Trauma is the leading non-obstetric cause of morbidity and mortality during pregnancy [1, 2], with some reports suggesting that between 5 and 20% of pregnant women are exposed to physical trauma [3, 4], most commonly occurring in the third trimester of gestation. Even though blunt trauma is the most frequent mechanism of injury, led by motor vehicle accidents , firearm injuries have the most fatal outcomes and higher fetus mortality rates, with a fetal injury rate between 59 and 80%, and a mortality rate between 30 and 70% [1, 5,6,7].
When a pregnant woman is a victim of a penetrating trauma, a higher risk of severe injury exists for the fetus, given maternal visceral organ injuries only occur in 20% of the cases . This is associated with anatomical changes during pregnancy, especially during the last trimester, when uterus position modifications with growth result in a more vulnerable fetal location.
Even though developments have been made in the management of abdominal gunshot wounds , they still have high morbidity and mortality rates . When treating a pregnant woman with trauma, the best method of treatment for the fetus is based on the appropriate resuscitation of the mother. Maternal mortality is the most common cause of fetal mortality due to trauma [2, 9] and for this reason, maternal well-being should be established first .
Non-operative management is considered the standard of care for blunt injuries and has decreased the rate of unnecessary laparotomy. Despite operative management is still considered the standard of care in penetrating trauma, studies report the tendency to perform an initial non-operative management in some patients with a strict selection criteria . A conservative approach of penetrating injuries in pregnant women is accepted when the entry site is anterior and below the uterine fundus, considering in this case maternal visceral injuries are less likely, if the fetus is previable or dead, maternal evaluation satisfactory and urinalysis negative for blood [3, 4, 10,11,12].
Upon arrival at our institution, the baby presented pneumoperitoneum in the abdominal X-rays. This could be explained by the injury of abdominal hollow viscera, but also it could be secondary to pulmonary barotrauma. Given the good hemodynamic condition of the baby, the soft abdomen, and the study of the bullet trajectory, a non-operative management was chosen. We believe that the patient presented in this case report was clearly benefited from the choice of an expectant approach regarding pneumoperitoneum at our institution, after initial emergency management at the general hospital. Understanding the mechanism of injury in order to identify the possible injuries and adequate management is essential. Molina et al.  report a case of a newborn with prenatal gunshot trauma that was explored by means of an unnecessary thoracotomy guided by the location of the entry wound in the thorax, with no thoracic injuries found. We had a similar patient at our institution in 1996, who had a prenatal gunshot wound with a thoracic entry. Initially, a thoracotomy was performed, with no bullet found in the thoracic cavity. A laparotomy was needed to remove the bullet, given its final position was in the abdomen. Entry wound, trajectory, the final position of the bullet, and pathological findings in images need to be analyzed before taking the patient to the operative room.
The literature regarding the management of the new-born who survived a prenatal gunshot is scarce, and there are only a few other cases similar to ours reported. We believe our experience with this case can be useful to other medical teams faced with the same challenging situation.
A consensus plan of action is necessary with all the team members involved in order to increase the chances of survival.