What is Intracranial Birth Injury?
Intracranial birth injury is understood to mean cerebral cerebral disorders of varying severity and localization that occur during childbirth due to mechanical damage to the skull and its contents.
Causes of Intracranial Birth Injury
The causes of intracranial birth injury can be divided into two groups.
Depending on the condition of the fetus:
- embryofetopathy – malformations with hemorrhagic syndrome, venous stasis in the tissues;
- fetal hypoxia associated with placental insufficiency;
- prematurity (fragility of tissues, a small amount of elastic fibers, increased vascular permeability, immaturity of the liver, prothrombin insufficiency, softness of the skull bones);
- tolerance – hypoxia associated with involution of the placenta.
Related to the features of the birth canal of the mother:
- stiff tissue of the birth canal;
- curvature, narrowing of the pelvis;
- water shortage;
- premature rupture of the fetal bladder, which facilitates the passage of the head through the birth canal.
In the violation of cerebral circulation, a significant role belongs to the difference between the atmospheric pressure acting on the underlying part of the head and the intrauterine pressure increasing with each contraction of the uterus. In the genesis of cerebral disorders, dislocation syndrome is of great importance. The main factor in the pathogenesis is mechanical damage to the skull and its contents. Even with normal childbirth, a transient obstruction of cerebral blood flow occurs. In the pathological course of childbirth, the summation of various factors occurs, while even moderate mechanical stress and deformation of the head can cause a violation of the integrity of intracranial vessels, duplicates of the dura mater, which leads to intracranial hemorrhage in premature babies. These disorders can occur even with the appearance of a normal course of labor.
The frequency of intracranial birth injury is 10-20% of all birth defects of the nervous system. In the structure of perinatal mortality, intracranial birth injury is 10-12%.
Pathogenesis during Intracranial Birth Injury
A mild degree of intracranial birth injury is considered as a concussion, in which an increase in neuro-reflex excitability, tremor of the chin, limbs, spontaneous Moro reflex, increased muscle tone, and revitalization of deep reflexes predominate. The syndrome is based on transient disorders of hemo- and cerebrospinal fluid dynamics.
Moderate severity corresponds to a brain contusion clinic. The anxiety of a child with a painful monotonous cry persists for a long time, the predominance of hypertension of flexor muscle groups of the upper extremities and extensor muscle groups of the lower extremities is characteristic. There may be a soporous state with adynamia, lethargy, polymorphic convulsions, focal symptoms.
A severe degree of damage is characteristic of compression of the brain. In this case, a coma can develop several hours or days after the birth. The child responds only to intense pain irritation with slight motor anxiety or silent crying. Sucking and swallowing are absent. Muscular atony, reflexes are not caused. Due to the immaturity of the nervous system, focal symptoms are difficult to identify, diffuse neurological disorders predominate.
All cases of intracranial birth injury can be divided into traumatic brain damage without intracranial hemorrhage and intracranial hemorrhage: epidural, subdural, subarachnoid, intracerebral, intraventricular, multiple intracranial hemorrhages of different localization.
Epidural hemorrhage usually occurs when the bones of the skull are damaged (delivery using obstetric forceps or a vacuum extractor). With this hemorrhage, blood accumulates between the bones of the skull and the dura mater (the so-called internal cephalohematoma). Unlike subdural hematoma, there is no blood in the cerebrospinal fluid, but there may be protein-cell dissociation.
Subdural hemorrhage. Main reasons:
- sharp displacement of the bones of the skull (rapid childbirth) with damage to blood vessels flowing into the superior sagittal and transverse sinuses, and cerebellar vessels;
- rupture of the cerebellar tent when the voltage of one of the leaves with hemorrhage in the occipital and temporal lobes increases, followed by compression of the medulla oblongata.
Clinical signs, gradual deterioration of general condition, respiratory failure (rapid, arrhythmic), pallor, cooling of the skin, decreased muscle tone, lack of unconditioned reflexes, in particular corneal, impaired sucking and swallowing, an increase in symptoms of intracranial hypertension, Gref’s symptom, regurgitation, vomiting focal and generalized clonic-tonic convulsions. Of the focal symptoms, there may be damage to the oculomotor nerve (usually ptosis and mydriasis) on the side of the hematoma.
The subdural hematoma of the posterior cranial fossa is particularly difficult, the light gap is usually absent, and the trunk symptomatology is rapidly growing.
Subarachnoid hemorrhage. At first, the presence of a syndrome of increased neuro-reflex excitability with general motor anxiety, tremor of the extremities, trembling, and convulsions may be characteristic. Meningeal symptoms are especially characteristic, of which stiff neck is most pronounced, head tipping is often noted. Cerebrospinal fluid mixed with blood or xanthochromic.
Intracerebral hemorrhage occurs mainly in premature infants. The clinic depends on the vastness and location of the hemorrhage. With extensive hemorrhage, the child is in a coma from the first day. There is no reaction to stimuli, the pupils are usually wide, especially on the side of the hematoma, with a sharp decrease or absence of the reaction of the pupils to light, floating movements of the eyeballs, muscle atony, hypo- or areflexia. Often join nystagmus, convulsions with a focal component, bradycardia, arrhythmic breathing.
Intraventricular hemorrhage. The main reason is the rupture of the vessels of the choroid plexus in premature babies during rapid childbirth. Clinically – deep coma, respiratory failure, cardiac activity, tonic convulsions, opisthotonus, narrowing of the pupils, anisocoria, floating eyeball movements, horizontal, vertical, rotatory nystagmus, tension of the large fontanel, impaired vegetative trophic functions, hyperthermia. Often a fatal outcome. A massive breakthrough in the fourth cerebral ventricle – instant death.
Symptoms of Intracranial Birth Injury
Features of the clinical picture are due to a wide range of cerebrovascular disorders. In newborns, a significant fluctuation in the general condition is noted – from a syndrome of increased neuro-reflex excitability to general inhibition of brain functions and even to a coma, with a periodic change in these conditions. The first hours, days are more often characterized by depression – children are sluggish, inactive, they have decreased muscle tone, deep reflexes and the main reflexes of newborns are depressed. The scream is weak, monotonous or, conversely, loud, irritable, piercing. Convulsions (focal or generalized) often occur. The combination of seizures with focal neurological symptoms is typical for intracranial hematomas, but it must be borne in mind that in newborns focal symptoms are difficult to identify, they do not always correspond to the localization of intracranial hemorrhage. With an increase in hematoma, cerebral edema and its dislocation, a fatal outcome is possible.
Sometimes during the first 3-4 days a period of relative well-being is possible (the so-called delayed onset of symptoms).
Diagnosis of Intracranial Birth Injury
Diagnosis of intracranial birth injury should be based on the account of the obstetric history (condition of the mother, especially the management of childbirth), the clinical data of the newborn, assessment of his condition at birth and in the future, the appearance of neurological disorders, etc.
Of great importance for clarifying the diagnosis are special research methods.
- Fundus examination – foci of hemorrhage in the form of stripes, spots, “puddles” in the macula, around the optic nerve disks, along the vessels.
- The EchoEG method allows you to detect the displacement of the M-echo (displacement of more than 2 mm – suspected hematoma).
- More accurate data can be obtained with neurosonography, computed tomography.
- Diaphanoscopy or transillumination is quite informative (an increase in the luminescence zone with hypertension-hydrocephalic syndrome, a decrease in the luminescence zone over the hematoma).
- Study of cerebrospinal fluid. Normally, the cerebrospinal fluid in a newborn is transparent, it may be slightly xanthochromic. Cytosis of 1-25 cells in 1 ml, pressure of 80-100 mm of water. Art. With intracranial hemorrhage, cerebrospinal fluid is cloudy or the color of meat slops due to blood. Protein content more than 0.66 g / l; cytosis of 125-350 cells in 1 ml. Pressure 150-300 mm of water. Art.
- X-ray of the skull (crack, impression of bones, etc.).
Treatment of Intracranial Birth Injury
The diagnosis must be deciphered taking into account clinical and paraclinical data. Treatment of intracranial birth injury often begins with resuscitation. Subsequent therapy includes measures for the regimen, care, the appointment of pathogenetic and symptomatic medications, if indicated, surgical intervention. Maximum rest, gentle regimen, craniocerebral therapy with hypothermia for 1-2 days are needed; do not apply to the chest (nipple with a wide opening).
Prescribe drugs that strengthen the vascular wall and increase blood coagulability (ascorbic acid, rutin, 10% solution of calcium chloride, vicasol). To reduce cerebral edema – magnesium sulfate, diacarb, glycerol, lasix. To reduce intracranial pressure, native plasma is also used – 10-15 ml / kg for 4-8 days and other dehydrating agents. In order to correct metabolic acidosis, a 4% sodium bicarbonate solution, cocarboxylase, is prescribed. With convulsive syndrome, seduxen, phenobarbital are used. With adrenal insufficiency, corticosteroids are used. For detoxification, hemodesis, reopoliglyukin, glucose solution with insulin, physiological saline are used.
It is necessary to control the state of the cardiovascular, respiratory systems. It is possible to use stimulating agents (dopamine, strophanthin, aminophylline, cordiamine, norepinephrine). They also use drugs that increase metabolic processes (B vitamins, encephabol, piracetam, pantogam). These same drugs are used in the future to treat the consequences of intracranial birth injury in combination with physiotherapy, therapeutic exercises, speech therapy sessions.
Prevention of Intracranial Birth Injury
- A balanced diet – foods that are high in fiber, refusing fried, canned and spicy foods.
- Quitting bad habits – smoking and alcohol.
- The correct management of a woman’s pregnancy.
- A regular examination by doctors during pregnancy.
- Timely identification and treatment of pregnancy complications.
- Competent and careful obstetric care during childbirth.