Multi-disciplinary management of pelvic injury in pregnancy

Multi-disciplinary management of pelvic injury in pregnancy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Multi-disciplinary management of pelvic injury in pregnancy Diana Schrick, Sándor Márton, Csaba Csontos, Diana Mühl This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6593123/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Oct, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 18 You are reading this latest preprint version Abstract Introduction: Polytrauma occurring during pregnancy presents unique challenges for clinicians, as it requires simultaneous care for two patients (mother and fetus). In addition to the physiological changes in the maternal condition, it is essential to meet the specific needs of the fetus and continuously assess its condition, necessitating a multidisciplinary approach. Case presentation: In this case, a young, 28-week pregnant woman with no known underlying diseases was severely injured (ISS 16) in a high-energy collision. Primary imaging studies confirmed a comminuted fracture with significant displacement of the right hip, avulsion fractures noted on the sacrum, and the sacroiliac joint was opened on the right side, with considerable hematoma visible in the pelvis, pre-sacrally. Abdominal ultrasound flowmetry confirmed the presence of a live fetus not in distress, and no retroplacental hematoma was observed. Before complex trauma care, the patient was admitted to the intensive care unit for perioperative management. The patient’s oxygen-carrying capacity was optimized through fluid resuscitation and transfusion. An epidural catheter was placed for opioid-sparing analgesia. Continuous extended maternal observation was conducted alongside daily fetal diagnostics. Following a cost-benefit assessment by obstetricians, neonatologists, trauma surgeons, and intensive care specialists, a temporary right lower limb extension was applied due to the pelvic ring injury. After a brief preparation, closed reduction and screw osteosynthesis were performed on the iliac bone and sacrum. The procedure was carried out in the presence of a perinatal care team prepared for immediate cesarean delivery. No signs of fetal distress were observed during the intervention. Postoperative observation happened without any complications. The patient was transferred to the local facility for complex rehabilitation. Subsequently, the woman gave birth to a healthy boy at term. Conclusion Our case described above is the first published report of the successful use of internal fixation of the pelvis with fetus in utero. Knowledge of the pillars of multidisciplinary care, establishing a unified approach, and protocolizing the care pathway are essential for better outcomes. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Background High-energy injuries (for instance, traffic accidents, most commonly) often combine with pelvic ring fractures (PRFs) during pregnancy as a ’locus minoris resistentiae’, which is a rare yet severe condition for both the mother and the fetus 1 . Prevalence of pelvic ring injury within blunt trauma-induced fractures is reported to be 5–8% 2 . Mortality rates are reported as 9% for the mothers and up to 60% for fetuses. There is a wide variety of these because several factors influence the mortality rate 3 , 4 . Pelvic ring injuries result in hemorrhage, thus hypovolaemia that independently escalates patient mortality, irrespective of the underlying diseases. This risk is notably exacerbated in pregnant women because of flow-dependent uteroplacental circulation 5 , 6 . Retrospective data indicate that surviving fetuses from mothers with fractures are more susceptible to premature birth, low birth weight, and enduring neurocognitive dysfunction 7 , 8 Previously published studies have revealed numerous uncertainties in the care of these patients 9 . But ultimately, trauma management is best approached by prioritizing maternal needs 1 . Case presentation A pregnant woman in her 20s without any chronic disease suffered a traffic accident in company with her husband. The car crashed into a tree. Seatbelts were fastened, the woman did not use the belt deflector, and the airbags did not open. The female was pregnant with a 27-week-old fetus. The first medical contact happened within 25 minutes at the accident site. Upon documentation, the oxyologist finds her with moderate hypotension (BP sys 88Hgmm) and tachycardia (HR 110/min). After removing the patient from the wreck, she was admitted to the nearest county hospital emergency department on a long spine board, cervical collar, and pelvic belt. When she presented herself at the emergency department, she was 15 on the Glasgow Coma Scale (GCS), and had a complaint of severe pain (8 on visual analogue scale; VAS). Upon primary examination, the patient was ABCDE unstable (tachycardia, deeper hypotension was detected), physical examination revealed indirect signs of pelvic injury (hematoma and pain) 10 , as depicted in Figure 1. Investigations An emergency gynecological exam was performed 11 , transabdominal ultrasound with no sign of retroplacental hemorrhage, and the cardiotocogram shows normal baseline tone of the uterus, profilactic intravenous magnesium was given for tocolytic effect. During stabilising the vital parameters, analgesia was provided with intravenous opioids and non-steroidal anti-inflammatory drugs. Furthermore, an epidural catheter was inserted in the lateral decubitus position at the level of lumbal 3-4 vertebrae to maintain sufficient analgesia (bupivacaine 0.25%) for the mother and sustain consistent uteroplacental blood flow to the fetus via vasodilatation. Fluid administration was performed with balanced crystalloids 12 . To prevent excessive hemodilution after bleeding, upon strict stratification of costs and benefits, blood transfusion was performed to maintain sufficient delivery of oxygen to end-organs, and selected blood was given to minimize the immunization risks. A low-dose CT scan was performed to detect the exact nature of the injuries. CT scan revealed a fracture of the right iliac bone with full dislocation and complete displacement of the sacroiliac joint, and a fracture of the massa lateralis of the sacrum with significant periosteal hemorrhage, causing a slight dislocation of the uterus, as represented in Figure 2 in axial and sagittal views.. A clinical radiologist performed 3D image reconstruction during transportation to the higher-level care centre (Department of Anaesthesiology and Intensive Care, University of Pécs, Medical School, Clinical Centre) to prepare for further treatment (intensive care and operative management of the injuries), as seen in Figure 3 a complex pelvic ring fracture with fetal part inside. Treatment The patient was admitted to the Central Intensive Care Unit of the University of Pécs, Medical School, to prepare for surgical treatment. During observation, obstetrical examination with ultrasound and flowmetry was performed regularly (daily). Upon consultation, profilactic steroid, for enhanced fetal lung maturation, to prevent infant respiratory distress syndrome, was given to the mother to prepare for a case of an emergency Cesarean section; furthermore, anti-D immunoglobulin prophylaxis was administered, because feto-maternal blood mixing could not be imminently excluded due to the high-energy injury. Clinical pharmacologists and clinical microbiologists were involved in the daily decision-making in the patient's pharmacotherapy. The patient was given a preventive dose of amoxicillin-clavulanic acid (1200mg twice daily). To minimize the usage of opioids during pregnancy, an epidural catheter was used, and local anesthetic (bupivacaine 0.25-0.5%) was administered to the patient via a patient-controlled analgesia (PCA) pump. Furthermore, paracetamol (1g) was used regularly. For mobilization and special nursing procedures, minimal sufentanil was administered to the patient. Venous-thromboembolic prophylaxis was executed with enoxaparin 4000IU once a day, respectively. A H2 receptor blocker (famotidine 40mg, twice daily) was used for the ulcer prophylaxis. Further blood transfusions were performed to correct maternal anemia and optimize fetal oxygen delivery. Prothrombin-complex concentrate (PCC 1000IU) and fibrinogen (2g) were administered before the operative management upon thromboelastic examination to prevent bleeding. During the preparation for the operation, the traumatologist inserted an extension into the condyles of the right femur and performed traction with 5kg to release the acetabulum from pressure. In our clinical center, there is a block system. Special hospitals are not at the same building, so it was a challange to decide where should we perform a surgery – at the department of obstetrics, which would be functionally better in case of any complication – or at the traumatology (which is at the same building with the intensive care); that is technically better. After a multidisciplinary consultation, we organized an obstetrician, a neonatologist, and a neonatal emergency team to the traumatology operation centre in case of any need 13 . We uploaded the epidural space with local anesthetics (lidocaine 1%) to perform opioid-sparing anesthesia, causing vasodilation in the lower part of the body to maintain better placental perfusion. Balanced, fast-track anesthesia (extubation right after the operation in the operating theatre) with low MAC (minimum alveolar concentration of anesthetic gases) was performed. The patient was hemodynamically stable during the whole procedure, and there was no sign of fetal compromise. Intraoperative vital parameters are shown in Figure 5. Operative treatment held some challenges as well, because the operation site was extremely close to the womb, with limited maneuvering capacities. Finding an optimal patient position was harsh. Finally, the patient was tilted left laterally to prevent the compression of the inferior vena cava (resulting in low preload and cardiac output syndrome) and to let the surgeons operate more freely, as shown in Figure 6 . The operating site was identified under an image-intensifier (X-ray). The usage of ionizing radiation was minimized during the procedure; overall radiation time was 3 minutes and 3 seconds, with 9.47 Gy cm2. Traumatologists performed the repositioning and reconstruction of the fracture of the os ilium with full bone width disclocation after a longitudinal incision, presented in Figure 7 . Above the tip of the right trochanter major, then penetrating the fracture gap with a Steinmann nail, drilling into the distal fragment of the second nail, and moving upward, pulling it up like a joystick next to the uterus. Lysis of the sacroiliac joint was reconstructed with screw osteosynthesis, by drilling two transverse screws into the massa lateralis part of the sacrum. The postoperative control CT scan visually represented in Figure 8 , the position of the inserted screws are coloured red, showing the regained postoperative anatomical status of the female pelvis . Postoperative observation was without any complications. Inflammation parameters showed a kinetics to systemic inflammatory response, and empiric antimicrobial therapy was continued. The postoperative fetal diagnostics (cardiotocograph, ultrasound) verified fetal well-being. As a residual complication of the injury, the patient experienced numbness on the lateral part of the right lower limb, the neurologist council suggested compression of the sciatic nerve due to the pelvic hematoma. Unfortunately, the MRI could not be performed because the patient had non-MRI-compatible metals in her ankle (previous malleolar osteosynthesis). Physiotherapy and a transcutaneous nerve stimulator were introduced as soon as possible with adequate analgesia. Upon the findings, the patient did not need further multiparametric observation and was discharged to the territorially competent hospital (with traumatology and obstetric facilities) for further observation and rehabilitation. Outcome and follow-up After early mobilization, the patient was discharged home, and she gave birth to a healthy baby boy at term via Cesarean section. Late rehabilitation began after delivery. Nowadays, the patient can live daily without barriers. The baby’s neurodevelopment seems to be normal so far. Discussion Pelvic ring injuries in pregnant women present significant risks to maternal and fetal health. Early recognition, stabilization, and vigilant monitoring of maternal vital signs are crucial. Vaginal bleeding/discharge serves as a critical fetal risk indicator in most of the patients 14 . Multidisciplinary collaboration and tailored interventions are essential in caring for these complex cases. Various classifications have been proposed for pelvic ring fractures. Combining the commonly used osteoligamentous pelvic ring injury classification schemes (AO/OTA and Young-Burgess) seems useful in acquiring information on mechanical and haemodynamic instability. The widely accepted Arbeitsgemeinschaft für Osteosynthesefragen classification system (with the 2018 revision) is used to determine the stability of the pelvic ring: type A with a stable pelvic ring, type B with a partially unstable pelvic ring, and type C with a volatile pelvic ring 15 . While the Young and Burgess classification is a modification of the earlier Tile classification, which takes into account force type, severity, direction, as well as injury instability 16 – 18 , shown in Fig. 9 . Management of a pregnant patient is always a challenge, to save two lives in parallel (mother & fetus), and may pose a dilemma for a medical practitioner to choose between them (the mother’s lives have top priority) 19 . Our case report aims to draw attention to the importance of multi-disciplinary management, care of patients, and the usage of different international guidelines to individualize treatment strategies to effectively manage the complexities associated with pelvic injuries during pregnancies to provide a better outcome. Pelvic fractures in pregnancy are rare, resulting in a paucity of evidence-based management. Controlled hypotension is recommended transiently to reduce the risk of bleeding, but maintaining normal uteroplacental blood flow is vital. The limited usage of vasopressors (first-choice noradrenaline) has been reported to reduce uterine blood flow. However, noradrenaline seems to have no detrimental effect on the well-being of the fetus 20 . With fluid administration (preferably balanced crystalloids), we must be careful to prevent hemodilution. A liberal approach to blood transfusion methods is essential to provide enough oxygen delivery with the least risk of immunization of the mother. To prevent trauma-induced coagulopathy, bedside point-of-care hemostasis assays should be performed regularly, and interventions should be performed at the exact points of hemostasis if needed, using exact substrates (fibrinogen, PCC). To reduce oxygen consumption, adequate analgesia with a multimodal approach is essential. Non-obstetric surgery may be required at any trimester during pregnancy, with the unique challenge of caring simultaneously for two patients. In the second trimester, patients are considered to be at the lowest risk for preterm delivery, and primary embryonic development is complete by the eighth week of gestation. Corticosteroids should be given upon consultation in the third trimester to facilitate fetal lung maturity; non-steroidal anti-inflammatory drugs should be avoided after 32 weeks of gestation to prevent the closure of premature patent ductus arteriosus 21 . The American College of Obstetricians and Gynecologists (ACOG) recommends fetal heart rate (FHR) measurement using Doppler ultrasound before and after any given surgery, regardless of gestational age, with the addition of contraction monitoring (CTG) in the fetus 22 . Most anesthetic agents cross the placenta and may affect fetal heart rate tracing, causing reduced variability. Fetal monitoring helps optimise maternal positioning (left lateral tilt to prevent vena cava compression syndrome), oxygenation, ventilation, and hemodynamic management of the mother. The American College of Obstetricians and Gynecologists has not yet clearly defined its recommendations for a mode of delivery after a pelvic fracture. In 2015, Stohlner et al. published a case report on external fixation for pelvic ring injury during pregnancy 23 . The article demonstrated a successful use of external fixation for initial temporary stabilisation and subsequent definitive management of a pelvic ring fracture in late pregnancy, which allowed the fetus to remain in utero until mature enough for delivery. Mennen et al. recently published a retrospective observational study 24 revealed that women with retained hardware after pelvic ring fixation could have vaginal delivery with a rare occurance postpartum complications, 168 fertile age patient were enrolled into this cited research of whom 13 had a pregnancy after surgical stabilization of pelvic ring fracture. Seven women had a total of 11 vaginal deliveries, and six women had Ceasarean sections. The decision for vaginal delivery was often the wish of the mother (n = 4; 57%) while the decision to opt for caesarean section was made by the surgeon or obstetrician (n = 5; 83%). One woman in the vaginal delivery group suffered a postpartum complication possibly related to her retained pelvic hardware. Thus, the rate of primary Cesarean sections is still high (46%), which might be influenced by physician bias. Several issues need to be addressed when establishing perioperative management of a severely injured pregnant patient; these are listed in Table 1 . Our case described above is the first published report of the successful use of internal fixation with fetal in utero. Our patient had a Cesarean section on the 39th gestational week of her pregnancy, and she gave birth safely to a healthy baby boy (Apgar 9). During the regular check-ups, nurses inspect the child's status (it was performed in the early neonatal age, and then in the 1st, 2nd, 3rd, 4th, 6th, 12th, and 15th months after birth, according to the governmental regulation). The physical and mental development of the baby did not show any lags in comparison with babies of the same age, so further neurodevelopmental examination was not performed. Table 1 Bullet points for the management of pelvic ring injuries in late pregnancies 1. Multimodal monitoring of the mother and the fetus 2. Adequate analgesia to reduce the oxygen consumption 3. Optimize fluid status and hemodynamics to maintain normal oxygen delivery to tissues 4. Assess timing and mode of delivery 5. Assess timing and mode for reconstructive surgery 6. Choose an ideal anesthetic technique: neuraxial, regional anesthesia if possible 7. Continue postoperative monitoring of the mother and the fetus 8. Start mobilization as soon as possible, and prevent thromboembolic events 9. Regular postnatal medical check-ups to detect any neurodevelopmental problems, and to initiate early intervention if needed Abbreviations 2D: 2-dimension 3D: 3-dimension ABCDE: airway-breathing-circulation-disability-exposure ACOG: American College of Obstetricians and Gynecologists AO: Arbeitsgemeinschaft für Osteosynthesefragen APC: anterior posterior compresion CT: computed tomography CTG: cardiotocography etCO2: end-tidal carbon dioxide FHR: fetal heart rate GCS: Glasgow Coma Scale HR: heart rate IABP: intra-arterial blood pressure ISS: injury severity score LC: lateral compression List of abbreviations MAC: minimum alveolar concentration MRI: magnetic resonance imaging NBP: non-invasive blood pressure OTA: Orthopaedic Trauma Association PCA: patient controlled analgesia PCC: prothrombin-complex concentrate PRF: pelvic ring fractures SpO2: peripheral oxygen saturation VAS: Visual Analogue Scale VS: vertical shear Declarations Ethics approval and consent to participate are not applicable, because it was not research. Consent for publication: The patient's consent was obtained and is available from the corresponding author. Availability of data and material: The datasets generated during and/or analysed during the current study are not publicly available due to containing personal information, but are available from the corresponding author on reasonable request. Most of the data are included in the manuscript anonymously. Competing interest: All authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Funding: This case report received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions: S.D., M.D., and M.S. contributed to the conception, data collection, and drafting of the manuscript. S.D. assisted with the literature review and interpretation of clinical data. S.D., M.D., M.S., and Cs.Cs. were involved in the patient's clinical management and contributed to the critical revision of the manuscript. All authors read and approved the final manuscript. Acknowledgements: The authors would like to express their sincere gratitude to the patient for their cooperation and willingness to share their medical journey to advance medical knowledge. Special thanks are also extended to our colleagues and the multidisciplinary team whose expertise and collaborative efforts were instrumental in the patient's diagnosis, treatment, and care. Authors' information: Diana Schrick, MD, PhD – specialist physician, assistant professor at University of Pécs, Medical School, Dept. of Anaesthesiology and Intensive Care Sándor Márton, MD, PhD – specialist physician, associate professor and chair of Division of Obstetric Anaesthesiology at University of Pécs, Medical School, Dept. of Anaesthesiology and Intensive Care Prof. Csaba Csontos, MD, PhD – specialist physician, full professor and institute director of the University of Pécs, Medical School, Dept. of Anaesthesiology and Intensive Care Prof. Diana Mühl, MD, PhD – specialist physician, full professor and chair of Intensive Care Division of the University of Pécs, Medical School, Dept. of Anaesthesiology and Intensive Care References Sakamoto J, Michels C, Eisfelder B, Joshi N. Trauma in Pregnancy. Emerg Med Clin North Am . 2019;37(2):317-338. doi:10.1016/J.EMC.2019.01.009 Al-Thani H, El-Menyar A, Sathian B, et al. 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Am J Obstet Gynecol . 1974;118(8):1099-1103. doi:10.1016/0002-9378(74)90689-9 Okeagu CN, Anandi P, Gennuso S, et al. Clinical management of the pregnant patient undergoing non-obstetric surgery: Review of guidelines. Best Pract Res Clin Anaesthesiol . 2020;34(2):269-281. doi:10.1016/J.BPA.2020.04.004 ACOG Committee Opinion No. 775: Nonobstetric Surgery During Pregnancy. Obstetrics and gynecology . 2019;133(4):E285-E286. doi:10.1097/AOG.0000000000003174 Stohlner V, Gill JR, Murphy CG, Carrothers AD. Definitive use of external fixation for pelvic ring injuries (open book/APC2) in pregnancy. BMJ Case Rep . 2015;2015:bcr2015212690. doi:10.1136/BCR-2015-212690 Mennen AHM, Posthuma JJ, Kooijman EM, et al. The mode of delivery after operative fixation of pelvic ring fractures–a retrospective observational study. European Journal of Trauma and Emergency Surgery . 2024;50(5):2441-2449. doi:10.1007/S00068-024-02618-4/TABLES/2 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 06 Oct, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 06 Aug, 2025 Reviews received at journal 21 Jun, 2025 Reviews received at journal 19 Jun, 2025 Reviews received at journal 19 Jun, 2025 Reviews received at journal 15 Jun, 2025 Reviewers agreed at journal 13 Jun, 2025 Reviewers agreed at journal 12 Jun, 2025 Reviewers agreed at journal 10 Jun, 2025 Reviewers agreed at journal 07 Jun, 2025 Reviews received at journal 05 Jun, 2025 Reviewers agreed at journal 05 Jun, 2025 Reviewers agreed at journal 05 Jun, 2025 Reviewers agreed at journal 28 May, 2025 Reviewers invited by journal 28 May, 2025 Editor invited by journal 08 May, 2025 Editor assigned by journal 07 May, 2025 Submission checks completed at journal 07 May, 2025 First submitted to journal 05 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Care","correspondingAuthor":false,"prefix":"","firstName":"Sándor","middleName":"","lastName":"Márton","suffix":""},{"id":463066298,"identity":"1351da3b-6dd4-490c-84e4-61a50c7cf227","order_by":2,"name":"Csaba Csontos","email":"","orcid":"","institution":"University of Pécs, Medical School, Department of Anaesthesiology and Intensive Care","correspondingAuthor":false,"prefix":"","firstName":"Csaba","middleName":"","lastName":"Csontos","suffix":""},{"id":463066299,"identity":"a6bddc02-e0c1-4a02-bc80-11a8b747f946","order_by":3,"name":"Diana Mühl","email":"","orcid":"","institution":"University of Pécs, Medical School, Department of Anaesthesiology and Intensive Care","correspondingAuthor":false,"prefix":"","firstName":"Diana","middleName":"","lastName":"Mühl","suffix":""}],"badges":[],"createdAt":"2025-05-05 09:38:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6593123/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6593123/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-025-08101-1","type":"published","date":"2025-10-06T15:58:09+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":83648297,"identity":"97989d84-66b9-449a-937f-edf4fd9ab2fe","added_by":"auto","created_at":"2025-05-30 06:21:24","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":352238,"visible":true,"origin":"","legend":"\u003cp\u003eIndirect sign of pelvic injury after the removal of the pelvic belt\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6593123/v1/20d83a9c0b93ceb6e739525c.png"},{"id":83648299,"identity":"8b8e10b3-ff48-4c7c-a9ff-6ae3067cc1ea","added_by":"auto","created_at":"2025-05-30 06:21:24","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":376124,"visible":true,"origin":"","legend":"\u003cp\u003e2D CT scan axial and sagittal views represent the fracture of the os ileum with complete bone width dislocation and sacroiliacal joint dehiscence, anteriorly fetal parts can be seen\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6593123/v1/44799a15d50f650facfee535.png"},{"id":83648300,"identity":"a74c8162-a1f7-4c91-ad7d-48b21f65447d","added_by":"auto","created_at":"2025-05-30 06:21:24","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":398965,"visible":true,"origin":"","legend":"\u003cp\u003e3D-image reconstruction of pelving ring fracture with the fetus in situ\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6593123/v1/1ba9373c5b1cad51b329cb13.png"},{"id":83649132,"identity":"ef43df96-b3ac-473d-ab8f-f311a0a4b23c","added_by":"auto","created_at":"2025-05-30 06:37:24","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":331470,"visible":true,"origin":"","legend":"\u003cp\u003e3D CT image reconstruction of the pelvic ring fracture (substracted image)\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6593123/v1/3051f6ddb5a96258055c0a54.png"},{"id":83649023,"identity":"7b6ba550-228e-4166-95b0-d0be40fca29d","added_by":"auto","created_at":"2025-05-30 06:29:24","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":90295,"visible":true,"origin":"","legend":"\u003cp\u003eVital parameters of the patient during anesthesia; abbreviations – HR: heart rate, SpO2: peripheral oxygen saturation, EtCO2: end-tidal carbon dioxide, NBP: non-invasive blood pressure, IABP: intra-arterial blood pressure\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6593123/v1/30dcd7e738e6a39f02aee74c.png"},{"id":83648303,"identity":"a95b0589-4a0f-4dbe-bf72-fea6403032fa","added_by":"auto","created_at":"2025-05-30 06:21:24","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":636254,"visible":true,"origin":"","legend":"\u003cp\u003eLeft lateral tilt position at the beginning of the surgery (from intraoperative photo documentation)\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-6593123/v1/b9989a77c49d4966878e5e00.png"},{"id":83648304,"identity":"249eef6a-1f15-4bcb-9bc9-f6b3ca338f1c","added_by":"auto","created_at":"2025-05-30 06:21:24","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":653174,"visible":true,"origin":"","legend":"\u003cp\u003eMinimal invasive operative pelvic reconstruction (from intraoperative photo documentation)\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-6593123/v1/c4c209ed226159341a75c24d.png"},{"id":83648305,"identity":"d37109b7-7d54-4cb5-9bfa-57864e26d6b8","added_by":"auto","created_at":"2025-05-30 06:21:24","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":421324,"visible":true,"origin":"","legend":"\u003cp\u003eCT 3D reconstruction image of the postoperative pelvic state, 5 osteosynthetic screws in situ (labelled with red)\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-6593123/v1/a428335560363a0011211769.png"},{"id":83648306,"identity":"f68e15ac-ef9a-436c-aa92-5cd4a0658535","added_by":"auto","created_at":"2025-05-30 06:21:24","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":610411,"visible":true,"origin":"","legend":"\u003cp\u003eYoung and Burgess Young and Borgess classification of Pelvic Ring Injuries. Photo originates from Alton et al. A.O. Classifications in Brief, published in Clin Orthop Relat Res, 2014\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e","description":"","filename":"9.png","url":"https://assets-eu.researchsquare.com/files/rs-6593123/v1/e413ef3c40f3cf87e1c68d34.png"},{"id":93419781,"identity":"beb181f4-9cbe-464d-a125-14dabd3176c0","added_by":"auto","created_at":"2025-10-13 16:07:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5287488,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6593123/v1/614e3198-2785-4f09-b8ef-c5e5cb411d66.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Multi-disciplinary management of pelvic injury in pregnancy","fulltext":[{"header":"Background","content":"\u003cp\u003eHigh-energy injuries (for instance, traffic accidents, most commonly) often combine with pelvic ring fractures (PRFs) during pregnancy as a \u0026rsquo;locus minoris resistentiae\u0026rsquo;, which is a rare yet severe condition for both the mother and the fetus\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Prevalence of pelvic ring injury within blunt trauma-induced fractures is reported to be 5\u0026ndash;8%\u003csup\u003e2\u003c/sup\u003e. Mortality rates are reported as 9% for the mothers and up to 60% for fetuses. There is a wide variety of these because several factors influence the mortality rate\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Pelvic ring injuries result in hemorrhage, thus hypovolaemia that independently escalates patient mortality, irrespective of the underlying diseases. This risk is notably exacerbated in pregnant women because of flow-dependent uteroplacental circulation\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Retrospective data indicate that surviving fetuses from mothers with fractures are more susceptible to premature birth, low birth weight, and enduring neurocognitive dysfunction\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003ePreviously published studies have revealed numerous uncertainties in the care of these patients\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. But ultimately, trauma management is best approached by prioritizing maternal needs\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA pregnant woman in her 20s without any chronic disease suffered a traffic accident in company with her husband. The car crashed into a tree. Seatbelts were fastened, the woman did not use the belt deflector, and the airbags did not open. The female was pregnant with a 27-week-old fetus. The first medical contact happened within 25 minutes at the accident site. Upon documentation, the oxyologist finds her with moderate hypotension (BP\u003csub\u003esys\u003c/sub\u003e 88Hgmm) and tachycardia (HR 110/min). After removing the patient from the wreck, she was admitted to the nearest county hospital emergency department on a long spine board, cervical collar, and pelvic belt. When she presented herself at the emergency department, she was 15 on the Glasgow Coma Scale (GCS), and had a complaint of severe pain (8 on visual analogue scale; VAS). Upon primary examination, the patient was ABCDE unstable (tachycardia, deeper hypotension was detected), physical examination revealed indirect signs of pelvic injury (hematoma and pain)\u003csup\u003e10\u003c/sup\u003e, as depicted in \u003cem\u003eFigure 1.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInvestigations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn emergency gynecological exam was performed\u003csup\u003e11\u003c/sup\u003e, transabdominal ultrasound with no sign of retroplacental hemorrhage, and the cardiotocogram shows normal baseline tone of the uterus, profilactic intravenous magnesium was given for tocolytic effect.\u003c/p\u003e\n\u003cp\u003eDuring stabilising the vital parameters, analgesia was provided with intravenous opioids and non-steroidal anti-inflammatory drugs. Furthermore, an epidural catheter was inserted in the lateral decubitus position at the level of lumbal 3-4 vertebrae to maintain sufficient analgesia (bupivacaine 0.25%) for the mother and sustain consistent uteroplacental blood flow to the fetus via vasodilatation. Fluid administration was performed with balanced crystalloids\u003csup\u003e12\u003c/sup\u003e.\u003csup\u003e\u0026nbsp;\u003c/sup\u003eTo prevent excessive hemodilution after bleeding, upon strict stratification of costs and benefits, blood transfusion was performed to maintain sufficient delivery of oxygen to end-organs, and selected blood was given to minimize the immunization risks. A low-dose CT scan was performed to detect the exact nature of the injuries. CT scan revealed a fracture of the right iliac bone with full dislocation and complete displacement of the sacroiliac joint, and a fracture of the massa lateralis of the sacrum with significant periosteal hemorrhage, causing a slight dislocation of the uterus, as represented in \u003cem\u003eFigure 2\u0026nbsp;\u003c/em\u003ein axial and sagittal views.. A clinical radiologist performed 3D image reconstruction during transportation to the higher-level care centre (Department of Anaesthesiology and Intensive Care, University of P\u0026eacute;cs, Medical School, Clinical Centre) to prepare for further treatment (intensive care and operative management of the injuries), as seen in \u003cem\u003eFigure 3\u0026nbsp;\u003c/em\u003ea complex pelvic ring fracture with fetal part inside.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTreatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient was admitted to the Central Intensive Care Unit of the University of P\u0026eacute;cs, Medical School, to prepare for surgical treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring observation, obstetrical examination with ultrasound and flowmetry was performed regularly (daily). Upon consultation, profilactic steroid, for enhanced fetal lung maturation, to prevent infant respiratory distress syndrome, was given to the mother to prepare for a case of an emergency Cesarean section; furthermore, anti-D immunoglobulin prophylaxis was administered, because feto-maternal blood mixing could not be imminently excluded due to the high-energy injury.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClinical pharmacologists and clinical microbiologists were involved in the daily decision-making in the patient\u0026apos;s pharmacotherapy. The patient was given a preventive dose of amoxicillin-clavulanic acid (1200mg twice daily). To minimize the usage of opioids during pregnancy, an epidural catheter was used, and local anesthetic (bupivacaine 0.25-0.5%) was administered to the patient via a patient-controlled analgesia (PCA) pump. Furthermore, paracetamol (1g) was used regularly. For mobilization and special nursing procedures, minimal sufentanil was administered to the patient.\u003c/p\u003e\n\u003cp\u003eVenous-thromboembolic prophylaxis was executed with enoxaparin 4000IU once a day, respectively. A H2 receptor blocker (famotidine 40mg, twice daily) was used for the ulcer prophylaxis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurther blood transfusions were performed to correct maternal anemia and optimize fetal oxygen delivery. Prothrombin-complex concentrate (PCC 1000IU) and fibrinogen (2g) were administered before the operative management upon thromboelastic examination to prevent bleeding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring the preparation for the operation, the traumatologist inserted an extension into the condyles of the right femur and performed traction with 5kg to release the acetabulum from pressure.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our clinical center, there is a block system. Special hospitals are not at the same building, so it was a challange to decide where should we perform a surgery \u0026ndash; at the department of obstetrics, which would be functionally better in case of any complication \u0026ndash; or at the traumatology (which is at the same building with the intensive care); that is technically better. After a multidisciplinary consultation, we organized an obstetrician, a neonatologist, and a neonatal emergency team to the traumatology operation centre in case of any need\u003csup\u003e13\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe uploaded the epidural space with local anesthetics (lidocaine 1%) to perform opioid-sparing anesthesia, causing vasodilation in the lower part of the body to maintain better placental perfusion. Balanced, fast-track anesthesia (extubation right after the operation in the operating theatre) with low MAC (minimum alveolar concentration of anesthetic gases) was performed. The patient was hemodynamically stable during the whole procedure, and there was no sign of fetal compromise. Intraoperative vital parameters are shown in \u003cem\u003eFigure 5.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOperative treatment held some challenges as well, because the operation site was extremely close to the womb, with limited maneuvering capacities. Finding an optimal patient position was harsh. Finally, the patient was tilted left laterally to prevent the compression of the inferior vena cava (resulting in low preload and cardiac output syndrome) and to let the surgeons operate more freely, as shown in \u003cem\u003eFigure 6\u003c/em\u003e. The operating site was identified under an image-intensifier (X-ray). The usage of ionizing radiation was minimized during the procedure; overall radiation time was 3 minutes and 3 seconds, with 9.47 Gy cm2. Traumatologists performed the repositioning and reconstruction of the fracture of the os ilium with full bone width disclocation after a longitudinal incision, presented in \u0026nbsp;\u003cem\u003eFigure 7\u003c/em\u003e. Above the tip of the right trochanter major, then penetrating the fracture gap with a Steinmann nail, drilling into the distal fragment of the second nail, and moving upward, pulling it up like a joystick next to the uterus. Lysis of the sacroiliac joint was reconstructed with screw osteosynthesis, by drilling two transverse screws into the massa lateralis part of the sacrum. The postoperative control CT scan visually represented in \u003cem\u003eFigure 8\u003c/em\u003e, the position of the inserted screws are coloured red, showing the regained postoperative anatomical status of the female pelvis\u003cem\u003e.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePostoperative observation was without any complications. Inflammation parameters showed a kinetics to systemic inflammatory response, and empiric antimicrobial therapy was continued. The postoperative fetal diagnostics (cardiotocograph, ultrasound) verified fetal well-being.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs a residual complication of the injury, the patient experienced numbness on the lateral part of the right lower limb, the neurologist council suggested compression of the sciatic nerve due to the pelvic hematoma. Unfortunately, the MRI could not be performed because the patient had non-MRI-compatible metals in her ankle (previous malleolar osteosynthesis). Physiotherapy and a transcutaneous nerve stimulator were introduced as soon as possible with adequate analgesia. Upon the findings, the patient did not need further multiparametric observation and was discharged to the territorially competent hospital (with traumatology and obstetric facilities) for further observation and rehabilitation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome and follow-up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter early mobilization, the patient was discharged home, and she gave birth to a healthy baby boy at term via Cesarean section. Late rehabilitation began after delivery. Nowadays, the patient can live daily without barriers. The baby\u0026rsquo;s neurodevelopment seems to be normal so far.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePelvic ring injuries in pregnant women present significant risks to maternal and fetal health.\u003c/p\u003e \u003cp\u003eEarly recognition, stabilization, and vigilant monitoring of maternal vital signs are crucial. Vaginal bleeding/discharge serves as a critical fetal risk indicator in most of the patients\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Multidisciplinary collaboration and tailored interventions are essential in caring for these complex cases.\u003c/p\u003e \u003cp\u003eVarious classifications have been proposed for pelvic ring fractures. Combining the commonly used osteoligamentous pelvic ring injury classification schemes (AO/OTA and Young-Burgess) seems useful in acquiring information on mechanical and haemodynamic instability. The widely accepted Arbeitsgemeinschaft f\u0026uuml;r Osteosynthesefragen classification system (with the 2018 revision) is used to determine the stability of the pelvic ring: type A with a stable pelvic ring, type B with a partially unstable pelvic ring, and type C with a volatile pelvic ring\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. While the Young and Burgess classification is a modification of the earlier Tile classification, which takes into account force type, severity, direction, as well as injury instability\u003csup\u003e\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e, shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig12\" class=\"InternalRef\"\u003e9\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eManagement of a pregnant patient is always a challenge, to save two lives in parallel (mother \u0026amp; fetus), and may pose a dilemma for a medical practitioner to choose between them (the mother\u0026rsquo;s lives have top priority)\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Our case report aims to draw attention to the importance of multi-disciplinary management, care of patients, and the usage of different international guidelines to individualize treatment strategies to effectively manage the complexities associated with pelvic injuries during pregnancies to provide a better outcome.\u003c/p\u003e \u003cp\u003ePelvic fractures in pregnancy are rare, resulting in a paucity of evidence-based management.\u003c/p\u003e \u003cp\u003eControlled hypotension is recommended transiently to reduce the risk of bleeding, but maintaining normal uteroplacental blood flow is vital. The limited usage of vasopressors (first-choice noradrenaline) has been reported to reduce uterine blood flow. However, noradrenaline seems to have no detrimental effect on the well-being of the fetus\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. With fluid administration (preferably balanced crystalloids), we must be careful to prevent hemodilution. A liberal approach to blood transfusion methods is essential to provide enough oxygen delivery with the least risk of immunization of the mother. To prevent trauma-induced coagulopathy, bedside point-of-care hemostasis assays should be performed regularly, and interventions should be performed at the exact points of hemostasis if needed, using exact substrates (fibrinogen, PCC). To reduce oxygen consumption, adequate analgesia with a multimodal approach is essential.\u003c/p\u003e \u003cp\u003eNon-obstetric surgery may be required at any trimester during pregnancy, with the unique challenge of caring simultaneously for two patients. In the second trimester, patients are considered to be at the lowest risk for preterm delivery, and primary embryonic development is complete by the eighth week of gestation. Corticosteroids should be given upon consultation in the third trimester to facilitate fetal lung maturity; non-steroidal anti-inflammatory drugs should be avoided after 32 weeks of gestation to prevent the closure of premature patent ductus arteriosus\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe American College of Obstetricians and Gynecologists (ACOG) recommends fetal heart rate (FHR) measurement using Doppler ultrasound before and after any given surgery, regardless of gestational age, with the addition of contraction monitoring (CTG) in the fetus\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Most anesthetic agents cross the placenta and may affect fetal heart rate tracing, causing reduced variability. Fetal monitoring helps optimise maternal positioning (left lateral tilt to prevent vena cava compression syndrome), oxygenation, ventilation, and hemodynamic management of the mother.\u003c/p\u003e \u003cp\u003eThe American College of Obstetricians and Gynecologists has not yet clearly defined its recommendations for a mode of delivery after a pelvic fracture. In 2015, Stohlner et al. published a case report on external fixation for pelvic ring injury during pregnancy\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. The article demonstrated a successful use of external fixation for initial temporary stabilisation and subsequent definitive management of a pelvic ring fracture in late pregnancy, which allowed the fetus to remain in utero until mature enough for delivery. Mennen et al. recently published a retrospective observational study\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e revealed that women with retained hardware after pelvic ring fixation could have vaginal delivery with a rare occurance postpartum complications, 168 fertile age patient were enrolled into this cited research of whom 13 had a pregnancy after surgical stabilization of pelvic ring fracture. Seven women had a total of 11 vaginal deliveries, and six women had Ceasarean sections. The decision for vaginal delivery was often the wish of the mother (n\u0026thinsp;=\u0026thinsp;4; 57%) while the decision to opt for caesarean section was made by the surgeon or obstetrician (n\u0026thinsp;=\u0026thinsp;5; 83%). One woman in the vaginal delivery group suffered a postpartum complication possibly related to her retained pelvic hardware. Thus, the rate of primary Cesarean sections is still high (46%), which might be influenced by physician bias.\u003c/p\u003e \u003cp\u003eSeveral issues need to be addressed when establishing perioperative management of a severely injured pregnant patient; these are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eOur case described above is the first published report of the successful use of internal fixation with fetal in utero. Our patient had a Cesarean section on the 39th gestational week of her pregnancy, and she gave birth safely to a healthy baby boy (Apgar 9). During the regular check-ups, nurses inspect the child's status (it was performed in the early neonatal age, and then in the 1st, 2nd, 3rd, 4th, 6th, 12th, and 15th months after birth, according to the governmental regulation). The physical and mental development of the baby did not show any lags in comparison with babies of the same age, so further neurodevelopmental examination was not performed.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBullet points for the management of pelvic ring injuries in late pregnancies\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Multimodal monitoring of the mother and the fetus\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Adequate analgesia to reduce the oxygen consumption\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Optimize fluid status and hemodynamics to maintain normal oxygen delivery to tissues\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Assess timing and mode of delivery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Assess timing and mode for reconstructive surgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Choose an ideal anesthetic technique: neuraxial, regional anesthesia if possible\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. Continue postoperative monitoring of the mother and the fetus\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. Start mobilization as soon as possible, and prevent thromboembolic events\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. Regular postnatal medical check-ups to detect any neurodevelopmental problems, and to initiate early intervention if needed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e2D: 2-dimension\u003c/p\u003e\n\u003cp\u003e3D: 3-dimension\u003c/p\u003e\n\u003cp\u003eABCDE: airway-breathing-circulation-disability-exposure\u003c/p\u003e\n\u003cp\u003eACOG: American College of Obstetricians and Gynecologists\u003c/p\u003e\n\u003cp\u003eAO: Arbeitsgemeinschaft f\u0026uuml;r Osteosynthesefragen\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAPC: anterior posterior compresion\u003c/p\u003e\n\u003cp\u003eCT: computed tomography\u003c/p\u003e\n\u003cp\u003eCTG: cardiotocography\u003c/p\u003e\n\u003cp\u003eetCO2: end-tidal carbon dioxide\u003c/p\u003e\n\u003cp\u003eFHR: fetal heart rate\u003c/p\u003e\n\u003cp\u003eGCS: Glasgow Coma Scale\u003c/p\u003e\n\u003cp\u003eHR: heart rate\u003c/p\u003e\n\u003cp\u003eIABP: intra-arterial blood pressure\u003c/p\u003e\n\u003cp\u003eISS: injury severity score\u003c/p\u003e\n\u003cp\u003eLC: lateral compression\u003c/p\u003e\n\u003cp\u003eList of abbreviations\u003c/p\u003e\n\u003cp\u003eMAC: minimum alveolar concentration\u003c/p\u003e\n\u003cp\u003eMRI: magnetic resonance imaging\u003c/p\u003e\n\u003cp\u003eNBP: non-invasive blood pressure\u003c/p\u003e\n\u003cp\u003eOTA: Orthopaedic Trauma Association\u003c/p\u003e\n\u003cp\u003ePCA: patient controlled analgesia\u003c/p\u003e\n\u003cp\u003ePCC: prothrombin-complex concentrate\u003c/p\u003e\n\u003cp\u003ePRF: pelvic ring fractures\u003c/p\u003e\n\u003cp\u003eSpO2: peripheral oxygen saturation\u003c/p\u003e\n\u003cp\u003eVAS: Visual Analogue Scale\u003c/p\u003e\n\u003cp\u003eVS: vertical shear\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate are not applicable, because it was not research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication: The patient's consent was obtained and is available from the corresponding author.\u003c/p\u003e\n\u003cp\u003eAvailability of data and material: The datasets generated during and/or analysed during the current study are not publicly available due to containing personal information, but are available from the corresponding author on reasonable request. Most of the data are included in the manuscript anonymously.\u003c/p\u003e\n\u003cp\u003eCompeting interest: All authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003eFunding: This case report received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003eAuthors' contributions: S.D., M.D., and M.S. contributed to the conception, data collection, and drafting of the manuscript. S.D. assisted with the literature review and interpretation of clinical data. S.D., M.D., M.S., and Cs.Cs. were involved in the patient's clinical management and contributed to the critical revision of the manuscript.\u0026nbsp;All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: The authors would like to express their sincere gratitude to the patient for their cooperation and willingness to share their medical journey to advance medical knowledge. Special thanks are also extended to our colleagues and the multidisciplinary team whose expertise and collaborative efforts were instrumental in the patient's diagnosis, treatment, and care.\u003c/p\u003e\n\u003cp\u003eAuthors' information:\u003c/p\u003e\n\u003cp\u003eDiana Schrick, MD, PhD – specialist physician, assistant professor at University of Pécs, Medical School, Dept. of Anaesthesiology and Intensive Care\u003c/p\u003e\n\u003cp\u003eSándor Márton, MD, PhD – specialist physician, associate professor and chair of Division of Obstetric Anaesthesiology at University of Pécs, Medical School, Dept. of Anaesthesiology and Intensive Care\u003c/p\u003e\n\u003cp\u003eProf. Csaba Csontos, MD, PhD – specialist physician, full professor and institute director of the University of Pécs, Medical School, Dept. of Anaesthesiology and Intensive Care\u003c/p\u003e\n\u003cp\u003eProf. Diana Mühl, MD, PhD – specialist physician, full professor and chair of Intensive Care Division of the University of Pécs, Medical School, Dept. of Anaesthesiology and Intensive Care\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSakamoto J, Michels C, Eisfelder B, Joshi N. Trauma in Pregnancy. \u003cem\u003eEmerg Med Clin North Am\u003c/em\u003e. 2019;37(2):317-338. doi:10.1016/J.EMC.2019.01.009\u003c/li\u003e\n\u003cli\u003eAl-Thani H, El-Menyar A, Sathian B, et al. Blunt traumatic injury during pregnancy: a descriptive analysis from a level 1 trauma center. \u003cem\u003eEur J Trauma Emerg Surg\u003c/em\u003e. 2019;45(3):393-401. doi:10.1007/S00068-018-0948-1\u003c/li\u003e\n\u003cli\u003eKvarnstrand 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. \u003cem\u003eActa Obstet Gynecol Scand\u003c/em\u003e. 2008;87(9):946-952. doi:10.1080/00016340802302184\u003c/li\u003e\n\u003cli\u003eVivian-Taylor J, Roberts CL, Chen JS, Ford JB. Motor vehicle accidents during pregnancy: a population-based study. \u003cem\u003eBJOG\u003c/em\u003e. 2012;119(4):499-503. doi:10.1111/J.1471-0528.2011.03226.X\u003c/li\u003e\n\u003cli\u003eYoo BJ. Pelvic Trauma and the Pregnant Patient: a Review of Physiology, Treatment Risks, and Options. \u003cem\u003eCurr Trauma Rep\u003c/em\u003e. 2018;4(3):225-232. doi:10.1007/S40719-018-0136-0/TABLES/2\u003c/li\u003e\n\u003cli\u003eMaxwell BG, Greenlaw A, Smith WJ, Barbosa RR, Ropp KM, Lundeberg MR. Pregnant trauma patients may be at increased risk of mortality compared to nonpregnant women of reproductive age: trends and outcomes over 10 years at a level I trauma center. \u003cem\u003eWomen\u0026rsquo;s Health\u003c/em\u003e. 2020;16. doi:10.1177/1745506520933021/ASSET/IMAGES/LARGE/10.1177_1745506520933021-FIG3.JPEG\u003c/li\u003e\n\u003cli\u003eEl Kady D, Gilbert WM, Xing G, Smith LH. Association of maternal fractures with adverse perinatal outcomes. \u003cem\u003eAm J Obstet Gynecol\u003c/em\u003e. 2006;195(3):711-716. doi:10.1016/J.AJOG.2006.06.067\u003c/li\u003e\n\u003cli\u003eLu WR, Wu P, Song G, Gu MQ, Xu Z, He L. Predictors of Adverse Pregnancy Outcomes Following Traumatic Injuries. \u003cem\u003eCurr Med Sci\u003c/em\u003e. 2024;44(3):642-647. doi:10.1007/S11596-024-2885-Z\u003c/li\u003e\n\u003cli\u003eEslami A, Chehrassan M, Alimoghadam S, Pisoudeh K, Kasaeian A, Elahifar O. Traumatic pelvic ring fracture during pregnancy: a systematic review. \u003cem\u003eEFORT Open Rev\u003c/em\u003e. 2024;9(7):700. doi:10.1530/EOR-23-0164\u003c/li\u003e\n\u003cli\u003eGalvagno SM, Nahmias JT, Young DA. Advanced Trauma Life Support\u0026reg; Update 2019: Management and Applications for Adults and Special Populations. \u003cem\u003eAnesthesiol Clin\u003c/em\u003e. 2019;37(1):13-32. doi:10.1016/J.ANCLIN.2018.09.009\u003c/li\u003e\n\u003cli\u003eGreco PS, Day LJ, Pearlman MD. Guidance for Evaluation and Management of Blunt Abdominal Trauma in Pregnancy. \u003cem\u003eObstetrics and Gynecology\u003c/em\u003e. 2019;134(6):1343-1357. doi:10.1097/AOG.0000000000003585\u003c/li\u003e\n\u003cli\u003eLopez CE, Salloum J, Varon AJ, Toledo P, Dudaryk R. The Management of Pregnant Trauma Patients: A Narrative Review. \u003cem\u003eAnesth Analg\u003c/em\u003e. 2023;136(5):830-840. doi:10.1213/ANE.0000000000006363\u003c/li\u003e\n\u003cli\u003eHough M, Nahmias J, Santos J, et al. Emergency cesarean section in pregnant trauma patients presenting after motor vehicle collision. \u003cem\u003eHeliyon\u003c/em\u003e. 2024;10(19):e38707. doi:10.1016/j.heliyon.2024.e38707\u003c/li\u003e\n\u003cli\u003eLi P, Zhou D, Fu B, Song W, Dong J. Management and outcome of pelvic fracture associated with vaginal injuries: a retrospective study of 25 cases. \u003cem\u003eBMC Musculoskelet Disord\u003c/em\u003e. 2019;20(1). doi:10.1186/S12891-019-2839-Y\u003c/li\u003e\n\u003cli\u003eMeinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and Dislocation Classification Compendium-2018. \u003cem\u003eJ Orthop Trauma\u003c/em\u003e. 2018;32 Suppl 1:S1-S170. doi:10.1097/BOT.0000000000001063\u003c/li\u003e\n\u003cli\u003eYoung JWR, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain radiography in early assessment and management. \u003cem\u003eRadiology\u003c/em\u003e. 1986;160(2):445-451. doi:10.1148/RADIOLOGY.160.2.3726125\u003c/li\u003e\n\u003cli\u003eKhurana B, Sheehan SE, Sodickson AD, Weaver MJ. Pelvic Ring Fractures: What the Orthopedic Surgeon Wants to Know. \u003cem\u003ehttps://doi.org/101148/rg345135113\u003c/em\u003e. 2014;34(5):1317-1333. doi:10.1148/RG.345135113\u003c/li\u003e\n\u003cli\u003eAlton TB, Gee AO. Classifications in brief: Young and Burgess classification of pelvic ring injuries. \u003cem\u003eClin Orthop Relat Res\u003c/em\u003e. 2014;472(8):2338-2342. doi:10.1007/S11999-014-3693-8/FIGURES/1\u003c/li\u003e\n\u003cli\u003eValko L, Csosza G, Merei A, et al. Management of acutely decompensated chronic thromboembolic pulmonary hypertension in late pregnancy: A case report. \u003cem\u003eBMC Pregnancy Childbirth\u003c/em\u003e. 2019;19(1). doi:10.1186/s12884-019-2545-7\u003c/li\u003e\n\u003cli\u003evan Nimwegen D, Dyer DC. The action of vasopressors on isolated uterine arteries. \u003cem\u003eAm J Obstet Gynecol\u003c/em\u003e. 1974;118(8):1099-1103. doi:10.1016/0002-9378(74)90689-9\u003c/li\u003e\n\u003cli\u003eOkeagu CN, Anandi P, Gennuso S, et al. Clinical management of the pregnant patient undergoing non-obstetric surgery: Review of guidelines. \u003cem\u003eBest Pract Res Clin Anaesthesiol\u003c/em\u003e. 2020;34(2):269-281. doi:10.1016/J.BPA.2020.04.004\u003c/li\u003e\n\u003cli\u003eACOG Committee Opinion No. 775: Nonobstetric Surgery During Pregnancy. \u003cem\u003eObstetrics and gynecology\u003c/em\u003e. 2019;133(4):E285-E286. doi:10.1097/AOG.0000000000003174\u003c/li\u003e\n\u003cli\u003eStohlner V, Gill JR, Murphy CG, Carrothers AD. Definitive use of external fixation for pelvic ring injuries (open book/APC2) in pregnancy. \u003cem\u003eBMJ Case Rep\u003c/em\u003e. 2015;2015:bcr2015212690. doi:10.1136/BCR-2015-212690\u003c/li\u003e\n\u003cli\u003eMennen AHM, Posthuma JJ, Kooijman EM, et al. The mode of delivery after operative fixation of pelvic ring fractures\u0026ndash;a retrospective observational study. \u003cem\u003eEuropean Journal of Trauma and Emergency Surgery\u003c/em\u003e. 2024;50(5):2441-2449. doi:10.1007/S00068-024-02618-4/TABLES/2\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6593123/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6593123/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003ePolytrauma occurring during pregnancy presents unique challenges for clinicians, as it requires simultaneous care for two patients (mother and fetus). In addition to the physiological changes in the maternal condition, it is essential to meet the specific needs of the fetus and continuously assess its condition, necessitating a multidisciplinary approach.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eIn this case, a young, 28-week pregnant woman with no known underlying diseases was severely injured (ISS 16) in a high-energy collision. Primary imaging studies confirmed a comminuted fracture with significant displacement of the right hip, avulsion fractures noted on the sacrum, and the sacroiliac joint was opened on the right side, with considerable hematoma visible in the pelvis, pre-sacrally. Abdominal ultrasound flowmetry confirmed the presence of a live fetus not in distress, and no retroplacental hematoma was observed. Before complex trauma care, the patient was admitted to the intensive care unit for perioperative management. The patient\u0026rsquo;s oxygen-carrying capacity was optimized through fluid resuscitation and transfusion. An epidural catheter was placed for opioid-sparing analgesia. Continuous extended maternal observation was conducted alongside daily fetal diagnostics. Following a cost-benefit assessment by obstetricians, neonatologists, trauma surgeons, and intensive care specialists, a temporary right lower limb extension was applied due to the pelvic ring injury. After a brief preparation, closed reduction and screw osteosynthesis were performed on the iliac bone and sacrum. The procedure was carried out in the presence of a perinatal care team prepared for immediate cesarean delivery. No signs of fetal distress were observed during the intervention. Postoperative observation happened without any complications. The patient was transferred to the local facility for complex rehabilitation. Subsequently, the woman gave birth to a healthy boy at term.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur case described above is the first published report of the successful use of internal fixation of the pelvis with fetus in utero. Knowledge of the pillars of multidisciplinary care, establishing a unified approach, and protocolizing the care pathway are essential for better outcomes.\u003c/p\u003e","manuscriptTitle":"Multi-disciplinary management of pelvic injury in pregnancy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-30 06:21:19","doi":"10.21203/rs.3.rs-6593123/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-06T19:02:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-21T14:53:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-19T12:48:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-19T06:07:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-15T06:25:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"295128621047327891676266311049635785042","date":"2025-06-13T08:54:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"81612857777343106335930169195519607312","date":"2025-06-12T06:28:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79973964431901512616119034527228120019","date":"2025-06-10T06:16:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"183473984801401558208629227595825954168","date":"2025-06-07T10:44:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-05T21:03:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"71811710196455501570657972498242685348","date":"2025-06-05T21:01:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"38954883903568607221793806777284453145","date":"2025-06-05T14:48:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"129170753116292655663454851888442164264","date":"2025-05-28T10:08:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-28T08:28:21+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-08T07:49:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-07T09:28:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-07T09:24:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-05-05T09:33:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cef0a483-aa7a-4d89-9121-69c5980b0501","owner":[],"postedDate":"May 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T16:02:50+00:00","versionOfRecord":{"articleIdentity":"rs-6593123","link":"https://doi.org/10.1186/s12884-025-08101-1","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2025-10-06 15:58:09","publishedOnDateReadable":"October 6th, 2025"},"versionCreatedAt":"2025-05-30 06:21:19","video":"","vorDoi":"10.1186/s12884-025-08101-1","vorDoiUrl":"https://doi.org/10.1186/s12884-025-08101-1","workflowStages":[]},"version":"v1","identity":"rs-6593123","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6593123","identity":"rs-6593123","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}