Trauma during pregnancy is a major global public health challenge and remains one of the leading non-obstetric causes of maternal and fetal morbidity and mortality. Although most pregnancies progress without significant complications, traumatic injuries may abruptly compromise maternal health, placental function, and fetal survival. Current evidence suggests that approximately 6–8% of pregnancies are affected by traumatic events, with outcomes ranging from minor maternal injuries to severe maternal complications, fetal distress, preterm birth, placental abruption, and fetal loss. The burden is particularly high in low- and middle-income countries, where delayed access to emergency care, inadequate trauma systems, and limited obstetric resources contribute to poorer maternal and neonatal outcomes. [1–3].

The epidemiology of trauma during pregnancy varies according to geographic location and socioeconomic conditions. Road traffic accidents, falls, interpersonal violence, occupational injuries, and domestic violence are consistently reported as the most common mechanisms of injury worldwide. In developing countries, poor road infrastructure, inadequate enforcement of traffic regulations, limited use of protective restraints, and underreporting of gender-based violence further increase the risk of pregnancy-related trauma. Beyond physical injury, trauma also imposes substantial psychological, social, and economic consequences for affected women and their families. [2,4]

Pregnancy is characterized by profound physiological and anatomical adaptations that influence the presentation and management of traumatic injuries. Maternal blood volume, cardiac output, respiratory function, coagulation pathways, and immune responses undergo significant changes to support fetal development. These physiological adaptations may initially mask signs of hypovolemia or shock despite substantial blood loss, delaying diagnosis and definitive treatment. Similarly, displacement of abdominal organs by the enlarging uterus alters injury patterns and increases susceptibility to uteroplacental injury, particularly during the second and third trimesters. Consequently, understanding pregnancy-specific physiological responses is essential for accurate clinical assessment and timely intervention. [1,5].

Traumatic injuries during pregnancy may lead to a wide spectrum of maternal and fetal complications depending on the severity, mechanism, and timing of injury. Maternal complications include hemorrhage, uterine rupture, placental abruption, premature rupture of membranes, emergency cesarean delivery, intensive care admission, and maternal death. Fetal consequences include fetal distress, intrauterine growth restriction, preterm birth, low birth weight, hypoxic brain injury, stillbirth, and neonatal death. Recent studies have emphasized that even apparently minor trauma may adversely affect pregnancy outcomes because of occult placental injury or delayed obstetric complications, highlighting the importance of continuous maternal and fetal monitoring following traumatic events. [3,6–8].

From a forensic perspective, trauma during pregnancy extends beyond clinical management and frequently requires meticulous medico-legal documentation. Accurate documentation of injury patterns, mechanisms of trauma, timing of presentation, photographic evidence where appropriate, and correlation between maternal injuries and fetal outcomes are essential for legal investigations, especially in cases involving assault, intimate partner violence, or suspected criminal acts. Comprehensive forensic evaluation not only facilitates judicial proceedings but also contributes to surveillance of violence against women and informs preventive public health policies. Increasing recognition of domestic violence as an important contributor to pregnancy-related trauma further underscores the need for collaboration between emergency physicians, obstetricians, forensic specialists, and law-enforcement agencies. [4,7].

Study Design and Setting A hospital-based analytical cross-sectional study was conducted over a six-month period from January 2025 to June 2025 at a tertiary care teaching hospital in Lahore, Punjab, Pakistan. The hospital serves as a major referral center for obstetric, gynecological, emergency, trauma, and forensic services, catering to patients from Lahore and neighboring districts. The study was designed and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies. Study Population The study population comprised pregnant women who presented with traumatic injuries to the Emergency Department, Department of Obstetrics and Gynecology, or Trauma Unit during the study period. Women diagnosed with trauma at any gestational age and admitted for evaluation or management were considered eligible for inclusion. Eligibility Criteria Inclusion Criteria • Pregnant women aged 18 years or older. • Pregnancy confirmed clinically and/or by ultrasonography. • History of traumatic injury occurring during pregnancy, irrespective of the mechanism of injury. • Patients willing to provide written informed consent or consent obtained from their legally authorized representative when clinically indicated. Exclusion Criteria • Women with trauma occurring before conception. • Patients with incomplete medical records preventing assessment of primary study variables. • Women with pre-existing fetal congenital anomalies diagnosed before the traumatic event. • Patients referred after definitive management at another healthcare facility with insufficient clinical documentation. • Women declining participation in the study. Sample Size and Sampling Technique The required sample size was calculated using the WHO sample size formula for cross-sectional studies: n = Z²P(1 − P)/d² where Z = 1.96 at the 95% confidence level, P represents the anticipated prevalence of trauma during pregnancy based on published literature, and d = 5% denotes the desired margin of error. Consecutive non-probability sampling was employed, and all eligible pregnant women presenting during the study period were recruited until the required sample size was achieved. Data Collection Procedure Data were collected prospectively using a predesigned and pilot-tested structured data collection proforma developed after an extensive literature review. Information was obtained through direct patient interviews, physical examination, hospital medical records, obstetric charts, laboratory reports, radiological findings, and medico-legal documentation where applicable. Study Variables Independent Variables The independent variables included maternal age, residence, educational status, occupation, socioeconomic status, parity, gravidity, gestational age, antenatal care status, previous obstetric history, mechanism of trauma (road traffic accident, fall, assault, domestic violence, occupational injury, or other causes), type of trauma (blunt or penetrating), anatomical site of injury, injury severity, time elapsed before hospital presentation, and associated medical comorbidities. Physiological Variables Physiological assessment included maternal pulse rate, systolic and diastolic blood pressure, respiratory rate, body temperature, oxygen saturation, Glasgow Coma Scale score, hemoglobin concentration, fetal heart rate, and ultrasonographic fetal well-being at presentation. Forensic Variables Forensic evaluation included the nature and mechanism of injury, injury location, external and internal injury patterns, presence of abrasions, contusions, lacerations, fractures, documentation of suspected interpersonal or domestic violence, medico-legal case registration status, photographic documentation where indicated, and forensic specialist opinion. Infectious Complications Infectious outcomes included wound infection, urinary tract infection, postoperative infection, sepsis, chorioamnionitis, and other clinically confirmed infections diagnosed during hospitalization. Maternal Outcomes Maternal outcomes included placental abruption, antepartum hemorrhage, premature rupture of membranes, preterm labor, emergency cesarean section, blood transfusion, intensive care unit admission, duration of hospital stay, maternal morbidity, and maternal mortality. Fetal and Neonatal Outcomes Fetal outcomes included fetal distress, miscarriage, intrauterine fetal demise, stillbirth, preterm birth, low birth weight, neonatal intensive care unit admission, neonatal complications, and neonatal mortality. Data Quality Assurance The study questionnaire was reviewed by experts in obstetrics, forensic medicine, emergency medicine, and public health to ensure content validity. A pilot study was conducted on approximately 10% of the estimated sample size at a healthcare facility not included in the final study. Necessary modifications were made before commencement of data collection. Data collectors received standardized training regarding study procedures, while completed questionnaires were checked daily for completeness and consistency. Statistical Analysis Data were entered, cleaned, and analyzed using IBM Statistical Package for the Social Sciences (SPSS) version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were assessed for normality using the Shapiro–Wilk test and summarized as mean ± standard deviation or median with interquartile range, as appropriate. Categorical variables were expressed as frequencies and percentages. Associations between categorical variables were evaluated using the Chi-square test or Fisher's exact test, whereas continuous variables were compared using the Independent Samples t-test or the Mann–Whitney U test, depending on data distribution. Variables demonstrating statistical significance in univariate analysis were entered into a multivariable logistic regression model to identify independent predictors of adverse maternal and fetal outcomes. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were calculated. A two-sided p-value <0.05 was considered statistically significant. Ethical Considerations Ethical approval was obtained from the Institutional Review Board (IRB) of the participating institution before the commencement of the study. Written informed consent was obtained from all participants prior to data collection. Participant confidentiality and anonymity were maintained throughout the study, and all collected information was used solely for research purposes. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki.

During the six-month study period from January 2025 to June 2025, a total of 185 pregnant women presenting with traumatic injuries were enrolled in the study. All participants completed the clinical, physiological, and forensic evaluations, and their maternal-fetal outcomes were successfully recorded.

Sociodemographic and Baseline Obstetric Characteristics

The mean maternal age of the study population was 26.8 ± 5.2 years (range: 18–42 years). The majority of participants (62.2%, n = 115) resided in urban areas, and more than half (54.1%, n = 100) belonged to low-socioeconomic households.

Regarding gestational age at the time of trauma:

• First trimester (<14 weeks): 18.4% (n = 34)
• Second trimester (14–27 weeks): 38.9% (n = 72)
• Third trimester (≥28 weeks): 42.7% (n = 79).

A total of 33.5% (n = 62) of patients had irregular or no antenatal care (ANC) visits prior to the traumatic event.

Mechanisms, Types, and Timing of Trauma

The leading mechanisms of trauma were:

• Falls: 39.5% (n = 73)
• Road Traffic Accidents (RTAs): 34.1% (n = 63)
• Interpersonal / Domestic Violence: 18.9% (n = 35)
• Occupational and Accidental Injuries: 7.5% (n = 14).

Blunt trauma was the predominant injury type (91.4%, n = 169), whereas penetrating trauma was observed in 8.6% (n = 16) of cases.

The lower abdomen and pelvis were the most common anatomical sites of trauma (52.4%, n = 97), followed by extremities (28.1%, n = 52) and head/neck (12.4%, n = 23).

Notably, 29.2% (n = 54) of patients presented to the hospital after a delay of more than 6 hours post-injury.

Physiological Parameters and Infectious Complications

Upon presentation, abnormal physiological findings were frequent:

• Tachycardia (heart rate > 100 bpm): 41.6% (n = 77)
• Hypotension (systolic BP < 90 mmHg): 17.3% (n = 32)
• Anemia (hemoglobin < 11.0 g/dL): 56.2% (n = 104)
• Abnormal fetal heart rate (FHR) patterns: 23.2% (n = 43).

Infectious complications during hospitalization occurred in 14.6% (n = 27) of patients. The most common were:

• Urinary tract infections: 7.6% (n = 14)
• Wound infections: 4.9% (n = 9)
• Clinical chorioamnionitis: 2.2% (n = 4).

Forensic Evaluation Findings

Forensic examination revealed cutaneous and soft tissue injuries in 78.4% (n = 145) of women:

• Contusions / Bruising: 44.3% (n = 82)
• Abrasions: 31.9% (n = 59)
• Lacerations: 14.1% (n = 26)
• Skeletal Fractures: 11.4% (n = 21).

Formal Medico-Legal Cases (MLC) were officially registered for 31.9% (n = 59) of trauma presentations, with the highest proportion of MLC registrations seen in cases of interpersonal violence (85.7% of violence cases).

Maternal and Fetal Outcomes

Overall, adverse maternal outcomes were observed in 36.2% (n = 67) of patients, while adverse fetal/neonatal outcomes occurred in 41.6% (n = 77).

Maternal complications included:

• Preterm labor: 22.2% (n = 41)
• Emergency cesarean section: 27.6% (n = 51)
• Antepartum hemorrhage (APH): 15.1% (n = 28)
• Placental abruption: 9.2% (n = 17)
• ICU admission: 6.5% (n = 12)
• Blood transfusion required: 21.1% (n = 39)
• Maternal mortality: 0.5% (n = 1, due to severe hemorrhagic shock following uterine rupture).

Fetal and neonatal complications included

• Low birth weight (<2.5 kg): 28.1% (n = 52)
• Preterm delivery (<37 weeks): 24.3% (n = 45)
• Fetal distress: 21.1% (n = 39)
• NICU admission: 16.8% (n = 31)
• Intrauterine fetal demise (IUFD) / Stillbirth: 7.6% (n = 14)
• Miscarriage (<24 weeks): 3.2% (n = 6).

Risk Factors and Multivariable Analysis

In the multivariable logistic regression model, independent risk factors significantly associated with adverse maternal-fetal outcomes included:

• Delayed Hospital Presentation (>6 hours): Adjusted Odds Ratio (AOR) = 3.42, 95% CI: 1.65–7.08, p = 0.001
• Third Trimester Trauma: AOR = 2.85, 95% CI: 1.38–5.89, p = 0.004
• Maternal Hypotension at Admission (SBP < 90 mmHg): AOR = 4.12, 95% CI: 1.72–9.86, p = 0.001
• Placental Abruption: AOR = 6.78, 95% CI: 2.14–21.48, p = 0.001
• Interpersonal / Domestic Violence: Crude OR = 2.41 (1.12–5.18), Adjusted AOR = 1.98 (0.86–4.55), p = 0.10.

Trauma during pregnancy is a critical clinical and public health challenge in developing nations. The present study provided a comprehensive evaluation of the risk factors, physiological alterations, forensic findings, and maternal–fetal outcomes among pregnant women presenting with traumatic injuries at a tertiary care center in Lahore, Pakistan. Primary Mechanisms and Demographics of Injury In our study, falls (39.5%) and road traffic accidents (34.1%) were identified as the primary causes of trauma during pregnancy, followed by interpersonal and domestic violence (18.9%). These findings align with existing literature from other low- and middle-income countries (LMICs), where poor urban infrastructure, lack of safety precautions, and unorganized traffic rules contribute to high rates of vehicular and accidental trauma. Domestic violence, though reported in nearly 19% of cases, is frequently underreported in traditional societies due to social stigma, fear, and lack of legal support. Physiological Adaptations and Diagnostic Challenges Pregnancy involves significant physiological changes—such as physiological hypervolemia, increased cardiac output, and altered baseline vital signs—that can mask substantial blood loss. In our cohort, 41.6% of women exhibited tachycardia and 17.3% presented with hypotension, while fetal distress was detected in 23.2% at presentation. Maternal physiological compensatory mechanisms often maintain normal blood pressure until nearly 30–35% of blood volume is lost, which can compromise uteroplacental perfusion long before overt maternal shock becomes evident. This highlights the vital importance of continuous fetal monitoring (such as cardiotocography and bedside ultrasound) even in apparently hemodynamically stable patients. Forensic Documentation and Legal Implications Forensic evaluation demonstrated soft tissue injuries (contusions, abrasions, and lacerations) in over three-quarters of the patients. Notably, Medico-Legal Cases (MLCs) were registered in 31.9% of trauma presentations, with the vast majority occurring in cases of interpersonal assault. In Pakistan, the integration of forensic findings with clinical obstetric management is essential for providing evidence in court, supporting survivors of domestic abuse, and establishing clear legal frameworks for assault-related pregnancy complications. Maternal and Fetal Complications Adverse maternal (36.2%) and fetal (41.6%) outcomes were significantly prevalent in this study. Placental abruption (9.2%), antepartum hemorrhage (15.1%), emergency cesarean delivery (27.6%), and intrauterine fetal demise/stillbirth (7.6%) were among the most critical complications observed. The placenta is non-elastic and lacks contractile tissue, making it susceptible to shear forces during blunt abdominal impact, leading to premature separation (abruption) even with minor external trauma. Key Risk Factors for Adverse Outcomes Multivariable logistic regression analysis identified several critical determinants of adverse outcomes: 1. Delayed Presentation (>6 hours): Patients arriving late had a 3.42-fold higher risk of adverse outcomes, largely due to unmanaged occult placental bleeding, missed fetal distress, or delayed surgical interventions. 2. Third Trimester Trauma: Late gestational age (AOR = 2.85) was associated with higher risks, as the enlarged gravid uterus extends beyond the protection of the bony pelvis, rendering it directly exposed to physical impacts. 3. Maternal Hypotension and Placental Abruption: Hemodynamic instability at admission (AOR = 4.12) and placental abruption (AOR = 6.78) were strong independent predictors of severe fetal loss and maternal morbidity.

• Public Awareness & Infrastructure: Implementation of stricter road traffic regulations, seatbelt awareness campaigns tailored for pregnant women, and home-fall prevention strategies.
• Domestic Violence Prevention: Strengthening support systems, routine screening for intimate partner violence during antenatal visits, and establishing confidential reporting pathways.
• Streamlined Emergency Protocol: Establishing standardized triage guidelines in hospital emergency departments to prioritize pregnant trauma patients, reducing unnecessary delays in obstetric and surgical interventions.

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