Objectives. Incidence of birth injuries. Introduction. Risk factors. Risk Factors - Macrosomia. Birth Injuries in Neonates: Diagnosis and Management

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Birth Injuries in Neonates: Diagnosis and Management Ayman Khmour, MD Clinical Advances In Pediatrics Symposium 2017 Objectives Describe common birth injuries Delineate current evaluation and

1 Birth Injuries in Neonates: Diagnosis and Management Ayman Khmour, MD Clinical Advances In Pediatrics Symposium 2017 Objectives Describe common birth injuries Delineate current evaluation and management Introduction Impairment of the neonate's body function or structure due to adverse event occurred at birth Avoidable, or unavoidable Despite skilled and competent obstetric care Prolonged labor or with an abnormal presentation. Include injuries related to use of intrapartum monitoring: FHR, fetal scalp blood for acid-base assessment Do Not Include injuries related to: amniocentesis, intrauterine transfusions and injuries after resuscitation procedures Incidence of birth injuries 1981-birth injuries ranked 6 th for neonatal death deaths per 100,000 live births 1993-birth injuries ranked 11 th for neonatal death. 3.7 deaths per 100,000 live births 2009-no mention as on of leading causes of death Risk factors Risk Factors - Macrosomia Retroscpective Macrosomic infants ( g, g, and >5000 g infants) vs normosomic g Risk factors for macrosomia: nonsmoking, AMA, married, DM, HTN and hx macrosomic infant or pregnancy loss Risks of labor complications, birth injuries, and newborn morbidity with each gradation of macrosomic birth weight Infant mortality rates infants>5000 g. BWt >4500 g more predictive of neonatal morbidity BWt >5000 g better indicator of infant mortality risk (Am J Obstet Gynecol 2003;188: ) Rosenburg et al, Neoreviews

Risk factors-macrosomia Risk factors-macrosomia Weight 4000-4500g birth injuries risk increase 2 fold Weight 4500-5000 g: risk increases by 3 fold Weight >5000

5 fold Boulet et al, 2003, Am J Obstet Gynecol Boulet et al, 2003, Am J Obstet Gynecol Risk Factor: Forceps / Vacuum Risk Factor: Forceps / Vacuum 1989-1993

likely than forceps to be complicated by postpartum hemorrhage and shoulder dystocia Comparable Risks of ICH, difficulty with feeding, and retinal hemorrhage

Demissie et al, BMJ 2004 Risk Factor: Forceps / Vacuum Risk Factors: Breech 2003 2011 Canadian Population-based cohort study MOD and Neonatal outcomes in term,

2 Risk factors-macrosomia Risk factors-macrosomia Weight g birth injuries risk increase 2 fold Weight g: risk increases by 3 fold Weight >5000 g: risk increases by 4.5 fold Boulet et al, 2003, Am J Obstet Gynecol Boulet et al, 2003, Am J Obstet Gynecol Risk Factor: Forceps / Vacuum Risk Factor: Forceps / Vacuum data; Comparable Neonatal mortality between vacuum and forceps Vacuum: lower risk of birth injuries, seizures & need for assisted ventilation Vacuum: more likely than forceps to be complicated by postpartum hemorrhage and shoulder dystocia Comparable Risks of ICH, difficulty with feeding, and retinal hemorrhage Sequential use of vacuum and forceps associated with increased risk of need for mechanical ventilation and maternal third and fourth degree perineal tears Demissie et al, BMJ 2004 Risk Factor: Forceps / Vacuum Risk Factors: Breech Canadian Population-based cohort study MOD and Neonatal outcomes in term, nonanomalous singletons Death, assisted ventilation, seizures, or specific birth injury VD and C/S both increased Higher neonatal mortality/morbidity in: 37 wks after VD C/S in labor C/S: reduction in short-term adverse outcomes but not in long-term maternal or child morbidity/mortality Demissie et al, BMJ

Erythema and Abrasions Injuries when dystocia to presenting part Soft tissue injuries When forceps applied: injury to site of application linear in orientation Resolution in few days with no therapy

pressures and tightening of nuchal cord Localized distribution No subsequent crops of new lesions PLT DDX: Neonatal Thrombocytopenia Infections DIC Usually fade within 2-3 days Usually on head, neck,

3 Erythema and Abrasions Injuries when dystocia to presenting part Soft tissue injuries When forceps applied: injury to site of application linear in orientation Resolution in few days with no therapy Affected areas should be kept clean to minimize risk for secondary infection Petechiae Risk Factors: tight nuchal cord, precipitous delivery, breech Sudden increase in intrathoracic & venous pressures and tightening of nuchal cord Localized distribution No subsequent crops of new lesions PLT DDX: Neonatal Thrombocytopenia Infections DIC Usually fade within 2-3 days Usually on head, neck, upper chest, lower back Underlying hemorrhagic disorder PLT needs to be measured &followed No specific treatment is necessary. No Corticosteroids or heparin Petechiae Ecchymoses/Bruising Ecchymoses/Bruising Common in traumatic and breech delivery More in premature babies Can cause significant hyperbilirubinemia blood loss: severe enough to cause anemia and, rarely, shock. No specific therapy needed. Phototherapy for jaundice as needed Spontaneous Resolution ~ 1 week Fanaroff and Martin s NPM-Textbook

Subcutaneous Fat Necrosis Ischemia to adipose tissue Subcutaneous Fat Necrosis Trauma, hypothermia Few weeks to show Firm, indurated nodules and plaques Back, buttocks, thighs, arms Self

C-section Scalp, buttocks, thighs Superficial: butterfly adhesive strips Deeper and freely bleeding wounds: sutured with finest material available Rarely required in delivery room.

Extracranial Head Injuries Extracranial Head Injuries Image: Wikipedia Caput Succedaneum Edematous swelling of scalp above periosteum Prolonged engagement of head or use of vacuum Extends

4 Subcutaneous Fat Necrosis Ischemia to adipose tissue Subcutaneous Fat Necrosis Trauma, hypothermia Few weeks to show Firm, indurated nodules and plaques Back, buttocks, thighs, arms Self limiting-in 6-8 wks Watch Ca++ levels up to 6 months SFN following therapeutic hypothermia (CMH patient) Fanaroff and Martin s NPM-Textbook 2015 Lacerations Inflicted with scalpel during C-section Scalp, buttocks, thighs Superficial: butterfly adhesive strips Deeper and freely bleeding wounds: sutured with finest material available Rarely required in delivery room. Wound left uncovered unless potential soiling Protective plastic. Rapid Healing; sutures removed after 5 days. Extracranial Head Injuries Extracranial Head Injuries Image: Wikipedia Caput Succedaneum Edematous swelling of scalp above periosteum Prolonged engagement of head or use of vacuum Extends across suture lines Benign; resolves within few days Hyperbilirubinemia Rarely may present with shock and require blood transfusion Head imaging if: No improvement in large caput hours Enlargement of swelling >24 hours Neurologic deficits and/or hemodynamic instability 4

Cephalhematoma Subperiosteal collection of blood due to rupture of vessels beneath periosteum Does Not cross the suture lines Usually no significant blood loss 1-2% of all deliveries Mostly due to

coli; present as erythematous, fluctuant masses CT or MRI Needle aspiration, I&D, debridement of necrotic skull, prolonged ABX Rarely may result in blood loss severe enough to require transfusion.

html Subgaleal Hemorrhage Collection of blood between epicranial aponeursis and periosteum of skull Incidence- 4/10000 in non instrumented deliveries 64/10000 in vacuum extraction deliveries Can

5 Cephalhematoma Subperiosteal collection of blood due to rupture of vessels beneath periosteum Does Not cross the suture lines Usually no significant blood loss 1-2% of all deliveries Mostly due to forceps or vacuum extraction Resolve over the course of 3-4 weeks Cephalhematoma DDX: Subgaleal hematoma Caput Succedaneum Cranial meningeocele: pulsations Complications: Infection and sepsis E. coli; present as erythematous, fluctuant masses CT or MRI Needle aspiration, I&D, debridement of necrotic skull, prolonged ABX Rarely may result in blood loss severe enough to require transfusion. Calcified Cephalhematoma Calcification: Skull deformities Often disappears over 3 to 6 months. Persistent calcification:? surgical excision Subgaleal Hemorrhage Collection of blood between epicranial aponeursis and periosteum of skull Incidence- 4/10000 in non instrumented deliveries 64/10000 in vacuum extraction deliveries Can result in 20-40% blood loss Mortality ~12-14%: shock and coagulopathy Early recognition is crucial Subgaleal Hemorrhage Fluid wave Handling water balloon Very fluctuant, shifting mass without discernable limitations. Ears Subgaleal Hemorrhage Hx of difficult operative delivery Ongoing monitoring, frequent VS Serial measurements of H/H and HC Each 1 cm increases = ~ 40 ml of blood loss CT or MRI Coagulation studies Aggressive volume resuscitation N/S, PRBC, PLT and FFP Rarely brain compression that require surgical evacuation of the hematoma Fanaroff and Martin s NPM-Textbook

Intracranial Injuries Intracranial Injuries Towner et al, 1999 NEJM Subdural Hematoma Most common ICH in neonates Hematoma between dura and arachnoid

dysfunction: irritability altered tone, loc Rarely: ICP, in HC, tense fontanelle, apnea, bradycardiacoma http://www.slideshare.

decompression within 24 hours due to midline shift Subdural Hematoma Treatment: Conservative if no signs of herniation.

6 Intracranial Injuries Intracranial Injuries Towner et al, 1999 NEJM Subdural Hematoma Most common ICH in neonates Hematoma between dura and arachnoid membrane Tentorial & interhemispheric CT for diagnosis Symptomatic by hours of life Respiratory depression, apnea, and/or seizures Neurologic dysfunction: irritability altered tone, loc Rarely: ICP, in HC, tense fontanelle, apnea, bradycardiacoma Subdural Hematoma Term baby Rt subdural hemorrhage Seizures Surgical decompression within 24 hours due to midline shift Subdural Hematoma Treatment: Conservative if no signs of herniation. Surgical evacuation if signs of herniation or in posterior fossa Serial H/H to assess for ongoing blood loss Volume replacement Investigation of a congenital coagulopathy (Image: MRI-Children s Mercy Hospital, Kansas City) 6

Posterior Fossa Subdural Hematoma Posterior Fossa Subdural Hematoma Posterior Fossa SDH Rare but severe and life threatening Delayed presentation; with/without signs of hydrocephalus low-pressure

org/neurologicaldisorders/images/cham_brain.jpg Blauwblomme et al.

7 Posterior Fossa Subdural Hematoma Posterior Fossa Subdural Hematoma Posterior Fossa SDH Rare but severe and life threatening Delayed presentation; with/without signs of hydrocephalus low-pressure venous bleeding Brainstem compression and neurological deterioration. Obstructive hydrocephalus as consequence of obstruction of Magendie foramina. Blauwblomme et al. Neurosurgery 2013 Subarachnoid Hemorrhage 2 nd most common ICH in neonates Caused by rupture of bridging veins in subarachnoid space Symptoms appear at hours Diagnosis by CT Treatment is conservative Rarely requires surgery Epidural Hemorrhage Very rare in neonates Injury to middle meningeal artery Linear skull fracture most of the time Presents with hypotonia, seizures, bulging fontanelles and change in loc Diagnosis-CT Treatment conservative if no signs of herniation surgical evacuation if signs of herniation Intraventricular Hemorrhage Usually with premature delivery Reported as a consequence of birth injury in term infants 4% in one study in healthy asymptomatic term infants Risk of IVH increases with operative deliveries, (highest in combined vacuum and forceps deliveries) Neurologic Injuries 7

side Traumatic facial palsies resolve in 2-3 weeks of birth Facial Nerve Injury Loss of nasolabial fold Partial closing of eye Inability to contract the lower facial muscles on affected

Asymmetry in eyelid closing Partially open lid on affected side Involvement of both eye and lip: differentiate facial from other diagnosis What is the Diagnosis?

html Brachial Plexus Injury Paralysis of upper arm muscles following Trauma (stretch) to spinal roots C5 to T1 4 pathologies: 1. Neurapraxia: nerve is shocked but not torn 2.

8 Facial Nerve Injury Incidence is 0.5-1% of live births Compression of facial nerve by forceps rarely agenesis of facial nerve nucleus (Mobius syndrome) Mandibular branch: most commonly affected Less movements on affected side Traumatic facial palsies resolve in 2-3 weeks of birth Facial Nerve Injury Loss of nasolabial fold Partial closing of eye Inability to contract the lower facial muscles on affected side "drooping" mouth. When crying, the mouth is drawn over to the unaffected side Gallery/FacialPalsy2.html Facial Nerve Injury Same infant! Asymmetry in eyelid closing Partially open lid on affected side Involvement of both eye and lip: differentiate facial from other diagnosis What is the Diagnosis? This infant has asymmetric crying facies Unaffected eye and forhead muscles 22q11 Absence of depressor anguli oris muscle Gallery/FacialPalsy2.html Brachial Plexus Injury Paralysis of upper arm muscles following Trauma (stretch) to spinal roots C5 to T1 4 pathologies: 1. Neurapraxia: nerve is shocked but not torn 2. Neuroma: damage some nerve fibers, scar tissue may press on remaining healthy nerve 3. Rupture: nerve torn apart; will not heal 4. Avulsion: nerve is torn from the spinal cord Brachial Plexus Injury Erb s palsy: Most common > 80% Upper portion (C5, C6, C7) Weakness of shoulder/biceps muscles Arm adducted, internally rotated, with extension at elbow, pronation of the forearm, and flexion of wrist 8

Brachial Plexus Injury Klumpke s palsy Involves lower roots (C8, T1) Typically affects hand muscles Claw Hand Brachial Plexus Injury Total plexus involvement All five nerves are involved (C5-T1) Loss

9 Brachial Plexus Injury Klumpke s palsy Involves lower roots (C8, T1) Typically affects hand muscles Claw Hand Brachial Plexus Injury Total plexus involvement All five nerves are involved (C5-T1) Loss of movement at shoulder, arm or hand. Horner s syndrome Associated with avulsion. Sympathetic chain injury T2 to T4 region. Ptosis, miosis, anhydrosis Brachial Plexus Injury Conservative management Physical therapy Nerve reconstruction nerve root avulsion between 6-9 months Botulinum toxin injections Brachial Plexus Injury Favorable Outcome: Early clinical improvement Elbow flexion at 3 months Normal or near-normal strength at 3 months Antigravity strength in biceps, triceps and deltoid muscles by 4.5 months Improves range of motion Pain management Yang et al, seminars in Perinatology 2014 Phrenic Nerve Injury Often with brachial plexus injury Breech delivery and lateral extension of neck Avulsion of C3-5 nerve roots Clinical signs: recurrent episodes of cyanosis followed by respiratory distress Phrenic Nerve Injury Management Infant positioned on the involved side O2 and IV fluids Plication of diaphragm, or pacing if no definite improvement after 1 month Prognosis Spontaneous recovery Susceptibility pneumonia Fanaroff and Martin s NPM-Textbook

$5% Clavicle Fracture Fractures Operative delivery Shoulder dystocia Higher birth weight Increased maternal age Diagnosis: Displaced fracture in newborn period Non displaced in days to weeks$ Conservative treatment Humerus Fracture Long Bone Fracture Incidence-0.

Conservative treatment Humerus Fracture Long Bone Fracture Incidence-0.

10 Most common; 1-1.5% Clavicle Fracture Fractures Operative delivery Shoulder dystocia Higher birth weight Increased maternal age Diagnosis: Displaced fracture in newborn period Non displaced in days to weeks Conservative treatment Humerus Fracture Long Bone Fracture Incidence-0.2/1000 deliveries RF-shoulder dystocia, macrosomia, C/S, breech and LBW Decreased arm movement, localized crepitation, pain with palpation Diagnosis: radiography Immobilization with elbow in 90 degrees Outcome is excellent Femur Fracture 0.13/1000 deliveries RF: Twin pregnancies, breech, prematurity, diffuse osteoporosis Asymptomatic or pain response to handling, pop or snap on delivery Diagnosis: radiography Pavlik harness is a optional newborns Outcome is excellent 57 Linear and Depressed Depressed fracture: 3.4/ births Depressed fracture: increased possibility of intracranial process Skull Fracture Further imaging with CT Neuroimaging and Neurosurgery consultation Depressed fracture <1cm with no neurodeficit: conservative management Arch Dis Child Fetal Neonatal Ed 2009;94:F137 doi: /adc Skull Fracture Ocular injuries Minor Injuries: Subconjunctival/retinal hemorrhages and lid edema Spontaneous resolution Ophthalmologic consultation for Significant Injuries: Hyphema (blood in anterior chamber) Vitrous hemorrhage, Orbital fracture, Lacrimal duct injury Disruption of descemets membrane of cornea (astigmatism and amblyopia) CMH patient 10

11 Points to remember Incidence of birth injuries has dramatically decreased in last 2 decades Macrosomia and instrumental deliveries are major risk factors Subgaleal hemorrhage is an emergency. Close monitoring and aggressive resuscitation is key Forceps: most common cause of facial nerve injury; usually self limiting Points to remember Erb s palsy: most common brachial plexus injury. Management is conservative until 3-4 months of life Shoulder dystocia: major risk factor for brachial plexus injury Management of clavicle, skull fracture (unless neurodeficit), humerus and femur fractures is conservative Planned C-section for breech presentation decreases mortality and morbidity Points to remember Posterior fossa hematoma can cause brain stem compression leading to respiratory compromise and needs close monitoring References Blauwblomme, T., M. Garnett, E. Vergnaud, N. Boddaert, M. Bourgeois, F. Dirocco, M. Zerah, C. Sainte-Rose and S. Puget. "The Management of Birth-Related Posterior Fossa Hematomas in Neonates." Neurosurgery 72, no. 5 (2013): ; discussion 762. Boulet, S. L., G. R. Alexander, H. M. Salihu and M. Pass. "Macrosomic Births in the United States: Determinants, Outcomes, and Proposed Grades of Risk." Am J Obstet Gynecol 188, no. 5 (2003): Brousil, J. and J. B. Hunter. "Femoral Fractures in Children." Curr Opin Pediatr 25, no. 1 (2013): Dessole, S., E. Cosmi, A. Balata, L. Uras, D. Caserta, G. Capobianco and G. Ambrosini. "Accidental Fetal Lacerations During Cesarean Delivery: Experience in an Italian Level Iii University Hospital." Am J Obstet Gynecol 191, no. 5 (2004): Dupuis, O., R. Silveira, C. Dupont, C. Mottolese, P. Kahn, A. Dittmar and R. C. Rudigoz. "Comparison of "Instrument-Associated" and "Spontaneous" Obstetric Depressed Skull Fractures in a Cohort of 68 Neonates." Am J Obstet Gynecol 192, no. 1 (2005): Hoffman, M. K., J. L. Bailit, D. W. Branch, R. T. Burkman, P. Van Veldhusien, L. Lu, M. A. Kominiarek, J. U. Hibbard, H. J. Landy, S. Haberman, I. Wilkins, V. H. Quintero, K. D. Gregory, C. G. Hatjis, M. M. Ramirez, U. M. Reddy, J. Troendle, J. Zhang and Labor Consortium on Safe. "A Comparison of Obstetric Maneuvers for the Acute Management of Shoulder Dystocia." Obstet Gynecol 117, no. 6 (2011): References Yang, L. J. "Neonatal Brachial Plexus Palsy--Management and Prognostic Factors." Semin Perinatol 38, no. 4 (2014): Kitaw Demissie, George G Rhoads, John C Smulian, Bijal A Balasubramanian, Kishor Gandhi, K S Joseph, Michael Kramer Operative vaginal delivery and neonatal and infant adverse outcomes: population based retrospective analysis BMJ VOLUME JULY 2004 Rosenberg A 2003, Neoreviews, Traumatic birth injury Textbook of Neonatal and perinatal medicine, Fanaroff and Martin 2015 Janet Lyons, MD, Tracy Pressey, MD, Sharon Bartholomew, MHSc, Shiliang Liu, MB, PhD, Robert M. Liston, MB, and K.S. Joseph, MD, PhD, Delivery of Breech Presentation at Term Gestation in Canada, , VOL. 125, NO. 5, MAY 2015 OBSTETRICS & GYNECOLOGY 11

Birth injuries. Dr. Nihad Al Doori 3 rd lecture

Birth injuries. Dr. Nihad Al Doori 3 rd lecture Birth injuries Dr. Nihad Al Doori 3 rd lecture Birth injuries are injuries that occur during the birth process. They are most likely to occur when the infant is : large, the presentation is breech, forceful