Joti Sharma, MD (Host): Hello, everyone. Welcome to another edition of our podcast, Neonatology Review, Isolette to CRIB. I'm your host, Dr. Joti Sharma. This is a podcast that we had started early, and due to just our clinical service work, we were not able to continue, but now we are back, and hopefully we'll be giving you a podcast every month.

The purpose of this podcast is to review high yield common topics in neonatology. While our focus is geared towards the perinatal neonatal boards, anyone learning or studying neonatology will find this podcast helpful. And for this episode, we have Dr. Sanjay Akangire back as our guest. As you may remember, he's been our guest in our previous episodes.

He is a Neonatologist here with us at Children's Mercy in Kansas City. Tell everyone hi, Dr. Akangire.

Sanjay Akangire, MD: Hi, everyone. Happy to be here again.

Host: And he is joining us today to talk about birth related neonatal conditions. In this podcast, we will define birth injuries, go over the risk factors, and then describe common birth injuries and discuss emergencies with bleeding, nerve injuries, and fractures. So let's get started.

Sanjay Akangire, MD: All right, so birth injury, it's a structural destruction to the neonate's body or functional deterioration due to event causing trauma to a neonate. These include avoidable and unavoidable injuries. Some injuries can be avoided if extreme caution is taken during delivery process and others are hard to avoid even if the clinicians are very cautious and vigilant.

Intrauterine transfusions and amniocentesis are not considered part of birth injuries. Injuries during resuscitation after birth are also not considered as birth injuries. Injuries with intrapartum heart rate monitoring devices and scalp electrodes are considered as birth injuries.

Host: Dr. Akangire, that's a great start and thank you for all the clarification as to what comes under the umbrella of birth injury and what does not. So now let's discuss the incidence and some of the risk factors that are associated with birth injuries.

Sanjay Akangire, MD: Sure, Dr. Sharma. So deliveries that happen with use of instruments such as forceps and vacuum are important risk factors. Use of forceps increases the risk of birth injuries by fourfold and use of vacuum increases the risk by threefold, in comparison to non instrumental deliveries. Macrosomia is an important risk factor for birth injuries, and the risk is increased based on the birth weight.

For 4 to 4.5 kilo infant, risk increases by two fold. For 4.5 to 5 kilo infant, risk increases by three fold. And if the birth weight is less than 5 kilos, the risk increases by 4.5 fold.

Host: I think you meant more than 5 kg, right? The risk increases by 4.5 fold.

Sanjay Akangire, MD: That is correct. More than five kilos.

Host: So it sounds like there is quite a potential for birth injuries based on risk factors. Can you go over some specific injuries based on risk factors which are predominantly instrumental deliveries and macrosomia? And this would include, large for gestational age and infant of a diabetic mother infants.

Sanjay Akangire, MD: Sure, Dr. Sharma. So forceps use increases the risk of facial nerve injuries, vacuum increases the risk of skull fracture and subgaleal hemorrhage. Breech presentation increases the risk of brachial plexus injury and macrosomia increases the risk of shoulder dystocia, clavicle fracture, cephalohematoma, and caput succedaneum.

Host: That's a great outline of the associated risk factors. So since you mentioned subgaleal hemorrhage, caput, and cephalohematoma, this can be classified as extracranial. Can you elaborate more on the extra and intracranial injuries that can be, that can occur or be related to birth?

Sanjay Akangire, MD: Sure, Absolutely, Dr. Sharma. So cranial injuries are divided into extracranial and intracranial injuries. Extracranial injuries include cephalohematoma, caput succedaneum, and subgaleal hemorrhage. To understand the location of extracranial injuries, it is important to understand the layers of scalp.

Outermost layer is skin, then epicranial aponeurosis, periosteum, skull, and then dura mater just under the skull.

Host: Yes, that's going from the outside to the inner layer of the scalp, and I have to say you have described it very nicely.

Sanjay Akangire, MD: Yeah, so if bleeding occurs under the skin it is called as caput succedaneum. If bleeding occurs under the epicranial aponeurosis it is called a subgaleal hemorrhage. If bleeding occurs under the periosteum, it is called as cephalohematoma. These layers and the location of bleeding can be a board question, again, can be a board question and is important to. And is important to know along with the figure of scalp layers.

Host: Dr. Akangire, that's an important point on this being a potential board question. Usually there is a diagram of the scalp layers, and you have to identify the location of the hemorrhage. That is very clear, especially the discussion on the different layers of scalp. Can you talk further on the three extracranial conditions in more detail?

Sanjay Akangire, MD: Sure, absolutely. So let's start with cephalohematoma. It is a subperiosteal blood collection due to rupture of blood vessels under the periosteum. This can occur in 1 to 2 percent of all deliveries regardless of the delivery mode. Cephalohematoma does not cross the suture lines as this bleed remains in single cranial plate.

Next one is caput succedaneum. It is accumulation of blood below the skin and above the periosteum. Caput succedaneum crosses the suture lines of the skull and it usually resolves in four to six days.

Host: I just want to point out that, it's important to note that both of this cephalohematoma and caput succedaneum are usually self limiting. What I wanna talk about. It's is subgaleal hemorrhage, which is the one that is more important to recognize early.

Sanjay Akangire, MD: That is correct Dr. Sharma. It is important to recognize subgaleal hemorrhage early because it if it goes undetected, can lead to hypovolumic shock. Alright, so subgaleal hemorrhage is accumulation of blood between periosteum and epicranial aponeurosis. This is a potential large space for blood collection that can accumulate 40 percent of infant's blood volume. Typically, incidence is four in 10,000 in non instrumented deliveries, but increases significantly to 64 in 10,000 with use of vacuum extraction. Mortality may be up to 14 percent due to shock and disseminated intravascular coagulation or DIC.

Host: That is why it is important to have a high degree of vigilance for subgaleal hemorrhage in instrumental delivery, especially vacuum extraction, because as you mentioned, this is a potential space where bleeding can occur without physical findings if it's not looked for and the patient can go into shock.

Sanjay Akangire, MD: That is absolutely correct, Dr. Sharma. So infants with concerns of subgaleal hemorrhage should be monitored very closely with serial hemoglobin levels and vital signs. Clinical signs with tachycardia along with hypotension, poor perfusion, falling hematocrit and increasing OFC or occipitofrontal circumference is a triad that is very suspicious for subgaleal hemorrhage.

 Palpation of bogginess around the skull is a classic sign. Head imaging like CT or MRI may be useful but not required for diagnosis of subgaleal hemorrhage. Once diagnosis of subgaleal hemorrhage is made and if infant is clinically deteriorating, aggressive volume resuscitation with normal saline, packed red blood cells, and fresh frozen plasma transfusion may be needed. Surgery is rarely indicated for this bleed.

Host: That is great information, Dr. Akangire. Can we briefly talk about intracranial injuries that can occur?

Sanjay Akangire, MD: Sure, Dr. Sharma, so let's start with subdural hematoma. This is the most common intracranial bleeding in neonates. Incidence of subdural hemorrhage is 2.9 per 100,000 deliveries. Vacuum and forceps use increases the incidence of subdural hemorrhage. Subdural hemorrhage occurs due to accumulation of blood between dura matter and arachnoid layer of the brain. This bleeding happens due to rupture of bridging veins. Infant may become symptomatic in the first 24 hours and further steps of management depends on extent of bleeding and symptoms.

Host: And can you describe how may this present?

Sanjay Akangire, MD: Important question, Dr. Sharma. So, infants with subdural hemorrhage usually present with respiratory depression, apnea and seizures, which are commonly focal in nature. And most of the times, infants with subdural hemorrhage are closely observed but may need neurosurgical evacuation, who demonstrate the signs and symptoms of raised intracranial pressure.

Host: So can we talk about the other two intracranial hematomas?

Sanjay Akangire, MD: Sure. So epidural hematoma is very rare in neonates. Subarachnoid hemorrhage, this is the second most cause of intracranial bleed in neonates. Literature suggests that many infants have subarachnoid hemorrhage but remain asymptomatic and the hemorrhage resolves in several days. Management is very similar to subdural hematoma in symptomatic infants.

Host: So this is actually a good review of intracranial and extracranial hemorrhage in neonates. So can we now review some of the nerve injuries that may occur?

Sanjay Akangire, MD: Okay, so let's start with facial nerve injury. Incidence is about 0.5 to 1 percent of live birth. This results from compression of branches of facial nerve, most commonly mandibular branch. This compression results in decreased contraction of the muscles affected, typically the muscles around the forehead, eyes, and mouth on the affected side.

Drooping is seen when there is facial nerve injury as mouth is drawn on the unaffected side due to normal muscle contractions. Okay, so here is a possible board question. Asymmetric crying faces is another condition in which there is congenital absence of depressor anguli oris muscle. That is responsible for downward movement of lips.

In this condition, eye and forehead muscles are unaffected and have normal contraction, unlike in infants with facial nerve injury. This condition resolves spontaneously.

Host: Yes, you pointed out a great differential diagnosis for facial nerve injury. What we need to be aware of about facial nerve injuries is that it is self limiting and most resolve spontaneously or with physical therapy in six to eight weeks. And further imaging with MRI is recommended if there's a suspicion of congenital brain abnormality or extensive brain injury is suspected.

So, after covering facial nerve injury, the next nerve injury that I think we should discuss is the brachial plexus injury.

Sanjay Akangire, MD: Sure, Dr. Sharma. So the incidence of brachial plexus injury is 0.5 to 2.5 per 1,000 live births. Risk factors include shoulder dystocia, breech presentation, macrosomia, and instrumental deliveries. Most common form is Erb-Duchenne palsy that is due to the injury to C5 to C6 nerve roots. In this palsy, arm is held in adduction and pronation position along with extension of elbow, pronation of forearm and flexion of wrist. This condition typically resolves spontaneously. l

Klumpke palsy is due to the injury to C8 to T1 nerve roots. In total arm paralysis, all nerve roots from C5 to T1 are affected. Also want to add here that Horner's syndrome occurs due to injury to sympathetic outflow that comes out of T1 nerve root and symptoms include meiosis, ptosis, enophthalmos of the affected side.

Host: So Dr. Akangire, while Erbs and Klumes are usually seen clinically, how common is total arm paralysis?

Sanjay Akangire, MD: Actually it is very uncommon but it does occur sometimes. Just want to add that diagnosis is mostly clinical in brachial plexus injuries. Close monitoring is needed. Physical therapy may be helpful, and if there is no improvement after three months, may need orthopedic consultation.

Host: That's a good point. So Dr. Akangire, you have discussed hematomas, nerve injuries. Can we now focus on some of the common fractures during the delivery process?

Sanjay Akangire, MD: Yes, absolutely Dr. Sharma. So let's start with the most common fracture. That is a clavicle fracture. Incidence is 1 to 1.5 percent from birth trauma. Risk factors include shoulder dystocia, macrosomia, and instrumental deliveries as you can imagine. This has excellent prognosis and no long term complications are expected.

Skull fractures can also occur during birth process. Common skull fractures are linear and are mostly monitored as they are non depressed. If the skull fractures are depressed, concerns for intracranial process increases. If there is no neurodeficit, these infants are closely monitored, but if clinical signs of neurodeficit are present, neurosurgical evaluation, including surgery, may be indicated.

Humerus and femur fractures can also occur during the birth process. But prognosis is excellent.

Host: That's a great summary. My understanding is that even the humerus and femur fractures do not usually require any orthopedic intervention.

Sanjay Akangire, MD: You are correct, Dr. Sharma. Usually healing of these fractures occur with immobilization of the affected extremity for several weeks, but close orthopedic outpatient follow up is recommended.

Host: Dr. Akangire, that's a very good succinct presentation of birth related injuries. Let's wrap up and review some take home points.

Sanjay Akangire, MD: Sure, Dr. Sharma. So incidence of birth injuries has decreased significantly in last two decades. Instrumental deliveries and macrosomia are significant risk factors for birth injuries. Infants with concerns for subgaleal hemorrhage based on clinical signs should be monitored very closely due to their potential for hemodynamic decompensation and need of aggressive resuscitation.

Erb-Duchenne palsy is the most common form of brachial plexus injury and typically resolves in three to six months. Physical therapy and orthopedic consultation may be needed. Facial nerve injury is a common birth injury and has a very good prognosis. Clavicle, humerus, and femur fractures are common fractures during birth process and have excellent prognosis.

Skull fracture, especially depressed fracture, needs close observation for possible neurodeficit.

Host: Okay, Dr. Akangire, we have come to the end of our presentation and as always, it's good to do some questions because we are board oriented. Do you have some questions that we could go over?

Sanjay Akangire, MD: Absolutely. I have a couple of questions, just like our previous podcasts. So, let's start with question one. The clinical signs of traumatic injury to the head during birth process can range from minor to life threatening. Of the following, the most correct statement about traumatic head injury during birth is A. Caput succedaneum usually enlarges after birth. Cephalohematomas are most often bilateral. Depressed skull fracture warrants surgical intervention. D, the most common risk factor for subgaleal hemorrhage is vacuum extraction and E, ultrasonography is the imaging of choice for the diagnosis of epidural hematoma.

Joti Sharma, MD (Host): Okay, Dr. Akangire, I am going to take this systematically. So, A is incorrect because caput succedaneum usually is present at birth and gets, it's present at birth and gets smaller after birth. Cephalohematomas are rarely bilateral. I've seen at least one or two, but it's mostly unilateral. Even depressed skull fractures rarely warrant surgical intervention.

And we know that, the imaging choice of diagnosis for epidural hematoma is a CT. So the answer is D. The most common risk factor for subcaleal hemorrhage is vacuum extraction, which you covered in your presentation.

Sanjay Akangire, MD: That is correct, Dr. Sharma. So the answer is D. The most common risk factor for subgaleal hemorrhage is vacuum extraction. Typically, the incidence is four in 10,000 in non instrumented deliveries, but increases to 64 in 10,000 with use of vacuum extraction. So the incidence significantly increases with the use of vacuum extraction.

So, going to question two, 38 week gestation newborn was born by vacuum assisted vaginal birth. Birth weight was 40 to 50 grams. Apgars were 7 and 8 at 1 and 5 minutes after birth. Baby is pink and vigorous on exam. On exam, you notice a soft circumscribed mass at the left parietal area of the skull, it does not cross the sagittal suture.

What is the most likely diagnosis? And the choices are a. Caput succedaneum. B. Cephalohematoma. C. Subgaleal bleed. D. Displaced Skull fracture.

Joti Sharma, MD (Host): Okay, Dr. Akangire. So this one, the patient is pink and vigorous on exam. So unlikely to be subgaleal. It is in the left parietal area and does not cross suture lines. So therefore, I think the most likely diagnosis is B, this is a cephalohematoma.

Sanjay Akangire, MD: That is correct Dr. Sharma. So it is B, cephalohematoma and as we covered cephalohematoma is subperiosteal blood collection due to rupture of blood vessels under periosteum. The differentiating feature here is that cephalohematoma does not cross the suture lines unlike caput succedaneum which crosses suture lines.

Joti Sharma, MD (Host): Thank you, Dr. Akangire. To the audience, our listeners, I hope you have enjoyed this succinct presentation on birth injuries. It's short enough for you to listen on your drive to work in the morning, and hopefully it gives you a better understanding of birth injuries.

So until next time, this is Neonatology Review, Isolette to Crib. I'm Dr. Joti Sharma. Thank you for listening.

Sanjay Akangire, MD: Thank you.