periods did not increase spinal cord blood flow. The group of animals which were not injured, but received hypertonic saline also showed no significant change in flow. The somatosensory evoked response of the treated animals was maintained for 4 hours after the injury where as the untreated animals began to lose their evoked responses 3 hours after injury.     

Minilaparoscopic cystectomy and appendectomy in late second trimester.

BACKGROUND AND OBJECTIVES: Laparoscopic ovarian cystectomy and appendectomy during the early second trimester have been widely reported. However, the use of both procedures in advanced gestation is rare. We propose a minilaparoscopic approach for performing these 2 procedures in a woman 24-weeks pregnant. METHODS: We describe the case and laparoscopic management of acute abdominal pain at the 24th week of pregnancy. Microlaparoscopy under ultrasound guidance was used for the first trocar insertion to prevent injury to the uterus. It was followed by minilaparoscopic ovarian cystectomy and appendectomy. RESULTS: Premature contractions occurred after the operation, but they were controlled with a single tocolytic agent, and an apparently healthy female baby was born uneventfully via Cesarean delivery at 41 weeks of gestation. CONCLUSION: Minilaparoscopic ovarian cystectomy and appendectomy can be carried out in the late second trimester without serious sequela.     

Comparison of Inflammatory Markers Between the Sevoflurane and Isoflurane Anesthesia in a Rat Model of Liver Ischemia/Reperfusion Injury

BackgroundSevoflurane and isoflurane had been reported to improve ischemia/reperfusion injury (I/R) through amelioration of the inflammatory response. We aimed to explore and compare the molecular mechanisms involved in sevoflurane and isoflurane anesthesia in liver ischemia-reperfusion of rat model.MethodsForty male Wistar rats were randomly divided into 4 groups: sham group, I/R group, sevoflurane group, and isoflurane group. The liver I/R injury model was established to investigate the effect of sevoflurane and isoflurane anesthesia on liver ischemia/reperfusion. The inflammatory markers and complement C3, C5a, and C6 were detected by enzyme-linked immunosorbent assay. Oxidative stress was detected by measuring the levels of malondialdehyde (MDA), superoxide dismutase (SOD), and nitric oxide (NO).ResultsOur results showed that sevoflurane anesthesia significantly decreased alanine transaminase, aspartate transaminase, and lactate dehydrogenase levels compared with isoflurane and controls. Sevoflurane inhibited I/R injury induced production of tumor necrosis factor α, interleukin 1, interleukin 6, and intercellular cell adhesion molecule-1 and promoted interleukin 10 production more significantly compared with isoflurane. Reduced MDA and NO and elevated SOD release suggested that oxidative stress was attenuated by sevoflurane and isoflurane anesthesia. Both sevoflurane and isoflurane anesthesia significantly decreased plasma C3 levels compared with the I/R injury group without differences.ConclusionSevoflurane anesthesia produced a more significant inhibitive effect on inflammatory cytokines and oxidative stress in liver I/R injury model than isoflurane, suggesting that sevoflurane is more suitable in surgery.