Incision Decision: Vertical or Horizontal Laparotomy in Traumatically Injured Pregnant Patients

Background Trauma is the leading cause of non-obstetric mortality in pregnant patients. While guidelines exist for the overall management of pregnant trauma patients, there is currently no consensus regarding the optimal laparotomy incision type in those requiring urgent operative intervention. Objective The purpose of this study is to compare the presentation, operative management, and outcomes between pregnant trauma patients who underwent a vertical versus a horizontal laparotomy incision for urgent operative intervention. Study design A retrospective cohort review was conducted at an American College of Surgeons-verified Level I trauma center from 2016 to 2022, including all pregnant trauma patients. For those requiring urgent operative interventions, outcomes were compared between patients who had a vertical versus a horizontal laparotomy incision. Results A total of 147 pregnant trauma patients were identified. Of those, 30 (20.4%) required urgent operative intervention and met inclusion criteria, with 11 (36.7%) patients in the midline laparotomy cohort and 19 (63.3%) in the horizontal incision cohort. Patients were similar in age, presenting heart rate, presenting GCS, Injury Severity Score (ISS), and hospital length of stay. Patients who ultimately required a midline laparotomy were more likely to be hypotensive on presentation (systolic blood pressure (SBP) of 86 vs. 120 mmHg, p = 0.005) and were more likely to be operatively co-managed by both trauma and obstetrics. Time from incision to delivery was similar for both vertical and horizontal incisions. Mortality in the vertical incision group was three (27.3%) patients versus zero (0.0%) in the horizontal incision group (p = 0.041). Conclusion This single-institution cohort is the first descriptive evaluation of laparotomy incision type in operative obstetric trauma. In the absence of signs of concomitant intra-abdominal maternal injury, a horizontal incision can be considered for select pregnant trauma patients with non-reassuring fetal heart patterns. Conversely, patients with severe maternal polytrauma or hypotension should be considered for a vertical incision. Together, these findings support current practice patterns.