Part 2: Birth trauma: injuries to the intraabdominal organs, peripheral nerves, and skeletal system

Ultrasound Instead of X-Ray to Diagnose Neonatal Fractures: A Feasibility Study Based on a Case Series

BACKGROUND

Fracture is a common birth injury in neonates, and its diagnosis mainly depends on chest X-ray examination, while ultrasound is typically not included in the diagnostic work-up of neonatal fractures. The aim of this study was to investigate the feasibility of using ultrasound to replace X-rays for the diagnosis of fractures in newborns and to determine the ultrasound characteristics of such fractures.

METHODS

Bedside ultrasound with an appropriate probe and scanning angle was performed on 52 newborn infants with suspected fractures based on physical examination findings, and the ultrasound results were compared with the X-ray examination results.

RESULTS

All 52 infants (100%) showed typical signs of fracture on ultrasound, including 46 cases of clavicle fracture, 3 cases of skull fracture, 2 cases of rib fracture, and 1 case of humerus fracture. Ultrasound was able to detect interrupted cortical continuity, displacement or angulation at the broken end, and callus formation during the recovery period. Chest X-ray examination was performed on 30 patients and identified 96.7% (29/30) of fractures, and the coincidence rate between ultrasound and X-ray was 100%. However, the sensitivity of ultrasound was higher than that of X-ray.

CONCLUSION

Ultrasound diagnosis of neonatal fracture is accurate, reliable, simple, and feasible. Therefore, it can replace X-ray examinations for the routine diagnosis of common types of neonatal bone fractures.

Liver laceration presented as intraabdominal bleeding in a newborn with hypoxic-ischemic encephalopathy

Objectives

Birth injuries usually occur with two different mechanisms: trauma due to mechanic stress during labor and hypoxic-ischemic injury. Sometimes these two mechanisms can occur at the same time with a complex clinical picture.

Case presentation

The baby girl was born at 372/7 weeks after a prolonged second stage of labor, weighing 3,725 g, and was admitted to the Neonatal Intensive Care Unit with the diagnosis of hypoxic-ischemic encephalopathy. During follow up she developed multiorgan failure and severe anemia. On the third postnatal day, abdominal bleeding was detected. Laceration in the liver capsule was found and appeared to be the source of bleeding.

Conclusions

Abdominal bleeding secondary to mechanical laceration of the liver is hard to diagnose and may coexist with perinatal asphyxia.

Diaphragmatic paralysis in young children: A literature review

Diaphragmatic paralysis (DP) is a rare cause of respiratory distress in young children. In the first years of life, the main cause is phrenic nerve injury after cardiothoracic surgery or obstetrical trauma. DP usually presents as respiratory distress. Asymmetrical thorax elevation, difficulty weaning from mechanical ventilation, pulmonary atelectasis, and repeated pulmonary infections are other suggestive signs or complications. DP is usually suspected on chest X-ray showing abnormal hemidiaphragm elevation. Although fluoroscopy was considered the gold standard for DP confirmation, it has gradually been replaced by ultrasound, which can be done at the bedside. Some electrophysiological tools may be useful for a better characterization of phrenic nerve injury and chance of recovery. The management of DP is mainly based on clinical severity. In mild asymptomatic cases, DP may only require close monitoring. In more severe cases, adequate ventilatory support and/or surgical diaphragmatic plication may be needed. Electrophysiological tools may help clinicians assess the ideal timing for diaphragmatic plication.

Birth Injury: Birth Asphyxia and Birth Trauma

Injury to a fetus or neonate during delivery can be due to several factors involving the fetus, placenta, mother, and/or instrumentation. Birth asphyxia results in hypoxia and ischemia, with global damage to organ systems. Birth trauma, that is mechanical trauma, can also cause asphyxia and/or morbidity and mortality based on the degree and anatomic location of the trauma. Some of these injuries resolve spontaneously with little or no consequence while others result in permanent damage and severe morbidity. Unfortunately, some birth injuries are fatal. To understand the range of birth injuries, one must know the risk factors, clinical presentations, pathology and pathophysiology, and postmortem autopsy findings. It is imperative for clinicians and pathologists to understand the causes of birth injury; recognize the radiographic, gross, and microscopic appearances of these injuries; differentiate them from inflicted postpartum trauma; and work to prevent future cases.

An unusual cause of neonatal shock: a case report

The authors present a premature male neonate who developed subcapsular hematoma of the liver (SHL) secondary to birth trauma during the delivery process. During cesarean section, it was discovered that the infant had suffered birth trauma to the abdomen that caused intra-abdominal hemorrhage, resulting in hypovolemic shock. It was diagnosed as SHL upon abdominal ultrasound. This premature newborn infant presented with hypotension and metabolic acidosis secondary to internal hemorrhage. He was managed with volume replacement including packed red blood cells (pRBC), fresh frozen plasma and cryoprecipitate transfusions. The infant’s clinical condition improved gradually, and he went home without any problems at 36 weeks of corrected gestational age. On follow-up visits, he was found to be growing and developing appropriately. High index of suspicion, appropriate work-up and prompt treatment of shock were the key steps in the management of this infant.

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

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.

Iatrogenic injury and unexpected hospital death in the newborn

Neonates are unusually vulnerable to iatrogenic injury due to small body size, delicate tissues, and immature immune systems. Investigation of an unexpected neonatal death in the hospital should begin with a review of the medical record and discussion with medical staff involved in the patient׳s care. Postmortem investigation should include a complete and well-documented autopsy. Additional investigations, such as microbiological studies and chemical and toxicological studies of postmortem and antemortem fluid samples, may be crucial in arriving at a diagnosis. Causes of iatrogenic injury include birth trauma, medication errors and adverse drug effects, hospital-acquired infection, and medical device malfunction, incorrect placement, and misuse. Autopsy is an important tool for understanding the cause of an unexpected death, improving the quality of care, and providing closure to parents and family.

Risk factors for fractured clavicle in the newborn

AIM

To disclose potential risk factors for sustaining a fractured clavicle in the newborn.

METHOD

A retrospective case-control analysis of women who gave birth to an infant with a fractured clavicle during a four-year period (2003-2006) was performed. A control group of newborns who did not sustain a fractured clavicle was formed (2:1) matched for maternal age, parity and gestational age at delivery.

RESULTS

The rate of fractured clavicle was 0.35%. Heavier newborns' birth weight (3632.9 ± 376.1 g vs. 3429.5 ± 513.0 g, P < 0.05) and the use of oxytocin (91.3% vs. 69.5%, P < 0.05) were associated with the occurrence of fractured clavicle during birth. Fractured clavicle was not well correlated with maternal height, maternal pregestational body mass index, maternal body mass index at delivery, maternal weight gain during pregnancy, induction of labor, duration of the second stage of labor, instrumental delivery or newborn birth weight of more than 4000 g.

CONCLUSION

We could not identify significant risk factors that could be dealt with in order to avoid a fractured clavicle being sustained during birth. Most fractured clavicles occur in normal newborns following normal labor and delivery.

Do resuscitation-related injuries kill infants and children?

Occasionally, individuals accused of inflicting fatal injuries on infants and young children will claim some variant of the "CPR defense," that is, they attribute the cause of injuries found at autopsy to their "untrained" resuscitative efforts. A 10-year (1994-2003) historical fixed cohort study of all pediatric forensic autopsies at the Miami-Dade County Medical Examiner Department was undertaken. To be eligible for inclusion in the study, children had to have died of atraumatic causes, with or without resuscitative efforts (N(atraumatic) = 546). Of these, 382 had a history of cardiopulmonary resuscitation (CPR; average age of 4.17 years); 248 had CPR provided by trained individuals only; 133 had CPR provided by both trained and untrained individuals; 1 had CPR provided by untrained individuals only. There was no overlap between these 3 distinct groups. Twenty-two findings potentially attributable to CPR were identified in 19:15 cases of orofacial injuries compatible with attempted endotracheal intubation; 4 cases with focal pulmonary parenchymal hemorrhage; 1 case with prominent anterior mediastinal emphysema; and 2 cases with anterior chest abrasions. There were no significant hollow or solid thoracoabdominal organ injuries. There were no rib fractures. The estimated relative risk of injury subsequent to resuscitation was not statistically different between the subset of decedents whose resuscitative attempts were made by trained individuals only, and the subset who received CPR from both trained and untrained individuals. In the single case of CPR application by an untrained individual only, no injuries resulted. The remaining 164 children dying from nontraumatic causes and who did not undergo resuscitative efforts served as a control group; no injuries were identified. This study indicates that in the pediatric population, injuries secondary to resuscitative efforts are infrequent or rare, pathophysiologically inconsequential, and predominantly orofacial in location. In our population, CPR did not result in any rib fractures or significant visceral injuries. Participation of nonmedical or untrained individuals in resuscitation did not increase the likelihood of injury.

Intrauterine rectovaginal tear during a manual attempt to rotate a neonate

Intrauterine rectovaginal tears in neonates are a rare and life-threatening complication of abnormal presentation during labor. Two previous cases have been presented in the literature, of which one had a fatal outcome. The authors present a third case of a severe rectovaginal intrauterine tear that had a favorable outcome.

Penetrating abdominal injury and peritonitis: A rare case of birth Injury

The incidence of birth injuries has decreased considerably because of the identification of risk factors at an earlier stage and taking the decision for caesarian section (LSCS) at proper time. Fractures, nerve palsies and central nervous system injuries comprise the majority of "birth injuries." In this study, we report a newborn that had a birth injury during LSCS. The baby sustained a penetrating abdominal injury by the knife of the surgeon, while performing LSCS. The bowel was injured at two sites, proximal jejunum and descending colon. The baby developed meconeum spillage and peritonitis. Exploratory laprotomy was done and the injuries were identified. The injured portions were resected and bowel continuity was reestablished. The baby had an uneventful recovery.

A matter of size: Part 2. Evaluating the large-for-gestational-age neonate

Large for gestational age (LGA) is another designation used to assess and monitor growth throughout the pregnancy and after delivery. Large for gestational age is an abnormal growth descriptor that assists in anticipating neonatal needs pre-and postnatally. Careful monitoring for abnormal growth trends in the fetus is imperative prenatally. The relative size of a neonate affects many aspects of prenatal and postnatal surveillance. Nursing care is guided by the maternal history and the delivery room complications that may occur. Anticipating complications in the delivery room is vital to the survival of LGA neonates. Nursing care for LGA neonates requires knowledge based on these potential complications. A thorough physical assessment with appropriate glucose monitoring and parental education is required. Size matters when it comes to the health and welfare of all sizes of neonates. Anticipatory guidance with prenatal monitoring and education can improve outcomes in the neonate at risk for LGA complications at birth.