Birth Related Hemorrhages

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In the neonatal period, conjunctival and retinal hemorrhages (and some intracranial hemorrhages) can be the result of nonaccidental injuries (violent shaking, direct trauma) or birth trauma, and careful consideration should be given to this differential diagnosis.

Birth-related conjunctival hemorrhages may be documented in delivery or neonatal medical notes/charts, or they may be seen on family photographs of a newborn child. Note, however, that their absence may be the result of sampling problems and may not exclude birth trauma (I once looked through more than 60 family photographs of one child to find the single photograph that showed a conjunctival hemorrhage that I had seen microscopically).

Birth-related retinal hemorrhages are extremely common but usually are not seen or documented because nobody looks for them. They are not seen on family photographs. The RetCam (a wide-angle "contact" eye fundus camera) was used in a prospective study (revised manuscript submitted to J American Association Pediatric Opthalmology and Strabismus: Hughes et al. "Incidence, distribution and duration of birth-related retinal hemorrhages: a prospective study.") of retinal hemorrhages in neonates (in our hands RetCam is safe and very easy to use in unsedated neonates, and it is well tolerated by the parents watching or holding the infant). In 50 full-term normal neonates, retinal hemorrhages were very common (32% overall) and often were extensive (Figure 4.14). Their incidence in normal vaginal deliveries was 33%, ventouse deliveries 88%, forceps deliveries 14%, and cesarean sections 7%. The hemorrhages can be unilateral or bilateral, and are intraretinal. Most resolved very rapidly (in a few days and certainly within 2 weeks after birth). However, denser and are intraretinal hemorrhages persisted up to 10 weeks after birth.

Fig.4.14. Wide angle fundus camera (RetCam) picture of the retina of a child 1 day after normal full-term delivery. Widespread superficial retinal blot hemorrhages extend from the central optic disc toward the periphery, where more dense hemorrhage is seen (arrow). Approximately one third of newborn infants have retinal hemorrhages, which usually clear very rapidly.

Fig.4.14. Wide angle fundus camera (RetCam) picture of the retina of a child 1 day after normal full-term delivery. Widespread superficial retinal blot hemorrhages extend from the central optic disc toward the periphery, where more dense hemorrhage is seen (arrow). Approximately one third of newborn infants have retinal hemorrhages, which usually clear very rapidly.

In a living infant (if a shaking injury is suspected), I would have an increased suspicion of "shaken baby syndrome" (bearing in mind the general clinical history and examination) in an infant presenting at 2 weeks with extensive flame-shaped hemorrhages and at 4 weeks with extensive intraretinal hemorrhages. However, even at 12 weeks an isolated hemorrhage can be related to birth trauma. In a dead child, "fresh" retinal hemorrhages with no demonstrable hemosiderin could not have occurred more than 48 to 72 hours before death (using the timing usually quoted by forensic pathologists, although care is always needed when quoting precise timing of pathologic processes). In a child born 2 weeks previously, it is extremely unlikely that such a "fresh" hemorrhage was caused by birth trauma.

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