Congenital hydrocephalus secondary to prenatal intracranial haemorrhage

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 hydrocephalus caused by cryptic intraventricular hemorrhage

Cryptic intracerebral hemorrhage as an etiological factor in fetal hydrocephalus has been postulated but not described at autopsy. Four fetuses with overt hydrocephalus diagnosed by in utero ultrasound examination were examined at autopsy at 19-22 weeks gestation. Although a hemorrhagic etiology was not evident on ultrasound, hemosiderin-containing macrophages and associated reactive changes were found to obstruct the otherwise well-formed cerebral aqueduct in all four. Coagulopathy due to thrombocytopenia was implicated in one case. Anomalies involving other parts of the body were identified in two cases, although a direct link to the hydrocephalus was not obvious. The abnormality was isolated in one case. In three cases, possible sites of hemorrhage in the ventricles were identified. This abnormality represents a significant proportion of the fetuses examined for hydrocephalus in our referral center. We discuss the importance of careful autopsy examination in the diagnosis of cryptic intracerebral hemorrhage and the implications for counseling.

Prenatally diagnosed fetal brain injuries with known antenatal etiologies

Periventricular leukomalacia of pre- or postnatal onset is responsible for severe neurological and intellectual impairment and cerebral palsy later in life. The etiology is multifactorial, involving hypoxic-ischemic insults of various origin. The disorder is characterized by multiple necrotic foci of the white matter found most frequently adjacent to the lateral ventricles. In the past, intrapartum factors were thought to be the major cause of neonatal brain damage, but recent investigations highlighted the role of antenatal risk factors. We present 4 cases of antenatally diagnosed brain injury with known and unusual etiology.

Fetal hydrocephalus and intrauterine cerebral ventriculoscopy: an animal model

OBJECTIVE

The aim of this study was to create an animal model of obstructive ventriculomegaly in the fetal lamb at 78 days of gestation by injecting maternal blood into the lateral ventricles under ultrasound guidance.

METHODS

An endoscope of 1.2 mm housed in a 1.6-mm trocar was introduced into the dilated lateral ventricle. The lambs were sacrificed after delivery.

RESULTS

All fetuses diagnosed with ventriculomegaly on ultrasound showed dilatation on the anatomical sections. The ventricles had a dilated aspect when compared to the controls. In 1 fetus the septum between the two ventricles was completely ruptured. Microscopically the ependymal cells were flattened and the cellular lining was disruptured.

CONCLUSION

The model proved suitable for ventriculoscopic examination at 128 days of gestation. This should allow to elaborate further on therapeutic studies in this controversial area.

Outcome of antenatally diagnosed intracranial hemorrhage: case series and review of the literature

OBJECTIVES

Prenatal diagnosis of intracranial hemorrhage (ICH) has been widely reported. Hemorrhages may occur either within the cerebral ventricles, subdural space or infratentorial fossa. The aim of this study was to determine the sonographic criteria for the diagnosis of fetal ICH, the role of in utero magnetic resonance imaging (MRI) and the outcome of this condition.

METHODS

The archives of our ultrasound laboratory and the literature were searched for all cases of antenatally diagnosed ICH. A grading system was used to classify the intraventricular lesions as suggested in postnatal sonographic studies.

RESULTS

Adding our series of 16 fetuses to the 93 cases identified in the literature, a group of 109 fetal ICHs was obtained: 89 were intracerebral (79 intraventricular and 10 infratentorial) and 20 were subdural hemorrhages. Intraventricular lesions were mostly classified as severe (32 each for Grades III and IV). In 27 cases antenatal MRI was performed additionally to ultrasound and confirmed the sonographic findings. Of the entire group, 65 infants (59%) were reported to be alive 1 month after birth (51 intraventricular hemorrhages, three infratentorial hemorrhages, 11 subdural hematomas). At 12 months, of the 48 infants whose follow-up was available, 25 or 52% were judged neurologically normal (17/36 or 47% among the intraventricular hemorrhages, 6/9 or 66% among the hematomas, and 2/3 or 66% among the infratentorial hemorrhages).

CONCLUSIONS

Fetal ICH may be accurately identified and categorized by antenatal sonography. The outcome is usually poor, especially for those fetuses affected by higher-grade intraventricular hemorrhages.

Fetal intracranial hemorrhage: is minor maternal trauma a possible pathogenetic factor?

OBJECTIVE

The occurrence of fetal intracranial hemorrhage before labor has been repeatedly observed. The aim of this study was to evaluate the sonographic appearance of fetal intracranial hemorrhage in relation to its location. Possible causative factors were also evaluated.

DESIGN

Five consecutive cases of fetal intracranial hemorrhage were identified at a single ultrasound unit between 1996 and 1999. In utero magnetic resonance imaging was also performed in four of these cases. Autopsy was performed after pregnancy termination or intrauterine fetal death (one case of each), and neurological follow-up was initiated in the three surviving infants.

RESULTS

Hydrocephaly was the predominant sonographic finding associated with intraventricular or subependymal hemorrhage; sonography provided the correct diagnosis in the former (two cases), whereas magnetic resonance imaging was necessary in the latter. Massive intraparenchymal hemorrhage was depicted as an irregular echoic mass, whereas extradural hemorrhage had a cystic appearance. History of minor maternal physical trauma without maternal or placental injury was elicited in all cases. Ultrasound examinations performed before or shortly after the trauma were available in all cases and showed normal fetal anatomy.

CONCLUSIONS

The sonographic appearance of fetal intracranial hemorrhage is variable, depending on its location. Even though sonography detected an intracranial anomaly in all cases, magnetic resonance imaging was necessary to establish the hemorrhagic nature of isolated subependymal and extradural hemorrhage. The similarity of histories involving minor maternal physical trauma in all cases, together with the absence of any known factor predisposing to fetal hemorrhage, may suggest that trauma is at least a contributing factor to the pathogenesis of fetal intracranial hemorrhage.

Obstetric profiles and perinatal mortality among Pacific Island immigrants in New South Wales, 1990-93

OBJECTIVES

To describe the obstetric profile and perinatal mortality of Pacific Island-born women giving birth in New South Wales (NSW) and assess risk factors associated with the high perinatal death rate previously noted in this immigrant group.

METHOD

Retrospective cohort study based on the Midwives Data Collection in NSW from 1990 to 1993. Births to 5,034 Pacific Island-born women were compared with births to 256,843 Australian-born women.

RESULTS

Pacific Island-born women had fewer teenage pregnancies and were of an older age and higher parity. They were more likely to be married or in a de facto relationship and to present for antenatal care later in the pregnancy. The proportion of low birthweight and preterm birth was similar in the two groups but Pacific Islanders had a higher perinatal mortality rate (14.6/1,000 vs. 10.3/1,000, RR = 1.42, 95% CI = 1.13-1.54). Even at normal and high birthweights, infants of Pacific Island-born women were at greater risk of perinatal death. After adjusting for maternal factors (marital status, insurance status, parity and maternal age) Pacific Islanders were 30% more likely to have a perinatal death (OR = 1.30, 95% CI 1.07-1.54).

CONCLUSIONS

Further analyses of the causes of perinatal death in Pacific Island-born women are needed so appropriate interventions can be implemented.

IMPLICATIONS

The need for the design and evaluation of culturally specific services aimed at improving antenatal care attendance in Pacific Islanders is emphasised. Conventional risk assessment may not adequately predict adverse perinatal outcomes in all populations.

Prenatal sonographic diagnosis of intracranial haemorrhage: report of a case with a sinusoidal fetal heart rate tracing, and review of the literature

The sinusoidal fetal heart rate pattern has been described in association with severe fetal anaemia, with fetal hypoxaemia, and with the administration of parenteral narcotics. Here, we report a case of decreased fetal movement in which a sinusoidal tracing was recorded. The sonographic diagnosis of a massive fetal intracranial haemorrhage was made. A non-interventive approach was taken and the fetus died soon after in utero. We review 28 previous cases in which the prenatal sonographic diagnosis of fetal intracranial haemorrhage was made, including the underlying maternal and fetal factors and neonatal outcomes. We propose that the sinusoidal tracing in this case was due to the intracranial bleed and suggest that fetal intracranial haemorrhage be considered in the sonographic evaluation of the fetus with a sinusoidal pattern.

Antenatal subdural hemorrhage causing fetal death before labor

Antepartum intracranial hemorrhage, which can cause fetal death prior to the onset of labor, is a rare event. This report documents the clinical findings and magnetic resonance imaging (MRI) of an uncommon case of antenatal acute subdural hematoma. MRI was extremely accurate in delineating the possible extent and location of the lesion. This is the first report to demonstrate MRI of subdural hemorrhage resulting in fetal death in utero.