Neonatal death following in utero traumatic splenic rupture

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.

An Extremely Premature Neonate with Severe Anemia

Spleen rupture in an extremely premature newborn is very rare event. High index of suspicion is required to make timely diagnosis and thereafter appropriate management. We present a rare case of an extremely premature, extremely low birthweight newborn who presented with severe anemia secondary to splenic rupture. It was managed conservatively without splenectomy resulting in complete resolution of symptoms. Although non-operative management of pediatric splenic injuries is now recognized as the treatment of choice, there is very little experience in premature newborns.

Spontaneous Splenic Hemorrhage in the Newborn

Spontaneous splenic hemorrhage in the newborn is a rare entity. The presentation is usually with a triad of bleeding, abdominal distension, and hemoperitoneum. Rapid diagnosis is essential as left untreated, death is inevitable. We present a case with an unusual initial presentation of a scrotal hematocele and ultrasonography suggesting an adrenal hemorrhage. At laparotomy, splenic preservation was unsuccessful, and therefore, splenectomy was performed. The child recovered well from the procedure.

Splenic rupture in a newborn with severe hemophilia--case report and review

Life-threatening splenic rupture is rare in neonates with severe hemophilia. There are only 3 cases of splenic rupture in neonates with hemophilia reported in the literature. We present the case of an infant, born to a hemophilia A carrier mother. The infant was asymptomatic until discharge at 48 hours of age, but presented on the third day of life with shock, abdominal distension, and severe anemia. Computed tomography of the abdomen confirmed the diagnosis of splenic rupture with hemoperitoneum. The infant recovered after extensive supportive care surgery and factor replacement.

Ruptured splenic cavernous hemangioma in a neonate

We present a case of a term neonate with hypovolemic shock after spontaneous vaginal delivery. Hemodynamic instability persisted despite resuscitation with packed red cells, fresh frozen plasma, and platelets. An ultrasound scan at 48 hours after birth followed by a computed tomographic scan demonstrated a splenic lesion and hemoperitoneum. She underwent an emergency laparotomy and splenectomy for splenic rupture. Histologic findings demonstrated a ruptured cavernous hemangioma of the spleen. Exsanguinating intraabdominal hemorrhage in the newborn infant is rare. The diagnosis and management, with particular reference to splenic cavernous hemangioma and splenic rupture, is discussed.

The association between developmental handicaps and traumatic brain injury during pregnancy: an issue that deserves more systematic evaluation

AIMS

Trauma during pregnancy is commonly viewed as benign for the foetus when the delivery occurs normally. This study revisits that point of view.

METHOD

We included eighteen patients having a neurological handicap with an anamnesis of an accident during pregnancy and a follow-up sufficient to determine a definite outcome.

RESULTS

Pregnancy outcome and observed management. Foetal abnormalities were detected in six cases between the first and the thirteenth day after the trauma. Emergency delivery or rapid birth after signs of foetal distress occurred in five cases. One baby died soon after birth. One-third of cases were not submitted to any investigation. VARIOUS NEUROLOGICAL HANDICAPS WERE RECORDED: Congenital microcephaly (three patients), congenital hydrocephalus (three), Infantile cerebral hemiplegy (six), quadriplegy with severe encephalopathy (four), diplegy (one), clumsiness with cerebellar atrophy (one), Moebius syndrome (one), mental retardation with autistic features (two), learning disability (one) auditory agnosia (one). Cerebral imaging showed macroscopic abnormalities in fourteen patients, evoking various pathogenetic hypotheses.

CONCLUSION

The association between maternal trauma and foetal brain lesions lacks sufficient investigation in many cases. Prospective studies are needed to clarify both medical and legal issues. Guidelines are proposed for obstetrical and paediatric management after significant maternal trauma.

Fatal fetal hemorrhage and placental pathology. Report of three cases and a new setting

We report three cases of late third trimester fetal death in utero consequent to fetal exsanguination from the chorionic vasculature. In general, fetal hemorrhage is unusual, exsanguination is rare and the location and basis of the hemorrhage varies widely. Intragestational and intrapartum hemorrhage is far more often of maternal rather than fetal origin. Even when severe, the former is almost always manageable whilst the latter may be clinically obscure, intractable, catastrophic and fatal. In this presentation, we review and characterize fetal hemorrhage by anatomical location and on the basis of its underlying origins. In our first two cases, the chorionic vascular failure is understood on the basis of mechanical factors, such as tearing by the presenting part or an amniotomy hook. Our third case demonstrates the first reported instance in which a severe chorionic vasculopathy has damaged a placental surface vessel sufficiently to permit spontaneous rupture and fetal exsanguination.

Nonoperative Management of Neonatal Splenic Rupture

Neonatal injury of the spleen is an uncommon but serious condition. Although the standard management of children with splenic injury is nonoperative, there is scant evidence in the literature to support handling neonates in the same way. We report a case of neonatal splenic rupture that was managed nonoperatively. A 3.6-kg full-term female born vaginally became tachycardic and pale on the second day of life. She had a distended abdomen and a hemoglobin of 5.8 g/dL. Her blood pressure remained within normal limits. She was transfused 20 cc/kg packed red blood cells. CT scan showed a grade V splenic rupture. Coagulopathy workup was negative. The assumption was that she had a ruptured spleen secondary to a traumatic delivery. She remained stable after the transfusion. It took 32 weeks for a CT scan to show complete healing. Traditionally, neonatal splenic rupture has been treated with splenectomy or splenorrhaphy. The first case of a neonate to be treated nonoperatively was reported in 2000. Our patient is only the second reported case. We chose to follow her with imaging to document healing and to rule out a tumor, as epidermoid cysts and hemangioendotheliomas can cause neonatal splenic rupture. We also review the literature to try to gain some insight into the management of this rare problem.

Fetal intracranial injuries in a preterm infant after maternal motor vehicle accident: a case report

OBJECTIVE

To present a case of fetal intracranial injuries in a preterm infant after maternal motor vehicle accident and to review the relevant literature.

DESIGN

Case report.

SETTING

Neonatal and pediatric intensive care unit of a children's hospital.

PATIENT

Preterm infant (gestational age, 30-6/7 wks) with intracranial injuries after maternal motor vehicle accident.

RESULTS

Whereas the mother had only a closed femur fracture, her infant sustained subdural, subarachnoid, and intracerebral hemorrhages in the left parietal and temporal lobes most likely attributable to direct fetal trauma. Massive fetomaternal hemorrhage may have led additionally to hypoxia-ischemia contributing indirectly to the injury. At the last follow-up visit (chronological age, 20 months; corrected age, 18 months), there was evidence of a persistent right-sided hemiparesis in an otherwise normally developed infant.

CONCLUSIONS

Motor vehicle accidents during pregnancy can be associated with fetal mortality and significant morbidity, even in the absence of severe maternal injuries. Direct (hemorrhagic) and indirect (hypoxic-ischemic) intracranial injuries should be actively sought with appropriate imaging studies.

Splenic injury presenting with isolated scrotal findings in a stable newborn

Splenic injury in a newborn is a rare occurrence. It typically presents as an acute abdomen in an unstable patient. The authors present a case of splenic injury in a stable newborn infant with isolated scrotal findings. Workup included a testicular ultrasound scan with colorflow Doppler as well as abdominal and pelvic computerized tomography. The patient was treated nonoperatively with serial hematocrits and examinations and was discharged home after a brief hospital course.

Nonoperative management of newborn splenic injury: a case report

Traumatic injury of the spleen is rare in newborns. Nonoperative management of pediatric splenic injuries is now recognized as the treatment of choice, but there is scant experience with the problem in neonates. The authors report their experience with a neonatal splenic rupture, managed nonoperatively.

Fetal CNS damage after exposure to maternal trauma during pregnancy

Nine case reports are presented to indicate the possible effects of maternal trauma on surviving fetuses. Previous reports have only addressed fatal consequences. Traumata occurred between gestational weeks 23 and 37. Seven mothers had motor-vehicle accidents (MVA), two had blunt abdominal traumata. Four mothers suffered severe injuries, such as cerebral contusion, fractures or placental abruption leading to emergency Cesarean section. Premature uterine contractions were observed in five mothers and hemorrhage in two. The nine children were born after 30 to 40 weeks of gestation. Seven had normal postpartal vital signs, one required resuscitation and one premature needed assisted ventilation. Clinical symptoms were variable: movement disorders (n = 3), hydrocephalus (n = 2), convulsions (n = 1), cerebral palsy (n = 1), and normal (n = 3). Follow-up ranged from 7 months to 5 years. Neuroimaging revealed periventricular leukomalacia (n = 2), localized vascular infarctions (n = 2), hemorrhage (n = 1), hydrocephalus (n = 2) and global damage (n = 1). The causative role of maternal accidents was extremely likely in one patient, and probable but unproved in the remaining cases.

Infant survival after cesarean section for trauma

HYPOTHESIS

Emergency cesarean sections in trauma patients are not justified and should be abandoned.

SETTING AND DESIGN

A multi-institutional, retrospective cohort study was conducted of level 1 trauma centers.

METHODS

Trauma admissions from nine level 1 trauma centers from January 1986 through December 1994 were reviewed. Pregnant women who underwent emergency cesarean sections were identified. Demographic and clinical data were obtained on all patients undergoing a cesarean section. Fetal distress was defined by bradycardia, deceleration, or lack of fetal heart tones (FHTs). Maternal distress was defined by shock (systolic blood pressure < 90) or acute decompensation. Statistical analyses were performed.

RESULTS

Of the 114,952 consecutive trauma admissions, more than 441 pregnant women required 32 emergency cesarean sections. All were performed for fetal distress, maternal distress, or both. Overall, 15 (45%) of the fetuses and 23 (72%) of the mothers survived. Of 33 fetuses delivered, 13 had no FHTs and none survived. Twenty infants (potential survivors) had FHTs and an estimated gestational age (EGA) of greater than or equal to 26 weeks, and 75% survived. Infant survival was independent of maternal distress or maternal Injury Severity Score. The five infant deaths in the group of potential survivors resulted from delayed recognition of fetal distress, and 60% of these deaths were in mothers with mild to moderate injuries (Injury Severity Score < 16).

CONCLUSIONS

In pregnant trauma patients, infant viability is defined by the presence of FHTs, estimated gestational age greater than or equal to 26 weeks. In viable infants, survival after emergency cesarean section is acceptable (75%). Infant survival is independent of maternal distress or Injury Severity Score. Sixty percent of infant deaths resulted from delay in recognition of fetal distress and cesarean section. These were potentially preventable. Given the definition of fetal viability, our initial hypothesis is invalid.

Fetal trauma: relation to maternal injury

Conventional surgical wisdom is that fetal death is a predictable consequence of severe maternal injury. In order to define the natural history of maternal-fetal trauma and better formulate management strategies, we reviewed our recent experience with 32 cases of maternal trauma at a major trauma center. There were three cases of fetal death; two were associated with severe maternal injury, but one had no significant injury to the mother. All cases had placental injury. Conversely, there were five cases of severe maternal trauma but only two unsuccessful pregnancy outcomes. We conclude that the extent of maternal injury does not necessarily correlate with the degree of fetal injury. Lethal placental or direct fetal injury can occur even in the absence of significant maternal injury. In selected cases, fetal salvage after maternal-fetal trauma may be achieved by early delivery and prompt pediatric surgical intervention.