Screening Helical CT for Evaluation of Blunt Traumatic Injury in the Pregnant Patient1
Catherine Lowdermilk, MD, 2,
Morris L. Gavant, MD,
Waleed Qaisi, MD,
O. Clark West, MD and
Stanford M. Goldman, MD
1 From the Department of Radiology, University of Tennessee, Memphis College of Medicine, 800 Madison Ave, Memphis, TN 38163 (C.L., M.L.G., W.Q.); Department of Radiology, the Regional Medical Center at Memphis, Elvis Presley Memorial Trauma Center, Tenn (C.L., M.L.G., W.Q.); and the Department of Radiology, University of Texas, Houston (O.C.W., S.M.G.). Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received January 27, 1999; revision requested February 19; final revision received May 28; accepted June 1. Address reprint requests to M.L.G.
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Figure 1a. Normal first trimester (10 weeks) pregnancy in a patient who was an unrestrained driver and sustained a closed head injury in an automobile crash. (a) Head CT scan shows diffuse axonal injury with intraparenchymal hematoma and intraventricular hemorrhage (arrow). (b) Pelvic CT scan reveals an enlarged uterus with a "bulging," peripherally enhancing, fluid collection that fills the endometrial cavity (arrow). Fetal parts were not seen. The patient's brain injury led to maternal and fetal death.
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Figure 1b. Normal first trimester (10 weeks) pregnancy in a patient who was an unrestrained driver and sustained a closed head injury in an automobile crash. (a) Head CT scan shows diffuse axonal injury with intraparenchymal hematoma and intraventricular hemorrhage (arrow). (b) Pelvic CT scan reveals an enlarged uterus with a "bulging," peripherally enhancing, fluid collection that fills the endometrial cavity (arrow). Fetal parts were not seen. The patient's brain injury led to maternal and fetal death.
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Figure 2a. Normal first trimester pregnancy in a patient who sustained severe blunt chest trauma in an automobile crash. (a) Chest CT scan shows lung contusions, hemorrhage, and atelectasis, which required endotracheal intubation, and a right pneumothorax, which required chest tube placement. (b) Pelvic CT scan shows a bulging, fluid-filled endometrial cavity (arrow) but no fetal parts. A corpus luteum cyst of pregnancy was seen in the right ovary (arrowhead). The patient had a spontaneous abortion the next day and fully recovered from her chest injuries, which also included a right clavicle and multiple rib fractures.
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Figure 2b. Normal first trimester pregnancy in a patient who sustained severe blunt chest trauma in an automobile crash. (a) Chest CT scan shows lung contusions, hemorrhage, and atelectasis, which required endotracheal intubation, and a right pneumothorax, which required chest tube placement. (b) Pelvic CT scan shows a bulging, fluid-filled endometrial cavity (arrow) but no fetal parts. A corpus luteum cyst of pregnancy was seen in the right ovary (arrowhead). The patient had a spontaneous abortion the next day and fully recovered from her chest injuries, which also included a right clavicle and multiple rib fractures.
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Figures 3, 4. (3) Normal early second trimester (12 weeks) pregnancy in a patient who was in an automobile crash but sustained no internal injuries. On a pelvic CT scan, the fetal parts (arrow) are barely detectable in the endometrial fluid. The hyperattenuation of the fetus should not be confused with active uterine hemorrhage. (4) Normal placental cotyledons of a second trimester (22 weeks) pregnancy in a woman who lost consciousness during an automobile crash but sustained no internal injuries. Abdominal CT scan reveals the normal placental cotyledons, which have central areas of low attenuation (*) and are surrounded by peripheral rings of normally enhancing placenta. Enlarged ovarian veins (o), which are normally seen in later stages of pregnancies, are present. The normal heterogeneously high-attenuation adnexa (arrows) have lifted out of the pelvis with the enlarging uterus. The fetal face and chest (c) are visible.
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Figures 3, 4. (3) Normal early second trimester (12 weeks) pregnancy in a patient who was in an automobile crash but sustained no internal injuries. On a pelvic CT scan, the fetal parts (arrow) are barely detectable in the endometrial fluid. The hyperattenuation of the fetus should not be confused with active uterine hemorrhage. (4) Normal placental cotyledons of a second trimester (22 weeks) pregnancy in a woman who lost consciousness during an automobile crash but sustained no internal injuries. Abdominal CT scan reveals the normal placental cotyledons, which have central areas of low attenuation (*) and are surrounded by peripheral rings of normally enhancing placenta. Enlarged ovarian veins (o), which are normally seen in later stages of pregnancies, are present. The normal heterogeneously high-attenuation adnexa (arrows) have lifted out of the pelvis with the enlarging uterus. The fetal face and chest (c) are visible.
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Figures 5, 6. Clinically silent partial placental abruption or infarction in late pregnancy. (5) Pelvic CT scan of a woman who was an unrestrained driver in an automobile crash during the 31st week of pregnancy reveals a peripheral area of placental infarction or abruption that does not enhance (arrow). Results of screening fetal US were normal, and the patient's only injury was an ankle fracture. She was discharged home and had a normal delivery at term. L = fetal liver, P = normal placenta. (6) Abdominal CT scan of a woman who was in an automobile crash in her last week of pregnancy shows a 5-cm nonenhancing partial abruption or infarction that involves the peripheral posterior placenta (arrow). Note the normal subcutaneous fat and well-formed tibia and fibula of the leg (L) in the term fetus. In the supine position, the mother's inferior vena cava (i) was compressed and the ovarian veins (o) were enlarged, common findings in the later stages of pregnancy. Results of screening fetal US were normal. The patient was discharged home and had a normal delivery at term.
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Figures 5, 6. Clinically silent partial placental abruption or infarction in late pregnancy. (5) Pelvic CT scan of a woman who was an unrestrained driver in an automobile crash during the 31st week of pregnancy reveals a peripheral area of placental infarction or abruption that does not enhance (arrow). Results of screening fetal US were normal, and the patient's only injury was an ankle fracture. She was discharged home and had a normal delivery at term. L = fetal liver, P = normal placenta. (6) Abdominal CT scan of a woman who was in an automobile crash in her last week of pregnancy shows a 5-cm nonenhancing partial abruption or infarction that involves the peripheral posterior placenta (arrow). Note the normal subcutaneous fat and well-formed tibia and fibula of the leg (L) in the term fetus. In the supine position, the mother's inferior vena cava (i) was compressed and the ovarian veins (o) were enlarged, common findings in the later stages of pregnancy. Results of screening fetal US were normal. The patient was discharged home and had a normal delivery at term.
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Figure 7. Hydronephrosis of pregnancy in a woman who was injured in an automobile crash during the 37th week of pregnancy but sustained no internal injuries. Abdominal CT scan reveals hydronephrosis (H), which is caused by mechanical compression of the ureter by the gravid uterus. Note the normal subcutaneous fat (arrow) of the thigh in the near-term fetus. Results of screening US of the fetus and other CT studies were normal. Subsequently, the patient had a normal delivery.
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Figure 8a. Severe visceral and skeletal injuries in a woman who was 18 weeks pregnant with twins when she was ejected from her car in an automobile crash. (a) Abdominal CT scan shows a laceration to the posterior liver (arrow), with an adjacent displaced rib fracture and splenic laceration (arrowhead). Intraperitoneal blood was present in the right subphrenic space. (b) Abdominal CT scan reveals a small right renal laceration (arrowhead) and a left renal infarction and laceration (*). Blood was present in the right subhepatic space. She also had severe lung contusions, multiple facial fractures, and a skull fracture. (c) Pelvic CT scan shows a poorly enhancing anterior placenta (arrows). Although results of screening fetal US had been normal, the patient had a spontaneous stillbirth 4 days after admission. A large placental abruption was found at pathologic examination. The patient was treated nonoperatively, and she recovered from her other internal abdominal injuries.
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Figure 8b. Severe visceral and skeletal injuries in a woman who was 18 weeks pregnant with twins when she was ejected from her car in an automobile crash. (a) Abdominal CT scan shows a laceration to the posterior liver (arrow), with an adjacent displaced rib fracture and splenic laceration (arrowhead). Intraperitoneal blood was present in the right subphrenic space. (b) Abdominal CT scan reveals a small right renal laceration (arrowhead) and a left renal infarction and laceration (*). Blood was present in the right subhepatic space. She also had severe lung contusions, multiple facial fractures, and a skull fracture. (c) Pelvic CT scan shows a poorly enhancing anterior placenta (arrows). Although results of screening fetal US had been normal, the patient had a spontaneous stillbirth 4 days after admission. A large placental abruption was found at pathologic examination. The patient was treated nonoperatively, and she recovered from her other internal abdominal injuries.
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Figure 8c. Severe visceral and skeletal injuries in a woman who was 18 weeks pregnant with twins when she was ejected from her car in an automobile crash. (a) Abdominal CT scan shows a laceration to the posterior liver (arrow), with an adjacent displaced rib fracture and splenic laceration (arrowhead). Intraperitoneal blood was present in the right subphrenic space. (b) Abdominal CT scan reveals a small right renal laceration (arrowhead) and a left renal infarction and laceration (*). Blood was present in the right subhepatic space. She also had severe lung contusions, multiple facial fractures, and a skull fracture. (c) Pelvic CT scan shows a poorly enhancing anterior placenta (arrows). Although results of screening fetal US had been normal, the patient had a spontaneous stillbirth 4 days after admission. A large placental abruption was found at pathologic examination. The patient was treated nonoperatively, and she recovered from her other internal abdominal injuries.
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Figures 9, 10. (9) Retroperitoneal hemorrhage and severe closed head injury in a patient who was in her second trimester of pregnancy when she was injured in an automobile crash. (a) Abdominal CT scan shows active retroperitoneal hemorrhage (arrow) at the level of the left renal vein that displaces the left kidney. The blood extends along the left hemidiaphragm. (b) On a pelvic CT scan, placental enhancement is absent (arrowheads), and a focal uterine wall defect is seen (arrow). Because of these findings and those of screening US, which had revealed no fetal heart tones or movement, complete placental abruption with possible uterine injury was suspected. The patient became coagulopathic, and the mother and fetus died. (10) Pelvic fracture in a woman who was an unrestrained driver in an automobile crash during the 22nd week of pregnancy. No fetal heart tones were heard at screening US. (a) Pelvic CT scan shows a right acetabular fracture (arrows). She also had right sacroiliac joint diastasis (not shown). (b) On an abdominal CT scan, only a small part of the placenta enhances (arrow). The patient had a spontaneous stillbirth the next day, and pathologic examination revealed acute placental infarction. She recovered from her skeletal injuries.
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Figures 9, 10. (9) Retroperitoneal hemorrhage and severe closed head injury in a patient who was in her second trimester of pregnancy when she was injured in an automobile crash. (a) Abdominal CT scan shows active retroperitoneal hemorrhage (arrow) at the level of the left renal vein that displaces the left kidney. The blood extends along the left hemidiaphragm. (b) On a pelvic CT scan, placental enhancement is absent (arrowheads), and a focal uterine wall defect is seen (arrow). Because of these findings and those of screening US, which had revealed no fetal heart tones or movement, complete placental abruption with possible uterine injury was suspected. The patient became coagulopathic, and the mother and fetus died. (10) Pelvic fracture in a woman who was an unrestrained driver in an automobile crash during the 22nd week of pregnancy. No fetal heart tones were heard at screening US. (a) Pelvic CT scan shows a right acetabular fracture (arrows). She also had right sacroiliac joint diastasis (not shown). (b) On an abdominal CT scan, only a small part of the placenta enhances (arrow). The patient had a spontaneous stillbirth the next day, and pathologic examination revealed acute placental infarction. She recovered from her skeletal injuries.
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Figures 9, 10. (9) Retroperitoneal hemorrhage and severe closed head injury in a patient who was in her second trimester of pregnancy when she was injured in an automobile crash. (a) Abdominal CT scan shows active retroperitoneal hemorrhage (arrow) at the level of the left renal vein that displaces the left kidney. The blood extends along the left hemidiaphragm. (b) On a pelvic CT scan, placental enhancement is absent (arrowheads), and a focal uterine wall defect is seen (arrow). Because of these findings and those of screening US, which had revealed no fetal heart tones or movement, complete placental abruption with possible uterine injury was suspected. The patient became coagulopathic, and the mother and fetus died. (10) Pelvic fracture in a woman who was an unrestrained driver in an automobile crash during the 22nd week of pregnancy. No fetal heart tones were heard at screening US. (a) Pelvic CT scan shows a right acetabular fracture (arrows). She also had right sacroiliac joint diastasis (not shown). (b) On an abdominal CT scan, only a small part of the placenta enhances (arrow). The patient had a spontaneous stillbirth the next day, and pathologic examination revealed acute placental infarction. She recovered from her skeletal injuries.
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Figures 9, 10. (9) Retroperitoneal hemorrhage and severe closed head injury in a patient who was in her second trimester of pregnancy when she was injured in an automobile crash. (a) Abdominal CT scan shows active retroperitoneal hemorrhage (arrow) at the level of the left renal vein that displaces the left kidney. The blood extends along the left hemidiaphragm. (b) On a pelvic CT scan, placental enhancement is absent (arrowheads), and a focal uterine wall defect is seen (arrow). Because of these findings and those of screening US, which had revealed no fetal heart tones or movement, complete placental abruption with possible uterine injury was suspected. The patient became coagulopathic, and the mother and fetus died. (10) Pelvic fracture in a woman who was an unrestrained driver in an automobile crash during the 22nd week of pregnancy. No fetal heart tones were heard at screening US. (a) Pelvic CT scan shows a right acetabular fracture (arrows). She also had right sacroiliac joint diastasis (not shown). (b) On an abdominal CT scan, only a small part of the placenta enhances (arrow). The patient had a spontaneous stillbirth the next day, and pathologic examination revealed acute placental infarction. She recovered from her skeletal injuries.
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Figure 11a. Renal laceration and skeletal injuries in a woman who was an unrestrained passenger in an automobile crash during the 29th week of pregnancy. No fetal heart tones were heard at screening US. (a) Pelvic CT scan shows an anterior laceration (arrowhead) in the right pelvic kidney, adjacent to the caudally located fetal head. Sacroiliac joint diastasis and pubic symphysis diastasis were also present (latter not shown). (b) On an abdominal CT scan, no placental enhancement (arrow) is seen. The fetal liver (L) is seen in the upper fetal abdomen. No fetal subcutaneous fat was present. Labor was induced the next day, resulting in a stillbirth, and the suspected complete placental abruption was confirmed. The patient recovered from her other skeletal and visceral injuries.
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Figure 11b. Renal laceration and skeletal injuries in a woman who was an unrestrained passenger in an automobile crash during the 29th week of pregnancy. No fetal heart tones were heard at screening US. (a) Pelvic CT scan shows an anterior laceration (arrowhead) in the right pelvic kidney, adjacent to the caudally located fetal head. Sacroiliac joint diastasis and pubic symphysis diastasis were also present (latter not shown). (b) On an abdominal CT scan, no placental enhancement (arrow) is seen. The fetal liver (L) is seen in the upper fetal abdomen. No fetal subcutaneous fat was present. Labor was induced the next day, resulting in a stillbirth, and the suspected complete placental abruption was confirmed. The patient recovered from her other skeletal and visceral injuries.
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Figure 12a. Severe visceral injuries in a woman who was a restrained driver in an automobile crash during the 26th week of pregnancy. Oligohydramnios, absent fetal movement, and cardiac decelerations were found at screening fetal US. (a) Abdominal CT scan shows a grade III splenic laceration (arrow) that was successfully nonoperatively managed. (b) Abdominal CT scan reveals a retroperitoneal hematoma with focal areas of active extravasation (white arrow) from an ovarian vein injury. There was a peripheral low-attenuation placental abruption (black arrow). Oligohydramnios was not appreciated at CT. High-attenuation hemorrhage or concentrated proteinaceous amniotic fluid surrounds the fetus. (c) Abdominal CT scan obtained at a lower level shows multiple areas of nonenhancing placenta (arrowheads). The patient had a spontaneous abortion the next day. She remained hemodynamically stable and recovered from her other internal injuries.
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Figure 12b. Severe visceral injuries in a woman who was a restrained driver in an automobile crash during the 26th week of pregnancy. Oligohydramnios, absent fetal movement, and cardiac decelerations were found at screening fetal US. (a) Abdominal CT scan shows a grade III splenic laceration (arrow) that was successfully nonoperatively managed. (b) Abdominal CT scan reveals a retroperitoneal hematoma with focal areas of active extravasation (white arrow) from an ovarian vein injury. There was a peripheral low-attenuation placental abruption (black arrow). Oligohydramnios was not appreciated at CT. High-attenuation hemorrhage or concentrated proteinaceous amniotic fluid surrounds the fetus. (c) Abdominal CT scan obtained at a lower level shows multiple areas of nonenhancing placenta (arrowheads). The patient had a spontaneous abortion the next day. She remained hemodynamically stable and recovered from her other internal injuries.
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Figure 12c. Severe visceral injuries in a woman who was a restrained driver in an automobile crash during the 26th week of pregnancy. Oligohydramnios, absent fetal movement, and cardiac decelerations were found at screening fetal US. (a) Abdominal CT scan shows a grade III splenic laceration (arrow) that was successfully nonoperatively managed. (b) Abdominal CT scan reveals a retroperitoneal hematoma with focal areas of active extravasation (white arrow) from an ovarian vein injury. There was a peripheral low-attenuation placental abruption (black arrow). Oligohydramnios was not appreciated at CT. High-attenuation hemorrhage or concentrated proteinaceous amniotic fluid surrounds the fetus. (c) Abdominal CT scan obtained at a lower level shows multiple areas of nonenhancing placenta (arrowheads). The patient had a spontaneous abortion the next day. She remained hemodynamically stable and recovered from her other internal injuries.
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Figure 13a. Isolated pubic ramus fracture in a woman who was a restrained passenger in an automobile crash during the 36th week of pregnancy. Fetal heart tones and motion were absent at screening US. (a) Pelvic CT scan shows an isolated fracture to the right superior pubic ramus (arrow), which was the only maternal injury. (b) Pelvic CT scan demonstrates the fetal head, which lies in the maternal pelvis anterior to the collapsed enhancing uterus (U). Amniotic fluid fills the peritoneal cavity. (c) Abdominal CT scan shows the fetus (F) floating in the upper abdomen anterior to the maternal pancreas. No surrounding uterus was seen. Intraperitoneal amniotic fluid fills the paracolic gutters and subphrenic and subhepatic spaces. Subcutaneous fat surrounds the near-term fetus. A complete posterior fundal uterine rupture was found at surgery, and the extruded fetus was dead. The patient recovered from her skeletal injury.
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Figure 13b. Isolated pubic ramus fracture in a woman who was a restrained passenger in an automobile crash during the 36th week of pregnancy. Fetal heart tones and motion were absent at screening US. (a) Pelvic CT scan shows an isolated fracture to the right superior pubic ramus (arrow), which was the only maternal injury. (b) Pelvic CT scan demonstrates the fetal head, which lies in the maternal pelvis anterior to the collapsed enhancing uterus (U). Amniotic fluid fills the peritoneal cavity. (c) Abdominal CT scan shows the fetus (F) floating in the upper abdomen anterior to the maternal pancreas. No surrounding uterus was seen. Intraperitoneal amniotic fluid fills the paracolic gutters and subphrenic and subhepatic spaces. Subcutaneous fat surrounds the near-term fetus. A complete posterior fundal uterine rupture was found at surgery, and the extruded fetus was dead. The patient recovered from her skeletal injury.
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Figure 13c. Isolated pubic ramus fracture in a woman who was a restrained passenger in an automobile crash during the 36th week of pregnancy. Fetal heart tones and motion were absent at screening US. (a) Pelvic CT scan shows an isolated fracture to the right superior pubic ramus (arrow), which was the only maternal injury. (b) Pelvic CT scan demonstrates the fetal head, which lies in the maternal pelvis anterior to the collapsed enhancing uterus (U). Amniotic fluid fills the peritoneal cavity. (c) Abdominal CT scan shows the fetus (F) floating in the upper abdomen anterior to the maternal pancreas. No surrounding uterus was seen. Intraperitoneal amniotic fluid fills the paracolic gutters and subphrenic and subhepatic spaces. Subcutaneous fat surrounds the near-term fetus. A complete posterior fundal uterine rupture was found at surgery, and the extruded fetus was dead. The patient recovered from her skeletal injury.
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Copyright © 1999 by the Radiological Society of North America.
