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

Abstract

A systematic review was performed to compare adverse maternal and neonatal outcomes among pregnant patients with gunshot wounds (GSW) to the abdominopelvic vs other region(s) at > 20 weeks gestation. A search of Medline Ovid, Elsevier Embase, EBSCO CINAHL, and Cochrane Library in July 2022 and reference searches resulted in 1742 studies, which were screened. The 41 included studies reported outcomes for 59 pregnant patients with GSW, of which 31 (52.5%) had an isolated abdominopelvic GSW and 28 (47.5%) had an extremity, thorax, head/neck, back/spine, poly-site, or other/unknown GSW. Stillbirth occurred in 26.7% of abdominopelvic GSW and 26% of non-abdominopelvic GSW. Maternal death occurred in 3.7% of abdominopelvic GSW and 10.7% of non-abdominopelvic GSW. Neonatal death occurred in 9.1% of abdominopelvic GSW and 5.3% of non-abdominopelvic GSW. Further research is needed to standardize the approach for the evaluation and management of patients with GSW in pregnancy.

Keywords

trauma acute care OBGYN gunshot wounds pregnancy

Introduction

While gunshot violence has increased from 10.1 firearm fatalities per 100 000 persons in 2004 to 14.7 per 100 000 in 2021, an increase of 45.5%,¹ the true incidence of gunshot wounds (GSW) in pregnancy is disputed.^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

Approximately 7% of pregnant people have traumatic injuries during pregnancy,⁵¹ and GSW accounts for 4% of these traumatic injuries.³ However, prior systematic reviews have not aggregated data restricted to GSW at or beyond 20 weeks when fetuses approach viability and at which point fetal death is classified as stillbirth.^52,53 Hence, management is often based on empirical data from low-volume studies, some of which may not be relevant to current clinical standards of care.^48,54

The primary objectives of this descriptive systematic review of case reports are to describe the clinical presentations, adverse maternal and neonatal outcomes, and quality of reports of pregnant patients presenting with GSW beyond 20 weeks gestation who survive transport to the hospital among contemporary studies published 1990 onward when stratified by entry site.

Methods

We performed this review based on PRISMA guidelines and registered with PROSPERO (CRD42022324818) before initiation of data extraction. With librarian assistance (T.F.H.), Medline Ovid, Elsevier Embase, EBSCO CINAHL, and Cochrane Library (CENTRAL and CDSR) were searched on July 22, 2022 (see Supplementary Appendix A for search strategy). A total of 1727 database search results were uploaded onto Rayyan, the research collaboration platform, in which publication date and data matching filters were used to assist with deduplication and screening. Reference lists of all identified articles were also hand-searched for inclusion, from which 15 additional articles were uploaded for screening. Keyword searches were performed in PubMed using language from the search strategy to ensure all relevant resulting articles were included in our collection. To minimize the effects of information bias, two authors (F.T.S. and B.J.F.H.) reviewed all titles and abstracts independently. Agreement regarding potential relevance or inconsistencies was reached by consensus or resolved by discussion with a third reviewer (S.P.C.). The same reviewers independently extracted relevant data from full-text copies of applicable articles, compared findings, and likewise resolved inconsistencies by discussion with the third reviewer.

The inclusion criteria were publications that were case reports, case series, and published registries that reported on pregnancies at or after 20 weeks of gestation affected by GSW and their maternal or neonatal outcomes. Exclusion criteria were studies published prior to 1990 (before perimortem cesareans were established as the primary method for maternal resuscitation),⁵⁰ studies lacking data on primary outcomes, studies in which the gestational age or subset of GSW data were not specified, and studies where neither the patient nor fetus survived arrival to the hospital. Co-primary outcomes were maternal and perinatal death (both stillbirth and neonatal death at discharge or within 28 days of life).⁵⁵ Secondary maternal outcomes included rates of blood transfusion, hysterectomy, intensive care unit (ICU) admission and intubation; secondary obstetric outcomes included rates of delivery during GSW hospitalization, latency from sentinel event to delivery, rates of spontaneous labor, labor induction, preterm birth, and delivery modes; neonatal secondary outcomes included 5-minute APGAR <7, Umbilical artery pH, and rates of fetal injury.

Search results were not limited by language. One article written in Farsi³³ was screened by a single coauthor (F.B.), who is a native Farsi-speaker. Two-person independent review and data-extraction was conducted using Google Translator for two articles^14,24 for which native-speakers could not be identified.

Using Microsoft Excel, two-person independent data-extraction occurred with stratification by bullet entry site—either an isolated abdominopelvic injury or an extremity, thorax, head/neck, back/spine, poly-site, or other/unknown injury (collectively referred to as “other” injury). The original intent was to assess outcomes by individual entry site. However, owing to an unanticipated low case detection during the systematic review and data extraction process, co-author consensus was to consolidate cases in abdominopelvic vs other categories, thereby dichotomizing data into meaningful and balanced comparators. The study protocol, data extracted from included studies, data used for all analyses, and any other materials used in the review are available upon request from the authors.

Given the descriptive nature of this systematic review, we used descriptive statistics to report maternal demographics and primary and secondary outcomes. Pooled proportions and mean averages for outcomes of interest were computed and displayed in table format.

Results

Of the 1742 titles and abstracts that were assessed for eligibility, 46 duplicates were detected and removed. Over 1200 articles were then excluded for not directly addressing trauma in pregnancy; an additional 229 were removed due to publication dates preceding the prespecified cut point, 87 lacked primary outcomes data, 26 pertained to non-GSW trauma, 7 address gestational ages less than 20 weeks, and an additional 6 titles had no associated abstract. Thirty-one of the residual 72 articles were removed due to: inability to isolate GSW data (20), lack of survival to hospitalization (5), gestational age not explicitly > 20 weeks (5), and lacking a full-length article (1) available for review. Forty-one articles were thus eligible for inclusion and were incorporated in this systematic review (Figure 1).

All 41 included studies in this review were case reports, case series, and small registries and were thus appraised by one reviewer (FS) based on recommendations to evaluate the methodological quality and risk of bias among uncontrolled clinical observations.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}

Table 1.

Methodological Quality Assessment of Included Studies.

Author (Ref)	Clear Selection Method	Exposure Adequately Ascertained	Outcome Adequately Ascertained	Adequate Follow up Time^a	Replicable and Applicable
Aboutanos⁴	N	Y	Y	Y	Y
Arsh⁵	Y	Y	Y	Y	Y
Awwad⁶	Y	Y	Y	Y	Y
Bansal⁷	N	Y	Y	Y	Y
Carugno⁸	N	Y	Y	Y	Y
Catanese⁹	N	Y	Y	N	Y
Díaz-Gómez¹⁰	N	Y	Y	N	Y
Esposito¹¹	Y	Y	Y	N	Y
Grinstein‐Cohen¹²	N	Y	Y	Y	Y
Gun¹³	N	Y	Y	Y	Y
Gündoğmuş¹⁴	N	Y	Y	Y	Y
Gungor¹⁵	N	Y	Y	Y	Y
Harold¹⁶	Y	Y	Y	Y	Y
Hashim¹⁷	N	Y	Y	Y	Y
Hutchison¹⁸	N	Y	Y	Y	Y
Karacan¹⁹	N	Y	Y	Y	Y
Kocamer²⁰	N	Y	Y	Y	Y
Kuczkowski²¹	N	Y	Y	N	Y
Ladd²²	N	Y	Y	N	Y
Lanoix²³	N	Y	Y	Y	Y
Lebeau²⁴	N	Y	Y	Y	Y
Mangham²⁵	N	Y	Y	Y	Y
McClain²⁶	N	Y	Y	N	Y
Mohamed²⁷	N	Y	Y	Y	Y
Molina²⁸	N	Y	Y	Y	Y
Muzumdar²⁹	N	Y	Y	Y	Y
Osnaya-Moreno³⁰	N	Y	Y	Y	Y
Overstreet³¹	N	Y	Y	Y	Y
Ozdemır³²	N	Y	Y	Y	Y
Panjaki³³	N	Y	Y	Y	Y
Pasley³⁴	N	Y	Y	Y	Y
Pham³⁵	N	Y	Y	Y	Y
Plotkin³⁶	N	Y	Y	Y	Y
Popov³⁷	N	Y	Y	N	Y
Raza³⁸	N	Y	Y	Y	Y
Ruhrnschopf³⁹	N	Y	Y	Y	Y
Sakadamis⁴⁰	N	Y	Y	Y	Y
Sela⁴¹	Y	Y	Y	Y	Y
Uyanıkoğlu⁴²	N	Y	Y	Y	Y
Wall⁴³	Y	Y	Y	Y	Y
Ward⁴⁴	N	Y	Y	Y	Y
Totals	6	41	41	34	41

Y, Yes; N, No.

^aIn studies with maternal and/or neonatal survival, patient(s) were explicitly followed till or beyond discharge.

In the GRADE⁵⁷ 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.) may have impacted the outcomes presented. Consequently, we have low confidence that the studies included in this review are representative of all maternal and perinatal outcomes of GSW in pregnancy.

Using the Cochrane Handbook’s framework for assessing the risk of bias due to missing results,⁵⁸ we identified two studies²⁷^,⁴⁰ where perinatal death was not reported and four studies^17,26,34,35 where maternal death was not reported. We performed abstract and presentation searches related to the titles and authors of these studies but could not obtain the relevant missing data. Given at least one primary outcome was reported in each of these six studies, these were determined to be unlikely to contribute to bias due to missing results and remained included in our review.

The studies in this review included 59 pregnancies complicated by GSW. Sixteen (16) of the 41 publications come from the United States, which accounts for 27% of published cases worldwide (Table 2).^{4,9-11,16,18,21-23,25,26,31,34-36,38} There were no cases of twins or higher order pregnancies. The mean maternal age of GSW patients was 26.7 years (25.1 years, abdominopelvic; 28.1 years, other), mean gestational age at which GSW occurred was 31 weeks 1 day (33 weeks 0 days, abdominopelvic; 29 wk 1 d, other) (Table 3). Owing to a paucity of data, maternal comorbidities remain unknown. Injury Severity Score (ISS) and Glascow Coma Scale (GCS) scores were only included in 3/59 and 6/59 cases, respectively.

Table 2.

General Characteristics of Studies and Cohorts.

Author	Study Location	Published in (year)	Study Period	Total GSW (N = 59)	Abdomen/Pelvis (N = 31)	Other^a (N = 28)
Aboutanos⁴	USA	2005	NR	1	0	1
Arsh⁵	Pakistan	2017	2013-2015	1	0	1
Awwad⁶	Lebanon	1994	1975-1991	14	10	4
Bansal⁷	India	2015	NR	1	1	0
Carugno⁸	Venezuela	2008	NR	1	1	0
Catanese⁹	USA	2002	NR	1	0	1
Díaz-Gómez¹⁰	USA	2011	NR	1	0	1
Esposito¹¹	USA	1991	1980-1989	1	0	1
Grinstein‐Cohen¹²	Israel	2012	2010	1	0	1
Gun¹³	Turkey	2011	NR	1	1	0
Gündoğmuş¹⁴	Turkey	2013	NR	1	0	1
Gungor¹⁵	Turkey	2006	NR	1	1	0
Harold¹⁶	USA	2019	NR	1	0	1
Hashim¹⁷	Pakistan	2017	NR	1	1	0
Hutchison¹⁸	USA	2018	NR	1	0	1
Karacan¹⁹	Turkey	2013	NR	1	0	1
Kocamer²⁰	Turkey	2014	NR	1	1	0
Kuczkowski²¹	USA	2003	NR	1	1	0
Ladd²²	USA	2017	NR	1	1	0
Lanoix²³	USA	1995	NR	1	0	1
Lebeau²⁴	Ivory Coast	2010	2005	1	0	1^b
Mangham²⁵	USA	2021	NR	1	0	1
McClain²⁶	USA	2019	NR	1	1	0
Mohamed²⁷	Somalia	2020	NR	1	1	0
Molina²⁸	Ecuador	2019	NR	1	1	0
Muzumdar²⁹	Canada	2006	NR	1	1	0
Osnaya-Moreno³⁰	Mexico	2013	NR	1	1	0
Overstreet³¹	USA	2002	NR	1	0	1
Ozdemır³²	Turkey	2021	NR	1	0	1
Panjaki³³	Iran	2018	2016	1	0	1
Pasley³⁴	USA	2012	1995	1	1	0
Pham³⁵	USA	2018	NR	1	1	0
Plotkin³⁶	USA	1994	NR	1	0	1
Popov³⁷	South Africa	2003	NR	1	0	1
Raza³⁸	USA	2022	NR	1	1	0
Ruhrnschopf³⁹	Argentina	2021	NR	1	1	0
Sakadamis⁴⁰	Greece	2003	NR	1	0	1
Sela⁴¹	Israel	2008	2001-2003	5	1	4
Uyanıkoğlu⁴²	Turkey	2016	NR	1	1	0
Wall⁴³	South Africa	2014	2006-2012	2	1	1
Ward⁴⁴	South Africa	1998	NR	1	1	0
Totals	-	-	-	59	31	28

GSW, Gunshot Wound(s); NR, Not Reported.

^aExtremities, Thorax, Head/Neck, Back/Spine, Poly-site, Other/Unknown.

^bLebeau²⁴ reported a maternal GSW with buttock entry resulting in abdominopelvic trauma.

Table 3.

Maternal Demographics.

Maternal Demographics	All GSW (59)	Abdomen/Pelvis (31)	Other^a (28)
Maternal age (years)
NR	23	14	9
<20	7	3	4
20-34	21	12	9
>35	8	2	6
Mean	26.7	25.1	28.1
Gravidity (n)
NR	40	25	15
1	10	3	7
n2+	9	3	6
Mean	2.1	2.7	1.8
Parity (n)
NR	40	25	15
0	10	3	7
1+	9	3	6
Mean	1.0	1.3	0.8
Gestational age (weeks)
NR	2^b	1	1
<37°	42	18	24
>37°	15	12^c	3
Mean	31 wk 1 d	33 wk 0 d	29 wk 1 d
GCS (on arrival) (n)
NR	53	30	23
3-8	2	0	2
8-12	0	0	0
12-15	4	1	3
Mean	11.5	15	10.8
ISS (on arrival) (n)
NR	56	30	26
<9	1	0	1
9-14	0	0	0
15-24	2	1	1
25+	0	0	0
Mean	12.3	16	10.5
Admission sBP (mmHg)
NR	36	23	13
<90	8	2	6
>90	15	6	9
Mean among < 90	70	65	71
Mean, total	100	100	100
LOS (days)
NR	39	23	16
Mean average	13.3	8.3	16.6

GSW, Gunshot Wound(s); NR, Not Reported; GCS, Glasgow Coma Scale; ISS, Injury Severity Score; sBP, Systolic Blood Pressure; LOS, Length of Stay.

^aExtremities, Thorax, Head/Neck, Back/Spine, Poly-site, Other/Unknown.

^bTwo articles^11,27 reported the patient’s gestational age as “third trimester.”

^cOne article²⁹ reported the patient as “full-term,” which has been recorded in our data as 39 weeks.

Of the data assessed, the primary outcomes stillbirth, neonatal death, and maternal death were included in 57, 41, and 55 cases, respectively (Table 4). The pooled proportion of stillbirth occurred in 15/57 cases (8/30, 26.7% abdominopelvic; 7/27, 26.0% other), and neonatal death occurred in 3/41 cases (2/22, 9.1% abdominopelvic; 1/19, 5.3% other). Maternal death occurred in 4/55 cases (1/27, 3.7% abdominopelvic; 3/28, 10.7% other), and all four cases were associated with neonatal survival (Supplemental Table 1).

Table 4.

Pooled Proportions of Primary Outcomes.

	All GSW (59)	Abdomen/Pelvis (31)	Other^a (28)
Stillbirth at >20 weeks (n)	15	8	7
NR	2	1	1
n/reported^b	15/57	8/30	7/27
%	26.3%	26.7%	26.0%
Neonatal death (n)	3	2	1
NR	3	1	2
n/reported^c	3/41	2/22	1/19
%	7.3%	9.1%	5.3%
Maternal death (n)	4	1	3
NR	4	4	0
n/reported^b	4/55	1/27	3/28
%	7.3%	3.7%	10.7%

GSW, Gunshot Wound(s); NR, Not Reported.

^aExtremities, Thorax, Head/Neck, Back/Spine, Poly-site, Other/Unknown.

^bReported = total – NR.

^cReported = total – Stillbirth (n) – Neonatal death NR.

Noteworthy maternal adverse outcomes included three cases of blood transfusion among patients with abdominopelvic entry sites, 66% (2/3) of which required > 4 units of blood compared with 5/10 (50%) requiring > 4 units among other GSW entry sites; on average, 4.3 and 7.0 units of blood were used to transfuse abdominopelvic vs other patients, respectively. Among seven cases that commented on hysterectomy, none occurred in the abdominopelvic group (0/4), and 1 occurred in the other group (1/3) (Table 5).

Table 5.

Maternal Adverse Outcomes.

Maternal Outcomes	All GSW (59)	Abdomen/Pelvis (31)	Other^a (28)
Transfusion (u pRBC)
NR	46	28	18
0	3	0	3
1 - 4	3	1	2
> 4	7	2	5
Mean average	6.4	4.3	7.0
Hysterectomy (n)
NR	52	27	25
No	6	4	2
Yes	1	0	1
Rate	1/7	0/4	1/3
%	14.3%	0%	33.3%
ICU Admission^b (n)
NR	48	28	20
No	3	2	1
Yes	8	1	7
Rate	8/11	1/3	7/8
%	73%	33%	88%
Intubation (n, %)
NR	44	28	16
No	4	2	2
Yes	2	1	1
Rate	2/6	1/3	1/3
%	33%	33%	33%

GSW, Gunshot Wound(s); NR, Not Reported; u pRBC, units packed red blood cells; ICU, intensive care unit.

^aExtremities, Thorax, Head/Neck, Back/Spine, Poly-site, Other/Unknown.

^bWhile we have reported maternal ICU admission in our study, we recognize ICU admission criteria is non-standardized and varies widely across hospital systems and geographic regions. Thus, we do not believe ICU admission is a meaningful metric to inform guidelines on managing GSW in pregnancy.

Hospital course was described in 11 cases (1/3, 33% of the abdominopelvic group admitted to the ICU; compared with 7/8, 88% of the other group). Intubation occurred in 1/3 of each group. On average, 83% of patients underwent delivery on hospital trauma admission (29/31, 93.5% abdominopelvic, 20/28, 71.4% other). The interval from insult to delivery exceeded 1 day in 1/18 (5.6%) abdominopelvic patients compared with 10/22 (45.5%) in the other group; when excluding fetal death and cases delivered on arrival, the mean average latency among patients remaining pregnant the day after sustaining GSW was 112 days for abdominopelvic patients and 63 days for other patients. Only one case of spontaneous labor was reported across both groups, occurring in a patient who was shot in the abdomen and pelvis, but delivered vaginally prior to arrival. Vaginal delivery was achieved in 13/41 patients (6/30, 20% of abdominopelvic; 7/27, 25.9% of other). While there were three perimortem cesareans reported in the other group, none were reported among the abdominopelvic group. There were no cases of operative vaginal delivery in either group. The most common indication for cesarean delivery among the abdominopelvic group was traumatic uterine rupture (6/16, 37.5%) (Supplemental Table 3), whereas nonreassuring fetal heart tracings were the most commonly referenced indication for delivery among the other group (7/14, 50%).

Preterm birth at < 37 weeks occurred in approximately 60% of both groups (13/22, 59.1% abdominopelvic; 11/19, 57.9% other). The mean gestational age at delivery of GSW patients was 33 weeks 1 day (33 weeks 4 days, abdominopelvic; 32 weeks 3 days, other). The mean average birth weight was 2299 g (2312 g abdominopelvic; 2272g other; 42.9% of both groups were born with low birth weights <2500 g).⁵⁹ A 5 min APGAR <7 occurred in 2/6 (33.3%) of isolated abdominopelvic entry site patients, and in 2/7 (28.6%) of patients with other entry site patterns (Table 6). None of the 59 reported cases published umbilical artery pH. Fetal injury (which for the purposes of this study was defined as any breech of the fetal skin barrier by the penetrating projectile) occurred in 20/27 (74.1%) abdominopelvic patients and 7/22 (31.8%) other patients. Fetal death occurred in 7/26 cases of fetal injury (Supplemental Table 4).

Table 6.

Neonatal Adverse Outcomes.

Neonatal Outcomes	All GSW (59)	Abdomen/Pelvis (31)	Other^a (28)
Gestational age at delivery (wk, d)
NR	3	1	2
Mean average	33 wk 1 d	33 wk 4 d	32 wk 3 d
Birth weight (grams)
NR or stillbirth	38	17	21
<2500 g	9	6	3
>2500 g	12	8	4
Mean average	2299	2312	2272
APGAR <7 at 5 min (n)
NR	44	23	21
<7	6	4	2
>7	9	4	5
Cord arterial pH (n)
NR	59	31	28
Fetal injury (n)
NR	10	4	6
No	22	7	15
Yes	27	20^c	7
Rate	27/49	20/27	7/22
%	55.1%	74.1%	31.8%

GSW, Gunshot Wound(s); wk, weeks; d, days; NR, Not Reported; APGAR, Appearance Pulse Grimace Activity Respirations.

^aExtremities, Thorax, Head/Neck, Back/Spine, Poly-site, Other/Unknown.

^bAverage birth weight is not calculated owing to non-standardized reporting (mean with standard deviation vs median with interquartile range).

^cTwo articles report fetal trauma to be “superficial”^6,8.

Discussion

This systematic review of GSW in pregnancy at or beyond 20 weeks gestation includes 59 contemporary cases stratified by abdominopelvic vs other entry sites. As gun violence increases globally,⁶⁰ data aggregation conducted in this review was intended to help obstetricians and surgeons better understand published patterns in management and reported maternal and neonatal outcomes when pregnancies approach or surpass viability.

Regarding the primary outcomes, while stillbirth occurred in approximately one quarter of cases regardless of entry point, neonatal death occurred more frequently and maternal death less frequently among published cases of isolated abdominopelvic entry sites than other entry sites. Although this may seem counterintuitive, it has been hypothesized that gestations extending into the abdominal cavity shield otherwise susceptible organs and large vascular structures critical to the preservation of maternal life.⁶¹ Regarding secondary outcomes, key elements of initial assessment, resuscitation, and management of these patients—including injury severity scores, quantities and rates of blood product utilization, fluid resuscitation, rates of intubation, and ICU admission—were infrequently reported.

Delivery at hospitalization was not universal in either grouping. However, it is noteworthy that over a quarter of cases in the “other” cohort were not delivered at trauma hospitalization (Table 7). While physicians should continue to employ their best clinical judgment in such cases, pregnancies that do not warrant immediate delivery may be associated with lengthy latency periods. Ultimately, vaginal delivery occurred in approximately 25% and 40% of abdominopelvic vs other entry sites, respectively. This may indicate that vaginal delivery should be pursued on a case-by-case basis pending evolving clinical status.

Table 7.

Obstetric Adverse Outcomes.

Obstetric Outcomes	All GSW (59)	Abdomen/Pelvis (31)	Other^a (28)
Total delivered this hospitalization (n)
NR	0	0	0
No	10	2	8
Yes	49	29	20
Rate	49/59	29/31	20/28
%	83.1	93.5%	71.4%
Latency: Admission to delivery (days)
NR	19	13	6
0 days	29	17	12
>1 day(s)	11	1	10
Average days (if not delivered on arrival)	67	112	63
Spontaneous labor on admission (n)
NR	4	3	1
No	54	27	27
Yes	1	1^b	0
Rate	1/55	1/28	0/27
%	1.8%	3.6%	0%
Labor induction (n)
NR	22	17	5
No	36	14	22
Yes	1	0	1
Rate	1/37	0/14	1/23
%	2.7%	0%	4.3%
Delivery (n)
NR	2	1	1
Normal vaginal	13	6	7
Operative vaginal	0	0	0
Perimortem CD	3	0	3
Non-perimortem CD	41	24	17
CD indications (n)
NR	15	9	6
NRFHT	10	3	7
Labor indications^c	0	0	0
Abruption	5	1	4
Repeat	0	0	0
Tr Ut Rupture^d	6	6	0
Other^e	9	6	3
Preterm birth < 37 wk (n, %)
NR	3	1	2
No	17	9	8
Yes	24	13	11
Rate	24/41	13/22	11/19
%	58.5%	59.1%	57.9%

GSW, Gunshot Wound(s); NR, Not Reported; NRFHT, Non-reassuring fetal heart tones; Tr Ut, Traumatic Uterine; CD, Cesarean Delivery.

^aExtremities, Thorax, Head/Neck, Back/Spine, Poly-site, Other/Unknown.

^bOne article²⁹ reports a patient who delivered spontaneously prior to delivery.

^cLabor indications include failed induction of labor, first and second stage arrest of labor.

^dFive articles^6,7,38,41,44 report the indication for cesarean delivery to be traumatic uterine rupture secondary to the gunshot wound(s).

^eFour 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.

We acknowledge several limitations. The nature of trauma precludes intervention trial data for obvious ethical reasons; as such, systematically assessing existing data on maternal and neonatal outcomes of GSW in pregnancy is limited to retrospective case reports and case series. These studies are fraught with many confounding variables including heterogeneity in outcomes metrics published (eg, sparse data on ISS, GCS, maternal vital signs, and other baseline characteristics such as comorbidity profiles). Unfortunately, we found that larger databases and registries either have not parsed GSW data from other forms of penetrating trauma^62-67 or have inextricably bundled gestational ages.^68-70

In the absence of large registries whose data fit predefined inclusion and exclusion criteria, remaining available data effectively resulted in systematically reviewing individual cases. By nature, these cases may not plausibly represent the same underlying source population and have an inherent risk of selection bias, which we acknowledge is a major limitation of this review. Admittedly, pooled portions outcomes are disproportionately weighted by a small number of studies. Such small denominators preclude generalizability of maternal and perinatal outcomes, hence our intentional decision to omit meta-analysis and refrain from comparisons between groups. The descriptive data we have presented should thus be interpreted with caution.

Another limitation is that data paucity restricted our ability to parse these findings into further meaningful comparison groups. For example, within the “other” cohort were patients with poly-site injury, which included patients with abdominal trauma who also sustained GSW elsewhere on their body (eg, extremity, thorax, head/neck, back/spine, and other/unknown). A further limitation of this study was that patients whose entry site was unknown were incorporated into the “other” cohort, which might mask inappropriate cross-over. We acknowledge that GSW outcomes may be skewed based on the wounding potential of the projectile, determined by the impact energy, target distance, missile design, tissue density and elasticity, and missile behavior within tissue.⁷¹

We recognize that regional and geographic differences in health care management may impact outcomes; our inability to account for these confounding differences remains a major limitation of this study. We have presented a table of the United Nations’ most recent income classifications⁷² of the included study locations, which are widely variable (Supplemental Table 4). Stratifying outcomes by country of origin within the context of gross domestic product (GDP) or other socio-economic factors is beyond the scope of this review. Such stratification may encourage undue biases that upper-middle, lower-middle, and low-income countries have lesser resources or worse outcomes than high income countries. Cuba serves to counter this bias; despite meeting the United Nations’ criteria of a developing, upper-middle income country,⁷² Cuba’s health indicators—including obstetric and neonatal outcomes—rival (and often outperform) those of high-income countries such as the United States and Canada.⁷³ Policy prioritization and resource allocation may play a role in Cuba’s better outcomes, as explored by Bragg and colleagues.

There are numerous strengths of our systematic review, which is the first to systematically assess GSW outcomes at these gestational age cutoffs. One strength of our analysis is that by recruiting multilingual coauthors and utilizing new open-access translation technologies, study inclusion was not restricted to English language, as evidenced by the incorporations of articles published in four unique languages (English, Farsi, French, and Turkish). Another strength of this systematic review is that gestational age thresholds were set to mimic clinically relevant windows wherein the decision for delivery might be impacted. Lastly, by excluding articles published prior to 1990, we avoid cases whose outcomes preceded modern technology (ICU) and resuscitative standards; however, this strength is at the cost of eliminating potential cases in an already low-volume field.

One additional objective of this systematic review was to begin dialogue on how to standardize the evaluation and management of pregnant patients with GSW. Little data exists to guide prevailing heuristics. The scientific ability to understand and predict an array of possible clinical outcomes for both mothers and their offspring, potentially altering management strategies employed, would be greatly enhanced from uniform data reporting at publication, and larger databases that display GSW separate from other forms of penetrating trauma.

To promote uniform data gathering, we have proposed a table of metrics that we encourage researchers and clinicians to incorporate in future works and databases published on GSW in pregnancy (Supplemental Table 5). Wherever possible, we recommend publishing raw data for each metric so the data may be parsed and analyzed as definitions for maternal and neonatal classifications evolve. Furthermore, publishing raw data (ie, maternal age by years and gestational age by week) would allow for valuable stratification of the population of interest and may better guide management strategies. These metrics, while not reported in every study in this review, account for practice variability across geographic regions and would enable researchers to develop robust guidelines for the evaluation and management of GSW in pregnancy.

In conclusion, notwithstanding significant limitations, our systematic review of case reports of pregnant patients with GSW beyond 20 weeks gestation provides data for counseling and policy making. With the increasing prevalence of gun violence in the United States, there is a continued need for data aggregation to guide clinicians in the acute care of the maternal-fetal dyad after traumatic firearm injuries.

Supplemental Material

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

Supplemental Material for A prospective randomised comparative study of dynamic, static progressive and serial static proximal interphalangeal joint extension orthoses by Fatema T. Shipchandler, Erin S. Huntley, Travis F. Holder, Talha Ali, Faranak Behnia, Suneet P. Chauhan, and Benjamin J. F. Huntley in The American Surgeon

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Travis F. Holder

Supplemental Material

Supplemental material for this article is available online.

References

Rees

Monuteaux

Steidley

, et al. Trends and disparities in firearm fatalities in the United States, 1990-2021. JAMA Netw Open. 2022;5(11):e2244221. doi:10.1001/jamanetworkopen.2022.44221

Gramlich

. What the data says about gun deaths in the U.S. Pew Research Center. https://www.pewresearch.org/fact-tank/2022/02/03/what-the-data-says-about-gun-deaths-in-the-u-s/. Accessed February 19, 2023.

Petrone

Talving

Browder

Teixeira

Fisher

Lozornio

Chan

. Abdominal injuries in pregnancy: A 155-month study at two level 1 trauma centers. Injury. 2011;42(1):47-49. doi:10.1016/j.injury.2010.06.026

Aboutanos

Malhotra

Duane

Ivatury

. Management of a pregnant patient with an open abdomen. J Trauma. 2005;59(5):1052-1056. doi:10.1097/01.ta.0000188648.81279.a8

Arsh

Darain

Ilyas

Zeb

. Consequences of traumatic spinal cord injury during pregnancy in Pakistan. Spinal Cord Ser Cases. 2017;3:17041. doi:10.1038/scsandc.2017.41

Awwad

Azar

Seoud

Mroueh

Karam

. High-velocity penetrating wounds of the gravid uterus: Review of 16 years of civil war. Obstet Gynecol. 1994;83(2):259-264.

Bansal

Kumar

Rao

. Intrauterine fetal death in gunshot injury to the gravid uterus: Forensic perspective. J Clin Diagn Res. 2015;9(8):HD01-HD02. doi:10.7860/JCDR/2015/13967.6333

Carugno

Rodriguez

Brito

Cabrera

. Gunshot wound to the gravid uterus with non-lethal fetal injury. J Emerg Med. 2008;35(1):43-45. doi:10.1016/j.jemermed.2007.06.042

Catanese

Gilmore

. Fetal gunshot wound characteristics. J Forensic Sci. 2002;47(5):1067-1069.

10.

Díaz-Gómez

Seigel

Schmidt

Pino

Bittner

. Acute hypopituitarism in a pregnant patient after cardiac gunshot injury. J Clin Anesth. 2011;23(5):414-417. doi:10.1016/j.jclinane.2010.09.009

11.

Esposito

Gens

Smith

Scorpio

Buchman

. Trauma during pregnancy: A review of 79 cases. Arch Surg. 1991;126:1073-1078.

12.

Grinstein-Cohen

Sarid

. A case report of gunshot terror attack in pregnancy: Implications for forensic nursing. J Forensic Nurs. 2012;8(3):138-143. doi:10.1111/j.1939-3938.2012.01140.x

13.

Gun

Erginel

Günendi

Celik

. Gunshot wound of the fetus. Pediatr Surg Int. 2011;27(12):1367-1369. doi:10.1007/s00383-011-2915-3

14.

Gündoğmuş

Akkaya

Karbeyaz

Keskin

. Residual pellet in fetal brain tissue following a gunshot injury to a pregnant woman: A case report. TJTES. 2013;19(4):371-374. doi:10.5505/tjtes.2013.89656

15.

Gungor

Sen

Uzunlar

Danisman

. Gunshot wound in pregnancy. Saudi Med J. 2006;27(7):1069-1070.

16.

Harold

Isaacson

Palatnik

. Femoral fracture in pregnancy: A case series and review of clinical management. Int J Womens Health. 2019;11:267-271. doi:10.2147/IJWH.S198345

17.

Hashim

Talat

. A Rare fetal firearm injury. J Coll Physicians Surg Pak. 2017;27(3):S36-S37.

18.

Hutchison

Uitvlugt

Crumb

DeCou

. Shot in the womb. J Pediatr Surg Case Rep. 2018;35:4-6. doi:10.1016/j.epsc.2018.04.016

19.

Karacan

Ilhan

Karacaoglu

Kocer

Usta

. (2013). Abdominal gunshot wound to pregnant woman at 22 weeks of gestation: A case report. BAUN Health Sci J. 2013;2(2):114-117. doi:10.5505/bsbd.2013.59144

20.

Kocamer

Gökçe

Aksoy

Deniz

İK

. Abdominal gunshot wound in pregnant woman: A case report. Perinatal J. 2014;22(2):110-113. doi:10.2399/prn.14.0222006

21.

Kuczkowski

Ispirescu

Benumof

. Trauma in pregnancy: Anesthetic management of the parturient with multiple gun shot wounds to the gravid uterus and fetal injury. J Trauma. 2003;54(2):420. doi:10.1097/01.TA.0000048092.06301.E7

22.

Ladd

Shaw

Munoz-Blanco

, et al. A case of a gunshot wound to the fetus in utero. J Trauma Acute Care Surg. 2017;82(4):814-816. doi:10.1097/TA.0000000000001391

23.

Lanoix

Akkapeddi

Goldfeder

. Perimortem cesarean section: Case reports and recommendations. Acad Emerg Med. 1995;2(12):1063-1067. doi:10.1111/j.1553-2712.1995.tb03151.x

24.

Lebeau

Diané

Kassi

, et al. [Gunshot wound to gravid uterus: a case report]. Mali Med. 2010;25(2):48-49.

25.

Mangham

Gordon

Einhaus

. Intracranial gunshot wounds in utero: Case report and review. Childs Nerv Syst. 2021;37(12):3973-3976. doi:10.1007/s00381-021-05124-9

26.

McClain

Mir

Kapadia

Murphy

Diesen

. In utero gunshot wound to the left upper extremity in a preterm infant. Am Surg. 2019;85(6):282-283. doi:10.1177/000313481908500604

27.

Mohamed

Eraslan

Ali

Mohamed

. Successfully managed grade IV renal injury and retained bullet in third-trimester pregnant woman. Urol Case Rep. 2020;29:101082.

28.

Molina

Aguayo

Cevallos

, et al. Prenatal gunshot wound, a rare cause of maternal and fetus trauma, a case report. Int J Surg Case Rep. 2019;59:201-204. doi:10.1016/j.ijscr.2019.05.034

29.

Muzumdar

Higgins

Ventureyra

. Intrauterine penetrating direct fetal head trauma following gunshot injury: a case report and review of the literature. Childs Nerv Syst. 2006;22(4):398-402. doi:10.1007/s00381-005-1200-y

30.

Osnaya-Moreno

Zaragoza Salas

Escoto Gomez

Mondragon Chimal

Torres Castaneda

MDL

Jimenez Flores

. Gunshot wound to the pregnant uterus: Case report. Rev Bras Ginecol Obstet. 2013;35(9):427-431. doi:10.1590/s0100-72032013000900008

31.

Overstreet

Mannino

Benirschke

. The role of placental pathology in the evaluation of interpersonal violence: a case of abdominal gunshot wound in a 27-week gravid uterus. J Perinatol. 2002;22(8):675-678. doi:10.1038/sj.jp.7210814

32.

Ozdemır

Atalay

. Transmediastinal gunshot wound in a pregnant patient with stable hemodynamics. Rev Bras Ginecol Obstet. 2021;43(2):145-147. doi:10.1055/s-0040-1715142

33.

Panjaki

Haghighi

Bujani

Zanan

MHM

Iran

. High risk pregnancy (report of a shotgun case). Iran. J. Obstet. Gynecol. Infertil. 2018;21(9):118-123. doi:10.22038/ijogi.2018.12143

34.

Pasley

Demetriades

. Penetrating fetal trauma with late complications: a case report. J Pediatr Surg. 2012;47(9):E9-E11. doi:10.1016/j.jpedsurg.2012.04.004

35.

Pham

VanWoudenberg

Chandrasekar

. Fetal gunshot brain injury leading to late postnatal hydrocephalus. J Neonatal Perinatal Med. 2018;11(4):427-431. doi:10.3233/NPM-17138

36.

Plotkin

Shah

Lofland

DeWolf

. Extracorporeal membrane oxygenation in the successful treatment of traumatic adult respiratory distress syndrome: Case report and review. J Trauma. 1994;37(1):127-130. doi:10.1097/00005373-199407000-00023

37.

Popov

Ngambu

Mantel

Rout

Moodley

. Acute spinal cord injury in pregnancy: An illustrative case and literature review. J Obstet Gynaecol. 2003;23(6):596-598. doi:10.1080/01443610310001604321

38.

Raza

Tyler

Najjar

. Resuscitative endovascular balloon occlusion of the aorta in the management of a gunshot wound and rupture of the uterus. Am Surg. 2022;88(4):784-786. doi:10.1177/00031348211054061

39.

Ruhrnschopf

Reusmann

Boglione

Arbio

Barrenechea

. Neonatal minimal invasive management of a prenatal gunshot trauma: case report. Ann Pediatr Surg. 2021;17(1):5-6. doi:10.1186/s43159-021-00075-x

40.

Sakadamis

Ballas

Rafailidis

Alatsakis

Sounidakis

Grolios

. Penetrating liver trauma in pregnancy. Eur. J. Trauma. 2003;29(5):324-326. doi:10.1007/s00068-003-1305-5

41.

Sela

Shveiky

Laufer

Hersch

Einav

. Pregnant women injured in terror-related multiple casualty incidents: injuries and outcomes. J Trauma. 2008;64(3):727-732. doi:10.1097/TA.0b013e3180340e0a

42.

Uyanıkoğlu

Hilali

Gengeç

Camuzcuoğlu

. Abruptio placenta caused by gunshot injury in second trimester: A case report. J. Clin. Anal. Med. 2016;7:139-141.

43.

Wall

Figueiredo

Laing

Clarke

. The spectrum and outcome of pregnant trauma patients in a metropolitan trauma service in South Africa. Injury. 2014;45(8):1220-1223. doi:10.1016/j.injury.2014.04.045

44.

Ward

van Deurzen

van Dongen

. Gunshot uterine rupture: A case report. Eur J Obstet Gynecol Reprod Biol. 1998;80(2):279-281. doi:10.1016/s0301-2115(98)00121-3

45.

Buchsbaum

Caruso

. Gunshot wound of the pregnant uterus. Case report of fetal injury, deglutition of missile, and survival. Obstet Gynecol. 1969;33(5):673-676.

46.

Geggie

. Gunshot wound of the pregnant uterus with survival of the fetus. Can Med Assoc J. 1961;84(9):489-491.

47.

Beattie

Daly

. Gunshot wound of the pregnant uterus. Am J Obstet Gynecol. 1960;80:772-774. doi:10.1016/0002-9378(60)90589-5

48.

Iliya

Hajj

Buchsbaum

. Gunshot wounds of the pregnant uterus: Report of two cases. J Trauma. 1980;20(1):90-92. doi:10.1097/00005373-198020010-00017

49.

Buchsbaum

Staples

Jr . Self-inflicted gunshot wound to the pregnant uterus: Report of two cases. Obstet Gynecol. 1985;65(3 Suppl):32S-35S.

50.

Emergency Cardiac Care Committee and Subcommittees, American Heart Association. JAMA. 1992;268(16):2171. doi:10.1001/jama.1992.03490160041023

51.

Huls

Detlefs

. Trauma in pregnancy. Semin Perinatol. 2018;42(1):13-20. doi:10.1053/j.semperi.2017.11.004

52.

Mendez-Figueroa

Dahlke

Vrees

Rouse

. Trauma in pregnancy: An updated systematic review. Am J Obstet Gynecol. 2013;209(1):1-10. doi:10.1016/j.ajog.2013.01.021

53.

Petrone

Jiménez-Morillas

Axelrad

Marini

. Traumatic injuries to the pregnant patient: A critical literature review. Eur J Trauma Emerg Surg. 2019;45(3):383-392. doi:10.1007/s00068-017-0839-x

54.

Browns

Bhat

Jonasson

Vidyasagar

. Thoracoabdominal gunshot wound with survival of a 36-week fetus. JAMA. 1977;237(22):2409-2410. doi:10.1001/jama.1977.03270490049027

55.

Barfield

Committee on fetus and newborn . Standard terminology for fetal, infant, and perinatal deaths. Pediatrics. 2016;137(5):e20160551. doi:10.1542/peds.2016-0551

56.

Murad

Sultan

Haffar

Bazerbachi

. Methodological quality and synthesis of case series and case reports. BMJ Evid Based Med. 2018;23(2):60-63. doi:10.1136/bmjebm-2017-110853

57.

Page

Higgins

JPT

Sterne

JAC

. Chapter 13: Assessing risk of bias due to missing results in a synthesis. In: Higgins

JPT

Thomas

Chandler

Cumpston

Page

Welch

(editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.3, 2022. www.training.cochrane.org/handbook

58.

Schünemann

Higgins

JPT

Vist

Glasziou

Akl

Skoetz

Guyatt

. Chapter 14: Completing ‘Summary of findings’ tables and grading the certainty of the evidence. In: Higgins

JPT

Thomas

Chandler

Cumpston

Page

Welch

(editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.3, 2022. www.training.cochrane.org/handbook

59.

World Health Organization . Low birth weight. 2023. https://www.who.int/data/nutrition/nlis/info/low-birth-weight

60.

McEvoy

Hideg

. Global Violent Deaths 2017: Time to Decide; 2017. https://www.smallarmssurvey.org/resource/global-violent-deaths-2017-time-decide. Accessed May 3, 2023.

61.

Brown

Small

. Chapter 32: Trauma and related surgery in pregnancy. In: Landon

Berghella

Galan

Grobman

Jauniaux

Kilpatrick

Driscoll

Cahill

, eds. Gabbe's obstetrics: normal and problem pregnancies. 8th ed. Elsevier; 2021:604.

62.

Aniuliene

Proseviciūte

Aniulis

Pamerneckas

. [Trauma in pregnancy: complications, outcomes, and treatment]. Medicina (Kaunas). 2006;42(7):586-591.

63.

Battaloglu

McDonnell

Chu

Lecky

Porter

. Epidemiology and outcomes of pregnancy and obstetric complications in trauma in the United Kingdom. Injury. 2016;47(1):184-187. doi:10.1016/j.injury.2015.08.026

64.

Mulder

Quiroz

Yang

, et al. The unborn fetus: The unrecognized victim of trauma during pregnancy. J Pediatr Surg. 2020;55(5):938-943. doi:10.1016/j.jpedsurg.2020.01.047

65.

Schuster

Becker

Young

Paglia

Mackeen

. Trauma in pregnancy: A review of the Pennsylvania Trauma Systems Foundation database. Trauma. 2018;20(1):30-37. doi:10.1177/1460408617703677

66.

Siddiqi

Guiab

Roberts

, et al. Maternal outcomes after trauma in pregnancy: A national database study. Am Surg. 2022;88(8):1760-1765. doi:10.1177/00031348221083940

67.

Zangene

Ebrahimi

Najafi

. Trauma in pregnancy and its consequences in Kermanshah, Iran from 2007 to 2010. Glob J Health Sci. 2014;7(2):304-309. doi:10.5539/gjhs.v7n2p304

68.

Brookfield

Gonzalez-Quintero

Davis

Schulman

. Maternal death in the emergency department from trauma. Arch Gynecol Obstet. 2013;288(3):507-512. doi:10.1007/s00404-013-2772-5

69.

Wallace

. Trends in pregnancy-associated homicide, United States, 2020. Am J Public Health. 2022;112(9):1333-1336. doi:10.2105/AJPH.2022.306937

70.

Weiss

Songer

Fabio

. Fetal deaths related to maternal injury. JAMA. 2001;286(15):1863-1868. doi:10.1001/jama.286.15.1863

71.

Gugala

Lindsey

. Classification of gunshot injuries in civilians. Clin Orthop Relat Res. 2003;408(408):65-81. doi:10.1097/00003086-200303000-00007

72.

United Nations . World Economic Situation and Prospects. 2023. https://www.un.org/development/desa/dpad/publication/world-economic-situation-and-prospects-2023/https://www.un.org/development/desa/dpad/publication/world-economic-situation-and-prospects-2023/

73.

Bragg

R Salke

Cotton

Jones

. No child or mother left behind; implications for the us from cuba's maternity homes. Health Promot Perspect. 2012;2(1):9-19. doi:10.5681/hpp.2012.002

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