|Year : 2014 | Volume
| Issue : 4 | Page : 478-480
Domestic violence as an unfortunate cause of splenic injury, fetal demise, and maternal morbidity
Shuchi M Jain1, Nilajkumar D Bagde1, Swarnalata Samal2
1 Department of Obstetrics and Gynecology, Mahatma Gandhi Institute of Medical Sciences, Sawangi, Wardha, Maharashtra, India
2 Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Sawangi, Wardha, Maharashtra, India
|Date of Web Publication||25-Jun-2014|
Shuchi M Jain
Department of Obstetrics and Gynecology, MGIMS, Sewagram, Wardha - 442 102, Maharashtra
Source of Support: None, Conflict of Interest: None
Abuse of pregnant women is a serious health problem with the potential to cause life-threatening injuries to the mother and her baby. This is a case of domestic violence leading to splenic injury and massive intraperitoneal hemorrhage leading to fetal demise. Fortunately, timely interventions saved the mother's life.
Keywords: Abdominal trauma, domestic violence, fetal demise, splenic injury
|How to cite this article:|
Jain SM, Bagde ND, Samal S. Domestic violence as an unfortunate cause of splenic injury, fetal demise, and maternal morbidity. Med J DY Patil Univ 2014;7:478-80
|How to cite this URL:|
Jain SM, Bagde ND, Samal S. Domestic violence as an unfortunate cause of splenic injury, fetal demise, and maternal morbidity. Med J DY Patil Univ [serial online] 2014 [cited 2021 Sep 17];7:478-80. Available from: https://www.mjdrdypu.org/text.asp?2014/7/4/478/135274
| Introduction|| |
Abuse of women during pregnancy is a health problem that is receiving attention in both research and clinical practice. It is an important perinatal health indicator associated with adverse maternal and fetal outcomes. The problem is global. Violence has been reported in 12% pregnant patients reporting to trauma services at a university in California.  International studies suggest a 1-25% incidence of physical violence by intimate partners during pregnancy. , A Nicaraguan study reports a 33% physical abuse during pregnancy in married women by their current or former intimate partner. 
Violence may lead to serious complications like placental abruption, preterm labor, fetal growth restriction, uterine rupture, and maternal death. The fetus may sustain direct injury or may be jeopardized indirectly as the perpetrator may prevent the women from seeking healthcare. 
We are reporting an act of domestic violence which not only led to multiple visceral injuries in the mother but also led to fetal demise in a full-term pregnant patient.
| Case Report|| |
A 22-year-old primigravida with 39 weeks gestation presented with history of assault by her husband with an iron rod over the abdomen at 2 p.m. She had one episode of vomiting and acute onset of abdominal pain after that. She also had loss of perception of fetal movements.
On examination, she was pale, pulse was 100/min, and blood pressure was 110/70 mm of Hg. Subconjunctival hemorrhage was present in the right eye. Multiple abrasions were present over neck, face, left lower arm, and right elbow. Abdominal examination revealed tenderness with guarding mainly in the right and left hypogastric regions. Uterus was term size, tense, and tender. Distention with free fluid was present in the abdomen. Fetal heart sound was not localized. Baby size was good. On per vaginal examination, the cervix was one finger loose, 1 cm long, membranes were present, and the pelvis was inadequate for baby size.
Sonography confirmed non-viable intrauterine pregnancy in radiology department, MGIMS, Sevagram; estimated fetal weight was 3100 g, and liver contusion in segment 5, splenic contusion in splenic hilum, and right renal contusion at upper and middle pole with free fluid in abdomen were present. These findings with hemoglobin concentration of 4.3 gm% and platelet count of 60 × 103/mm 3 were consistent with intraabdominal hemorrhage. So, decision of emergency laparotomy was undertaken. Laparotomy revealed a hemoperitoneum of 2½ L with no evidence of fresh bleeding. Lower segment cesarean section was performed and a fresh stillborn baby was extracted. Five hundred milliliters of retroplacental clot was removed. Uterus was sutured in double layer. Blood was trickling from upper part of the abdomen from the splenic site, so the surgeon was consulted. The surgeons then explored the rest of the abdomen. There was a tear in the spleen with a horizontally placed hematoma over the spleen medially, of around 4 × 4 cm in size, with no fresh bleed. An active bleeder was present in the splenic ligament which was caught and ligated. There was a retroperitoneal hematoma that was extending from the posterior border just below the liver up to middle of descending colon on the right side, of about 15 × 8 cm. There was no fresh bleed or extension of the hematoma. The other solid organs were normal. Medical absorbable gelatin sponge was placed over splenic hematoma as there was no fresh bleed. Intraabdominal drain was kept and abdomen was sutured in layers. Intraoperatively, two units of blood were transfused. The patient made an uneventful recovery and was discharged on the tenth day.
| Discussion|| |
The United Nations (UN) General Assembly has defined domestic violence as "any act of gender-based violence that results in, or is likely to result in physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion, or arbitrary deprivation of liberty in public or private life." In India, violence against women has its roots in patriarchal system that has historically viewed women as inherently inferior to men. Reasons for violence are mainly unplanned pregnancies, unwanted or mistimed pregnancy, or women who's husbands or partners are unemployed or manual workers. , An Indian study reported poverty, dowry, dislike by husband, husband having extramarital affairs, not having male child, or pregnancy-associated illness as the reasons for violence. 
In a review of literature, Peterson found that severe blunt trauma to the mother leads to spontaneous abortion, fetal death, placental abruption, preterm labor, and fetal injuries.  Yost et al. reported a greater risk of neonatal death in babies born to women who had experienced physical abuse.
Pregnant women are at risk of multiple sites of injury, especially on the abdomen which may be fatal for both the mother and her baby. In a study by Purwar et al., 20% of women were hit on the abdomen.  Potential adverse outcomes include rupture of uterus, spleen, liver, and diaphragm. Spleen is susceptible to rupture during pregnancy because of physiological enlargement. It requires immediate diagnosis and urgent management. The reported maternal mortality of splenic rupture is 45%, and there is 47-82% risk of fetal death.
All health workers should be suspicious of physical abuse and screen for domestic violence in cases of abdominal trauma. A systematic review to determine the effectiveness of screening for decreasing intimate partner violence concluded that screening instruments designed to screen intimate partner violence are effective in detecting domestic abuse.  However, a study of health professionals reports that 60% physicians did not receive any educational content during their medical schooling to identify spouse abuse.  To prevent abuse to pregnant women, the predictors must be identified and incorporated into routine screening and intervention protocols by physicians, nurses, and others involved in the care of pregnant women. Protocols for referral of abused women to appropriate community resources should be established and followed.
In this case, multiple injuries to vital organ and late presentation could have been fatal for the mother. Residing in an endemic area for malaria, the woman was lucky that her spleen could be managed conservatively. Timely suspicion, investigation, and intervention led to saving the life of the mother, though the baby could not be saved.
Healthcare workers are frequently and unknowingly in contact with abused patients. It is important for the physicians to identify these patients during routine consultations and they have a legal obligation to take appropriate action on suspicion of possible domestic abuse of their patient. There is a need for effective interventions focusing on women's partner. Future research needs to address primary and secondary prevention of violence before and during pregnancy.
| References|| |
|1.||Shah KH, Simons RK, Holbrook T, Fortlage D, Winchell RJ, Hoyt DB. Trauma in pregnancy: Maternal and fetal outcomes. J Trauma 1998;45:83-6. |
|2.||McFarlane J, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy. Severity and frequency of injuries and associated entry into prenatal care. JAMA 1992;267:3176-8. |
|3.||Stewart DE, Cecutti A. Physical abuse in pregnancy. CMAJ 1993;149:1257-63. |
|4.||Amaro H, Fried LE, Cabral H, Zuckerman B. Violence during pregnancy and substance use. Am J Public Health 1990;80:575-9. |
|5.||Gazmararian JA, Adams MM, Saltzman LE, Johnson CH, Bruce FC, Marks JS, et al. The relationship between pregnancy intendedness and physical violence in mothers of newborns. The PRAMS Working Group. Obstet Gynecol 1995;85:1031-8. |
|6.||Chhabra S. Physical violence during pregnancy. J Obstet Gynaecol 2007;27:460-3. |
|7.||Petersen R, Gazmararian JA, Spitz AM, Rowley DL, Goodwin MM, Saltzman LE, et al. Violence and adverse pregnancy outcomes: A review of the literature and directions for further research. Am J Prev Med 1997;13:366-73. |
|8.||Purwar MB, Jeyaseelan L, Varhadpande U, Motghare V, Pimplakute S. Survey of physical abuse during pregnancy. J Obstet Gynecol Res 1999;25:165-71. |
|9.||Nelson HD, Bougatsos C, Blazina I. Screening women for intimate partner violence: A systematic review to update the U.S. Preventive Services Task Force recommendation. Ann Intern Med 2012;156:796-808. |
|10.||Tilden VP, Schmidt TA, Limandri BJ, Chiodo GT, Garland MJ, Loveless PA. Factors that influence clinicians' assessment and management of family violence. Am J Public Health 1994;84:628-33. |