From Neonatal-Perinatal Medicine -- Diseases of the fetus and infant
1992

On subdurals from birth trauma:


"Subdural hemorrhage has become a very rare neonatal neurological disorder. The two principal locations of subdural hemorrhage are over the cerebral hemispheres and in the posterior fossa. When this type of bleeding has occurred, common historical events include the mother being primiparous with the total labor and delivery occurring in less than 2 to 3 hours, a difficult delivery involving high or midforceps application, or the infant being large for gestational age. In this type of hemorrhage the events of labor simply produce excessive molding of the calvarium with relatively sudden stretching and tearing of the superficial venous channels over the cerebral hemispheres or venous sinuses in the posterior fossa. The clinical presentation depends on the quantity and location of blood.

Subdural hemorrhage over the cerebral hemispheres occurring at the time of birth MAY BE CLINICALLY SILENT, CLINICALLY APPARENT IN THE FIRST FEW DAYS AFTER BIRTH, OR NOT APPARENT UNTIL AS LATE AS THE SIXTH WEEK OF LIFE. When this type of hemorrhage is manifested early, the signs are those of increasing intercranial pressure in the presence of jaundice or anemia. When an infant shows evidence of a convex subdural hematoma as late as the fourth to sixth week, there is usually an increasing head circumference, poor feeding or
vomiting, failure to thrive, altered states of consciousness, and occasionally seizures."

Neonatology-Perinatal Medicine
Diseases of the Fetus and Infant
Edited by
Avory A. Fanaroff, M.B., F.R.C.P. (Edinburgh), D.C.H.
Professor and Vice Chairman, Department of Pediatrics, Case Western
Reserve University School of Medicine, Director of Neonatology,
Rainbow Babies and Childrens Hospital, Cleveland Ohio
Richard J. Martin, M.B., F.R.A.C.P.
Professor of Pediatrics, Department of Pediatrics, Case Western
Reserve University School of Medicine, C0-Director of Neonatology,
Rainbow Babies and Childrens Hospital, Cleveland Ohio
Fifth Edition
Copyright 1992 by Mosby-Year Book, Inc.
 

Evaluation of Infants With Subdural Hematoma Who Lack External Evidence of Abuse
PEDIATRICS Vol. 105 No. 3 March 2000, pp. 549-553
Received Sep 28, 1998; accepted Jun 2, 1999.

Mark W. Morris*, §, Sally Smith*, , §, Joanne Cressman*, and Joey Ancheta From the * Departments of Pediatric Medicine and Pediatric Radiology, All Children's Hospital, St Petersburg, Florida; Department of Pediatrics, University of South Florida, School of Medicine, Tampa, Florida; and § Suncoast Child Protection Team, Pinellas County, Florida.

Objective. Advances in radiologic technique have increased the recognition of subdural hematoma. No study to date has addressed the role of child protective investigation into the cause and management of subdural hematoma in children who lack other indicators of abuse.

Methods. Medical records, radiology studies, and social service notes for all infants and children referred for child abuse investigation who had any form of intracranial hemorrhage were reviewed. The study covered the 12 months of 1997. All referrals were to the Suncoast Child Protection Team (St Petersburg, FL).

Results. There were 19 investigations because of subdural hematoma. Eight children had retinal hemorrhage as well as other major findings of trauma, such as bruises and/or fractures; all 8 were victims of child abuse. Two infants had tiny subdurals adjacent to accidental linear skull fractures. Nine infants were investigated for the possibility of abuse that had no findings of trauma apart from the subdural hematoma. These 9 cases form the basis for this study. The age range was 11 days to 15 months. Inflicted cerebral trauma was the medical diagnosis in 8 of the 9 cases; 1 case had a final diagnosis of possible inflicted injury in a high-risk setting.

Conclusions. Infants with subdural hematoma but no other findings of abuse present a difficult challenge to child protection workers. Investigation by a medically oriented team can uncover the circumstances of the trauma in most instances and can usefully direct protective efforts. The high incidence of severe sequelae in infants with inflicted cerebral trauma warrants a vigorous approach.
 

Surfactant therapy and intracranial hemorrhage: review of the literature and results of new analyses JH Gunkel and PL Banks

Ross Laboratories Division of Abbott Laboratories, Columbus, OH 43215.

BACKGROUND AND OBJECTIVE. Surfactant replacement is a powerful therapy for newborns with respiratory distress syndrome, but limited observations suggest that alterations of cerebral blood flow can accompany the use of several available surfactants. An early European multicenter controlled study with beractant demonstrated an increased rate of intracranial hemorrhage in treated patients. Nine additional controlled studies were subsequently performed and included follow-up evaluations through 2 years adjusted age. This clinical experience provided a database of approximately 1700 infants to examine retrospectively for any relationship between surfactant therapy and intracranial hemorrhage. METHODS. Cumulative incidence rates, hazard ratios, and 95% confidence intervals for intracranial hemorrhage were computed for each study and for appropriately pooled studies of similar design. Where an association between surfactant and the risk of intracranial hemorrhage was found, additional analyses were performed to attempt to identify intermediate physiologic events that might link administration of surfactant to the occurrence of intracranial hemorrhage. These analyses were guided by literature reports of hemodynamic changes observed in association with surfactant therapy. RESULTS. During the controlled studies with beractant, treated newborns of 600 to 750 g birth weight were at higher risk for grades I and II intracranial hemorrhage than control newborns. There was no increased risk for grades III and IV
hemorrhage among these newborns, nor was there increased risk of hemorrhage among any other patient groups. This finding did not result in increased morbidity for the affected patients; at 2 years adjusted age, they were not different from the control infants of 600 to 750 g birth weight. Retrospective examination of the database could not pinpoint the mechanism behind the finding, but it might have been related to changes in cerebral blood flow after surfactant uncompensated by ventilator management of oxygenation and ventilation. CONCLUSIONS. Surfactant therapy may set in motion hemodynamic changes that could predispose to intracranial hemorrhage in certain circumstances, but this can probably be compensated by careful management of oxygenation and ventilation. A relationship between surfactant therapy and intracranial hemorrhage is probably not isolated to any particular surfactant preparation or method of delivery; studies comparing surfactants have shown no differences in rates of intracranial hemorrhage.

Volume 92, Issue 6, pp. 775-786, 12/01/1993
Copyright © 1993 by The American Academy of Pediatrics

 

Because of the increased propensity for intracranial hemorrhage with any type of delivery in neonates with hemophilia, Buchanan has suggested that a prophylactic dose of recombinant factor concentrate be administered empirically to all neonates at risk for severe hemophilia on the basis of family history or excessive bleeding.4 The Medical and Scientific Advisory Committee of the National Hemophilia Foundation has recommended that all newborns with unexplained subgaleal or intracranial hemorrhage be evaluated for a bleeding disorder

My son who has a Factor VIII level of 34-38%(50-150% being normal)and is diagnosed with mild hemophilia was not given any prophylactic concentrate at birth because we were unaware or his disorder. Yet, they claim his SDH at 3 months could not be attributed to either birth or his bleeding disorder.

 
 Dr. Towner replies:
 To the Editor: Another explanation for intracranial hemorrhage in some of the neonates in our study could indeed be the presence of an inherited bleeding disorder. Our study was based on discharge diagnoses reported to the state of California, and there is no way to determine whether any of the infants with intracranial hemorrhage were evaluated for a bleeding disorder. Still, delivery by cesarean section during labor did not change the risk of intracranial hemorrhage. I routinely advise the avoidance of operative vaginal deliveries (especially by vacuum extraction) for fetuses at risk for inherited bleeding disorders or those whose mothers have immune thrombocytopenia, because of the potential for hemorrhage, especially subgaleal hemorrhage.
 
 I agree that all obstetricians should have adequate training in the use of instruments to aid vaginal delivery. Nonetheless, the findings of our study are reassuring in that the incidence of intracranial hemorrhage was not exceedingly high when instruments were used by the average practitioner.
 
 Regarding the role of the type of vacuum cup, the incidence of intracranial hemorrhage with vacuum extraction has decreased from 1 in 286 with the Malmstrom cup, reported in 1979,1 to 1 in 860 with predominantly plastic cups, as reported in our study. Since obstetrical practice has changed in the past 20 to 25 years, the type of vacuum cup may not be an important factor at all. Obstetricians should not be fooled into thinking that the plastic cups are gentler on the fetus and thus not capable of causing injury. The FDA advisory aroused concern about a potential increase in neonatal injuries in association with vacuum extraction. However, in the cases voluntarily reported to the FDA, the plastic vacuum cups were considered to be medical devices. There may have been increased awareness of the reporting of device-related injuries recently, which may explain this apparent increase in neonatal injuries.
 
 
 Dena Towner, M.D.
 University of California Davis Medical Center
 Sacramento, CA 95817
 
 References
 
 
   1.. Plauche WC. Fetal cranial injuries related to delivery with the Malmstrom vacuum extractor. Obstet Gynecol 1979;53:750-757.[Medline]
 


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