Transmediastinal Gunshot Wound in a Pregnant Patient with Stable Hemodynamics

Abstract

Transmediastinal gunshot wounds (TGWs) may lead to life-threatening injuries of vital organs such as large vessels, the esophagus, and lungs. Although they are not commonly encountered in pregnant women, additional caution should be given to these patients. Physical examination for the diagnosis and the choice of treatment modality contain controversial points in hemodynamically stable patients, and resuscitation has excessive importance due to physiological changes in pregnancy. We present a hemodynamically stable 26-week pregnant woman brought to the emergency department for TGW. She had a 1-cm diameter of bullet entrance hole on the right anterior 4th intercostal space, 2 cm lateral to the sternum, and a 3-cm diameter exit hole on the right posterior 12th intercostal space on the midscapular line. With our conservative approach, she had an uncomplicated pregnancy period, and gave birth to a healthy baby at term.

Maternal and Neonatal Outcomes of Gunshot Wounds in Pregnancy: A Systematic Review of Case Reports

“…56 Table 1 demonstrates the results of the appraisal, finding all 41 studies to be detailed enough to be replicated, relevant to contemporary practice, and demonstrate adequately ascertained exposure (GSW) and coprimary outcomes (maternal and/or neonatal death). While 82% (34/41) of studies had adequate follow-up of surviving patient(s) until or beyond discharge, [4][5][6][7][8][12][13][14][15][16][17][18][19][20][23][24][25][27][28][29][30][31][32][33][34][35][36][38][39][40][41][42][43][44] few studies (6/41) with a clear selection method were limited to the case series and small registries in this review. 5,6,11,16,41,43 In the GRADE 57 assessment of our review based on observational studies, our certainty of evidence was downgraded due to risk of selection bias and upgraded as possible confounders not discussed in the studies (comorbidities, obstetric history, socioeconomic status, degree of education, global variation in standards of care, etc.)…”

“…56 Table 1 demonstrates the results of the appraisal, finding all 41 studies to be detailed enough to be replicated, relevant to contemporary practice, and demonstrate adequately ascertained exposure (GSW) and coprimary outcomes (maternal and/or neonatal death). While 82% (34/41) of studies had adequate follow-up of surviving patient(s) until or beyond discharge, 4-8,12-20,23-25,27-36,38-44 few studies (6/41) with a clear selection method were limited to the case series and small registries in this review. 5,6,11,16,41,43…”

“…d Five articles 6,7,38,41,44 report the indication for cesarean delivery to be traumatic uterine rupture secondary to the gunshot wound(s). e Four articles report fetal injury, 6 surgical inaccessibility to maternal trauma site, 6 lack of a GSW exit site, 17,20 anticipated delay in the operating room, 23 artificial rupture of membranes, 28 and "cornical presentation" 32 as indications for cesarean delivery.…”

“…GSW, Gunshot Wound(s); NR, Not Reported; NRFHT, Non-reassuring fetal heart tones; Tr Ut, Traumatic Uterine; CD, Cesarean Delivery. a Extremities, Thorax, Head/Neck, Back/Spine, Poly-site, Other/Unknown. b One article 29 reports a patient who delivered spontaneously prior to delivery. c Labor indications include failed induction of labor, first and second stage arrest of labor. d Five articles 6,7,38,41,44 report the indication for cesarean delivery to be traumatic uterine rupture secondary to the gunshot wound(s). e Four articles report fetal injury, 6 surgical inaccessibility to maternal trauma site, 6 lack of a GSW exit site, 17,20 anticipated delay in the operating room, 23 artificial rupture of membranes, 28 and “cornical presentation” 32 as indications for cesarean delivery.…”

“…2,3 The primary literature on maternal and neonatal outcomes of GSW in pregnancy is limited, with most publications consisting of case reports or small case series. 4-44 Several reports 45-49 predate the classification of perimortem cesarean delivery as the primary method of maternal resuscitation. 50…”