Journal of International Oral Health

CASE REPORT
Year
: 2018  |  Volume : 10  |  Issue : 2  |  Page : 99--102

Facial fracture in pregnancy: Case report and review


Chithra Aramanadka, Srikanth Gadicherla, Anand Shukla, Adarsh Kudva 
 Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal, Karnataka, India

Correspondence Address:
Dr. Chithra Aramanadka
Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal, Karnataka
India

Abstract

Pregnancy is a condition in which physiologic changes are continuing to accommodate the developing embryo. Management of trauma in a pregnant patient is complex and involves multispecialty departments. Facial bone fracture is rare. Understanding the physiology is of prime importance for oral and maxillofacial surgeon to provide adequate treatment. This article describes the management guidelines for an oral and maxillofacial pregnant patient.



How to cite this article:
Aramanadka C, Gadicherla S, Shukla A, Kudva A. Facial fracture in pregnancy: Case report and review.J Int Oral Health 2018;10:99-102


How to cite this URL:
Aramanadka C, Gadicherla S, Shukla A, Kudva A. Facial fracture in pregnancy: Case report and review. J Int Oral Health [serial online] 2018 [cited 2022 Aug 17 ];10:99-102
Available from: https://www.jioh.org/text.asp?2018/10/2/99/230861


Full Text

 Introduction



Pregnancy is a physiologic condition where the maternal wellbeing imparts on the growth of the fetus. There are many alterations happening in the maternal body to accommodate the growing fetus. Hence it is important to know the effects of trauma and management of maxillofacial trauma in pregnancy. We describe a case of mandibular fracture in a pregnant patient

 Case Report



A 24-year-old female patient reported to the oral and maxillofacial outpatient department with a complaint of pain in the lower jaw for 2 days. History revealed that she had a fall at her house and she was 16-week pregnant [Figure 1].{Figure 1}

Radiograph (orthopantamograph) was done with a protective lead apron and revealed the presence of fracture in the right side of the parasymphysis region of the mandible. Gynecology consultation was done in view of her pregnancy status and obtained advice regarding the antibiotics and analgesics and fitness for the open reduction under local anesthesia. She was started with the course of amoxicillin and paracetamol. Open reduction and internal fixation were done with titanium plates and screws under lidocaine local anesthesia and adrenaline 1:2,000,000. The patient recovered well from the procedure, and her hospital stay was uneventful [Figure 2].{Figure 2}

 Discussion



Pregnancy is one of the important aspects of human life. Several changes occur during the pregnancy state. Understanding the physiology makes the clinician to decide the appropriate treatment plan.

Physiological changes during pregnancy

There is increase in the cardiac output by 35%–50% in the first 10 weeks of pregnancy which is maintained until delivery. Pregnant women may develop a “physiologic anemia” because of change in the plasma volume ratio to the red cell volume. This may lead to difficulty in diagnosing the blood loss as the mean arterial pressure remains same.[1],[2],[3]

Hence, the patient has to be monitored at least 4–8 h after the presentation even when the patient is stable. Pregnancy demonstrates hypercoagulability or prothrombotic phase at a later stage. However, oral surgery procedures do not require immobilization of the limbs.

During the period of 2–4 weeks, embryo is within the predifferentiation stage while it is resistant to teratogenic effects. It undergoes organogenesis stage during the 4–10 weeks following the last menstrual period and embryo is highly sensitive to radiation and teratogenic effects.

In the second and third trimesters, maternal positional changes may affect the cardiac output.

When the patient is placed in the supine position, the gravid uterus can cause compression of inferior vena cava thus reduces the venous return to the heart. Hence, the decreased preload will result in the sudden decrease in the cardiac output (10%–30%). At this stage, the patient can have symptomatic maternal tachycardia and hypotension, dizziness, and sweating. The patient can have symptoms of presyncope. This may result fetal compromise due to reduced perfusion to uterus.[4]

Hence, it is advisable to position the patient to the 15° tilt or pull the uterus manually to the left lateral to avoid the compression on inferior vena cava.

In pregnancy, oxygen consumption increases and residual capacity reduces. This results in an overall decreased maternal oxygen reserve. There are significant changes in the mucosa of upper airway. It becomes hyperemic and edematous with increased mucus production.[4] Intubation must be done by an experienced anesthetist.

There is around 50% increase in the renal blood flow with the increase in the glomerular filtration rate which produces increase in the body water content required for the mother and the fetus. Increased activity of the renin–angiotensin–aldosterone system activity during pregnancy leads to sodium and water retention.

Pregnant woman will have frequent urination due to this; there can be asymptomatic bacteriuria which can progress to urinary tract infection and eventually pyelonephritis if untreated.

Changes in the serum concentration of liver proteins, particularly albumin, can lead to peripheral edema caused by loss of oncotic pressure.[5]

Trauma in pregnancy

Management of trauma victim in pregnancy is a difficult task itself. Maintenance of patent airway is a challenge because of the physiologic alteration in the upper airway. Hormonal changes and increased blood volume contribute to edema and friability of the upper airway. Nasal congestion and reduced diameter of nasal passages are also due to hormonal changes and increased blood volume. Increased nasal engorgement may affect patients' ability to breathe and leads to increased rhinitis during pregnancy. Laryngoscopy and intubation are also more difficult to perform because of the maternal airway edema. Maternal respiratory changes with term gestation include increased minute ventilation (50%), increased oxygen consumption (20%), and decreased functional residual capacity (20%). These changes lead to rapid oxygen Desaturation and apnea. Increased airway closure may occur during tidal ventilation, resulting in increased ventilation/perfusion mismatch and maternal hypoxia.[6]

Focussed assessment by ultrasonography in trauma (FAST has to be done at the earliest in the emergency department.

Arrest of bleeding and closure of wound require the administration of local anesthesia.

Local anesthetic drugs such as lidocaine can be safely used with avoidance of intravascular administration. Vasoconstrictor adrenaline reduces the toxicity of the drug and increases the duration of action. Plain lidocaine solution in intravascular route has the contractile activity on uterine smooth muscle. There is a possibility of formation of methemoglobinemia in the fetus witht he use of prilocaine and benzocaine. However reports suggests the incidence of adverse events with the use of adrenaline alone. It may increase levels of thrombin and clotting factor VIII. It may add to the state of hypercoagulability in the later stage of pregnancy.[7]

Reports suggest tetanus prophylaxis, causes no known risk to mother or fetus.[1],[7]

Effect of drugs on fetus and lactating mother

Category B drugs can be safely used in pregnant patients. These include acetaminophen, amoxicillin azithromycin, cephalexin, chlorhexidine (topical), clindamycin, erythromycin, penicillin, terconazole (topical), lidocaine (with or without epinephrine), and prilocaine.[8]

There is no significant association between using nonsteroidal anti-inflammatory drugs (NSAIDs) during pregnancy and an increased risk of teratogenicity, low birth weight, and premature birth, but there is an increased risk of miscarriage due to the inhibitory action of NSAIDS on prostaglandin synthesis which is required for the integrity of the embryo on the endometrium. In the third trimester, they are known to cause prolongation of pregnancy and premature closure of ductus arteriosus.

Studies have shown that acetaminophen has no effect on the fetus.[8],[9],[10],[11]

The current thinking is that antenatal corticosteroid administration reduces neonatal morbidity in preterm infants. The American College of Obstetricians and Gynecologists Committee on Obstetric Practice supports a single course of corticosteroids to those pregnant patients between 24 and 34 weeks of gestation who are at risk to preterm delivery within 7 days.[10]

Precautions to be taken when dealing with pregnant patient

All the females with childbearing age have to be suspected for conception when arrived to the emergency department.

Pneumatic antishock garment is not advisable in second and third trimester of pregnancy.[12]

Detailed history should be obtained to rule out domestic violence. Proven cases should be informed to the regulatory bodies.

Primary survey

Mother will take the precedence over the fetusABCDE Protocol must be followedOxygen supplementation to improve the fetoplacental oxygen supplyVigorous volume resuscitation for normotensive patients as well.[13]

Secondary survey

Head-to-toe examination has to be performed to diagnose any internal bleed. There are 6 conditions which alarm potentially dangerous situation which are as follows:[1]

Vaginal bleedingRuptured membranesBulging perineumPresence and patterns of contractionsAbnormal fetal heart rate and rhythmKleihauer–Betke test.[1]

After 25 weeks of pregnancy, if cesarean delivery is done within 5 min of maternal death, there is high chance of survival of fetus.

Radiographic examination

Imaging should not be withheld for the radiation hazard because utility of mother intern leads to fetal benefits. The minimum dosage required to cause teratogenicity during this phase is 100 mGy (milligray).[12] Hence, routine radiographs should be taken to diagnose the facial fracture with proper shielding to the abdomen.

Estimated fetal exposure

Radiation risk is negligible with the dose of 5 rads. Head computed tomography scan poses fetal exposure of <0.0504. More than 100 studies are required for a cumulative 5 rad dose. Gynecological consultation should be obtained before the management of the facial injuries. One has to be suspicious about the development of pregnancy-induced hypertension, occasionally with systolic blood pressure of 160 mmHg and diastolic blood pressure of 110 mmHg, which must be taken into account when treating a pregnant woman with traumatic injuries.[13]

Points concerned to oral and maxillofacial surgery

Suspect the patient for domestic violence, if so refer the patientIf airway is compromised due to facial fractures, intubation should be doneAdequate volume resuscitationPreliminary management for the facial fractures with wiring should be doneConsideration to be given for the management of injury to mother and fetus as wellElective procedures can be postponed until delivery. If internal fixation is mandatory, then use local anesthesia, whenever appropriate. General anesthesia should be considered only if the fractures are life-threatening to the patientClass B drugs can be prescribed to prevent infection and pain.

Weiner et al. described that minor trauma during pregnancy associated with satisfactory maternal and fetal outcome, hospitalization, and observation may not be warranted.[14]

Although the present case describes minor injury to the mother, it was appropriate decision to perform fixation of the fracture to return the patient back to normal function. There is general opinion as to avoid radiographic evaluation during pregnancy. However, facial radiographs carry subminimal dosage to cause teratogenic effects. Orthopantomogram confirmed the presence of fracture in the present case. This case could have been managed conservatively by advising the patient to consume only soft diet for 3 months. The open reduction and internal fixation will aid the mother to provide good nutrition which is important for the developing fetus. Hence, it was decided for open reduction and internal fixation under local anesthesia. Use of local anesthesia with adrenaline is advocated in the second trimester and it avoids the side effects of general anesthesia.

Future meta-analysis would be required to know the effectiveness of conservative management to internal fixation in pregnant women.

 Conclusion



Management of maxillofacial injury in a pregnant woman is challenging to the surgeon. The treatment has to be categorized based on the severity while considering the two living bodies. It is wise to postpone the management of facial trauma if not life threatening or perform procedures with minimal stress under local anesthesia (in the second trimester). Oral hygiene should be maintained at all times to prevent infection.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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