Parturitional Brain Injury Definition of parturitional injury Thierry A.G.M. Huisman, MD • Any condition that affects the fetus adversely Director Pediatric Radiology and Pediatric Neuroradiology Johns Hopkins Hospital during labor and delivery • May be caused by: – Hypoxia and infection (birth injury) – Mechanical forces (birth trauma) Definition of parturitional injury Introduction • Life starts with a mechanical trauma – Squeezed together by a muscular wrapping • Any condition that affects the fetus adversely – Pushed through a narrow, bony canal with multiple bumps during labor and delivery – Getting your neck extended, rotated and pulled – Life line (umbilical cord) may be compressed – Possibly additional “medieval” instrumentation • May be caused by: – All of this for many minutes or even hours – Hypoxia and infection (birth injury) – Mechanical forces (birth trauma) Introduction Introduction • Life starts with a mechanical trauma • Life starts with a “stress” trauma – Or even worse, within minutes you are squeezed – And than suddenly lots of light, noise and many and “ejected” crying/emotional people around you,…. 1 Subjects who try to relive the „Scientific approach” “I am stuck feeling” Tortuguero expedition. www.philsheldon.wordpress.com Guettler FV, et al. Magnetic resonance imaging of the active second stage of labour: Proof of principle Eur Radiol 2012;22:2020-2026 Epidemiology Epidemiology • Significant variability across the world • Dramatically decreased in last decades • Birth trauma in 3% of all live births • Accounts for less than 2% of neonatal deaths • Even when the injuries are benign, birth trauma may result in significant anxiety for a family Disability adjusted life year (DALY): Measure of overall disease burden expressed as number of years lost due to ill-health, disability or early death Reichard R. Birth injury of the cranium and CNS. Brain Pathology 2008;18:565-570 Risk factors for Birth Trauma Kinds of mechanical injury • Mechanical injury to • Maternal risk factors • Infant risk factors – The brain and skull – Diabetes – Macrosomia (>3500g) – The spinal cord – Obesity – Delayed and prolonged – The head and neck region – Small pelvis delivery • Skin lacerations and hematomas – Large weight gain – Abnormal presentation • Clavicular fracture – Induction of labor – Instrumented delivery • Brachial plexus injury – Epidural analgesia – Perinatal depression • Facial nerve injury – Primiparity – Shoulder dystocia • Phrenic nerve injury – History of macrosomic • Laryngeal nerve injury infant • Nasal injury Adapted from: Parker LA, et al. early recognistion and treatment of birth trauma: Injuries to the head and face. Advances in neonatal care, 2005;6:288-297 www.birthinjury.org 2 Incidence of types of birth trauma Extracranial injuries Extracranial • Scalp abrasions and hematomas lacerations – Frequent – Vaginal and instrumental delivery (10%) – Scalp, face, cheek, ear – Rarely of clinical significance www.newborns.stanford.edu Hughes CA, et al. Birth trauma in the head and neck. Arch Otolaryngol Head neck Surg 1999;125:193-199 Extracranial injuries Extracranial injuries • Caput succedaneum • Clinical presentation usually allows to • Subgaleal hematoma differentiate the various swellings • Cephalohematoma • Difference is the location, composition and CS SH CH etiology of the fluid collection Bumps may look very similar, clinical significance is however very different!!! Serous-Sanguineous fluid Serous-Sanguineous fluid www.newborns.stanford.edu Caput succedaneum Caput succedaneum • Serous-sanguinous fluid collection within the scalp • Present at delivery, decreases spontaneously within 24- between skin and galea or epicranial aponeurosis 48h • Results from high pressure exerted on infant‟s head • Soft swelling, irregular margins, petechiae, purpura during labor and/or ecchymosis, pitting edema • Presenting portion of the scalp, usually the vertex • Fluid shifts from side to side with head position • Crosses sutures, often crosses the midline www.newborns.stanford.edu 3 Caput succedaneum Caput succedaneum • 20-40% of vacuum extractions ~> +10d artificial caput also known as “chignon” • Difficult, prolonged deliveries, PROM (no amniotic fluid to cushion), primigravidas • May also be seen intrauterine: Oligohydramnios, Braxton-Hicks contractions Primigravida, diabetic mother, shoulder dystocia • No treatment, imaging used to exclude other extracranial hematomas Subgaleal hematoma Subgaleal hematoma • Serous-Sanguinous fluid collection between • Results from tearing of emissary veins galea aponeurosis and periosteum (connects dural sinuses with scalp veins) • May be mistaken for caput succedaneum • Most often after vacuum assisted delivery because swelling (also) crosses sutures • May also occur spontaneously, or due to skull • Not always clinically apparent immediately post fractures or rupture of synchondrosis partum, but develops/enlarges over hours-days Person sent on a special mission Subgaleal hematoma Subgaleal hematoma • Potentially life threatening condition • Bleeding disorders can result in large hematomas and • Subgaleal space extends from the orbital ridges to the delayed presentations nuchal ridge, ears and connects into the neck along the – Vitamin K deficiency superficial neck fascia (260 ml, term infants) – Thrombocytopenia – No tamponading characteristics – Hemophilia – Blood volume term neonate: 85 mL/kg – DIC, consumption coagulopathy ~> Hypovolemic shock and death may occur • Neonate may develop hyperbilirubinemia • Usually resolution in 2-3 weeks, good long term outcome • Occasionally blood transfusion, blood products or surgical evacuation www.medutah.edu 4 Subgaleal hematoma Cephalohematoma • Sanguinous fluid collection between periosteum and bony calvarium • Usually not present at birth (unless long labor), develops within 24h • Firm, tense mass, does not cross sutures Hyperdense, crossing sutures, extending into the neck region Cephalohematoma Cephalohematoma Ellipsoid, contained blood collection, limited to the bounderies of the sutures Bilateral, contained by the sutures, some additional subgaleal fluid Cephalohematoma Cephalohematoma • Result from shear forces during birth that tear • Hemorrhage slowly lifts periosteum from calvarium emissary and diploic veins resulting in • Tamponade by periosteum hemorrhage in the subperiostal space • Most frequently in parietal location, R:L=2:1 (?) • May be unilateral or bilateral • May cross midline in occipital region • Co-existing CS or SH may obscure suture boundaries www.newborns.stanford.edu 5 Cephalohematoma Cephalohematoma • More common in primigravidas, macrosomia, instrument assisted delivery, prolonged/difficult • Prognosis is excellent, usually resolves labor and deviant position spontaneously within weeks-months, unless,… • May also be present in utero • Complications – Oligohydramnios – Underlying skull fracture (5-18%) – Premature rupture of membranes – Anemia • Twice as often in boys than in girls (?) – Hyperbilirubinemia • Overlying skin is not discolored – Infection • Mass cannot be transilluminated or shifted Often linear fracture • Painful on palpation www.mediphotos.blogspot.com Cephalohematoma Cephalohematoma • Infection: • Calcification on follow up – If infant has local erythema, unexplained fever or ~> Surgical augmentation of bony sepsis, cephalohematoma may be source of infection prominence or molding helmet (E. Coli and Staph aureus) – Cellulitis, osteomyelitis or meningitis may result – Scalp electrodes, needle aspiration for decompression Chen M-H, et al. MRI features of an infected cephalohematoma in a neonate. Journal of Clinical Neuroscience 2006;13:849-852 Extracranial hematomas Extracranial hematomas • Problem in daily life – Often several hematomas affecting multiple compartments are present simultaneously – Clear differentiation may be limited acute cephalohematoma Acute subgaleal hemorrhage Reichard R. Birth injury of the cranium and CNS. Brain Pathology 2008;18:565-570 Subgaleal hematoma + cephalohematoma + subcuatenous edema 6 Extracranial hematomas Differential diagnosis of bumps Meningocele Spontaneous recovery on follow up Epidermal inclusion cyst Posttraumatic encephalocele Skull fractures Skull fractures • Skull fracture must be suspected if there is an cephalohematoma or intracranial • Linear fractures hemorrhage – Usually asymptomatic, heal • Caused by compression during labor without intervention while skull pushed against maternal – Frequently parietal bone pelvis or due to forceps blades – Cephalohematoma may be associated • Kind of fractures JAMA 1999;135:697-703 – Linear fractures – No relation between size of – Depressed fractures cephalohematoma and – Occipital osteodiastasis presence of fracture – Leptomingeal cysts (rare complication) Skull fractures Skull fractures • Depressed fractures • Depressed fractures – Indentation of skull – Often associated with additional hematomas – Ping pong ball type defect – May obscure the lesion or anatomical boundaries – Surgical intervention may be required Ping pong fracture + subgaleal hematoma + SDH 7 Skull fractures Skull fractures • Leptomeningeal cysts • Occipital osteodiastasis • Occur along fracture lines • Separation of squamous and lateral occipital bone • Meninges are trapped within the fracture line, CSF • Anterior displacement and upward rotation of squamous pulsations widens fracture line ~> growing fracture portion by suboccipital pressure (breech delivery) • Posterior fossa SDH, brainstem/cerebellum injury Reichard R. Birth injury