KAUMARABHRITYA SYLLABUS
B PART - 4TH POINT
PRASAVAKALEENA
ABHIGHATA /
BIRTH INJURIES
DEFINITION
• An impairment of the infants body function
or structure due to adverse influences that
occur at birth
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(National vital statistics report)
RISK FACTORS
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Primiparity
Small maternal stature
Maternal pelvic anomalies
Prolonged or unusually rapid labor
Oligohydramnios
Malpresentation of the fetus
• Use of mid forceps or vaccum
extraction
• Versions and extractions
• Very low birth weight or extreme
prematurity
• Fetal macrosomia or large fetal head
• Fetal anomalies
TYPES
• Head and neck injuries
• Nerve injury
• Facial injuries
• Fractures
• Intra-abdominal injury
• Soft tissue injuries
HEAD AND NECK INJURIES
EXTRACRANIAL INJURIES
• CAPUT SUCCEDANEUM
• CEPHALHEMATOMA
• SUBGALEAL HEMORRHAGE
CAPUT SUCCEDANEUM
• A caput succedaneum is a
serosanguinous fluid collection above the
periosteum. It presents as a soft tissue
swelling with purpura and ecchymosis
over the presenting portion of the scalp. It
may extend across the midline and across
suture lines.
• The edema disappears within the 1st few
days of life.
• Molding of the head and overriding of the
parietal bones disappear during the 1st
weeks of life.
• Rarely, a hemorrhagic caput may result in
shock and require blood transfusion.
MANAGEMENT
• No specific treatment is needed
• But if extensive ecchymoses are
present, hyperbilirubinemia may develop
• Shock – Blood transfusion
CEPHALHEMATOMA
• A cephalhematoma is a subperiosteal
blood collection caused by rupture of
vessels beneath the periosteum.
Clinical features
• Swelling, usually over a parietal or
occipital bone
• Swelling does not cross a suture line and
is often not associated with discoloration
of the overlying scalp.
• Limited to the surface of one cranial bone.
Diagnosis
• Physical examination
• Skull radiograph
• cranial computed tomography
• If infection is suspected, aspiration of the
mass
• If sepsis, antibiotics
• hyperbilirubinemia – photo therapy
SUBGALEAL HEMORRHAGE
• A subgaleal hemorrhage is bleeding
between the galea aponeurosis of the
scalp and the periosteum.
FEATURES
• A subgaleal hemorrhage presents as a
firm-to-fluctuant mass that crosses suture
lines.
• The mass is typically noted within 4 hours
of birth.
LABORATORY FINDINGS
• serial hemoglobin and hematocrit
monitoring,
• coagulation profile to investigate for the
presence of a coagulopathy.
• Bilirubin levels also need to be monitored
TREATMENT
• Supportive
• Transfusions may be required if blood loss
is significant.
• In severe cases, surgery may be required
to cauterize the bleeding vessels.
• These lesions typically resolve over a 2–3
week period
CRANIAL INJURIES
• LINEAR SKULL FRACTURES
• DEPRESSED SKULL FRACTURES
LINEAR SKULL FRACTURES
• Usually affect the parietal bones.
• The pathogenesis is related to
compression from the application of
forceps, or from the skull pushing against
the maternal symphysis or ischeal spines.
• Rarely, a linear fracture may be
associated with a dural tear, with
subsequent development of a
leptomeningeal cyst.
DEPRESSED SKULL FRACTURES
• Indications for surgery include
• radiographic evidence of bone
fragments in the cerebrum
• presence of neurologic deficits
• signs of increased intracranial pressure
• signs of cerebrospinal fluid beneath the
galea
• failure to respond to closed manipulation.
• Indications for nonsurgical management
include
• Depressions less than 2 cm in width and
depressions over a major venous sinus
• Without neurologic symptoms
INTRACRANIAL INJURY
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Intracranial haemorrhage
Epidural hemorrhage
Subdural hemorrhage
Subarachnoid hemorrhage
Intraparenchymal haemorrhage
Germinal matrix hemorrhage /
intraventricular haemorrhage
INTRACRANIAL HAEMORRHAGE
• Bleeding can occur
– External to the brain into the
epidural, subdural or subarachnoid space
– In to the parenchyma of the cerebrum or
cerebellum
– Into the ventricles from the subependymal
germinal matrix or choroid plexus
RISK FACTORS
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forceps delivery
vacuum extraction
precipitous deliver
prolonged second stage of labor
macrosomia
SYMPTOMS
• apnea
• seizures
EPIDURAL HEMORRHAGE
• Epidural hemorrhage primarily arises from
injury to the middle meningeal artery, and
is frequently associated with a
cephalhematoma or skull fracture.
CLINICAL MANIFESTATIONS
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Diffuse neurologic symptoms
Increased intracranial pressure
Bulging fontanels
Localized symptoms,
Lateralizing seizures
Eye deviation.
DIAGNOSIS
• cranial computed tomography showing a
high-density lentiform lesion in the
temporoparietal region
• Skull radiographs
MANAGEMENT
• Surgical management
• Aspiration of blood from the accompanying
cephalhaematoma
SUBDURAL HEMORRHAGE
• most frequent intracranial hemorrhage
related to birth trauma
• Laceration of the tentorium, with rupture of
the straight sinus, vein of Galen transverse
sinus, or infratentorial veins causing a
posterior fossa clot and brainstem
compression
• Laceration of the falx, with rupture of the
inferior sagittal sinus resulting in a clot in
the longitudinal cerebral fissure
• Laceration of the superficial cerebral
vein, causing bleeding over the cerebral
convexity
• Occipital osteodiastasis, with rupture of
the occipital sinus, resulting in a posterior
fossa clot
CLINICAL FEATURES
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Respiratory symptoms such as apnea
Seizures
Focal neurologic deficits
Lethargy
Hypotonia
Other neurologic symptoms
DIAGNOSIS
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Cranial computed tomography
Cranial ultrasonography
MRI.
Coagulation profile
SUBARACHNOID HEMORRHAGE
• Subarachnoid hemorrhage is caused by
rupture of the bridging veins of the
subarachnoid space or small
leptomeningeal vessels
MANIFESTATIONS
• Seizures, often occurring on the second
day of life
• Irritability
• Depressed level of consciousness
• Focal neurologic signs.
DIAGNOSIS
• Cranial computed tomography.
• Cranial ultrasonography
• Lumbar puncture shows an increased
number of red blood cells
MANAGEMENT
• Resolves without intervention
• Monitoring head growth
INTRAPARENCHYMAL
HAEMORRHAGE
• TYPES
• Intra cerebral
Causes:
• rupture of an av malformation or aneurysm
• coagulation disturbances
• extracorporeal membrane oxygenation
therapy
• secondary to a large ICH in any other
compartment
• Intracerebellar :
more common in preterm than the
term babies. May be a primary
haemorrhage or may result from venous
hemorrhagic infarction or from extension
of GMH/ IVH
CLINICAL FEATURES
• In the preterm infant
– IPH is often clinically silent in either
intracranial fossa , unless the hemorrhage is
quite large
• In the term infant, manifestations are
– Seizures
– Hemiparesis
– Gaze preference
– Irritability
– Depressed level of consciousness
DIAGNOSIS
• CT Scans
• MRI
• Cranial ultrasonography
MANAGEMENT
• Symptomatic treatment and support
• Neurosurgical intervention
GERMINAL MATRIX
HEMORRHAGE
(INTRAVENTRICULAR HAEMORRHAGE)
• Causes:
• Trauma,
• Perinatal asphyxia
• Secondary to venous hemorrhagic
infarction in the thalamus
FACTORS IN THE PATHOGENESIS
• Intra vascular factors
– Ischemia / reperfusion
– Fluctuating cerebral blood flow
– Increase in CBF
– Increase in cerebral venous pressure
– Platelet dysfunction
– Coagulation disturbances
• Vascular factors
– Tenuous involuting capillaries with large
diameter lumen
• Extra vascular factors
– Deficient vascular support
– Excessive fibrinolytic activity
CLINICAL FEATURES
In the preterm newborn
• Usually clinically silent
• Decreased levels of consciousness and
spontaneous movement
• Hypotonia
• Abnormal eye movement
• Skew deviation
In term newborns
• Seizures
• Irritability
• Apnea
• Lethargy
• Vomiting with dehydration
• Full fontanels
DIAGNOSIS
• Cranial ultra sonography
• CT or MRI
MANAGEMENT
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Prevention
Supportive care
Careful monitoring
Surgical intervention
NERVE INJURY
BRACHIAL PLEXUS INJURY
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Erb’s palsy
Klumpke’spalsy
Injury to the upper plexus,
Erb-Duchenne paralysis
BRACHIAL PLEXUS INJURY
• Risk factors
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Macrosomia
shoulder dystocia
instrumented deliveries
malpresentation
ERB-DUCHENNE PARALYSIS
• 5th and 6th cervical nerves injury
• The infant loses the power to abduct the
arm from the shoulder, rotate the arm
externally, and supinate the forearm
• Erb’s palsy may also be associated with
injury to the phrenic nerve,
which is innervated with
fibers from C3–C5
• Adduction and internal rotation of the arm
with pronation of the forearm.
• Biceps reflex is absent
• Moro reflex is absent on the affected side.
• The involved arm is held in the ‘‘waiter’s
tip’’ position, with adduction and internal
rotation of the shoulder, extension of the
elbow, pronation of the forearm, and
flexion of the wrist and fingers.
KLUMPKE’SPALSY
• Involves the C8 and T1 nerves, resulting in
weakness of the intrinsic hand muscles
and long flexors of the wrist and fingers
• The grasp reflex is absent but the biceps
reflex is present.
• Flaccid extremity with absent reflexes.
ASSOCIATED LESIONS
• Hematomas of the sternocleidomastoid
muscle, and fractures of the clavicle and
humerus.
• Ipsilateral Horner’s syndrome
(ptosis, miosis, and anhydrosis) when
there is accompanying injury to the
sympathetic fibers of T1.
TYPES
• Neuropraxia with temporary conduction
block
• Axonotmesis with a severed axon, but with
intact surrounding neuronal elements
• Neurotmesis with complete postganglionic
disruption of the nerve
• Avulsion with preganglionic disconnection
from the spinal cord
DIAGNOSIS
• Physical examination.
• Radiographs of the shoulder and upper
arm
MANAGEMENT
• Initial treatment is conservative.
• The arm is immobilized across the upper
abdomen during the first week
• Physical therapy with passive range-ofmotion exercises at the shoulder, elbow
and wrist should begin after the first week.
• Infants without recovery by 3 to 6 months
of age may be considered for surgical
exploration
FACIAL NERVE PALSY
(BELL’S PALSY)
• Risk factors
– forceps delivery
– prolonged second stage of labor
Clinical manifestations
• weakness of both upper and lower facial
muscles.
• At rest, the nasolabial fold is flattened and
the eye remains persistently open on the
affected side.
• During crying, there is inability to wrinkle
the forehead or close the eye on the
ipsilateral side, and the mouth is drawn
awayfrom the affected side.
• lacerations and bruising
• neurologic findings
TREATMENT
• protection of the involved eye by
application of artificial tears and taping to
prevent corneal injury.
• neurosurgical repair of the nerve should
be considered only after lack of resolution
during 1 year of observation
PHRENIC NERVE INJURY
• The phrenic nerve arises from the third
through fifth cervical nerve roots.
• Injury to the phrenic nerve leads to
paralysis of the ipsilateral diaphragm.
CLINICAL MANIFESTATIONS
• respiratory distress, with diminished breath
sounds on the affected side.
• Chest radiographs show elevation of the
affected diaphragm, with mediastinal shift
to the contralateral side.
• Ultrasonography or fluoroscopy can
confirm the diagnosis by showing
paradoxical diaphragmatic movement
during inspiration
TREATMENT
• Initial treatment is supportive
• Oxygen
• Respiratory failure may be treated with
continuous positive airway pressure or
mechanical ventilation.
• Gavage feedings.
• Plication of the diaphragm
LARYNGEAL NERVE INJURY
• Symptoms
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Stridor
respiratory distress
hoarse cry
dysphagia,
Aspiration
• Diagnosis is made by direct
laryngoscopy
Treatment
• Small frequent feedings may be required
to decrease the risk of aspiration.
• Intubation
• Tracheostomy
• Bilateral paralysis tends to produce more
severe distress, and therefore requires
intubation and tracheostomy placement
more frequently
SPINAL CORD INJURY
• Clinical findings
• decreased or absent spontaneous
movement
• absent deep tendon reflexes
• absent or periodic breathing
• lack of response to painful stimuli below
the level of the lesion.
• Lesions above C4 are almost always
associated with apnea
• Lesions between C4 and T4 may have
respiratory distress secondary to varying
degrees of involvement of the phrenic
nerve and innervation to the intercostal
muscles
MANAGEMENT
• If cord injury is suspected in the delivery
room, the head, neck, and spine should be
immobilized.
• Therapy is supportive.
FACIAL INJURIES
NASAL SEPTAL
DISLOCATION
• Nasal septal dislocation involves
dislocation of the triangular cartilaginous
portion of the septum from the vomerine
groove
CLINICAL FEATURES
• airway obstruction.
• deviation of the nose to one side
• The nares are asymmetric, with flattening
of the side of the dislocation (Metzenbaum
sign).
• Application of pressure on the tip of the
nose (Jeppesen and Windfeld test) causes
collapse of the nostrils, and the deviated
septum becomes more apparent.
MANAGEMENT
• Definitive diagnosis can be made by
rhinoscopy
• manual reduction performed by an
otolaryngologist using a nasal elevator.
• Reduction should be performed by 3 days
of age
OCULAR INJURIES
• Rupture of Descemet’s membrane of the
cornea
• lid lacerations
• hyphema (blood in anterior chamber)
• vitreous hemorrhage
• Purtscher’s retinopathy
• corneal edema,
• corneal abrasion
CONGENITAL MUSCULAR
TORTICOLLIS
• atrophic muscle fibers surrounded by
collagen and fibroblasts.
• tearing of the muscle fibers or fascial
sheath with hematoma formation and
subsequent fibrosis.
CLINICAL FEATURES
• The head is tilted toward the side of the
lesion and rotated to the contralateral side,
• chin is slightly elevated.
• If a mass is present, it is firm, spindleshaped, immobile, and located in the
midportion of the sternocleidomastoid
muscle, without accompanying
discoloration or inflammation.
DIAGNOSIS
• physical examination
• Radiographs should be obtained to rule
out abnormalities of the cervical spine.
• Ultrasonography may be useful both
diagnostically and prognostically.
TREATMENT
• active and passive stretching
• surgery
FRACTURES
CLAVICULAR FRACTURE
• clavicle is the most frequently fractured
bone during birth
Risk factors
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higher birth weight
prolonged second stage of labor
shoulder dystocia
instrumented deliveries
MANAGEMENT
• Asymptomatic incomplete fractures require
no treatment.
• Complete fractures are treated with
immobilization of the arm for 7 to 10 days
LONG BONE FRACTURES
Risk factors
• breech presentation
• cesarean delivery
• low birthweight
CLINICAL FEATURES
• decreased movement of the affected
extremity, swelling, pain with passive
movement, and crepitus
DIAGNOSIS
• Diagnosis is made radiographically
• Ultrasonography
TREATMENT
• immobilization and splinting
• Closed reduction and casting are required
only when the bones are displaced.
• Proximal femoral fractures may require a
spica cast or use of a Pavlik harness
INTRA-ABDOMINAL INJURY
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Liver injury is the most common
Three potential mechanisms lead to intraabdominal injury:
(1) direct trauma,
(2) compression of the chest against the
surface of the spleen or liver
(3) chest compression leading to tearing of
the ligamentaous insertions of the liver or
spleen
CLINICAL MANIFESTATIONS
• With hepatic or splenic rupture, patients
develop sudden pallor, hemorrhagic
shock, abdominal distention, and
abdominal discoloration.
• Presentation of a liver rupture with scrotal
swelling and discoloration has been
described.
• Subcapsular hematomas may present
more insidiously, with anemia, poor
feeding, tachypnea, and tachycardia.
• Adrenal hemorrhage may present as a
flank mass
DIAGNOSIS
• abdominal ultrasound
• Computed tomography
• Abdominal radiographs may show
nonspecific intraperitoneal fluid or
hepatomegaly.
• Abdominal paracentesis is diagnostic if a
hemoperitoneum is present
TREATMENT
• volume replacement and correction of any
coagulopathy.
• If the infant is hemodynamically
stable, conservative management is
indicated.
• With rupture or hemodynamic instability, a
laparotomy is required to control the
bleeding.
• Patients with adrenal hemorrhage may
require hormone replacement therapy.
SOFT TISSUE INJURIES
• Petechiae and ecchymoses
• Lacerations and abrasions
• Subcutaneous fat necrosis