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Fig. 5.22 The lethal penetrating hole in the fetal face and
an exit hole in the fetal thorax. (Rreproduced from [155]
under the CC Attribution License). Entry and exit wounds
on the uterus of the same patients are presented in Fig. 25.44
brain injury without external marks of intrauterine fetal head injury. It is commonly the result of
severe head injury detected at emergent CS.
5.3.4 Diagnosis
5 Fetal Trauma
Fetal injuries due to maternal penetrating abdominal trauma are diagnosed (1) preoperatively,
when there is an indication for maternal diagnostic imaging with ndings of potential fetal injuries or with abnormal CTG ndings, (2) during
maternal abdominal exploration for maternal
injuries with conrmed uterine injury, (3) clinically, immediately after delivery, and (4) with
delayed newborn or child presentation.
5.3.4.1 Preoperative Diagnosis
Two scenarios for the diagnosis of preoperative
fetal injuries exist. First, fetal injuries can be
expected with CTG signs of fetal distress without
an indication for maternal abdominal exploration.
Second, fetal injuries can be detected on maternal
imaging diagnostics on plain X-rays, transabdominal US [153], or abdominal CT.Imaging preoperative fetal injuries is more challenging with
stabbing because there are fewer fetal deformations and less possibility of retained foreign bodies visible on diagnostic imaging.
Fig. 5.23 Fatal penetrating stab wound to the lower thorax
in a pale fetus. The wound is similar to the one in Fig.5.22.
Sometimes, it is difcult to conclude whether maternal
hypotension of fetal injury is the cause of fetal death. A
fetal autopsy is not described. (Reproduced with permission from [156] under the CC BY 4.0 Attribution License)
5.3.4.2 Intraoperative Diagnosis
Most fetal injuries are detected during the exploration of maternal intra-abdominal wounds, such
as an abdominal gunshot wound, and most stab
wounds indicate maternal abdominal exploration. A uterine wound carries a high probability
of fetal injury, and CS should be considered in a
viable fetus (see Sect. 25.4.4).
ab
5.3 Penetrating Fetal Trauma
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a
b
Fig. 5.24 The rst presentation of a 3-year-old child. (a)
The bulging on the skin in the right temporal region; (b) A
thin skin scar in the right temporal region [152]
5.3.4.3 Postdelivery Diagnosis
Even if the wounds seem supercial, primarily if
projectiles are not found, focused plain X-rays,
or babygram can show retained metal parts/bullets (Fig. 5.25) in the fetus [157] or fractures
from projectile energy transmission. Therefore, a
plain X-ray is recommended for gunshot wounds.
For head injuries, brain US or head CT denes
the extent of bleeding and retained foreign bodies
[153, 158].
5.3.4.4 Delayed Diagnosis
Delayed presentation, even after many years, can
be noted as progressive deformities or enlarging
lumps caused by retained foreign bodies [159],
bony (Fig.5.26), or internal defects as in the form
of diaphragmatic hernia [160]. Also, fetal neurologic impairment should raise suspicion of a
post-traumatic cause from intrauterine fetal
injury [154].
Metal bodies are seen on plain X-rays
(Fig.5.27). As in blunt trauma, a specic condition is growing skull fracture. Growing skull
Fig. 5.25 (a) Frontal and (b) lateral, plain abdominal X-rays of the abdomen showing the radiopaque bullet in the right
thigh. (Reproduced with permission from [150] under the CC BY)
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5 Fetal Trauma
Fig. 5.26 A 2.5-year-old abandoned child with a pulsating bulge in the right temporal region. Knife stab wound
to the maternal abdomen at 30weeks of pregnancy. (a) A
3D CT scan reveals a large right temporal bone defect; (b)
MRI showing herniation of the cicatricial cerebral tissue
through the skull defect and a mild “blow out” of the
homolateral temporal ventricular horn [152]
Fig. 5.27 Chest X-ray (posteroanterior and right lateral)
revealing radiopaque shadow (bullet) in a 10-year-old boy
without signs of a postnatal gunshot injury. There were no
scars on the skin. (Reproduced with permission from
[159] under the CC Attribution License)
5.3 Penetrating Fetal Trauma
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fracture requires severe head injury to result in a
skull fracture, a tear in the dura mater, or brain
injury. The outward driving force, such as a normally growing brain, is the mechanism underlying the formation of the growing fracture [161].
These elements explain why most growing fractures occur in very young children or intrauterine
fetal head injuries [152].
5.3.5 Treatment
5.3.5.1 Obstetric Management
With a live fetus, risks of prematurity must be
weighed against the benets of delivery for and
treatment of the suspected fetal injury. Indications
for emergent CS in an alive and viable fetus are:
• radiologic signs of penetrating head injury or
visible intracranial foreign bodies,
• radiologic signs of thoracoabdominal injury
or visible intracranial foreign bodies,
• CTG abnormalities.
5.3.5.2 General Wound Treatment
Due to a small number of cases, there are no rm
recommendations for specic penetrating fetal
injuries.
Principles of stab or gunshot wound to the
delivered viable fetus should follow neonatal and pediatric surgery principles.
tem’s progressive maturation and the placenta’s
increased permeability during the last months of
pregnancy. Vaccine effectiveness of ≥2 properly
timed doses of tetanus toxoid given to pregnant
women against neonatal tetanus mortality is 94%
[163]. Transplacental immunization circumvents
the necessity for immunization in early neonatal
life (up to 13months) [164]. Guidelines about vaccination or prophylaxis for emergent CS shortly
after immunization do not exist. There is no evidence of adverse fetal effects from vaccinating
pregnant women with an inactivated virus, bacterial vaccine, or toxoid. A growing body of robust
data demonstrates the safety of such use [165].
Prophylactic Antibiotics
In most cases, antibiotics are not even mentioned.
As in nonpregnant population broad-spectrum
antibiotics, FDA class B, eventually, class C
should be administered to the mother. With the
continuation of pregnancy, transplacental antibiotic transfer protects a fetus. There are no recommendations on fetal antibiotic prophylaxis if
emergent CS is performed at the time of injury.
5.3.5.3 Subcutaneous andLimb Injury
Tangential skin injuries resulting from stab and
gunshot wounds (Fig.5.20a) need only debridement and dressings. For the deeper penetration
into the limbs (Figs. 5.20b and 5.28) with the
Since infants have been born alive with soft
tissue and visceral injuries, the hazards of prematurity must be weighed against the potential benets of operation to the injured premature infant
delivered by CS.When fetal weight approaches
2,500g, these hazards are greatly diminished.
Tetanus Vaccinations/Prophylaxis
For maternal prophylaxis, see Sect. 25.4.4.1. To
avoid generalized neonatal tetanus, maternal vaccination during the last trimester (not earlier) of
pregnancy induces intrauterine active fetal immunization [162]. This is due to the fetal immune sys-
Fig. 5.28 Bullet entrance hole in a fetus treated conservatively. Post-injury plain X-ray did not reveal metal
parts, but the newborn was lost in follow-up. (Reproduced
with permission from [166])
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5 Fetal Trauma
possibility of injury of important structures
(nerves, blood vessels, bones, tendons, joints), no
clear guidelines exist [166]. However, exploration is recommended except in puncture wounds
without signs of compartment or signicant
edema. The neurovascular decit is an absolute
indication for exploration. The radiologic examination is necessary to dene retained metal parts
with only the entrance wound on limbs.
5.3.5.4 Head Injury
Neuroprotection
One of the unsolved issues is post-traumatic neuroprotection. Many potential targets for neuroprotection—antagonists of the NMDA receptors
for glutamate, magnesium sulfate, and tianeptine
block the effects of inammatory cytokines,
NSAIDs, and growth factors—are effective in
animals and invitro experiments. However, there
is no rm data on humans [167].
Brain Surgery
Several authors recommend postponed removal
of projectiles when the newborn does not show
(1) signicant neurologic decits, (2) intracranial
bleeding, (3) increased intracranial pressure, or
(4) infective complications mandating exploration [153, 168]. Repeated US or CT examinations
should be used to monitor fetal course noninvasively. The possible adverse effect could be lead
poisoning with the potential of a child’s failure to
thrive [169]. Some authors claim it is only present when the bullet is included in the circulating
uids like synovial [170] or cerebrospinal [171,
172]. If any of the conditions above are present,
immediate exploration is mandatory [158].
5.3.5.5 Thoracoabdominal Injury
In hemodynamically unstable fetuses, surgical
exploration is mandatory.
In the stable fetus, gunshot wounds to the thorax or abdomen indicate thoracotomy or laparotomy, while stab wounds could be managed
nonoperatively. Peripheral thoracic gunshot
wounds could be treated with a chest tube. The
risk of delayed complications includes a diaphragmatic hernia [160]. Wound exploration is
mandatory [173]. Further exploration is recommended with the pleural or peritoneal injury due
to a high possibility of organ injury when the
dagger to fetal body ratio is considered [174].
Further procedures depend on the injury type and
principles that follow pediatric surgery principles
(closure of pleural, peritoneal, diaphragmatic,
bowel injuries/defects, and bleeding control)
(Fig.5.29).
Absorbable sutures are used to repair minor
lacerations in the lungs or bowel (Fig.5.29).
After bowel resections or simple sutures,
breastfeeding can start on postoperative day 2 if
the newborn is stabilized without mechanical
ventilation [174].
5.3.6 Prognosis
The fetus has a worse prognosis than the mother,
with an injury rate of 59–80% and a perinatal
mortality rate of 40–71% [92, 175, 176]. The
In stable newborns with noncomplicated
penetrating intracranial injury, when all
issues related to prematurity are solved, the
idea to postpone the operation at around
1year of age minimizes the risk of further
brain injury, with a potential of lead poisoning. The infant’s age for safe projectile
removal depends on the localization of the
projectile and the infant’s condition.
Fig. 5.29 Lung laceration from the gunshot wound
repaired with primary suture. (Reproduced with permission from [174] under the CC BY Attribution License)
5.3 Penetrating Fetal Trauma
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perinatal mortality during 1957–1967 was 71%
[23], unchanged from 1845–1964 [177]. After
1967, there was a decrease to 59% [23]. From
1845 to 1954, fetal mortality of viable fetuses
was 55% [178]. In the same period, the fetal mortality among those with vaginal deliveries was
66%; among those who had abdominal deliveries, 46%. Perinatal mortality of viable fetuses up
to 1972 was 59% [179].
Fetal trauma after stabbing injuries to the uterine cavity occurred in approximately 50%, with
fetal survival of 80% [180–182]. All parts of the
fetal body are equally affected.
Factors that have an impact on fetal outcome
are (1) fetal factors, in addition to (2) maternal
factors (placental injury, placental abruption, disseminated intravascular coagulation, and
maternal hypovolemia), and (3) availability of
tertiary centers for high-risk neonates. Fetal factors that have an impact on fetal outcome are:
• the second trimester of pregnancy,
• multiple > single wounds,
• gunshot > stabbing wounds,
• thoracoabdominal wounds.
Pregnancy loss was signicantly greater in
women in the second trimester than in the rst
trimester. The second trimester represents the
most vulnerable period for all types of fetal
trauma because the gravid uterus ascends out of
the bony pelvis in the cephalad direction to reach
the level of the umbilicus by 24weeks; here, the
gravid uterus may sustain a direct traumatic
injury. In the third trimester, the fetus is well protected by the thickened uterine wall and the
amniotic uid [120]. However, in both gunshot
and stab wounds, the fetus presents a larger target
as the pregnancy progresses and is more likely to
sustain an injury [14, 183–186].
Fetal morbidity depends on the gestational
age, location, and extent of injured structures and
organs. However, functional impairment is
mostly lesser [160, 173], except for head injuries
(see 5.3.6.1), than in children and adults.
With gunshot wounds, fetal injuries range
from 60 to 90%, and overall perinatal mortality is
up to 70% [14, 179, 184, 187]. A signicant portion of fetal death in stabbing and gunshot
wounds is due to immaturity from ill-timed delivery. Until 1977, fetal mortality was 78% if intrauterine gunshot wounding occurred preterm, but
only 40% for injuries at term [188].
Several decades ago, after stabbing injuries to
the uterine cavity, fetal trauma occurred in 93%,
with fetal mortality of 47% [186]. Recent fetal
mortality decreased to 27.3% [180].
5.3.6.1 Penetrating Head Injury
Intrauterine penetrating fetal head injury has a
high mortality [158]. With maternal abdominal
stab wounds, the fetal head is injured in 10% of
cases [152]. Many survived newborns have neurologic deciencies. The incidence and the extent
of neurologic decit depend on the factors listed
in the following tables (Tables 5.4 and 5.5):
As for fetal mortality, gunshot wounds carry a
much higher rate of a post-injury neurologic decit than fetal head stab injuries. Despite attenuation from the uterine wall and amniotic uid,
projectiles from explosive weapons transmit
more energy to the surrounding tissues. An additional consequence is a higher risk of surrounding necrosis and infective complications
necessitating further conservative and surgical
therapy, mainly debridement, and abscess drainage. In cases of fetal cerebral ischemia, reperfusion injury also contributes to brain damage.
Prematurity and preterm delivery could also contribute to neurocognitive development [153].
Also, additional general anesthesia in neonates
Table 5.5 Factors contributing to the neurologic decit
after fetal penetrating head injuries
Related to head injury Unrelated to head injury
Type of wound/weapon Maternal hemorrhage or
septic shock
Extent of primary brain
damage
Severity of primary brain
damage
Secondary brain damage Prematurity
Number of operations/
general anesthesia
Fetal hemorrhage/hypoxia
Socioeconomic factors
Lead toxicity
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5 Fetal Trauma
contributes to cognitive impairment. Maternal
hemorrhagic or septic shock also contributes to
worse outcome, primarily if associated with placental abruption, placental tear, or disseminated
intravascular coagulation. Retroplacental bleeding can lead to feto-maternal transfusion, fetal
anemia, hypovolemia, and hypoxia (see Sect.
25.3.6).
The degree and dynamics of neurologic de-
ciencies are challenging for prognosis due to a
small number of patients. However, all survived
fetuses developed hydrocephalus, seizures, and
intellectual or cognitive disabilities. Children
<5years at the time of injury had more intellectual impairment than children with similar injuries later. Socioeconomic factors are also
important. Long-term functional therapy inuences long-term neurodevelopmental outcomes
as for any other type of injury, while it is of
utmost importance for a head injury.
5.3.6.2 Penetrating Thoracoabdominal
Injury
Fetal thoracoabdominal gunshot wounds 40years
ago had a mortality rate of ≈100% [188, 189],
while current mortality is 50% [156].
5.3.6.3 Perimortem Cesarean Section
The outcome of postmortem CS for all causes
was poor until recently. In the German duchy
Kurhessen in 1848, there were 107 cases with no
survivors [190]. In 1864, in 147 cases at the
Berlin Obstetrical Society, only three infants survived [191]. Katz etal. reviewed the literature
from 1879 through 1985 and reported 269 cases
with 188 infant survivors with probable underreporting of unsuccessful cases [190]. Katz etal.
associated infant survival with the time interval
between maternal death and delivery. In their
review of cases from 1900 to 1985, there were 61
cases with neonatal survival and known time
intervals. Fifty-seven (93%) were born within
15min, and only two had neurological damage,
one mild and one severe. Seventy percent of the
survivors were born within 5min [190]. There
are cases with live infants with postmortem CS
between 7 and 22min after documented maternal
cardiac arrest. Follow-up of infants demonstrated
no evidence of neurologic damage [191, 192].
Strong etal., in 1989, reported that about half of
the perimortem CS in the literature had produced
live infants. However, the incidence of neurological sequel increases with increasing delays to
delivery. The long-term survival rate for healthy
infants was 15% [193].
Of infants delivered by this method in general,
approximately 15% survive and are discharged
from the hospital in good condition [194–196].
The survival of these infants depends on how soon
they are extracted, their maturity, the duration and
nature of the mother’s illness, the performance of
postmortem maternal CPR, and the availability of
neonatal intensive care [197]. Although recent
reviews conclude that despite reports of 30years
supporting perimortem CS, they fail to prove that
it improves maternal and neonatal outcomes
[198]. Of the 330 reported cases of postmortem
CS during the eighteenth century, only 7 living
children recovered. Then, in 1916, fetal survival
of 42.3% was published [199].
If the mother is stabilized, but the extent of
maternal injuries precludes maternal salvage,
there is another option except for perimortem
CS.Improved life support for premature infants
and their mothers who sustained fatal injury
increased the possibility of successful pregnancy
outcomes. This is primarily applicable for maternal injury resulting in brain death. Mother is
maintained on life support systems until the fetus
reaches maturity [200].
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