Blunt prenatal trauma resulting in fetal epidural or subdural hematoma: case report and systematic review of the literature

Recognition and management of traumatic fetal injuries

Trauma during pregnancy is the leading non-obstetric cause of morbidity and mortality, and accounts for five per 1000 fetal deaths. Direct fetal injury due to trauma during pregnancy is rare, and limited information is available about how to optimize fetal outcomes after injury. Early recognition and appropriate management of direct fetal trauma may improve outcomes for the fetus. There are currently no available guidelines to direct management of the injured fetus. We provide a detailed literature review of the management and outcomes of direct fetal injury following blunt and penetrating injury during pregnancy, and describe a suggested initial approach to the injured pregnant patient with a focus on evaluation for fetal injury. We identified 45 reported cases of blunt trauma resulting in direct fetal injury, with 21 surviving past the neonatal period, and 33 of penetrating trauma resulting in direct fetal injury, with 24 surviving past the neonatal period. Prenatal imaging identified fetal injury in 19 cases of blunt trauma and was used to identify bullet location relative to the fetus in 6 cases. These reports were used to develop management algorithms for the injured fetus.

Fetal epidural hematoma secondary to a mild blunt prenatal trauma: case report and review of the literature

Fetal intracranial hemorrhage affects 1 in every 10,000 pregnancies. In most cases, the etiology of the bleeding is multifactorial, and they can be either related to the mother or the fetus. Blunt prenatal trauma was occasionally associated with these hemorrhages, nevertheless, reports of hematomas secondary to mild traumas are rare. Within the prenatal intracranial bleedings, the most frequent are the subarachnoid hematoma and intraparenchymal, scarcely ever the epidural hematoma. Treating these bleedings is challenging due to the ongoing pregnancy. Thus, the prognosis is often reserved, with a mortality rate of 43% and 25% of neurological sequelae. Here, we report a singular case of a fetal epidural hematoma secondary to a mild blunt trauma at the third trimester with a good outcome.

Post-Hemorrhagic Hydrocephalus and Outcomes Amongst Neonates With Intraventricular Hemorrhage: A Systematic Review and Pooled Analysis

Introduction Intraventricular hemorrhage (IVH) is a common cause of morbidity and mortality in preterm neonates. IVH leads to complications such as posthemorrhagic hydrocephalus (PHH), which commonly occurs in neonates with a more severe degree of IVH. Hence, we aimed to evaluate the characteristics and outcomes of PHH in neonates with IVH. Methods We performed a systematic review of cases reported from January 1978 to December 2020 through the PubMed database, using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the keywords 'intraventricular hemorrhage,' 'cerebral intraventricular hemorrhage,' and 'newborn.' A total of 79 articles were considered for analysis, and data on neonatal and maternal characteristics and outcomes were collected. The analysis was performed by using the χ2 test, Wilcoxon rank-sum test, and multivariate logistic regression model. Results We analyzed a total of 101 IVH cases, 54.5% were male and 62.4% preterm. Thirteen point nine percent (13.9%) presented with grade I, 35.6% grade II, and grade III respectively, and 8% grade IV IVH. Among the 59 (58.4%) neonates with PHH, 33.6% had resolved PHH and 24.8% had unresolved. In adjusted regression analysis, we found that neonates with resolved PHH have lower odds of having neurodevelopmental delay (OR:0.15, 95%CI:0.03-0.74; p=0.02) and death (OR:0.9;95%CI:0.01-0.99; p=0.049) as compared to unresolved PHH. Conclusion Our study showed that neonates with resolved PHH have a statistically significant lower risk of neurodevelopmental delay (NDD) and mortality. Future studies should be planned to evaluate the role of treatment and its effect on outcomes in IVH neonates with PHH as a complication.

Management of Intracranial Hemorrhage and Skull Fracture After Blunt Intrauterine Trauma

BACKGROUND

Fetal trauma during pregnancy can have a significant impact on the developing brain. Fetal trauma can lead to several intracranial pathologies including hypoxic-ischemic injury, skull fractures, and intracranial hemorrhages. Blunt trauma to a fetus resulting in the need for neurosurgical intervention is a rare occurrence and seldom described in the literature.

CASE DESCRIPTION

Here we present the case of a 28-year-old, 36-week pregnant woman who was brought to the hospital by ambulance following a high-speed motor vehicle collision as the restrained driver. On computed tomography of the abdomen, the fetus was found to have a left-sided skull fracture with intracranial hemorrhage. The fetus was emergently delivered by way of caesarean section for lack of fetal movement and indeterminate heart tracings. Postnatally, the neonate had a Glasgow Coma Scale of 7. A postnatal head computed tomography better defined the skull fractures and multiple areas of intracranial hemorrhage. The baby was taken to the operating room for evacuation of the hematomas. At 16 months of age, the baby was well with only mild developmental delay, although a ventriculoperitoneal shunt was needed in a delayed fashion at 3 months of age.

CONCLUSIONS

We present a rare situation where emergent caesarean section delivery followed by neonatal craniotomy was necessary. Our case illustrates that good outcomes can be achieved with rapid identification of fetal intracranial injury and intervention.

Delayed Appearance of a Traumatic Fetal Intracranial Hemorrhage

Background

Fetal intracranial injury is a potentially devastating sequelae of maternal trauma, but there is little guidance regarding fetal evaluation in this setting.

Case

A 23-year-old woman at 27-week gestation was admitted after a high-speed motor vehicle accident. The initial obstetrical ultrasound was unremarkable, but persistently minimal fetal heart rate variability was observed. Ultrasound on day 3 after the accident showed an intracranial hyperechogenic lesion and subdural fluid collection. The neonate, following an uneventful birth at 39 weeks, had seizures and abnormal muscle tone. MRI was consistent with in utero intracranial hemorrhage.

Conclusion

Serial fetal imaging following maternal trauma, particularly when accompanied by abnormal fetal heart rate tracings, should be considered when fetal injury is a concern, even in the setting of a normal initial ultrasound.