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Retained bullet fragments in pregnancy-capable individuals: Implications for surgical and public health practice
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Retained bullet fragments in pregnancy-capable individuals: Implications for surgical and public health practice
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Journal Article
Retained bullet fragments in pregnancy-capable individuals: Implications for surgical and public health practice
2025
Overview
The United States is facing a gun violence public health crisis that disproportionately affects young people and people of color. Since 2001, the rate of nonfatal firearm assaults among women in the United States has more than tripled, and women under the age of 45 experience nonfatal firearm injuries at a rate over three times higher than women over age 45. 2 RBFs are associated with elevated blood lead levels. 3 Retained bullet fragments are of particular concern in pregnant patients because pregnancy is a hypermetabolic state that can mobilize lead into the bloodstream. 4 Lead is toxic for fetal development and can enter fetal circulation through the placenta. 4 Elevated maternal blood lead is associated with numerous abnormalities in fetal development, including physical and cognitive defects. 4 Despite the established correlation between RBFs and elevated lead levels and substantial evidence linking lead and adverse fetal outcomes, little has been done to address RBFs during pregnancy. The American College of Obstetricians and Gynecologists (ACOG) – the leading body in the United States for clinical practice guidelines in women's health – encourages risk-factor-based lead screening, but does not currently list RBFs as a risk factor for lead exposure. 7 The Centers for Disease Control and Prevention guidelines for identifying and managing lead exposure in pregnancy-capable people do identify retained bullets as lead exposure and encourage shared decision-making around potential RBF removal and lead testing. 8 For the management of elevated blood lead levels in pregnancy, ACOG guidelines recommend more frequent measurement of lead levels, removal of the exposure if possible, calcium and iron supplementation, chelation if severe, and possible avoidance of breastfeeding after birth. 7 While surgical removal of RBFs may not be advisable in most cases, surgeons caring for patients immediately after firearm injury should educate patients on the potential impact of RBFs, emphasizing the importance of this lead exposure in future pregnancies and encouraging early establishment of prenatal care.
