Альманах клинической медицины. 2021; 49: 231-238
Тяжелая черепно-мозговая травма плода при автомобильной аварии: обзор литературы и клиническое наблюдение
https://doi.org/10.18786/2072-0505-2021-49-015Аннотация
Автомобильные аварии - основная причина травм беременных. Даже при нетяжелой аварии высок риск повреждения и неблагоприятного исхода для плода, особенно в случае отслойки плаценты. При этом основными травмирующими агентами могут стать такие средства индивидуальной защиты, как ремень и подушка безопасности. Среди частых вариантов внутриутробного повреждения при тупой травме живота в результате автомобильной аварии можно выделить черепно-мозговую травму в виде переломов костей черепа и различных внутричерепных кровоизлияний. Несмотря на распространенную точку зрения относительно высокой летальности в этой популяции, нередки случаи благополучного исхода травмы плода без формирования клинически значимого неврологического дефицита. В статье анализируются основные варианты исхода внутриутробного повреждения головного мозга и факторы, их определяющие. В качестве иллюстрации описан случай автомобильной черепно-мозговой травмы плода на 38-й неделе развития с переломом костей черепа, ушибом мозга и субарахноидальным, эпидуральным и субдуральным, паренхиматозным и внутрижелудочковым кровоизлияниями вследствие компримирующего воздействия ремня безопасности; при этом мать практически не пострадала. По окончании лечения пациент выписан из стационара в удовлетворительном состоянии без клинически значимой неврологической симптоматики. Динамическое наблюдение ребенка в течение 8 месяцев позволило выявить признаки замедления созревания головного мозга в виде появления доброкачественных эпилептиформных паттернов детства и паттернов магнитно-резонансной томографии.
По всей видимости, ведущими факторами, обеспечивающими благоприятный исход внутриутробной тяжелой черепно-мозговой травмы в отсутствие фатального повреждения матери и плода, служат правильная акушерская тактика, поздний срок беременности и отсутствие массивного паренхиматозно-вентрикулярного кровоизлияния. Помимо непосредственного клинического выздоровления после тяжелого внутриутробного травматического повреждения головного мозга важно динамическое наблюдение ребенка ввиду повышенного риска развития отдаленных церебральных структурных и функциональных нарушений, прежде всего пароксизмальных, поведенческих и когнитивных.
Список литературы
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Almanac of Clinical Medicine. 2021; 49: 231-238
Severe brain trauma to the fetus in a car accident: Literature review and a clinical case
https://doi.org/10.18786/2072-0505-2021-49-015Abstract
Car accidents are the main cause of trauma during pregnancy. Even a non-severe accident is associated with a high risk of injury and unfavorable outcome for the fetus, especially in the event of placental abruption. Major agents leading to a trauma could also include safety belt and safety airbags. Blunt abdominal trauma during a car accident is associated with such type of intrauterine injury as fetal skull fractures and various intracranial hemorrhages. Despite a common viewpoint on relatively high death rates in this population, it is not infrequent that fetal trauma has a favorable outcome without any clinically significant neurological deficiency.
The paper presents an analysis of the main outcomes of intrauterine brain injury and associated factors. As an illustration, we describe a case of a car accident related brain injury to a fetus at 38 week of gestation, with skull fracture, brain contusion, and subarachnoidal, epidural and subdural, parenchymal and intraventricular hemorrhages induced by the safety belt, with the mother being virtually uninjured. After treatment, the patient was discharged from the hospital in a satisfactory state, without clinically significant neurological symptoms and signs. A 8-months follow-up of the infant showed some delay in brain maturation manifesting as benign epileptiform discharges of childhood and magnetic resonance imaging patterns.
It is highly likely, that the leading factors ensuring a favorable outcome of a intrauterine severe brain trauma (without fatal trauma to the mother and fetus) are as follows: correct obstetric strategy, late gestational age and absence of a massive parenchymal and/or intraventricular bleeding. After the short-term clinical recovery from a severe intrauterine brain trauma and in addition to it, proper follow-up of the child is essential because of a high risk of long-term cerebral and functional abnormalities, mostly paroxysmal, behavioral and cognitive.
References
1. El-Kady D, Gilbert WM, Anderson J, Danielsen B, Towner D, Smith LH. Trauma during pregnancy: an analysis of maternal and fetal outcomes in a large population. Am J Ob-stet Gynecol. 2004;190(6):1661-1668. doi: 10.1016/j.ajog.2004.02.051.
2. Mattox KL, Goetzl L. Trauma in pregnancy. Crit Care Med. 2005;33(10 Suppl):S385-S389. doi: 10.1097/01.ccm.0000182808.99433.55.
3. Pearlman MD, Tintinallli JE, Lorenz RP. A prospective controlled study of outcome after trauma during pregnancy. Am J Obstet Gynecol. 1990;162(6):1502-1507; discussion 15071510. doi: 10.1016/0002-9378(90)90913-r.
4. Pearlman MD. Motor vehicle crashes, pregnancy loss and preterm labor. Int J Gynaecol Obstet. 1997;57(2):127-132. doi: 10.1016/s0020-7292(96)02829-9.
5. Weiss HB, Songer TJ, Fabio A. Fetal deaths related to maternal injury. JAMA. 2001;286(15): 1863-1868. doi: 10.1001/jama.286.15.1863.
6. Hyde LK, Cook LJ, Olson LM, Weiss HB, Dean JM. Effect of motor vehicle crashes on adverse fetal outcomes. Obstet Gynecol. 2003;102(2):279-286. doi: 10.1016/s0029-7844(03)00518-0.
7. Kvarnstrand L, Milsom I, Lekander T, Druid H, Jacobsson B. Maternal fatalities, fetal and neonatal deaths related to motor vehicle crashes during pregnancy: a national population-based study. Acta Obstet Gynecol Scand. 2008;87(9):946-952. doi: 10.1080/00016340802302184.
8. Amezcua-Prieto C, Ross J, Rogozinska E, Mighiu P, Marti'nez-Ruiz V, Brohi K, Bueno-Ca-vanillas A, Khan KS, Thangaratinam S. Maternal trauma due to motor vehicle crashes and pregnancy outcomes: a systematic review and me-ta-analysis. BMJ Open. 2020;10(10):e035562. doi: 10.1136/bmjopen-2019-035562.
9. Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS, editors. Williams Obstetrics. 24th ed. New York: McGraw Hill; 2014.
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14. Goodwin TM, Breen MT. Pregnancy outcome and fetomaternal hemorrhage after non-catastrophic trauma. Am J Obstet Gynecol. 1990;162(3):665-671. doi: 10.1016/0002-9378(90)90979-h.
15. Klinich KD, Schneider LW, Moore JL, Pearlman MD. Investigations of crashes involving pregnant occupants. Annu Proc Assoc Adv Au-tomot Med. 2000;44:37-55.
16. Ali J, Yeo A, Gana TJ, McLellan BA. Predictors of fetal mortality in pregnant trauma patients. J Trauma. 1997;42(5):782-785. doi: 10.1097/00005373-199705000-00005.
17. Motozawa Y, Hitosugi M, Abe T, Tokudome S. Effects of seat belts worn by pregnant drivers during low-impact collisions. Am J Obstet Gynecol. 2010;203(1):62.e1-e8. doi: 10.1016/j.ajog.2010.02.047.
18. Yamada S, Nishijima K, Takahashi J, Takahashi N, Tamamura C, Yoshida Y. Intrauterine fetal death caused by seatbelt injury. Taiwan J Obstet Gynecol. 2017;56(4):558-560. doi: 10.1016/j.tjog.2016.08.009.
19. Lavin JP Jr, Miodovnik M. Delayed abruption after maternal trauma as a result of an automobile accident. J Reprod Med. 1981;26(12): 621-624.
20. Dahmus MA, Sibai BM. Blunt abdominal trauma: are there any predictive factors for abruptio placentae or maternal-fetal distress? Am J Obstet Gynecol. 1993;169(4):1054-1059. doi: 10.1016/0002-9378(93)90053-l.
21. Jain V, Chari R, Maslovitz S, Farine D; Maternal Fetal Medicine Committee, Bujold E, Gagnon R, Basso M, Bos H, Brown R, Cooper S, Gouin K, McLeod NL, Menticoglou S, Mundle W, Pylyp-juk C, Roggensack A, Sanderson F. Guidelines for the Management of a Pregnant Trauma Patient. J Obstet Gynaecol Can. 2015;37(6): 553-574. English, French. doi: 10.1016/s1701-2163(15)30232-2.
22. Morris JA Jr, Rosenbower TJ, Jurkovich GJ, Hoyt DB, Harviel JD, Knudson MM, Miller RS, Burch JM, Meredith JW, Ross SE, Jenkins JM, Bass JG. Infant survival after cesarean section for trauma. Ann Surg. 1996;223(5):481-488; discussion 488-491. doi: 10.1097/00000658199605000-00004.
23. Brown HL. Trauma in pregnancy. Obstet Gynecol. 2009;114(1):147-160. doi: 10.1097/AOG.0b013e3181ab6014.
24. Fries MH, Hankins GD. Motor vehicle accident associated with minimal maternal trauma but subsequent fetal demise. Ann Emerg Med. 1989;18(3):301-304. doi: 10.1016/s0196-0644(89)80418-4.
25. Baethmann M, Kahn T, Lenard HG, Voit T. Fetal CNS damage after exposure to maternal trauma during pregnancy. Acta Paediatr. 1996;85(11):1331-1338. doi: 10.1111/j.1651-2227.1996.tb13920.x.
26. Strigini FA, Cioni G, Canapicchi R, Nardini V, Capriello P, Carmignani A. Fetal intracranial hemorrhage: is minor maternal trauma a possible pathogenetic factor? Ultrasound Obstet Gynecol. 2001;18(4):335-342. doi: 10.1046/j.0960-7692.2001.00486.x.
27. Piastra M, Pietrini D, Massimi L, Caldarelli M, De Luca D, Del Lungo LM, De Carolis MP, Di Rocco C, Conti G, Zecca E. Severe subdural hemorrhage due to minimal prenatal trauma. J Neurosurg Pediatr. 2009;4(6):543-546. doi: 10.3171/2009.7.PEDS08223.
28. Safdari M, Safdari Z, Pishjoo M. Intrauterine Fetal Traumatic Brain Injury Following Motor Vehicle Accident; A Case Report and Review of the Literature. Bull Emerg Trauma. 2018;6(4): 372-375. doi: 10.29252/beat-060417.
29. Breysem L, Cossey V, Mussen E, Demaer-el P, Van de Voorde W, Smet M. Fetal trauma: brain imaging in four neonates. Eur Radiol. 2004;14(9):1609-1614. doi: 10.1007/s00330-004-2357-6.
30. Segui-Gomez M, Levy J, Graham JD. Airbag safety and the distance of the driver from the steering wheel. N Engl J Med. 1998;339(2):132-133. doi: 10.1056/NEJM199807093390219.
31. Christensen EE, Dietz GW. A radiographically documented intra-uterine femoral fracture. Br J Radiol. 1978;51(610):830-831. doi: 10.1259/0007-1285-51-610-830.
32. Zeina AR, Kessel B, Mahamid A, Gazmawi J, Shrim A, Nachtigal A, Alfici R. Computed tomographic diagnosis of traumatic fetal subdural hematoma. Emerg Radiol. 2013;20(2):169-172. doi: 10.1007/s10140-012-1067-7.
33. Hall EJ. Scientific view of low-level radiation risks. Radiographics. 1991;11(3):509-518. doi: 10.1148/radiographics.11.3.1852943.
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