Subdural haemorrhage in newborns

ЧУВАШСКИЙ ГОСУНИВЕРСИТЕТ МЕДИЦИНСКИЙ ФАКУЛЬТЕТ
КАФЕДРА АКУШЕРСТВА И ГИНЕКОЛОГИИ


Lancet 2004; 363: 846-51

Frequency and natural history of subdural haemorrhages in babies and relation to obstetric factors

E H Whitby, P D Griffiths, S Rutter, M F Smith, A Sprigg, P Ohadike, N P Davies, A S Rigby, M N Paley

Section of Academic Radiology, University of Sheffield, Sheffield, UK; Department of Radiology, Sheffield Children's Hospital, Sheffield; Department of Cardiology, University of Hull, Kingston-upon-Hull, UK; and Department of Obstetrics and Gynaecology and Regional Neonatal Intensive Care Unit, Jessop wing, Central Sheffield Teaching Hospitals, Sheffield

Correspondence to: Dr Elspeth Whitby, Academic Radiology, MRI Department, Floor C, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK (e-mail:e.whitby@sheffield.ac.uk)

Summary

Background Subdural haematomas are thought to be uncommon in babies born at term. This view is mainly based on findings in symptomatic neonates and babies in whom subdural haemorrhages are detected fortuitously. We aimed to establish the frequency of subdural haemorrhages in asymptomatic term neonates; to study the natural history of such subdural haematomas; and to ascertain which obstetric factors, if any, are associated with presence of subdural haematoma.

Methods We did a prospective study in babies who were born in the Jessop wing of the Central Sheffield University Hospitals between March, 2001, and November, 2002. We scanned neonates with a 0·2 T magnetic resonance machine.

Findings 111 babies underwent MRI in this study. 49 were born by normal vertex delivery without instrumentation, 25 by caesarean section, four with forceps, 13 ventouse, 18 failed ventouse leading to forceps, one failed ventouse leading to caesarean section, and one failed forceps leading to caesarean section. Nine babies had subdural haemorrhages: three were normal vaginal deliveries (risk 6·1%), five were delivered by forceps after an attempted ventouse delivery (27·8%), and one had a traumatic ventouse delivery (7·7%). All babies with subdural haemorrhage were assessed clinically but no intervention was needed. All were rescanned at 4 weeks and haematomas had completely resolved.

Interpretation Presence of unilateral and bilateral subdural haemorrhage is not necessarily indicative of excessive birth trauma.


Spontaneous subdural haemorrhage in newborn babies

Po-Yin Cheung, Laila Obaid, Hasmukh Rajani

Neonatal Intensive Care Unit, Royal Alexandra Hospital, 10240 Kingsway Avenue, Edmonton, Alberta T5H 3V9, Canada (e-mail:poyin@ualberta.ca)

In their study of the frequency and natural history of subdural haemorrhages in term newborn babies, E H Whitby and colleagues (March 13, p 846) [1] conclude that the presence of subdural haemorrhage is not necessarily indicative of excessive birth trauma, and that subdural haemorrhages that completely resolve by age 4 weeks are mostly benign, clinically asymptomatic, and of no long-term importance. Although we agree with their conclusions, one should be alert to possible underlying causes, including coagulation abnormalities, that might contribute to the development of subdural haemorrhage in uneventful perinatal courses.

A term baby girl was born by non-instrumented, vaginal delivery. Her mother (gravida 2, para 1) had an unremarkable pregnancy apart from a previous early miscarriage. The girl's birthweight was 2585 g (3rd percentile), length 49 cm (50th percentile), and head circumference 33 cm (25-50th percentile). The placenta was small but unremarkable otherwise. Striking sutural diastasis (1·7 cm) with full, opened anterior and posterior fontanelles were noted. She was neurologically normal and clinically asymptomatic.

Cranial ultrasonography and subsequent CT scans diagnosed subdural haemorrhage (figure). Preliminary investigations revealed a low haemoglobin concentration (111 g/L), normal platelet counts, normal international normalised ratio, but a slightly long partial thromboplastin time (51 s). Subsequent coagulopathy work-up showed that both the baby girl and her mother were heterozygous for the prothrombin 20210 mutation. Congenital infections were excluded. The subdural haemorrhage resolved completely, and she had normal neurodevelopment at 18 months of age.

Cranial ultrasonography
(top)and subsequent CT examination (bottom) of neonate

 

Ultrasonography shows 6-mm thick subdural collection along left outer cortex associated with mild shifting of midline structures to right and smaller left lateral ventricle. CT shows subdural haemorrhage.

The pathogenic mechanism for intracranial haemorrhage in neonates is complicated, but thrombophilia with coagulation abnormalities including factor V Leiden and prothrombin 20210 mutations are not uncommon in those with haemostatic and thromboembolic complications [2]. Petaja and colleagues [3] suggested intraventricular haemorrhage as one of the disease states triggered by thrombophilic coagulation abnormalities. The G20210A polymorphism in the prothrombin gene is not rare in white populations (1-2%) [4] and has been associated with recurrent miscarriages and lower birthweight in newborn babies of heterozygous mothers [5].

In our case, several factors, including maternal obstetric history, small but unremarkable placenta, low birthweight, and a slightly long partial thromboplastin time raised the possibility of this mutation. The presence of thrombophilic risk factors in this uneventful delivery might have been coincidental or a real predisposition for the development of idiopathic subdural haemorrhage. Nonetheless, our case illustrates the importance of identifying potential causes of subdural haemorrhage in newborn babies. Furthermore, it shows that cranial ultrasonography in experienced hands can be a low-cost, convenient alternative to MRI imaging.

 

1 Whitby EH, Griffiths PD, Rutter S, et al. Frequency and natural history of subdural haemorrhages in babies and relation to obstetric factors. Lancet 2004; 363: 846-51.
2 Aronis S, Bouza H, Pergantou H, Kapsimalis Z, Platokouki H, Xanthou M. Prothrombotic factors in neonates with cerebral thrombosis and intraventricular hemorrhage. Acta Paediatr Suppl 2002; 91: 87-91.
3 Petaja J, Hiltunen L, Fellman V. Increased risk of intraventricular hemorrhage in preterm infants with thrombophilia. Pediatr Res 2001; 49: 643-46.
4 Poort SR, Rosendaal FR, Reitsma PH, Bertina RM. A common genetic variation in the 3?-untranslated region of the prothrombin gene is associated with elevated plasma prothrombin levels and an increase in venous thrombosis. Blood 1996; 88: 3698-703.
5 Grandone E, Margaglione M, Colaizzo D, et al. Lower birth-weight in neonates of mothers carrying factor V G1691A and factor II A(20210) mutations. Haematologica 2002; 87: 177-81.

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