Mechanical birth-related trauma to the neonate: An imaging perspective

Insights into Imaging, Jan 2018

Mechanical birth-related injuries to the neonate are declining in incidence with advances in prenatal diagnosis and care. These injuries, however, continue to represent an important source of morbidity and mortality in the affected patient population. In the United States, these injuries are estimated to occur among 2.6% of births. Although more usual in context of existing feto-maternal risk factors, their occurrence can be unpredictable. While often superficial and temporary, functional and cosmetic sequelae, disability or even death can result as a consequence of birth-related injuries. The Agency for Healthcare research and quality (AHRQ) in the USA has developed, through expert consensus, patient safety indicators which include seven types of birth-related injuries including subdural and intracerebral hemorrhage, epicranial subaponeurotic hemorrhage, skeletal injuries, injuries to spine and spinal cord, peripheral and cranial nerve injuries and other types of specified and non-specified birth trauma. Understandably, birth-related injuries are a source of great concern for the parents and clinician. Many of these injuries have imaging manifestations. This article seeks to familiarize the reader with the clinical spectrum, significance and multimodality imaging appearances of neonatal multi-organ birth-related trauma and its sequelae, where applicable. Teaching points • Mechanical trauma related to birth usually occurs with pre-existing feto-maternal risk factors. • Several organ systems can be affected; neurologic, musculoskeletal or visceral injuries can occur. • Injuries can be mild and transient or disabling, even life-threatening. • Imaging plays an important role in injury identification and triage of affected neonates.

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Mechanical birth-related trauma to the neonate: An imaging perspective

Insights Imaging Mechanical birth-related trauma to the neonate: An imaging perspective Apeksha Chaturvedi 0 1 Abhishek Chaturvedi 0 1 A. Luana Stanescu 0 1 Johan G. Blickman 0 1 Steven P. Meyers 0 1 0 Department of Radiology, Seattle Children's Hospital , Seattle, WA , USA 1 Department of Imaging Sciences, University of Rochester Medical Center , 601, Elmwood Avenue, Box 648, Rochester, NY 14642 , USA 2 Apeksha Chaturvedi Mechanical birth-related injuries to the neonate are declining in incidence with advances in prenatal diagnosis and care. These injuries, however, continue to represent an important source of morbidity and mortality in the affected patient population. In the United States, these injuries are estimated to occur among 2.6% of births. Although more usual in context of existing feto-maternal risk factors, their occurrence can be unpredictable. While often superficial and temporary, functional and cosmetic sequelae, disability or even death can result as a consequence of birth-related injuries. The Agency for Healthcare research and quality (AHRQ) in the USA has developed, through expert consensus, patient safety indicators which include seven types of birth-related injuries including subdural and intracerebral hemorrhage, epicranial subaponeurotic hemorrhage, skeletal injuries, injuries to spine and spinal cord, peripheral and cranial nerve injuries and other types of specified and non-specified birth trauma. Understandably, birth-related injuries are a source of great concern for the parents and clinician. Many of these injuries have imaging manifestations. This article seeks to familiarize the reader with the clinical spectrum, significance and multimodality imaging appearances of neonatal multiorgan birth-related trauma and its sequelae, where applicable. Teaching points Mechanical trauma related to birth usually occurs with preexisting feto-maternal risk factors. Several organ systems can be affected; neurologic, musculoskeletal or visceral injuries can occur. Injuries can be mild and transient or disabling, even lifethreatening. Imaging plays an important role in injury identification and triage of affected neonates. Neonate; Mechanical trauma; Macrosomia; Instrumental delivery; Cephalopelvic disproportion Introduction The process of birth, whether spontaneous or assisted, is inherently traumatic for the newborn. Birth-related injuries encompass both mechanical and hypoxic-ischemic events. This review focuses mostly on mechanical trauma sustained by the neonate owing to the forces of labor and delivery. For conciseness of this review, birth-related hypoxic-ischemic injuries to the neonate will not be separately addressed. Trauma related to birth may affect several organ systems of the neonate (ESM_1). The exact incidence of mechanical trauma of birth may be somewhat underestimated. Incidence is 0.82%, prevalence has been estimated at 9.5 per 1000 live births [1]. Less than 2% of neonatal deaths result from birth trauma [2]. Fig. 1 Illustration demonstrating the layers of scalp, skull, meninges and brain on a coronal section (a) Birth-related trauma can occur without identifiable risk factors; however, it is more common in context of predisposing feto-maternal risk factors. Risk factors can be fetal (macrosomia-birth weight > 4500 g, malpresentation or shoulder dystocia (defined as passage of more than 60 s between the delivery of the head and body [3], resulting in requirement of additional obstetric maneuvers for delivery of fetal shoulders [4])); maternal (diabetes, primiparity, small pelvis); or obstetric (epidural analgesia, induced or instrumental delivery). Over the following paragraphs, we discuss the clinical context and imaging findings of birth -related Fig. 2 Illustration depicting hemorrhages by location within the different layers of the meninges (left of image) and scalp (right of image) Fig. 3 Caput succedaneum and subgaleal hemorrhage Grayscale ultrasound images (a-c) of the scalp in a newborn male demonstrate a fluid collection that crosses midline, is deep to the subcutaneous fat/galeal aponeurosis and superficial to the periosteum/calvarium (noted as thick echogenic interface) consistent with a subgaleal hemorrhage. Axial CT (d) image in a 1-day-old male with history of traumatic delivery demonstrate scalp soft tissue overlying bilateral parietal regions and crossing the sagittal suture (arrows). Follow-up coronal MR image (e) demonstrates a deep subaponeurotic scalp fluid collection crossing the sagittal suture and extending anteriorly into the right temporal region, consistent with subgaleal hematoma (arrows). A more superficial overlying fluid collection with a similar distribution also noted (arrowheads). This collection is within the subcutaneous fibrofatty tissues superficial to galea aponeurosis and is consistent with caput succedaneum injuries categorized by different portions of the neonate’s anatomy. Injuries to the head and face Extracranial Scal (...truncated)


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Apeksha Chaturvedi, Abhishek Chaturvedi, A. Luana Stanescu, Johan G. Blickman, Steven P. Meyers. Mechanical birth-related trauma to the neonate: An imaging perspective, Insights into Imaging, 2018, pp. 103-118, Volume 9, Issue 1, DOI: 10.1007/s13244-017-0586-x