The consequences of high-risk behaviors: trauma during pregnancy.

BACKGROUND: Trauma during pregnancy places two lives at risk. Knowledge of risk factors for trauma during pregnancy may improve outcomes. METHODS: We reviewed the charts of 188 such patients admitted to a Level I trauma center from 1996 to 2004. A comparison was made of injury severity and outcome from a cohort of nonpregnant female trauma patients selected with a similar temporal occurrence and age range. RESULTS: Motor vehicle collisions comprised 160 cases, 67 using a restraint device. Of 84 patients tested, 45 tested positive for intoxicants, 16 positive for 2 or more intoxicants. A significant trend toward less testing through the study period was observed (p = 0.0002). Injury severity was assessed by Revised Trauma Score (RTS). RTS <11 or admission to operating room or intensive care units (OR/ICU) classified patients as severely injured. The six maternal fatalities had an RTS <11 or OR/ICU disposition. Fetal outcomes included 155 live in utero, 18 live births, and 15 fatalities correlating with injury severity by either criteria (p < 0.0001). Of the fetal fatalities, 7 occurred with RTS = 12, but only 3 fatalities occurred in the 147 cases not admitted to OR/ICU. Gestational age correlated (p < 0.0001) with fetal outcomes. The 18 live births had mean gestational ages of 35 +/- 4 weeks as compared with fetal fatalities at 20 +/- 9 weeks, and fetuses alive in utero at 22 +/- 9 weeks gestation. Coagulation tests prothrombin time (PT), international normalized ratio (INR) (both p < 0.008), and partial thromboplastin time (PTT) (p < 0.0001) correlated with maternal outcome. A matched cohort of nonpregnancy trauma cases during the same time frame indicated that, despite a significantly higher percentage of severely injured patients, fewer fatalities occurred. This might reflect a greater risk for the pregnant trauma patient. CONCLUSIONS: This study of trauma in pregnancy cases revealed a high percentage with risk behaviors. There was a significant trend toward less intoxicant testing in recent years. Coagulation tests were the most predictive of outcomes. Lower gestational age correlated with fetal demise.

Thrombelastography monitoring of resistance to enoxaparin anticoagulation in thrombophilic pregnancy patients.

The anticoagulant effect of enoxaparin is readily observed by Thrombelastography (TEG), particularly on the reaction time (R) to form a clot, and is completely reversed by heparinase. In this study, recalcified citrated whole blood with heparinase (CNHR) and without (CNR), along with TEG R time, was used to derive a delta R (CNR-CNHR). This delta R (DeltaR) was then used to measure enoxaparin anticoagulation, which was correlated by linear regression (r(2)=0.806) with plasma anti-Xa in 48 thrombophilic pregnancy patients. In a follow up study whole blood from 15 thrombophilic and 15 normal pregnancy subjects was titrated ex vivo with enoxaparin and TEG DeltaR determined. Linear dose responses (all r(2)>0.9) of DeltaR versus plasma enoxaparin concentration were obtained for each subject. A large variation in slope was observed for both thrombophilic (>7 fold, 217 to 1,588 s DeltaR/unit anti-Xa) and normal (>3 fold, 788 to 2,758) pregnancy subjects. The average slope for the thrombophilic group (710 s DeltaR/unit anti-Xa) was significantly (P=0.002) lower than the normal pregnancy group (1,354 s), indicating resistance to enoxaparin anticoagulation in the thrombophilic group. This technique may help gauge the appropriate dose of enoxaparin for each individual, check for residual anticoagulation before invasive procedures, and perhaps help screen for thrombophilic subjects.