Fetal intracranial hemorrhage: sonographic criteria and merits of prenatal diagnosis

Findings of Reduced Head Circumference with COVID-19 Infection in the Third Trimester: A Retrospective Cohort Study

Background: COVID-19 is linked to multiple adverse pregnancy outcomes but with inconsistent evidence associating the disease with fetal growth restriction (FGR) and small for gestational age (SGA). There are limited data on the impact of COVID-19 on neonatal growth measurements, specifically microcephaly without SGA or low birth weight. We hypothesize that COVID-19 is associated with smaller neonatal head measurements without increasing the risk of small for gestational age. This relationship may be related to the timing of COVID-19 exposure in pregnancy. Methods: An Institutional Review Board (IRB) approved retrospective cohort study enrolled 140 COVID-19-infected and 136 COVID-19-uninfected patients. Inclusion criteria: (a) singleton birth between 28 April 2020 and 31 December 2022; and (b) maternal COVID-19 infection diagnosed via polymerase chain reaction (PCR). Exclusion criteria: Less than 12 years of maternal age, major fetal anomalies, and fetal loss < 15 weeks. The outcomes were a comparison of newborn growth measurements (length, weight, and head circumference (HC) at birth), Ponderal Index (PI), and development of SGA between SARS-CoV-2-infected and uninfected patients. Maternal and neonatal characteristics were descriptively summarized, and multivariate analyses and linear regression models were performed. Baseline maternal demographics did not differ amongst cohorts. Results: Compared to the uninfected cohort, COVID-19 diagnosed in the third trimester was associated with a lower neonatal HC compared to newborns of uninfected patients (β = -0.38 [0.38 SD lower], 95% CI -0.65 to -0.10, p = 0.024). There was no significant difference among cohorts in birth length, weight, or diagnosis of small for gestational age. Conclusions: We found that COVID-19 infection in the third trimester was associated with a lower neonatal head circumference without associated SGA. The cause underlying this association is unknown. Further research to determine the risk of neurotropic fetal infection by SARS-CoV-2, like ZIKA's effect on the fetal immune system leading to microcephaly, is urgently needed.

Fetal intracranial hemorrhage and infarct: Main sonographic and MRI characteristics: A review article

Early detection of fetal intracranial hemorrhage and infarct during pregnancy is crucial for preventing lethal and debilitating complications in neonatal life. Every radiologist must be aware of the imaging features of these conditions to refer patients to specialists. Sonographic and MRI features of fetal intracranial hemorrhage and infarct have been discussed in many previous articles. The aim of this article is to organize and categorize these findings into a practical guideline for improved application in diagnosing these diseases. The use of MRI sequences, such as DWI and multiplanar EPI should be developed for suspected prenatal infarct and intracranial hemorrhage and can serve as additional tools for early detection. In this review article, we first explain possible etiologic factors contributing to the development of fetal IVH and infarct. Then we discuss the different imaging features of these disorders on sonography and MRI separately, as well as their differential diagnosis. Finally, the mortality and morbidity associated with these two concerning fetal abnormalities will be addressed.

Prenatal sonographic diagnosis and postnatal outcomes of fetal intracranial hemorrhage: Two case report

Intracranial hemorrhage (ICH) in pregnancy, estimated at 1 in 10,000 cases, presents significant diagnostic challenges prenatally despite advanced imaging techniques such as ultrasonography (US) and magnetic resonance imaging (MRI). Detecting ICH is crucial for pregnancy management and future treatment decisions aimed at improving fetal survival and reducing brain damage. This report presents the diagnosis and outcomes of 2 cases of prenatal ICH. The first case involves a 30-year-old pregnant woman with irregular prenatal care diagnosed with ICH at 32 weeks of gestation via US and MRI. She chose to continue the pregnancy, delivering a 3160 g male infant at 36 weeks via cesarean section. Following NICU care including resuscitation and ventriculoperitoneal shunt placement, the infant was discharged. Subsequent examinations showed a reduction in ventricle size. In the second case, a 27-year-old woman taking acenocoumarol for a mechanical heart valve developed fetal subdural hemorrhage detected by US and MRI. She opted to terminate the pregnancy, resulting in a stillborn male infant weighing 1530 g. Fetal ICH presents with varying severity and prognostic implications, diagnosed and graded using US. Fetal cranial MRI may help clarify the etiology. Management remains controversial, with termination of pregnancy potentially warranted in severe cases due to poor prognosis. Further research is needed to refine management and improve outcomes in fetal ICH.

Prenatal diagnosis and postnatal outcome of fetal intracranial hemorrhage: a single-center experience

OBJECTIVE

To assess prenatal ultrasonographic findings and postnatal outcomes in fetuses with intracranial hemorrhage (ICH).

METHODS

This retrospective study included fetuses prenatally diagnosed with ICH between December 2012 and August 2023. Maternal characteristics, prenatal ultrasonographic findings, and postnatal outcomes were reviewed.

RESULTS

Twenty-seven fetuses with ICH were reviewed. Intracranial hemorrhage was classified as grade 3 and 4 in 24 fetuses. Twenty-two fetuses had ICH, four had ICH with subdural hemorrhage, and one had ICH with subarachnoid hemorrhage. Ventriculomegaly was the most common ultrasonographic finding, and was observed in 22 of the 27 (81.5%) fetuses. Seven fetuses were lost to follow-up, and four intrauterine fetal deaths occurred. The remaining 16 fetuses were delivered at a median gestational age of 35+2 weeks. The infants were followed-up for 40.1 months (range, 4-88). Nine of the 16 infants underwent ventriculoperitoneal placement. One infant underwent brain surgery for severe epilepsy. Motor impairment, including cerebral palsy, was observed in 13 infants (81.2%). Neurologic impairment occurred in six infants (37.5%), developmental delay in nine (56.2%), and epilepsy in 11 (68.7%).

CONCLUSION

Fetal ICH is a rare complication diagnosed during pregnancy, which results in subsequent fetal neurological sequelae or death. This study demonstrated that the common ultrasonographic findings in fetal ICH were progressive ventriculomegaly and increased periventricular echogenicity. Fetuses diagnosed with prenatal ICH, especially those affected by higher-grade ICH, may be at an increased risk of long-term neurodevelopmental problems.

The association between fetal intracranial hemorrhages detected on MRI and neurodevelopment

PURPOSE

Fetal intracranial hemorrhage is rarely identified in prenatal imaging. When identified, sparse data regarding neurodevelopmental outcomes worsens prenatal dilemmas. This MRI-based study aimed to assess prenatal characteristics and neurodevelopmental outcomes of fetal intracranial hemorrhage.

METHODS

A historical cohort study which identified fetal intracranial hemorrhage in 22 individual fetal MRI scans, as part of the assessment of abnormal prenatal sonographic findings. Severity was graded by the grading system commonly used in neonates, with modifications. Prenatal data was collected. Neurodevelopmental outcome was assessed clinically by Vineland-II Adaptive Behavior Scales.

RESULTS

Eight fetuses had intraventricular hemorrhage grade I-II, twelve had intraventricular hemorrhage grade III-IV, and two had infratentorial hemorrhage. The most prevalent risk factors were maternal chronic diseases and chronic use of medications. There was male predominance. Pregnancy was terminated in eleven cases. No surviving child who participated in the Vineland assessment had a grade IV hemorrhage. Vineland scores were normal in 9/11 children and moderately low in 2/11. The mean composite score of the cohort was not different from the mean score expected for age. Clinically, one child had hypotonia.

CONCLUSIONS

Prognosis for fetuses with ICH without parenchymal involvement is potentially more favorable than expected from the intraventricular hemorrhage grading-scale adopted from the preterm neonates. Parenchymal involvement may predict a worse outcome, but it is not the sole predicting feature. This information may be valuable during prenatal counseling.

SARS-CoV-2 Infection in the Second Trimester of Pregnancy: A Case Report of Fetal Intraventricular Hemorrhage After Critical COVID-19 Infection and a Brief Review of the Literature

More than three and a half years have passed since the start of the coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and there have been several studies in the literature about the different damage and symptom patterns related to the condition; particular attention has been paid to the transmission of the disease from pregnant mothers to fetus. In this report, we present the case of a 36-year-old patient with a history of two cesarean sections (CS), two miscarriages, and hypothyroidism on replacement therapy, who contracted COVID-19 during the 15th week of gestation. Ultrasound (US) examination at 22 weeks revealed regular fetal biometry and bilateral ventriculomegaly, highly suggestive of massive intracerebral hemorrhage. The patient opted for the interruption of pregnancy. Given the critical maternal COVID-19 complications, especially tracheoesophageal fistula and the patient's two previous cesareans, we decided on an abortive CS at 23 weeks of gestation, and the samples were sent to the Pathology Department. Histologic analysis showed massive intervillous deposition of fibrin and inflammatory infiltration with hotspots of necrotic deciduitis and confirmed massive cerebral hemorrhage in the fetus. This morphological appearance was consistent with COVID-19 infection and probable fetal oxygenation compromise related to deciduitis. Immunoexpression of anti-SARS-CoV-2 S1 antibody was almost entirely positive at the level of syncytiotrophoblast cells and maternal leukocytes in the absence of a clear signal in the fetal circulation. Conversely, in the brain, immunoexpression of angiotensin-converting enzyme 2 (ACE2) and the S1 subunit of the spike protein of SARS-CoV-2, detected by a monoclonal antibody, was almost entirely negative, suggesting that there was no infection in the brain and that the massive intraventricular hemorrhage was probably a secondary effect of placental damage.

Cerebral Lateral Ventricular Asymmetry: Normal Variant or an Indicator of Underlying Pathology

INTRODUCTION

Isolated lateral ventricular asymmetry has been associated with a favorable prognosis; however, prenatal evaluations in existing studies have been conducted using ultrasonography (US). This study aimed to describe the magnetic resonance imaging (MRI) findings, progression of ventricular asymmetry, and perinatal outcomes in fetuses prenatally diagnosed with isolated ventricular asymmetry.

METHODS

This retrospective study included patients who underwent MRI for isolated fetal ventricular asymmetry at a tertiary center between January 2012 and January 2020. Information, including pregnancy history, US, MRI findings, and perinatal outcomes, was obtained from medical records.

RESULTS

The study cohort included 17 women with fetal ventricular asymmetry but without ventriculomegaly at the time of index US. Mild ventriculomegaly subsequently developed in 13 patients; 12 of them showed spontaneous resolution before delivery. MRI identified low-grade intraventricular hemorrhage (IVH) in 13 fetuses. Postnatally, 12 newborns underwent neonatal cranial US where two of them showed evidence of germinal matrix hemorrhage. Both newborns appeared normal at birth without neonatal complications.

CONCLUSION

MRI identified low-grade IVH in most fetuses with isolated ventricular asymmetry. These fetuses were also likely to develop mild ventriculomegaly with spontaneous resolution. Although perinatal outcomes appeared good, careful follow-up in both prenatal and postnatal periods is warranted.

Perinatal and long-term outcome of fetal intracranial hemorrhage: systematic review and meta-analysis

OBJECTIVE

Fetal intracranial hemorrhage (ICH) is associated with an increased risk of perinatal mortality and morbidity. Healthcare professionals often find it challenging to counsel parents due to its rarity and diverse presentation. The aim of this systematic review and meta-analysis was to investigate the perinatal outcome of fetuses with ICH.

METHODS

MEDLINE, EMBASE, ClinicalTrials.gov and The Cochrane Library databases were searched. Inclusion criteria were studies reporting the outcome of fetuses, newborns and infants diagnosed with ICH. The primary outcome was perinatal death (PND), defined as the sum of intrauterine (IUD) and neonatal death (NND). The secondary outcomes were stillbirth, NND, IUD, termination of pregnancy, need for surgery/shunting at birth, cerebral palsy (defined according to the European Cerebral Palsy Network and classified as diplegia, hemiplegia, quadriplegia, dyskinetic or mixed), neurodevelopmental delay and intact survival. All outcomes were explored in the included fetuses with ICH. A subgroup analysis according to the location of the hemorrhage (intra-axial and extra-axial) was also planned. Meta-analysis of proportions was used to combine data, and pooled proportions and their 95% CI were reported.

RESULTS

Sixteen studies (193 fetuses) were included in the meta-analysis. PND occurred in 14.6% (95% CI, 7.3-24.0%) of fetuses with ICH. Among liveborn cases, 27.6% (95% CI, 12.5-45.9%) required shunt placement or surgery after birth and 32.0% (95% CI, 22.2-42.6%) had cerebral palsy. Furthermore, 16.7% (95% CI, 8.4-27.2%) of cases had mild neurodevelopmental delay, while 31.1% (95% CI, 19.0-44.7%) experienced severe adverse neurodevelopmental outcome. Normal neurodevelopmental outcome was reported in 53.6% of fetuses. Subgroup analysis according to the location of ICH showed that PND occurred in 13.3% (95% CI, 5.7-23.4%) of fetuses with intra-axial bleeding and 26.7% (95% CI, 5.3-56.8%) of those with extra-axial bleeding. In fetuses with intra-axial hemorrhage, 25.2% (95% CI, 11.0-42.9%) required shunt placement or surgery after birth and 25.5% (95% CI, 15.3-37.2%) experienced cerebral palsy. In fetuses with intra-axial hemorrhage, mild and severe neurodevelopmental delay was observed in 14.9% (95% CI, 12.0-27.0%) and 32.8% (95% CI, 19.8-47.4%) of cases, respectively, while 53.2% (95% CI, 37.0-69.1%) experienced normal neurodevelopmental outcome. The incidence of mortality and postnatal neurodevelopmental outcome in fetuses with extra-axial hemorrhage could not be estimated reliably due to the small number of cases.

CONCLUSIONS

Fetuses with a prenatal diagnosis of ICH are at high risk of perinatal mortality and adverse neurodevelopmental outcome. Postnatal shunt placement or surgery was required in 28% of cases and cerebral palsy was diagnosed in approximately one-third of infants. Due to the rarity of ICH, multicenter prospective registries are warranted to collect high-quality data. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Prenatal Evaluation of Intracranial Hemorrhage on Fetal MRI: A Retrospective Review

BACKGROUND AND PURPOSE

The evaluation and characterization of germinal matrix hemorrhages have been predominantly described on postnatal head sonography in premature neonates. However, germinal matrix hemorrhages that are seen in premature neonates can be also seen in fetuses of the same postconceptual age and are now more frequently encountered in the era of fetal MR imaging. Our aim was to examine and describe the MR imaging findings of fetuses with intracranial hemorrhage.

MATERIALS AND METHODS

A retrospective review of diagnostic-quality fetal MRIs showing intracranial hemorrhage from January 2004 to May 2020 was performed. Images were reviewed by 2 radiologists, and imaging characteristics of fetal intracranial hemorrhages were documented. Corresponding postnatal imaging and clinical parameters were reviewed.

RESULTS

One hundred seventy-seven fetuses with a mean gestational age of 25.73 (SD, 5.01) weeks were included. Germinal matrix hemorrhage was identified in 60.5% (107/177) and nongerminal matrix hemorrhage in 39.5% (70/177) of patients. Significantly increased ventricular size correlated with higher germinal matrix hemorrhage grade (P < .001). Fetal growth restriction was present in 21.3% (20/94) of our population, and there was no significant correlation with germinal matrix grade or type of intracranial hemorrhage. An increased incidence of neonatal death with grade III germinal matrix hemorrhages (P = .069) compared with other grades was identified; 23.2% (16/69) of the neonates required ventriculoperitoneal shunts, with an increased incidence in the nongerminal matrix hemorrhage group (P = .026).

CONCLUSIONS

MR imaging has become a key tool in the diagnosis and characterization of intracranial hemorrhage in the fetus. Appropriate characterization is important for optimizing work-up, therapeutic approach, and prenatal counseling.

Antenatal diagnosis of fetal intraventricular hemorrhage: systematic review and meta-analysis

AIM

To determine how the severity of antenatally diagnosed germinal matrix-intraventricular hemorrhage (GMH-IVH) relates to morbidity and mortality, and to explore potential risk factors.

METHOD

We conducted a systematic review and individual patient data meta-analysis of antenatally diagnosed fetal GMH-IVH. The primary outcomes were mortality and morbidity. Potential associations with clinical factors during pregnancy were explored. Analysis employed Fisher's exact test and logistic regression.

RESULTS

We included 240 cases from 80 studies. Presence of venous infarction was associated with mortality (odds ratio [OR] 4.3, 95% confidence interval [CI] 1.4-13.25), motor impairment (OR 103.2, 95% CI 8.6-1238), epilepsy (OR 6.46, 95% CI 2.64-16.06), and developmental delay (OR 8.55, 95% CI 2.12-48.79). Shunt placement was associated with gestational age at GMH-IVH diagnosis and in utero progression. Many cases had uncomplicated pregnancies but possible co-occurring conditions included twin gestation, small for gestational age, and congenital anomalies.

INTERPRETATION

Severity of fetal GMH-IVH, specifically venous infarction, is associated with overall mortality and morbidity. Risk factors for fetal GMH-IVH are poorly understood and controlled studies are required.

WHAT THIS PAPER ADDS

Preterm germinal matrix-intraventricular hemorrhage (GMH-IVH) grading can be applied to fetuses. Many fetal germinal matrix hemorrhages occur in otherwise typical pregnancies. Half of fetuses with post-hemorrhagic ventricular dilatation receive a shunt after delivery. Fetuses with grade I or II GMH-IVH have few sequelae. Fetuses with periventricular hemorrhagic infarction have a high burden of motor impairment.

Fetal subdural hematoma, sickle cell disease and storage pool disease: A case report

A fetal subdural hematoma (SDH) was diagnosed in a patient with sickle cell disease (SCD) during a routine ultrasound exam in the 30th week of pregnancy. A scan performed a few days earlier had revealed no abnormalities. After interdisciplinary consultation with neurosurgeons and neonatologists, a cesarean section was performed since acute subdural bleeding was hypothesized and the mother's condition was critical. After surgery, the diagnostic procedures revealed that the child and the mother had also suffered from thrombocytopathy, which probably jointly contributed to causing the bleeding; in general, anemia and hypoxia may also play an important role. The newborn had a good neurological outcome.

Ultrasound features do not reflect the underlying cause and therefore predicting the prognosis is challenging. In most cases, prenatal counseling is difficult because of the unknown underlying cause and because there are no ultrasound or magnetic resonance imaging criteria to define which cases can benefit from delivery or expectant management. Where there is acute bleeding, the child could benefit from delivery and surgical evacuation of the hematoma. Further investigation to identify the cause of the bleeding can improve management and prognosis.

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Fetal subdural hematoma is difficult to recognize in utero.

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Ultrasound features do not reflect the underlying cause, which remains unknown in most cases.

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Sickle cell disease, storage pool disease and factor X deficiency jointly contributed to the bleedings described in our case.

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When there is acute fetal subdural bleeding, the child could benefit from delivery and surgical evacuation of the hematoma.

Prenatal Diagnosis, Management, and Outcome of Fetal Subdural Haematoma: A Case Report and Systematic Review

BACKGROUND

Fetal subdural haematoma (SDH) is associated with poor prognosis.

OBJECTIVE

The conflicting evidence from the literature presents a challenge in prenatal counselling. We present a case study and systematic review of the literature for the management and outcome of fetal SDH.

METHODS

Systematic search of electronic database.

RESULTS

A total 45 cases were extracted from 39 papers. Prenatal ultrasonographic features were intracranial echogenicity (42%), lateral ventriculomegaly (38%), presence of an intracranial mass (31%), macrocephaly (24%), midline deviation of cerebral falx (20%), and intracranial fluid collection (11%). Further secondary features were noted including reversed diastolic flow in the middle cerebral artery (11%), echogenic bowel (4%), hydrops fetalis (2%), and elevated middle cerebral artery peak systolic velocity (2%) (all highly likely to be associated with fetal anaemia). The rates of termination of pregnancy, stillbirth, and neonatal death were 18% (8/45), 16% (7/45), and 11% (5/45), respectively. Overall, therefore, the fetal and perinatal mortality was 32% (12/37). Amongst the 24 survivors with available neurological outcome, 42% (10/24) and 58% (14/24) had abnormal and normal neurological outcome, respectively. Underlying aetiology of fetal SDH was not identified in 47% (21/45). Fetal SDH with an identifiable underlying aetiology was the only factor associated with a higher chance of normal neurological outcome when compared to fetal SDH without a detectable cause (78.5 vs. 21.4%, p = 0.035).

CONCLUSIONS

Stillbirth and neonatal death occurred in a significant proportion of fetal SDH. 58% of survivors had normal neurological outcome, and better prognosis was seen in SDH with identifiable underlying aetiology.

Fetal stroke and cerebrovascular disease: Advances in understanding from lenticulostriate and venous imaging, alloimmune thrombocytopaenia and monochorionic twins

Fetal stroke is an important cause of cerebral palsy but is difficult to diagnose unless imaging is undertaken in pregnancies at risk because of known maternal or fetal disorders. Fetal ultrasound or magnetic resonance imaging may show haemorrhage or ischaemic lesions including multicystic encephalomalacia and focal porencephaly. Serial imaging has shown the development of malformations including schizencephaly and polymicrogyra after ischaemic and haemorrhagic stroke. Recognised causes of haemorrhagic fetal stroke include alloimmune and autoimmune thrombocytopaenia, maternal and fetal clotting disorders and trauma but these are relatively rare. It is likely that a significant proportion of periventricular and intraventricular haemorrhages are of venous origin. Recent evidence highlights the importance of arterial endothelial dysfunction, rather than thrombocytopaenia, in the intraparenchymal haemorrhage of alloimmune thrombocytopaenia. In the context of placental anastomoses, monochorionic diamniotic twins are at risk of twin twin transfusion syndrome (TTTS), or partial forms including Twin Oligohydramnios Polyhydramnios Sequence (TOPS), differences in estimated weight (selective Intrauterine growth Retardation; sIUGR), or in fetal haemoglobin (Twin Anaemia Polycythaemia Sequence; TAPS). There is a very wide range of ischaemic and haemorrhagic injury in a focal as well as a global distribution. Acute twin twin transfusion may account for intraventricular haemorrhage in recipients and periventricular leukomalacia in donors but there are additional risk factors for focal embolism and cerebrovascular disease. The recipient has circulatory overload, with effects on systemic and pulmonary circulations which probably lead to systemic and pulmonary hypertension and even right ventricular outflow tract obstruction as well as the polycythaemia which is a risk factor for thrombosis and vasculopathy. The donor is hypovolaemic and has a reticulocytosis in response to the anaemia while maternal hypertension and diabetes may influence stroke risk. Understanding of the mechanisms, including the role of vasculopathy, in well studied conditions such as alloimmune thrombocytopaenia and monochorionic diamniotic twinning may lead to reduction of the burden of antenatally sustained cerebral palsy.