Volume 166 Number 2
9. Wilson CA, Keye WR. A survey of adolescent dysmenorrhea and premenstrual symptom frequency . .l Adoles Health Care 1989;10:317-22. 10. Teperi .l, Rimpela M. Menstrual pain, health and behaviour in girls. Soc Sci Med 1989;29: 163-9. 11. Emans S.l, Grace E, Woods ER, Smith DE, Klein K, Merola J. Adolescents' compliance with the use of oral contraceptives . .lAMA 1990;257:3377-81. 12. Furstenberg FF, SheaJ, Allison P, Herceg-Baron R, Webb D. Contraceptive continuation among adolescents attending family planning clinics. Fam Plann Perspect 1983;15:211-17. 13. Hofferth SL. Contraceptive decision making. In: Hayes CD, ed. Risking the future: adolescent sexuality, pregnancy and childbearing. Washington: National Academy Press 1987, vol 2.
Dysmenorrhea and use of oral contraceptives
14. Philliber S, Nameroe PB, Kaye .lW, Kunkes CH. Pregnancy risk taking among adolescents. .l Adolesc Res 1986; 1:463-81. 15. Durant RH,Jay MS. A social psychologic model offemale adolescents' compliance with contraceptives. Semin Adolesc Med 1987;3:135-44. 16. Durant RH, Sanders JM. Sexual behavior and contraceptive risk taking among sexually active adolescent females. J Adolesc Health Care 1989;10:1-9. 17. White HR, Johnson V. Risk taking as a predictor of adolescent sexual activity and use of contraception. J Adolesc Res 1988;3:317-31. 18. Johnson J. Level of knowledge among adolescent girls regarding effective treatment for dysmenorrhea. J Adolesc Health Care 1988;9:398-402.
Nonsurgical management of penetrating uterine trauma in pregnancy: A case report Debra K. Grubb, MD Los Angeles, California A woman at 30 weeks' gestation with stab wounds entering the uterus was managed nonsurgically by serial examinations and continuous fetal monitoring. Delivery occurred 4 weeks later with good maternal and fetal outcome. (AM J OasTET GYNECOL 1992;166:583-4.)
Key words: Abdominal injuries, pregnancy, stab wounds
Penetrating abdominal trauma is an uncommon complication of pregnancy, with gunshot wounds much more common than stab wounds. I We report a case of multiple stab wounds to the abdomen of a pregnant woman, with documented penetration of the uterus, which was managed non surgically with a good outcome.
Case report A 26-year-old Hispanic woman at 30 weeks of gestation in her first pregnancy was brought to the hospital by ambulance after her husband inflicted multiple stab wounds to the abdomen and upper extremities with a steak knife. On admission, the patient was hemodynamically stable and the fetal heart rate was 140 From the Department of Obstetrics and Gynecology, Universit} of Southern California. Received for publication June 18, 1991; accepted August 8, 1991. Reprint requests: Debra K. Grubb, MD, Women's Hospital, Room 5K40, 1240 N. Mission Road, Los Angeles, CA 90033. 611133027
beats/min. Stab wounds to the hands, right upper arm, and abdomen were cleaned and dressed. Obstetric ultrasonography revealed a single fetus in a breech presentation, with an estimated fetal weight of 1928 gm and no evidence of fetal injury. The fetal head was directly below one of the wounds. There was a normal amniotic fluid volume, and the placenta was anterior with no evidence of retroplacental blood clot. Continuous fetal heart rate monitoring, serial hematocrit determinations, and serial abdominal examinations were undertaken. A Kleihauer-Betke test for fetal erythrocytes was negative. An amniocentesis was performed to rule out amnionitis. The amniotic fluid was grossly bloody, but Gram stain and subsequent culture did not reveal any organisms. The hematocrit was stable over 24 hours at 30%, the fetal heart rate was reactive without decelerations, and no signs of peritonitis developed. The patient was then observed in the hospital for an additional 48 hours. No signs of infection developed, and she was discharged from the hospital. In the obstetrics clinic, there were normal heart tones and her wounds were healing well. At 34 weeks of
583
584 Grubb
gestation, she was admitted to the hospital in labor. The cervix was completely effaced and 4 cm dilated, and the fetus was in a transverse lie. Fetal heart rate monitoring was normal. External version to the vertex position was performed without difficulty. On rupture of the membranes, the fluid was noted to be dark brown with particulate matter present. The first stage of labor lasted 9 112 hours and required oxytocin augmentation. The second stage of labor lasted I hour. A vigorous female infant weighing 2540 gm with Apgar scores of 8 at 1 minute and 8 at 5 minutes was delivered spontaneously. The uterus was explored manually and was intact. The infant had a clinical estimation of gestational age of 35 weeks. The peripheral hematocrit at birth was 60% and was stable. A poorly healed laceration about 5 mm long that was noted over the infant's left parietal bone closed spontaneously on the second day of life.
Comment Evaluation of the pregnant patient with either gunshot or stab wounds of the abdomen must take into consideration the physiologic changes of pregnancy while following the principles of trauma management. Pregnant women have an increased tolerance to blood loss because of their increased blood volume and are also less likely to have guarding and rigidity with peritoneal irritation. Although a patient with a gunshot
February 1992 Am J Obstet Gynecol
wound generally requires surgical exploration, a patient with a stab wound to the abdomen may require exploratory laparotomy only if there is evidence of intraperitoneal hemorrhage or bowel perforation. 2 Cesarean section may be required if fetal distress ensues. The decision to deliver the fetus is frequently complicated by fetal prematurity and the difficulty in determining the extent and likelihood of repair of the fetal injury. In this patient grossly bloody amniotic fluid suggested that the peritoneal cavity and uterus had been penetrated. Because there was no evidence of maternal or fetal hemorrhage or bowel injury, exploratory laparotomy was deferred. It seems unlikely, in view of the injury noted at delivery, that earlier delivery would have improved the outcome of the infant in any way. This case supports recommendations in the literature that injuries known to penetrate the uterus may be managed with the fetus left in utero if there is no evidence of fetal distress or amnionitis. REFERENCES 1. Buchsbaum HJ. Penetrating injury of the abdomen. In:
Buchsbaum Hj, ed. Trauma in pregnancy. Philadelphia: WB Saunders, 1979:82. 2. Lavin JP, Polsky SS. Abdominal trauma during pregnancy. Clin Perinatol 1983; 10:423-38.
9. Wilson CA, Keye WR. A survey of adolescent dysmenorrhea and premenstrual symptom frequency . .l Adoles Health Care 1989;10:317-22. 10. Teperi .l, Rimpela M. Menstrual pain, health and behaviour in girls. Soc Sci Med 1989;29: 163-9. 11. Emans S.l, Grace E, Woods ER, Smith DE, Klein K, Merola J. Adolescents' compliance with the use of oral contraceptives . .lAMA 1990;257:3377-81. 12. Furstenberg FF, SheaJ, Allison P, Herceg-Baron R, Webb D. Contraceptive continuation among adolescents attending family planning clinics. Fam Plann Perspect 1983;15:211-17. 13. Hofferth SL. Contraceptive decision making. In: Hayes CD, ed. Risking the future: adolescent sexuality, pregnancy and childbearing. Washington: National Academy Press 1987, vol 2.
Dysmenorrhea and use of oral contraceptives
14. Philliber S, Nameroe PB, Kaye .lW, Kunkes CH. Pregnancy risk taking among adolescents. .l Adolesc Res 1986; 1:463-81. 15. Durant RH,Jay MS. A social psychologic model offemale adolescents' compliance with contraceptives. Semin Adolesc Med 1987;3:135-44. 16. Durant RH, Sanders JM. Sexual behavior and contraceptive risk taking among sexually active adolescent females. J Adolesc Health Care 1989;10:1-9. 17. White HR, Johnson V. Risk taking as a predictor of adolescent sexual activity and use of contraception. J Adolesc Res 1988;3:317-31. 18. Johnson J. Level of knowledge among adolescent girls regarding effective treatment for dysmenorrhea. J Adolesc Health Care 1988;9:398-402.
Nonsurgical management of penetrating uterine trauma in pregnancy: A case report Debra K. Grubb, MD Los Angeles, California A woman at 30 weeks' gestation with stab wounds entering the uterus was managed nonsurgically by serial examinations and continuous fetal monitoring. Delivery occurred 4 weeks later with good maternal and fetal outcome. (AM J OasTET GYNECOL 1992;166:583-4.)
Key words: Abdominal injuries, pregnancy, stab wounds
Penetrating abdominal trauma is an uncommon complication of pregnancy, with gunshot wounds much more common than stab wounds. I We report a case of multiple stab wounds to the abdomen of a pregnant woman, with documented penetration of the uterus, which was managed non surgically with a good outcome.
Case report A 26-year-old Hispanic woman at 30 weeks of gestation in her first pregnancy was brought to the hospital by ambulance after her husband inflicted multiple stab wounds to the abdomen and upper extremities with a steak knife. On admission, the patient was hemodynamically stable and the fetal heart rate was 140 From the Department of Obstetrics and Gynecology, Universit} of Southern California. Received for publication June 18, 1991; accepted August 8, 1991. Reprint requests: Debra K. Grubb, MD, Women's Hospital, Room 5K40, 1240 N. Mission Road, Los Angeles, CA 90033. 611133027
beats/min. Stab wounds to the hands, right upper arm, and abdomen were cleaned and dressed. Obstetric ultrasonography revealed a single fetus in a breech presentation, with an estimated fetal weight of 1928 gm and no evidence of fetal injury. The fetal head was directly below one of the wounds. There was a normal amniotic fluid volume, and the placenta was anterior with no evidence of retroplacental blood clot. Continuous fetal heart rate monitoring, serial hematocrit determinations, and serial abdominal examinations were undertaken. A Kleihauer-Betke test for fetal erythrocytes was negative. An amniocentesis was performed to rule out amnionitis. The amniotic fluid was grossly bloody, but Gram stain and subsequent culture did not reveal any organisms. The hematocrit was stable over 24 hours at 30%, the fetal heart rate was reactive without decelerations, and no signs of peritonitis developed. The patient was then observed in the hospital for an additional 48 hours. No signs of infection developed, and she was discharged from the hospital. In the obstetrics clinic, there were normal heart tones and her wounds were healing well. At 34 weeks of
583
584 Grubb
gestation, she was admitted to the hospital in labor. The cervix was completely effaced and 4 cm dilated, and the fetus was in a transverse lie. Fetal heart rate monitoring was normal. External version to the vertex position was performed without difficulty. On rupture of the membranes, the fluid was noted to be dark brown with particulate matter present. The first stage of labor lasted 9 112 hours and required oxytocin augmentation. The second stage of labor lasted I hour. A vigorous female infant weighing 2540 gm with Apgar scores of 8 at 1 minute and 8 at 5 minutes was delivered spontaneously. The uterus was explored manually and was intact. The infant had a clinical estimation of gestational age of 35 weeks. The peripheral hematocrit at birth was 60% and was stable. A poorly healed laceration about 5 mm long that was noted over the infant's left parietal bone closed spontaneously on the second day of life.
Comment Evaluation of the pregnant patient with either gunshot or stab wounds of the abdomen must take into consideration the physiologic changes of pregnancy while following the principles of trauma management. Pregnant women have an increased tolerance to blood loss because of their increased blood volume and are also less likely to have guarding and rigidity with peritoneal irritation. Although a patient with a gunshot
February 1992 Am J Obstet Gynecol
wound generally requires surgical exploration, a patient with a stab wound to the abdomen may require exploratory laparotomy only if there is evidence of intraperitoneal hemorrhage or bowel perforation. 2 Cesarean section may be required if fetal distress ensues. The decision to deliver the fetus is frequently complicated by fetal prematurity and the difficulty in determining the extent and likelihood of repair of the fetal injury. In this patient grossly bloody amniotic fluid suggested that the peritoneal cavity and uterus had been penetrated. Because there was no evidence of maternal or fetal hemorrhage or bowel injury, exploratory laparotomy was deferred. It seems unlikely, in view of the injury noted at delivery, that earlier delivery would have improved the outcome of the infant in any way. This case supports recommendations in the literature that injuries known to penetrate the uterus may be managed with the fetus left in utero if there is no evidence of fetal distress or amnionitis. REFERENCES 1. Buchsbaum HJ. Penetrating injury of the abdomen. In:
Buchsbaum Hj, ed. Trauma in pregnancy. Philadelphia: WB Saunders, 1979:82. 2. Lavin JP, Polsky SS. Abdominal trauma during pregnancy. Clin Perinatol 1983; 10:423-38.
