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Birth Trauma

Birth Trauma. Alix Paget-Brown, MD Division of Neonatology, Department of Pediatrics, University of Virginia. Outline. Overview of birth injuries Discussion of specific traumatic birth injuries Cases (with treats). Birth injuries. Incidence 6-8:1000 live births

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Birth Trauma

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  1. Birth Trauma Alix Paget-Brown, MD Division of Neonatology, Department of Pediatrics, University of Virginia

  2. Outline • Overview of birth injuries • Discussion of specific traumatic birth injuries • Cases (with treats)

  3. Birth injuries • Incidence • 6-8:1000 live births • <2% of neonatal deaths/stillbirths • From 1970 – 1985, 88% decrease in mortality resultant from birth trauma (to 7.5:100,000) • Risk factors • Primigravida • Prolonged or precipitous labor • Size discrepancies (LGA, small pelvic outlet…) • Instrumentation • Oligohydramnios

  4. Outline • Epidemiology, diagnosis, prognosis of: • Scalp injuries • Subgaleal hemorrhage • Cephalhematoma • Caput succedaneum • Intracranial hemorrhage • Subdural hemorrhage • Neurologic injuries (NOT hypoxic-ischemic encephalopathy) • Brachial plexus injuries • Spinal cord injuries • Orthopedic injuries • Clavicular fractures • Long bone fractures • Intra-abdominal injuries • Liver/splenic rupture • Adrenal hemorrhage

  5. Outline • Epidemiology, diagnosis, prognosis of: • Scalp injuries • Subgaleal hemorrhage • Cephalhematoma • Caput succedaneum • Intracranial hemorrhage • Subdural hemorrhage • Neurologic injuries (NOT hypoxic-ischemic encephalopathy) • Brachial plexus injuries • Spinal cord injuries • Orthopedic injuries • Clavicular fractures • Long bone fractures • Intra-abdominal injuries • Liver/splenic rupture • Adrenal hemorrhage

  6. Subgaleal Hemorrhage • Incidence/pathology • 1.5:10,000 live births • Neonatal emergency • 90% of subgaleal hematomas have history of vacuum delivery • 40% associated with underlying head trauma (skull fracture/intracranial hemorrhage) • Occurs due to tearing of emissary veins connecting dural sinuses and scalp veins • Accumulation of blood (up to 260ml) between the galeal/epicranial aponeurosis of the scalp and the periosteum

  7. Subgaleal Hemorrhage • Diagnosis/Presentation • Boggy, enlarging posterior (predominantly occipital) mass starting at delivery – 72 hours • Crosses suture lines, can obscure fontanelles • Dropping hematocrit (quickly!!!), shock, hypovolemia, seizures… • Head CT

  8. Subgaleal hemorrhage

  9. Subgaleal Hemorrhage cont’d • Work up • Physical exam, serial hematocrit, serial bilirubin, coags, consider head CT, coagulopathy evaluation • Treatment • Supportive • Blood transfusion, FFP and cryoprecipitate as needed, anti-epileptic medications as needed • Prognosis • Mortality up to ~ 25% • Neurological outcome dependent on the presence of shock, intracranial pathology

  10. CephalhematomaHematoma • Common (vaginal +/- instrumentation) • Diagnosis: • Sub-periosteal bleeding overlying one cranial bone (usually parietal, sometimes occipital) • Does not cross suture lines • 5-20% have underlying skull fractures (usually linear) • No workup needed (usually)

  11. CephalhematomaHematoma • Complications: • Anemia, hypovolemia, hyperbilirubinemia, infection • Treatment: • Observation • Treatment of hypovolemia, hyperbilirubinemia as needed • Do NOT aspirate (increased risk of infection) • Resolves in 2 weeks – 6 months • Occasionally leaves residual calcifications

  12. CephalhematomaHematoma

  13. Caput succedaneum • Very common, occurs in vaginal deliveries • Edema in presenting part of the scalp, sometimes with bleeding/petechiae/bruising • Workup • None • Treatment • None • Resolution • Several days

  14. Caput succedaneum

  15. Locations of scalp hematomas

  16. Outline • Epidemiology, diagnosis, prognosis of: • Scalp injuries • Subgaleal hemorrhage • Cephalhematoma • Caput succedaneum • Intracranial hemorrhage • Subdural hemorrhage • Neurologic injuries (NOT hypoxic-ischemic encephalopathy) • Brachial plexus injuries • Spinal cord injuries • Orthopedic injuries • Clavicular fractures • Long bone fractures • Intra-abdominal injuries • Liver/splenic rupture • Adrenal hemorrhage

  17. Subdural Hemorrhage • Incidence • 2.9:10,000 live births (subdural or intracranial hemorrhage) • Usually subsequent to an instrumented delivery or difficult delivery placing extreme stress on the newborn head • Diagnosis • Physical exam: lethargy, stupor, coma, seizures in the immediate perinatal period • Head CT • Work up • Head CT, EEG (as needed) • Blood work/sepsis evaluation • Coagulation work up • Treatment • Neurosurgical consultation, possible need for surgical evacuation • Prognosis • Guarded • Closely related to exam at presentation, rapidity of treatment

  18. Subdural Hemorrhage

  19. Outline • Epidemiology, diagnosis, prognosis of: • Scalp injuries • Subgaleal hemorrhage • Cephalhematoma • Caput succedaneum • Intracranial hemorrhage • Subdural hemorrhage • Neurologic injuries (NOT hypoxic-ischemic encephalopathy) • Brachial plexus injuries • Spinal cord injuries • Orthopedic injuries • Clavicular fractures • Long bone fractures • Intra-abdominal injuries • Liver/splenic rupture • Adrenal hemorrhage

  20. Brachial plexus injuries • Incidence • 0.5-2:1000 live births • Only ~ 50% associated with shoulder dystocia • Resulting from stretch/avulsion of the C5-T1 nerve roots • May have underlying bony injury • 5% of brachial plexus injuries have associated phrenic nerve injury

  21. Duchenne-Erb Palsy • Most common brachial plexus injury • Injury of C5-C6 • Presentation • The extremity lies adducted, prone, and internally rotated. Moro, biceps, and radial reflexes are absent on the affected side. Grasp reflex is usually present. • Work up • Chest and extremity radiographs to evaluate the presence of bony trauma/phrenic nerve injury

  22. Duchenne-Erb Palsy • Treatment • Goal: prevent contractures (return of function happens ‘by itself’) • 1st week – tie the infant’s sleeve to the shirt across the chest • 2nd week – begin range of motion to prevent contractures • Controversial – nerve graft to replace injured segment • Prognosis • 88% recovery at 4 months; 92% at 12 months; 93% at 48 months

  23. Duchenne-Erb Palsy

  24. Klumpke palsy • Very rare, usually following vaginal breech delivery • C7-T1 nerve roots affects • Weakness of the intrinsic muscles of the hand in the newborn period • Classically, it produces flexion and supination of the elbow, extension of the wrist, hyperextension of the metacarpophalangeal joints, and flexion of the interphalangeal joints with the “claw hand” posture beyond the neonatal period • Frequently associated with Horner syndrome (ipsilateral ptosis and pupil constriction) when the cervical sympathetic fibers at T1 are involved

  25. Klumpke

  26. Phrenic nerve injury • Part of the complex of brachial plexus injuries • Associated with higher brachial complex damage (C3, 4, 5…) • More frequent with difficult breech deliveries • 80% involve the right side, 10% are bilateral • Presentation with abdominal breathing, cyanosis, respiratory failure

  27. Phrenic nerve injury • Diagnosis • Pathognemonic chest radiograph, arterial blood gases showing hypoxemia/ventilatory failure, fluoroscopy/ultrasound showing diaphragmatic paresis • Treatment • Supportive • Possible need for diaphragmatic plication, pacing • Prognosis • Mortality ~ 50% for bilateral lesions, 10-15% for unilateral lesions • Recovery in 6-12 months

  28. Phrenic Nerve Injury

  29. Spinal cord injuries • Incidence • Unknown, possibility of some still-births resulting from upper cervical spinal injury • Cause from excessive traction (breech deliveries) or torsion (vaginal deliveries) • May happen in-utero • Cause • Hemorrhage, stretch, transection of the cord

  30. Spinal cord injuries • Presentation • Upper c-spine • Paralysis, severe respiratory depression • Lower c-spine • Hypotonia, some respiratory compromise • T-spine • Paraplegia, urinary and respiratory compromise

  31. Spinal cord injuries • Management • Supportive measures • No role for laminectomy/surgery • Possible role for methylprednisolone • Diagnosis • MRI • X-ray of the cervical and thoracic spines • Prognosis • Very poor, dependent on the level/severity of the lesion

  32. Outline • Epidemiology, diagnosis, prognosis of: • Scalp injuries • Subgaleal hemorrhage • Cephalhematoma • Caput succedaneum • Intracranial hemorrhage • Subdural hemorrhage • Neurologic injuries (NOT hypoxic-ischemic encephalopathy) • Brachial plexus injuries • Spinal cord injuries • Orthopedic injuries • Clavicular fractures • Long bone fractures • Intra-abdominal injuries • Liver/splenic rupture • Adrenal hemorrhage

  33. Clavicular fracture • Common, can complicate normal atraumatic deliveries • Diagnosis • Physical exam, chest x-ray • Suspect in infant with pain reaction • Can present as ‘pseudoparalysis’ • MUST rule out other nerve/spinal damage

  34. Clavicular fracture • Treatment • Aimed at pain reduction • Pin sleeve to chest • May require surgical intervention if fractured ends don’t approximate well • Prognosis • Excellent • Initiation of callus formation in 7-10 days

  35. Clavicular fracture

  36. Long bone fracture • Complication associated with prolonged labor, difficult delivery • Diagnosis • First sign may be cracking felt by obstetrician • Loss of motion of the extremity, pain on passive motion, swelling • X-ray of affected extremity • Rule out radial nerve compression in humeral head fractures

  37. Long bone fracture • Treatment • Splinting • May require open reduction only in cases of non-approximation • Prognosis • Great • Healing to cease immobilization sufficient in 8-10 days, complete recovery in 2-4 weeks

  38. Outline • Epidemiology, diagnosis, prognosis of: • Scalp injuries • Subgaleal hemorrhage • Cephalhematoma • Caput succedaneum • Intracranial hemorrhage • Subdural hemorrhage • Neurologic injuries (NOT hypoxic-ischemic encephalopathy) • Brachial plexus injuries • Spinal cord injuries • Orthopedic injuries • Clavicular fractures • Long bone fractures • Intra-abdominal injuries • Liver/splenic rupture • Adrenal hemorrhage

  39. Liver/Splenic rupture • Very rare but deadly • Presents from immediately postpartum – several days postpartum • Risk factors • Pre/post dates, hepatomegaly, significant resuscitative efforts, difficult delivery requiring traction (breech, c-section) • Presentation • Pallor, shock, vascular collapse, anemia, abdominal distention • May be insidious or fulminant • Hepatic bleed usually after rupture of hepatic hematoma (>4-5cm)

  40. Liver/Splenic rupture • Diagnosis • Abdominal ultrasound showing free fluid • Paracentesis • Treatment • Aggressive fluid/colloid resuscitation, coagulation correction (FFP, cryoprecipitate, platelets as needed) • Surgical repair

  41. Adrenal hemorrhage • Increased risk with prematurity, asphyxia, neonatal neuroblastoma • Presentation • Pallor, hypotension, shock, vomiting, diarrhea, fever, tachypnea, flank mass • Diagnosis • Ultrasound, cortisol level (not diagnostic if low…) • Treatment • Red cell transfusion, i.v. steroids

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