Thurs., 10/8/09 Pediatrics & Injury Prevention, Paper #32, 3:32 pm OTA-2009
Childbirth after Pelvic Fractures: Debunking the Myths
Lisa K. Cannada, MD1 (4, 7-Smith &Nephew; 5A-Medtronic Sofamor Danek; 7-Zimmer,
Synthes, DePuy, A Johnson &Johnson Company);
Yamini Natarajan, BS2 (7-University of Texas-Southwestern);
Sara Strebe, MD2 (7-Zimmer, RJOS, FOT); Heather A. Vallier, MD3 (7-OREF, Synthes);
Beth Ann Cureton, BS3 (7-OREF, RJOS, Zimmer); Jennifer Barr, MD4(7-Zimmer, RJOS);
Zhen Qin, MS4(7-Zimmer, RJOS); George V. Russell, Jr., MD4(7- Stryker; Synthes ; 8-Zimmer); Carol E. Copeland, MD5 (n);
1St. Louis University Medical Center, Saint Louis, Missouri, USA;
2University of Texas-Southwestern, Dallas, Texas, USA;
3Metrohealth Medical Center, Cleveland, Ohio, USA;
4University of Mississippi, Jackson, Mississippi, USA;
5Sinai Hospital, Baltimore, Maryland, USA
Purpose: For women of childbearing age, pelvic trauma may have far-reaching implications. To our knowledge, the ability to deliver successfully vaginally after a pelvic fracture has not been evaluated thoroughly in the literature. The hypotheses of the current investigation are twofold: (1) sexual dysfunction can be expected even in women with stable pelvic fractures treated nonoperatively; and (2) women who have been treated nonoperatively for pelvic fracture, and those treated surgically with fixation involving the sacroiliac joint or ramus screws, can deliver children vaginally.
Methods: Women with pelvic fractures between the ages of 16 and 45 years were identified at 3 Level 1 trauma centers. The medical records were reviewed for data regarding their injury. Radiographs were reviewed and fractures classified according to the OTA classification and Young and Burgess(Y&B) classification. Stable fractures (SF) were grouped as OTA 61 B1 and B2 (Y&B LC1 and APC1). All other pelvic fractures were considered unstable (USF). The patients completed a questionnaire regarding genitourinary (GU) function and childbirth history (if applicable). Their obstetricians completed a birth history of the women who had children after their pelvic fracture. Characteristics of the sample were described using descriptive statistics; nonparametric statistics (chi-square and Fisher exact test) were used to analyze the sample group comparisons. Data were analyzed using SPSS version 15.0.
Results: 102 women completed forms. The average age of the women at the time of their trauma was 27 years (range, 16-45). There were 56 SFs and 41 USF patterns. Five radiographs were unavailable for review. 52 women (51%) required surgical stabilization of their fracture. 36 women (35%) had GU complaints after their pelvic fracture. 37 women (36%) complained of painful intercourse after their pelvic fracture. There was no significant difference between dyspareunia and fracture stability (P = 0.48) or need for surgical stabilization (P = 0.52). 48 women (47%) have had a baby since their pelvic fracture; 18 had more than 1 child. 20 women (42%) delivered vaginally (NSVD) and 28 women (58%) had a cesarean section (CS). 6 of the women with NSVD had surgery for their fracture with percutaneous fixation (iliosacral screws, ramus screw, external fixation). 18 women who had a CS had surgical fixation of their pelvic fracture, 7 had transsymphyseal fixation, and 11 percutaneous fixation. The reasons given by the obstetrician for CS were: 7 with anterior hardware, 10 medical (breech, abruption, twins, previous CS), and 11 due to pelvic fracture history. Significant differences were noted between CS rate and stability of fracture (P <0.01) and requiring surgery for pelvic fracture (P <0.01).
Conclusions: As trauma surgeons, we are aware of the spectrum of severity of injury and the morbidity of treatments for pelvic fractures. In our study, one-third of all patients had GU complaints and dyspareunia, regardless of fracture pattern and/or need for surgery. A common thought process in the lay population and even in the obstetric community is that women who have had pelvic fracture cannot deliver vaginally. However, there are no large-scale studies to corroborate this. We had a 42% rate of NSVD after pelvic fracture including those with USF and/or surgical stabilization that does not cross the symphysis. There was no patient with successful NSVD with transsymphyseal fixation and the women were not given a trial of labor. Our study demonstrates that even with a USF and/or surgical stabilization sparing the symphysis, NSVD is possible after pelvic fractures.
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant