Severe brain trauma to the fetus in a car accident: Literature review and a clinical case

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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.

About the authors

N. A. Vostrikov

The Center of Traumatology, Orthopedics and Neurosurgery

Author for correspondence.
ORCID iD: 0000-0002-3141-3663

Nikolay A. Vostrikov - Postgraduate Student, Chair of Neurology, Neurosurgery and Neurorehabilitation; Neurosurgeon.

203-59 Moskovskaya ul., Kirov, 610050.

Tel.: +7 (901) 419 56 03.

Russian Federation

I. V. Ponomareva

Regional Clinical Hospital No. 3

ORCID iD: 0000-0001-6499-3054

Irina V. Ponomareva - MD, PhD, Head of Department of Neurology No. 2, Polyclinic No. 2; Neurologist, Epileptologist.

287 Pobedy prospekt, Chelyabinsk, 454021.

Russian Federation

O. V. Cheremisinov

Kirov Regional Clinical Hospital

ORCID iD: 0000-0002-2630-4091

Oleg V. Cheremisinov - MD, PhD, Radiologist, Department of Radiology.

42 Vorovskogo ul., Kirov, 610027.

Russian Federation

M. A. Sherman

Kirov State Medical University

ORCID iD: 0000-0001-5740-1022

Mikhail A. Sherman - MD, PhD, Associate Professor, Head of Chair of Neurology, Neurosurgery and Neurorehabilitation.

112 K. Marksa ul., Kirov, 610998.

Russian Federation


  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.
  10. Shah KH, Simons RK, Holbrook T, Fortlage D, Winchell RJ, Hoyt DB. Trauma in pregnancy: maternal and fetal outcomes. J Trauma. 1998;45(1):83-86. doi: 10.1097/00005373199807000-00018.
  11. Stafford PA, Biddinger PW, Zumwalt RE. Lethal intrauterine fetal trauma. Am J Obstet Gynecol. 1988;159(2):485-489. doi: 10.1016/s0002-9378(88)80115-7.
  12. Rothenberger D, Quattlebaum FW, Perry JF Jr, Zabel J, Fischer RP. Blunt maternal trauma: a review of 103 cases. J Trauma. 1978;18(3):173-179.
  13. Farmer DL, Adzick NS, Crombleholme WR, Crombleholme TM, Longaker MT, Harrison MR. Fetal trauma: relation to maternal injury. J Pediatr Surg. 1990;25(7):711-714. doi: 10.1016/s0022-3468(05)80002-8.
  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.
  34. McCollough CH, Schueler BA, Atwell TD, Braun NN, Regner DM, Brown DL, LeRoy AJ. Radiation exposure and pregnancy: when should we be concerned? Radiographics. 2007;27(4): 909-917; discussion 917-918. doi: 10.1148/rg.274065149.
  35. Vergani P, Strobelt N, Locatelli A, Paterlini G, Tagliabue P, Parravicini E, Ghidini A. Clinical significance of fetal intracranial hemorrhage. Am J Obstet Gynecol. 1996;175(3 Pt 1):536-543. doi: 10.1053/ob.1996.v175.a73598.
  36. Klinich KD, Flannagan CA, Rupp JD, Sochor M, Schneider LW, Pearlman MD. Fetal outcome in motor-vehicle crashes: effects of crash characteristics and maternal restraint. Am J Obstet Gynecol. 2008;198(4):450.e1-e9. doi: 10.1016/j.ajog.2008.02.009.
  37. Sadro CT, Zins AM, Debiec K, Robinson J. Case report: lethal fetal head injury and placental abruption in a pregnant trauma patient. Emerg Radiol. 2012;19(2):175-180. doi: 10.1007/s10140-011-1017-9.
  38. Recker MJ, Cappuzzo JM, Li V. Management of Intracranial Hemorrhage and Skull Fracture After Blunt Intrauterine Trauma. World Neurosurg. 2020;138:352-354. doi: 10.1016/j.wneu.2020.03.089.
  39. Leroy-Malherbe V, Bonnier C, Papiernik E, Groos E, Landrieu P. The association between developmental handicaps and traumatic brain injury during pregnancy: an issue that deserves more systematic evaluation. Brain Inj. 2006;20(13-14):1355-1365. doi: 10.1080/02699050601102202.
  40. Ghi T, Simonazzi G, Perolo A, Savelli L, San-dri F, Bernardi B, Santini D, Bovicelli L, Pilu G. Outcome of antenatally diagnosed intracranial hemorrhage: case series and review of the literature. Ultrasound Obstet Gynecol. 2003;22(2):121-130. doi: 10.1002/uog.191.
  41. Joseph JR, Smith BW, Garton HJ. Blunt prenatal trauma resulting in fetal epidural or subdural hematoma: case report and systematic review of the literature. J Neurosurg Pediatr. 2017;19(1): 32-37. doi: 10.3171/2016.7.PEDS16282.
  42. Doose H, Neubauer BA, Petersen B. The concept of hereditary impairment of brain maturation. Epileptic Disord. 2000;2 Suppl 1:S45-S49.
  43. Wohlrab G, Schmitt B, Boltshauser E. Benign focal epileptiform discharges in children after severe head trauma: prognostic value and clinical course. Epilepsia. 1997;38(3):275-278. doi: 10.1111/j.1528-1157.1997.tb01117.x.
  44. Мухин КЮ. Доброкачественные эпилептиформные паттерны детства и ассоциированные с ними состояния. Русский журнал детской неврологии. 2018;13(3):7-24. doi: 10.17650/2073-8803-2018-13-3-7-24.
  45. Doose H, Baier WK. Benign partial epilepsy and related conditions: multifactorial pathogenesis with hereditary impairment of brain maturation. Eur J Pediatr. 1989;149(3):152-158. doi: 10.1007/BF01958268.
  46. Stephani U, Doose H. Benign idiopathic partial epilepsy and brain lesion. Epilepsia. 1999;40(3): 373-376. doi: 10.1111/j.1528-1157.1999.tb00721.x.
  47. Мухин КЮ, Кузьмич ГВ, Балканская СВ, Батышева ТТ, Куренков АЛ, Горина ТП. Особенности эпилептиформной активности ЭЭГ у детей с перивентрикулярной лейкомаляцией и церебральным параличом при отсутствии эпилепсии. Журнал неврологии и психиатрии им. С.С. Корсакова. 2012;112(7-2):71-6.
  48. Kim SE, Lee JH, Chung HK, Lim SM, Lee HW. Alterations in white matter microstructures and cognitive dysfunctions in benign childhood epilepsy with centrotemporal spikes. Eur J Neurol. 2014;21(5):708-717. doi: 10.1111/ene.12301.
  49. Doose H, Neubauer B, Carlsson G. Children with benign focal sharp waves in the EEG - developmental disorders and epilepsy. Neuro-pediatrics. 1996;27(5):227-241. doi: 10.1055/s-2007-973771.
  50. Owattanapanich N, Lewis MR, Benjamin ER, Wong MD, Demetriades D. Motor vehicle crashes in pregnancy: maternal and fetal outcomes. J Trauma Acute Care Surg. 2021 Jan 25. Epub ahead of print. doi: 10.1097/TA.0000000000003093.
  51. Hartl R, Ko K. In utero skull fracture: case report. J Trauma. 1996;41(3):549-552. doi: 10.1097/00005373-199609000-00031.
  52. Yamasato K, Kurata N, Towner D. Delayed Appearance of a Traumatic Fetal Intracranial Hemorrhage. Case Rep Obstet Gynecol. 2018;2018:1465034. doi: 10.1155/2018/1465034.
  53. Eeg-Olofsson O, Lundberg S, Raininko R. MRI in rolandic epilepsy. Epileptic Disord. 2000;2 Suppl 1:S51-S53.

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Copyright (c) 2021 Vostrikov N.A., Ponomareva I.V., Cheremisinov O.V., Sherman M.A.

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