DEPARTMENT OF PEDIATRICS WITH COURSE
OF MEDICAL GENETICS
LECTURE:
“Birth trauma”
Determination
Birth trauma is a damage of fetus
tissues and organs during birth, caused
by pathology of antenatal or intranatal
period.
Groups of birth traumas:
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Birth trauma of CNS.
Birth trauma of spinal cord and peripheral nervous
system.
Birth trauma of soft tissues(birth tumour, hemorrhage
under aponeurosis, cephalhematoma).
Birth trauma of skin(scratch, wound, bubbles with
haemorrhagic content, haematomas) and hypodermic
cellulose (adiponecrosis).
Birth trauma of muscles.
Birth trauma of bones(break of collar-bone., thighs etc.).
Birth trauma of internal organs (liver, kidneys rupture)
Birth trauma of CNS
(intracranial hemorrhage)
1.
2.
3.
4.
5.
6.
Types of intracranial hemorrhages:
- Intraventricular hemorrhage (peri- and
intraventricular)
- Subarachnoidal hemorrhages
- Subdural hemorrhages
- Epidural hemorrhages
- Parenchymatous hemorrhages
- Cerebella hemorrhages
Birth trauma of CNS (intracranial hemorrhage)
Etiology and pathogenesis
 Birth traumatism
The direct factor of the birth trauma of CNS development is the
mechanical influencing as a result of:
v disparities of mother’s pelvis size and size of the fetus head (large fetus,
narrow pelvis)
v
swift or protracted births
v
wrong executed obstetric manipulations and operations (imposition of
obstetric tongs)
More frequently epidural, subdural, intraventricular hemorrhages of the
III-IV stages have traumatic genesis.
 Perinatal hypoxia and related to it haemodinamic (hypotension)
and metabolic (acidosis, excessive activating of LP) violations
Child, that had chronic antenatal hypoxia in past, can have ICH even at the normal
birth course, because hypoxia and birth trauma are connected according to
pathogenic factors. Correlation of the traumatic and hypoxic hemorrhages into the
brain is 1:10.
More frequently intraventricular hemorrhages of the I-II stages and petechial
hemorrhages into the gray matter have hypoxic genesis.
Birth trauma of CNS (intracranial hemorrhage)
Etiology and pathogenesis
 Perinatal features of coagulative and thrombocytal hemostasis
(deficit of vitamin-К-dependent factors), especially for prematurely
born children
As a result of coagulative, anticoagulative and fibrinolytic systems
disbalance children are inclinated to appearance of the ischemic trombotic defeat of the cerebrum and PVL.
 Prematurity and morphological-functional immaturity
75% of the premature children have intraventricular hemorrhages of
different stages as a result of presence of germinal (embryonic) matrix
at the organisms of children that have less than 35 weeks of gestational
age. The vessels bloodstream in the germinal matrix depends on the
system arterial pressure changes: at the increase of arterial pressure
there is an overflow of the microcirculation and the ICH appear, in case
of hypotension there is an ischemia of cerebral tissues, renewal of
bloodstream in ischemic areas can cause a hemorrhage.
Birth trauma of CNS (intracranial hemorrhage)
Etiology and pathogenesis
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Prenatal infections (defeats of vascular wall)
 Inefficient care (hypothermia, inobservance of
the medical-protection mode)
 Iatrogenic influencing (rapid i/v infusions,
excessive oxygen therapy, overdosing of
anticoagulants and antiaggregants)
Birth trauma of CNS
(intracranial hemorrhage)
Typical clinical manifestations:
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Sudden worsening of the general state
Change of scream character (“cerebral scream”)
Bulging of the large fontanel
Local eye symptoms
Violations of thermoregulation
Vegeto-visceral and pseudobulbar disorders
Motive disorders
Cramps
Disorders of muscle tone
Posthemorragic anaemia
Metabolic violations
Addition of somatic diseases
Intraventricular hemorrhages
Clinics:
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Flaccidity, adynamy
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Bulging of the large fontanel
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Decrease of the muscle tone
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Disappearance of the sucking and swallowing reflexes
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Attacks of аpnoe, respiratory disturbance
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Local neurological symptoms (paresis of vision,
permanent nystagmus, symptom of Grefe)
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Arterial pressure and tachycardia decrease
Intraventricular hemorrhages
Diagnostics:
Liquor analysis: hemorrhagic character, cytosis to 1000 cells in 1
mcl, the amount of protein increases. In a few days after the
hemorrhage liquor becomes xantochromic, the concentration of
sugar goes down.
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Neurosonography:
PVH of the I stage - subepindemal hemorrhage in the germinal
matrix
PVH of the II stage - breach of hemorrhage in the cerebral ventricles
without dilatation
PVH of the III stage- intraventricular hemorrhage with the ventricles
dilatation
PVH of the IV stage– intraventricular and parenchymatous
hemorrhages
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Doppler: bloodstream fluctuation
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ECG: focal changes, paroxysmal activity
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Subarachnoidal hemorrhages
Clinics:
1.
2.
3.
Hyperexcitability ( anxiety, cerebral scream,
inversion of sleep, increase of motive activity,
hypertension, increase of muscle tone).
Liquor-hypertension syndrome (throwing back of
head, cramps, rigidity of the occiput muscles ,
bulging of the large fontanel, skull gaping,
pathological increase of the head circumference).
Local neurological symptoms (strabismus,
nistagmus, anisocoria, symptom of Grefe, violation
of swallowing).
Subarachnoidal hemorrhages
Diagnostics:
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Lumbar puncture and liquor analysis (executed
necessarily): haemorrhagic or xantochromic character,
high cytosis, the protein amount increases.
Neurosonography: local expansion and
hyperechogenicity of the sulci of Silviev and
interhemispheric fissure. The most frequent hemorrhage
localization is the parietal-temporal area of cerebrum and
cerebellum hemispheres
Subdural hemorrhages
Clinics of supratentorial hemorrhages:
Supratentorial hemorrhages are caused by damages of sagittal sine and
veins, that enter it.
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Period of “imagine prosperity” of 2-3 days
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Liquor- hypertension syndrome (throwing back of head, cramps,
bulging of the large fontanel, skull gaping, pathological increase of the
head circumference)
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Symptoms of distribution of cerebrum middle structures (anxiety,
rigidity of the occiput muscles, mydriasis on the defeat side, paresis of
look)
Clinics of supratentorial hemorrhages:
Supratentorial hemorrhages are caused by break of the tentorium of
cerebellum and hemorrhage into back cranial fossa.
The state of child is heavy from the moment of birth with further
appearance of symptoms of brainstem squeezing (violation of suction
and swallowing, anisocoria, nistagmus, cramps). A pallor, flaccidity,
disorders of breathing, bradycardia, muscle hypotonia, hyporeflexia
grow in a dynamics.
Subdural hemorrhages
Diagnostics:
NSG: uneven strengthening of echogenicity of the tentorium
of cerebellum, thrombus in the back cranial fossa, local
expansion and hyperechogenicity of the interhemispheric
fissure, displacement of interhemispheric fissure,
compression of lateral ventricles.
Epidural hemorrhages
Clinics:
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Epidural hemorrhages more frequently appear in case of
mature children, if there was the damage of the skull
bones. Their typical location is between the pachymeninx
and skull bones, they combine with cephalohematomas.
Period of “imagine prosperity” 3-6 hours
Hyperexcitability, acute anxiety
Cramps
Mydriasis on the side of defeat, hemiparesis on an
opposite side
Stagnant disks of optic nerve
Example of diagnosis of ICH:
Birth trauma of CNS: periventricular hemorrhage
of the I stage, acute period, severe course,
convulsive syndrome.
Main principles of treatment of ICH are
similar that perinatal defeats of CNS
Features of the ICH treatment
1.
2.
3.
4.
Monitoring of basic vital functions parameters (AP, pulse,
BF, T of the body, diuresis, body weight, amount of
entered liquid, transcutaeus pulsoxymetry, biochemical
indexes).
Haemostatic therapy – indicated to all new-born with
ICH.
The usage of preparations of complex action is obligatory
(actovegin i/vdroplet or i/m of 1 ml 1 time a day).
In the period of rehabilitation – application of resorbtive
therapy (lydasa) and nootrops is necessary.
Birth traumas of spinal cord and peripheral nervous
system
Etiology
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Reasons of spinal cord defeat
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Forced increase of distance between shoulders and skull base caused by:
Breech presentation
Difficulties at remove of head or shoulders of a child
Traumatic remove of head during the operation of caesarian section
Imposition of obstetric forceps
Use of receptions of Covyanov
Excessive compression in births along a spine.
Reasons of the peripheral nervous system defeat
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Wrong executed obstetric manipulations, that cause the defeats of peripheral
motoneuron with further violation of muscles function.
Birth traumas of spinal cord and peripheral nervous
system
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Pathogenesis
Damages of spine (distribution of the neck
vertebrae, compression break of vertebral body)
Hemorrhage in a spinal cord and its membranes
An ischemia in the vertebral arteries basin
Damage of intravertebral disks
Edema, haematomas and sprains, breaks of spinal
bone-muscle- ligamentous apparatus.
Clinics of spinal cord birth traumas
Damage of upper neck segments (C1-C4):
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Spinal shock
Spastic tetraparesis
SDR
Vasomotoric violations
Central disorders of urination
Diaphragm paresis (C3-C4):
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Dyspnea, paradoxical breathing
Attacks of cyanosys
Skewness of thorax, lag in the act of breathing of the staggered half of thorax.
At auscultation – diminished breath sounds on the side of paresis
At Rö-research– a high location of diaphragm dome, displacement of
mediastinum to a healthy side.
Clinics of spinal cord birth traumas
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Damage of thorax (T1-T12):
Thorax falls back during inhalation
Respiratory insufficiency
Spastic paresis of lower extremities
The loss of all types of sensitiveness below the defeat
level
Central disorders of urination
Damage of lumbosacral area:
Flaccid paresis of lower extremities
Violations of the pelvic organs functions
In the sequel –the wrong forming of gluteus muscles,
atrophy of muscles of lower extremities.
Clinics of birth traumas of the peripheral nervous
system
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Upper paralysis of Erb:
Typical position of extremity (a hand is clasped to the
trunk, turned inward in a shoulder, pronated in a forearm,
manus in a state of palm's bending, shoulder is dropped, a
head is inclined to the damaged shoulder)
Impossibility of abduction of shoulder
Absence of spontaneous motions in humeral and elbow
joints
Impossibility of bending of forearm
Absence of Moro reflex on the defeat side
Hypotonia of the hand muscles
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Symptom of “doll’s hand”
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Clinics of birth traumas of the peripheral nervous
system
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Lower paralysis of Klumpke:
Typical position of manus (a manus hangs down or is in
position of clawhand (griffin claw) – in case of the defeat
of radial nerve, “seal paw” - at the defeat of elbow nerve)
Absence of motions in an elbow and radiocarpal joints
Motions in a humeral joint are saved
Limitation of reflex of Moro on the side of defeat,
absence of reflex of Babkin, grasping reflex
Edema of the manus, a manus is cold to the feel.
Symptom of Horner (ptosis, miosis, enophtalmus) on the
defeat side
Clinics of birth traumas of the peripheral nervous
system
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Total obstetric paralysis of upper extremity:
Hypotonia of the hand muscles
Hand hanging down along a trunk
Absence of spontaneous motions
Absence of Moro’s, Babkin’s, grasping reflexes on
the side of defeat
Pallor of the hand skin, a hand is cold to the feel
Absence of pain sensitiveness
Craniospinal birth trauma
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Combined trauma of brain (ICH) and spinal brain, caused by the
action of the force vector to the turnings around the spine axis.
Patomorphologic changes:
Spasm of vertebral arteries, ischemia of vertebro-basilar area
Edema of brainstem and cerebellum
Ischemia-hypoxia
Hemorrhagies
Circulatory ischemic necrosises
Clinical syndromes of the acute period:
Spinal shock
SDR
Gross violations of haemodynamics
Cramps
Hearth neurological symptoms
Syndrome of suppression or excitation of CNS
Examples of diagnoses
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Craniospinal birth trauma: birth trauma of CNS, PVH of
the II stage, spinal birth trauma, damage of upper neck
segments (C1-C4), acute period, severe course, syndrome
of vegetovisceral disorders, spastic tetraparesis.
Birth trauma of thorax (T1-T12) of spinal cord, acute
period, moderate severety, spastic paresis of lower
extremities
Birth trauma of the peripheral nervous system, lower
paralysis of Dezherin-Klyumpke, period of rehabilitation,
easy course, syndrome of motive violations
Treatment of spinal birth trauma and trauma of
the peripheral nervous system in the acute period
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Immobilization of head and neck or staggered extremity
Anaesthetic therapy (0,01 ml50% solution of analgin 2 times per
day intramuscular, 0,1 mgs/kg 0,25% solution of droperidol 2
times per day intravenously slowly, 1 ml/kg 0,25% solution of
novocaine 2 times per day intravenously slowly)
Oxygen therapy
Correction of muscle hypotonia (0,5% solution of galantamin
0,18 mgs/kg hypodermic 1 time a day, 0,05% solution of
proserinum 0,009 mgs/kg intramuscular 1 time a day)
Improvement of processes of myelinization (vitamins V1, V6, 5
mgs/kg intramuscular 1 time a day)
Syndromal therapy (correction of SDR, vegetovisceral violations
etc.) at a spinal trauma
Treatment of perinatal defeat of CNS and birth
trauma in a period of rehabilitation
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Complexity of treatment (the joint participating in
treatment of neurologist, orthopaedist, oculist, doctor
MPC, psychologist, speech therapist, teacher).
Orthopaedic measures warns the development of
anomalous poses, contractures in the child’s organism.
Medical gymnastics and massage.
Stimulation of psychical and vocal development.
Physical therapy treatment: electrophoresis with
anticholiesterasis preparations (galantamin, proserin),
preparations, that improve bloodcirculation in the
vertebrobasilar system ( nicotine acid, aminophylline),
resolving preparations (lidasa, aloe), hydrotherapy,
paraffin-, ozoceritotherapy, hot woolen wrappings.
Thanks for your attention!