CASE REPORT

Niger J Paed 2015; 42 (3):234 –236

Audu LI

Unexplained massive subdural

haematoma in a newborn delivered

by elective caesarian section: a case

report

Mukhtar-Yola M

Otunete AT

Mairami AB

Nwatah VE

Mahmud MR

Ugwuanyi CU

Umar AU

DOI:http://dx.doi.org/10.4314/njp.v42i3.13

Accepted: 26th March 2015

Abstract: Symptomatic subdural

haematoma (SDH) in term infants

typically occur following trau-

matic vaginal delivery. Emer-

gency Caesarean Section (EmC/S)

carried out after failed attempts at

vaginal delivery may also be com-

plicated by symptomatic SDH but

spontaneous symptomatic SDH

complicating Elective Caesarean

Section (ElC/S) is a rarity. We

describe a case of massive SDH in

a term baby delivered by Elective

C/S in the absence of risk factors

for intracranial haemorrhage. The

aim of this presentation is to high-

light the significance of acute sub-

dural haematoma in the diagnostic

work up of neonates presenting

with acute neurologic symptoms in

the absence of traumatic delivery.

(

)

Audu LI

Mukhtar-Yola M, Otunete AT

Mairami AB, Nwatah VE

Ugwuanyi CU

Department of Paediatrics,

Mahmud MR

Department of Surgery (Neurosurgery)

Key words: Symptomatic sub-

dural haematoma, Caesarean sec-

tion, severe birth injuries, neonatal

seizure

Umar AU

Department of radiodiagnosis,

National Hospital Abuja

Nigeria.

Email: drauduli@yahoo.com

Introduction

sequently suggested intracranial bleed the location and

intensity of which was confirmed with Magnetic Reso-

nance Imaging of the brain. The cause of this haemor-

rhage was not known.

Subdural Hematoma is reportedly the most common

type of intracranial haemorrhage encountered in the term

1

newborn . It is more commonly associated with vaginal

delivery than operative abdominal delivery. Among ba-

bies delivered per vagina, the incidence is further in-

creased with the use of Forceps or Vacuum extraction

Case Description

A female term Neonate with a birth weight of 3.2kg

presented to our clinic on the 4 day of life with a his-

2

th

device . The speculated mechanism of SDH involves

tear of the Falx and Tentorium or bridging cortical veins

resulting from the increased circumferential pressure

during labour and the subsequent squeezing of the head

tory of poor suck and somnolence which had lasted for

about 24 hours. There was no history of fever, seizures,

vomiting or preceding trauma. The pregnancy was su-

pervised in a private hospital. There were no significant

maternal illnesses, medications or trauma in pregnancy

and antenatal ultrasound was normal. Delivery was by

ElC/S conducted by a very senior Consultant Obstetri-

cian, on account of a previous C/S and baby cried well

at birth. She received Vitamin K at birth, was clinically

stable and sucking well until a day before presentation

when a decrease in her level of physical activity was

noticed. Since birth, she was cared for by her mother

assisted by other relations who, despite doctor’s reassur-

ance, insisted on seeking a second opinion in a different

hospital. The baby was therefore not formally referred to

our hospital.

3

in the birth canal causing sutural overlap . Most cases

are often asymptomatic with minimal size haematoma

which resolves spontaneously without any complica-

tions. Severe symptomatic SDH has been reported in

babies d₄elivered by Emergency Caesarean Section

(

EmC/S) but rarely in babies delivered by Elective

Caesarean Section (ElC/S). The occurrence of massive

symptomatic SDH in a term baby delivered by ElC/S

prompted this report. We present a term baby delivered

by elective caesarian section that was apparently normal

at birth but developed acute neurologic signs (poor suck,

somnolence, full and tense AF, abnormal tone and re-

rd

flexes and unilateral mydriasis) on the 3 day of life. In

the absence of a history of traumatic delivery, a clinical

diagnosis of complicated intracranial infection was our

initial consideration. The brain Ultrasound finding as

well as the low haematocrit and blood stained CSF sub-

On examination, she was lethargic, pale, mildly jaun-

diced with a temperature of 36.8.C and SPO2 of 98%.

Weight on admission was 2.9kg and the OFC was 35cm.

2

35

She was not dysnoiec and had no echymotic or petechial

haemorrhagic lesions. The pulse was regular at 130/min

and there were no cardiac murmurs. Although she was

conscious, the anterior fontanel was full and tense while

tone and reflexes were increased in all limbs. The right

pupil was about 5mm dilated and non reactive while the

left pupil was normal. Fundoscopy was not done. A

clinical diagnosis of complicated meningitis with intrac-

ranial ‘collection’ was made and relevant investigations

were ordered.

Fig 2: MRI at 3 month shows right cerebral atrophy

Right cerebral

atrophy

Lumbar puncture revealed blood stained CSF which

yielded no bacterial growth while the CSF biochemistry

was not reliable as a result of the blood stain. Transfon-

tanel ultrasound showed a ‘right cerebral hemispheric

mass associated with marked shift of the right hemi-

sphere to the left’. Magnetic Resonance Imaging (MRI)

showed a massive SDH extending from the right frontal

to the occipital area (hyper intense on T1w1, hypo in-

tense on T2w and not suppressed on Flair), associated

with shift of midline structures to the contra lateral side

by about 1.22cm. (Fig. 1) The Haematocrit was 30%,

Discussion

Subdural Haematoma (SDH) is reportedly common in

neonates. It is reportedly seen in 1_,8₃ .2% -46% of new-

1

born babies in developed countries Similar prevalence

studies are not readily available from Nigeria . Most

cases are however asymptomatic occurring in babies

following spontaneous vaginal delivery (SVD). In a pro-

spective MRI evaluation of neonatal brains in North

Carolina USA by Looney et al1 16 of 88 (18.2%) as-

ymptomatic neonates had SDH. Vaginal delivery was a

significant risk factor in affected babies. The incidence

of asymptomatic SDH was as high as 46% in Hawai in a

prospective series reported by Rooks et al3. Spontane-

ous resolution usually occurs and long term neurologic

complications are uncommon. On the other hand, the

vast majority of symptomatic SDH in term babies are

sequels of traumatic vaginal delivery with or without

9

platelet count was 240 x 10 and white blood cell was

9

1

0.9 x 10 . Urea and Electrolyte results were normal.

Prthrombin Time and Partial Thromboplastin Time were

not done.

Fig 1: Right fronto-parietal-occipital subdural haematoma with

midline shift

2,5

instrumentation .

Spontaneous SDH may occur as a result of coagulation

Subdural

haematoma

6

abnormalities such as fetal or maternal thrombocyto-

7

penia or exposure to low molecular weight heparin as

8

reported by Bauder et al . Although our patient was not

Mid-line

Shift

extensively investigated for acquired or congenital

haemorrhagic diathesis, the absence of bleeding from

any other parts of the body or subsequent bleeding dur-

ing the course of hospital stay and follow up made this

an unlikely consideration. She also received a dose of

intramuscular vitamin K at birth. Furthermore, the plate-

let counts of the baby and the mother were normal. Non-

traumatic symptomatic SDH may also occur in critically

ill neonates resulting from Hypoxic- septic insult to

rd

On the 3 day of admission, she was transfused with

packed red blood cells followed by craniotomy and

evacuation of 50mls of blood. The subdural drain was

removed after 3 day_ns_d. She had only a transient episode

of seizure on the 2 post operative day, otherwise re-

covery was uneventful. She was treated with Phenobar-

9

dural venous structures . Our patient neither had any

evidence of hypoxia at birth nor haematologic/

microbiologic evidences suggestive of sepsis.

bitone and antibiotics and was discharged home on the

th

1

2 day of admission for follow-up at the Neonatal and

Neurosurgical clinics. A repeat brain MRI at 3 months

showed right cerebral atrophy (Fig. 2) but follow up

clinical assessment has consistently demonstrated nor-

mal motor functions and age specific milestones (good

neck control at 4 months, able to sit and walk without

support at the age of 6months and one year respec-

tively). The baby was last seen in the clinic at the age of

Emergency C/S following failed assisted labour

increases the incidence of C/S related SDH. For in-

stance, six of the ten cases of symptomatic SDH re-

5

ported by Azubuike et al in Nigeria, were delivered by

emergency C/S when forceps and or vacuum extraction

had failed. O₀ne of the nine cases of SDH reported by

1

Whitby et al from Sheffield was in a baby delivered

1

9 months and had commenced regular pre-nursery

by emergency C/S following failed vacuum extraction.

Severe maternal assault was reportedly responsible for

SDH in a preterm baby delivered by emergency Caesar-

school. Hearing test (distraction test) was grossly normal

and she was able to make two word sentences clearly.

11

ean section as a result of fetal distress . It is therefore

obvious that SDH when seen in babies delivered by C/S

commonly results from documented trauma before or

during labour, which contrasts with the situation of the

baby in our report. We however acknowledge the fact

2

36

that the occurrence of minimal trauma during the deliv-

ery process cannot be absolutely excluded.

traumatic delivery, the differential diagnoses will in-

clude complicated meningitis, intracranial abscess and

congenital cerebral malformations. Where ultrsasogra-

phy or magnetic resonance imaging facilities are not

available, diagnosis may be delayed and this will impact

negatively on the outcome.

In a prospective ser₂ies and critical review of the litera-

1

ture, Vinchion et al stated that although SDH may oc-

cur spontaneously, non accidental head injury must al-

ways be ruled out. The absence of prenatal or parturient

risk factors for SDH in our patient prompted considera-

tion for accidental or non accidental post natal trauma

which however could not be substantiated. From the

foregoing, we believe our case was an unusual occur-

rence of severe symptomatic SDH in a term baby with

no identifiable risk factors. Although the APGAR scores

were not documented, the good cry at birth and the ab-

sence of symptoms in the first 3 post natal days pre-

cluded Perinatal asphyxia or significant birth related

head injury.

Conclusion

Symptomatic SDH could occur in term babies in the

absence of identifiable risk factors and early cranial

ultrasonography in a term baby with acute neurologic

signs offers a reliable diagnostic clue. Prompt neurosur-

gical intervention improves long term outcome.

Unlike asymptomatic SDH, acute symptomatic SDH is

usually a neurological emergency that requires urgent

hematoma evacuation to prevent mortality or long term

neurologic morbidity . Our patient had emergency cra-

niotomy and haematoma evacuation done within 72

hours of admission and this we believe contributed to

the favourable outcome. In the absence of a history of

Conflict of interest: None

Funding: None

13

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