1. INJURIES OF THE FETUS & NEWBORN Ruth Ramos Taguiling, MD FPOGS

2. INTRODUCTION Birthing is one of the most wonderful & treasured moments in the life of a woman. But birthing is not without complications

3. INTRODUCTION The types of injury to the fetus is dependent on the manner of delivery Fetal injuries may be due to: –1. Human errors –2. Congenital –3. Spontaneous

4. Injuries of the Fetus & NB Lecture Outline: I – Head Injuries II- Nerve Injuries III – Skeletal & Muscle Injuries IV – Congenital Injuries

5. I. HEAD INJURY TYPES: 1.Spontaneous Intracranial Hemorrhage 2. Traumatic Intraventricular Hemorrhage 3. Cephalhematoma

6. MAJOR TYPES OF INTRACRANIAL HEMORRHAGE IN THE NEWBORN TYPEGestational Age Incidence & Severity Cause/s & Pathogenesis SubduralTerm> PretermUncommon, Serious Venous Tears, Trauma common SubarachnoidPreterm>TermCommon, BenignTrauma- Term “Hypoxia”-Preterm Intra- cerebellar Preterm>TermUncommon, Serious Multifactorial Intra- ventricular PretermCommon, Serious Germinal Matrix, Multifactorial MiscellaneousTerm>PretermUncommon, Variable Trauma, Hemorrhagic Infarction, Coagulopathy, Vascular Defect, ECMO

7. A. Spontaneous Intracranial Hemorrhage Etiology: 1.Immaturity, fetus less than 1500gm. (Hayden & colleagues,1985) 2. Mature Healthy fetus Prospective study by Whitby & associates (2004) used MRI imaging (presence of subdural hemorrhage) –6%= spontaneous delivery –28%= forceps delivery

8. INTRAVENTRICULAR HEMORRHAGE (GERMINAL MATRIX HEMORRHAGE ) Common in preterm infants Major cause of mortality & long-term disability Bleeding originates in the sub- ependymal germinal matrix but may rupture thru the ependyma into the ventricular system

9. INTRAVENTRICULAR HEMORRHAGE FOUR CATEGORIES GRADE I = bleeding localized to germinal matrix GRADE II= bleeding into the ventricle but the clot does not distend the ventricle GRADE III= bleeding into the ventricle with ventricular dilatation 35% with adverse neurologic outcome GRADE IV= intraparenchymal extension Has the highest mortality rate 80%-90% associated with poor neurologic outcome

10. INTRAVENTRICULAR HEMORRHAGE INCIDENCE: 1990- 1999: = birth weight < 1000gm= 43%; 13% were grade III /grade IV 2000- 2002: = over-all incidence decreased - 22% 3% were severe

11. INTRAVENTRICULAR HEMORRHAGE DIAGNOSIS: –Cranial Ultrasound Hemorrhages can occur within 6 hours of birth 90%= within the first 5 days of life

12. INTRAVENTRICULAR HEMORRHAGE PATHOGENESIS: 1. ANATOMIC A.germinal matrix is composed of thin- walled blood vessels without supportive tissue with tendency to rupture spontaneously in response to stress (hypoxia-ischemia, changes in blood pressure or cerebral perfusion & pneumothoraces)

13. PATHOGENESIS: 2. PHYSIOLOGIC A. Immature cerebrovascular autoregulation system (pressure-passive circulation) in response to systemic hypotension B. Immaturity in the coagulation system & increased fibrinolytic activity in immature infants

14. INTRAVENTRICULAR HEMORRHAGE ANTENATAL PREVENTION 1. antenatal corticosteroid 2. maternal transfer to tertiary hospital POSTNATAL PREVENTION Goal: To stabilize BP a.to prevent fluctuation in cerebral perfusion b.correction of coagulation disturbances c.stabilization of germinal matrix vasculature Prophylactic endomethacin

15. B. TRAUMATIC INTRAVENTRICULAR HEMORRHAGE Birth Trauma is no longer a common cause of intracranial hemorrhage. 3.1 per 100,000 births= incidence of mechanical birth injury as reported by O’Mahony & colleagues (2005)

16. Traumatic Intraventricular Hemorrhage Mechanical Injuries from IC hge: –subdural hemorrhage from tentorial tears –massive infratentorial hemorrhage have neurological abnormalities from the time of birth (Volpe, 1995)

17. Intraventricular Hemorrhage Diagnostic Tests: 1. Ultrasound of the head 2. CT Scan 3. MRI

18. C. CEPHALOHEMATOMA Incidence= 1.6 % of all births Etiology: 1. Injury to the periosteum of the skull during labor & delivery 2. Defective fetal hemostasis

19. Differences between Caput Succedaneum & Cephalohematoma CAPUT SUCCEDANEUMCEPHALOHEMATOMA LocationAbove periosteumBelow periosteum, limited by periosteal edge SizeMaximal at birthGrows larger ResolutionGrows smaller hours to days Weeks to months

20. CEREBRAL PALSY A clinical diagnosis Refers to a group of nonprogressive motor impairement Etiology: result of injury to the developing brain that occurs prenatally, perinatally or postnatally. 75%-80%= events during pregnancy 10%= intrapartum events ( birth asphyxia) 10%= postnatal causes (head injury; CNS infection)

21. CEREBRAL PALSY RISK FACTORS: 1. Prematurity 2. Low birth weight 3. Perinatal infections (maternal, intrauterine & neonatal) Congenital viral infection (toxoplasmosis, CMV,rubella, HSV, syphylis =5-10%) Chorioamnionitis Meningitis

22. II. NERVE INJURIES 1. SPINAL INJURY 2. BRACHIAL PLEXOPATHY 3. FACIAL PARALYSIS

23. A. SPINAL INJURY Overstretching of the spinal cord & associated hemorrhage following excessive traction during delivery with actual fracture or dislocation of the vertebrae Assoc. w/: forceps rotation breech delivery

24. B. BRACHIAL PLEXOPATHY Incidence: 1:500 to 1:1000 term births Etiologies: 1. Shoulder Dystocia 2. Intrauterine CVA (strokes) 3. Overstretching of brachial plexus from fetal movement during the pregnancy 4. Basic maldevelopment of the brachial plexus.

25. BRACHIAL PLEXUS Three types of brachial plexus damage: 1.Erb or Duchenne paralysis C5 & C6 & occasionally C7 Injury leads to paralysis of the deltoid & infraspinatus muscles & flexor muscles of the forearm

26. 1. ERB-DUCHENNE PARALYSIS Abnormal positioning of the scapula called "winging“ Result in having a humerus that is pulled in towards the body (adducted) and internally rotated. The forearm extended - "waiters tip" position.

27. 2. KLUMPKE PARALYSIS Involves lower trunk lesions fr nerve roots C7, C8, and T1 elbow becomes flexed and forearm supinated (opened up, palm-upwards) “ clawlike deformity “ Sensation in the palm of the hand is diminished.

28. Brachial Plexopathy Types of Brachial Plexus damage 3. Total involvement of all brachial plexus nerve roots Results: a. flaccidity of both arm & hand b. Horner Syndrome on the affected side - ptosis & pupillary meiosis resulting from interruption of nerve fibers from the cervical sympathetic chain

29. FACIAL PARALYSIS

30. C. FACIAL PARALYSIS Incidence: < 1 to 7.5 per 1000 term births Pressure on the facial nerve as it emerges from the stylomastoid foramen Maybe apparent at delivery or may develop shortly after birth

31. FACIAL PARALYSIS Spontaneous recovery within a few days is the rule. May arise from SVD CS Forceps Delivery –caused by pressure exerted by the posterior blade when the forceps have been placed obliquely on the fetal head.

32. III. SKELETAL & MUSCLE INJURIES 1. Clavicular fractures –Common, unpredictable & unavoidable complications of normal birth –Incidence: 3- 18 per 1000 live births –30 fold increase with shoulder dystocia but 75 % are not due to shoulder dystocia.

33. Skeletal & Muscle Injuries 2. Humeral Fractures –not common –usually a greenstick type –Due to difficult delivery of shoulders in cephalic deliveries & of extended arms in breech deliveries –4% of infants with shoulder dystocia

34. Skeletal & Muscular Injuries 3. Femoral Fractures- rare & associated with breech delivery

35. Skeletal & Muscular Injuries 4. Skull Fracture 3.7 per 100,000 births (1990 & 2000) 75% = with instrumental deliveries Fracture could be due to vigorous labor & delivery or during CS from lifting hand pressure by the surgeon or from upward hand pressure by an assistant

36. Skeletal & Muscular Injuries 5. Mandibular Fracture

37. MUSCULAR INJURIES Injury to the sternocleidomastoid m. –during breech delivery –or internal podalic version will lead to tear of the muscle or fascial sheath leading to hematoma & gradual cicatricial contraction producing torticollis later in life

38. IV. CONGENITAL INJURIES 1. AMNIOTIC BAND SYNDROME –Focal ring constriction of the extremities & actual loss of digits or a limb –2 proposed causes of this condition: 1. localized germ plasma failure 2. early rupture of amnion

39. IV. CONGENITAL INJURIES 2. CONGENITAL POSTURAL DEFORMITIES Mechanical factors: –chronic oligohydramnios –inappropriate size & shape of the uterine cavity –produce deformities such as talipes, scoliosis, hip dislocation,limb reduction, body wall defects, hypoplastic lung

41. End…. Thank you!