DEPARTMENT OF PEDIATRICS WITH COURSE DEPARTMENT OF PEDIATRICS WITH COURSE OF MEDICAL GENETICSOF MEDICAL GENETICS

LECTURELECTURE::

““Birth traumaBirth trauma””

Determination

Birth trauma is Birth trauma is aa damage of fetus damage of fetus tissues and organs during birth, caused tissues and organs during birth, caused by pathology of antenatal or intranatal by pathology of antenatal or intranatal periodperiod..

Groups of birth traumas: Birth trauma of CNS. Birth trauma of spinal cord and peripheral nervous

system. Birth trauma of soft tissues(birth tumour, hemorrhage

under aponeurosis, cephalhematoma). Birth trauma of skin(scratch, wound, bubbles with

haemorrhagic content, haematomas) and hypodermic cellulose (adiponecrosis).

Birth trauma of muscles. Birth trauma of bones(break of collar-bone., thighs etc.). Birth trauma of internal organs (liver, kidneys rupture)

Birth trauma of CNS(intracranial hemorrhage)

Types of intracranial hemorrhages:

1. - Intraventricular hemorrhage (peri- and intraventricular)

2. - Subarachnoidal hemorrhages

3. - Subdural hemorrhages

4. - Epidural hemorrhages

5. - Parenchymatous hemorrhages

6. - Cerebella hemorrhages

Birth trauma of CNS (intracranial hemorrhage)Etiology and pathogenesis

Birth traumatismThe direct factor of the birth trauma of CNS development is the mechanical

influencing as a result of: disparities of mother’s pelvis size and size of the fetus head (large fetus, narrow

pelvis) swift or protracted births wrong executed obstetric manipulations and operations (imposition of obstetric

tongs)

More frequently epidural, subdural, intraventricular hemorrhages of the III-IV stages have traumatic genesis.

Perinatal hypoxia and related to it haemodinamic (hypotension) and metabolic (acidosis, excessive activating of LP) violations

Child, that had chronic antenatal hypoxia in past, can have ICH even at the normal birth course, because hypoxia and birth trauma are connected according to pathogenic factors. Correlation of the traumatic and hypoxic hemorrhages into the brain is 1:10.

More frequently intraventricular hemorrhages of the I-II stages and petechial hemorrhages into the gray matter have hypoxic genesis.

Birth trauma of CNS (intracranial hemorrhage)

Etiology and pathogenesis Perinatal features of coagulative and thrombocytal hemostasis

(deficit of vitamin-К-dependent factors), especially for prematurely born children

As a result of coagulative, anticoagulative and fibrinolytic systems disbalance children are inclinated to appearance of the ischemic -trombotic defeat of the cerebrum and PVL.

Prematurity and morphological-functional immaturity

75% of the premature children have intraventricular hemorrhages of different stages as a result of presence of germinal (embryonic) matrix at the organisms of children that have less than 35 weeks of gestational age. The vessels bloodstream in the germinal matrix depends on the system arterial pressure changes: at the increase of arterial pressure there is an overflow of the microcirculation and the ICH appear, in case of hypotension there is an ischemia of cerebral tissues, renewal of bloodstream in ischemic areas can cause a hemorrhage.

Birth trauma of CNS (intracranial hemorrhage)

Etiology and pathogenesis

Prenatal infections (defeats of vascular wall)

Inefficient care (hypothermia, inobservance of the medical-protection mode)

Iatrogenic influencing (rapid i/v infusions, excessive oxygen therapy, overdosing of anticoagulants and antiaggregants)

Birth trauma of CNS(intracranial hemorrhage)

Typical clinical manifestations: Sudden worsening of the general state Change of scream character (“cerebral scream”) Bulging of the large fontanel Local eye symptoms Violations of thermoregulation Vegeto-visceral and pseudobulbar disorders Motive disorders Cramps Disorders of muscle tone Posthemorragic anaemia Metabolic violations Addition of somatic diseases

Intraventricular hemorrhages

Clinics: Flaccidity, adynamy

Bulging of the large fontanel

Decrease of the muscle tone

Disappearance of the sucking and swallowing reflexes

Attacks of аpnoe, respiratory disturbance

Local neurological symptoms (paresis of vision, permanent nystagmus, symptom of Grefe)

Arterial pressure and tachycardia decrease

Intraventricular hemorrhagesDiagnostics:

Liquor analysis: hemorrhagic character, cytosis to 1000 cells in 1 mcl, the amount of protein increases. In a few days after the hemorrhage liquor becomes xantochromic, the concentration of sugar goes down.

Neurosonography:PVH of the I stage - subepindemal hemorrhage in the germinal matrixPVH of the II stage - breach of hemorrhage in the cerebral ventricles

without dilatation PVH of the III stage- intraventricular hemorrhage with the ventricles

dilatationPVH of the IV stage– intraventricular and parenchymatous

hemorrhages Doppler: bloodstream fluctuation ECG: focal changes, paroxysmal activity

Subarachnoidal hemorrhages

Clinics:

1. Hyperexcitability ( anxiety, cerebral scream, inversion of sleep, increase of motive activity, hypertension, increase of muscle tone).

2. Liquor-hypertension syndrome (throwing back of head, cramps, rigidity of the occiput muscles , bulging of the large fontanel, skull gaping, pathological increase of the head circumference).

3. Local neurological symptoms (strabismus, nistagmus, anisocoria, symptom of Grefe, violation of swallowing).

Subarachnoidal hemorrhages

Diagnostics:

Lumbar puncture and liquor analysis (executed necessarily): haemorrhagic or xantochromic character, high cytosis, the protein amount increases.

Neurosonography: local expansion and hyperechogenicity of the sulci of Silviev and interhemispheric fissure. The most frequent hemorrhage localization is the parietal-temporal area of cerebrum and cerebellum hemispheres

Subdural hemorrhagesClinics of supratentorial hemorrhages:

Supratentorial hemorrhages are caused by damages of sagittal sine and veins, that enter it.

Period of “imagine prosperity” of 2-3 days Liquor- hypertension syndrome (throwing back of head, cramps,

bulging of the large fontanel, skull gaping, pathological increase of the head circumference)

Symptoms of distribution of cerebrum middle structures (anxiety, rigidity of the occiput muscles, mydriasis on the defeat side, paresis of look)

Clinics of supratentorial hemorrhages:Supratentorial hemorrhages are caused by break of the tentorium of

cerebellum and hemorrhage into back cranial fossa.The state of child is heavy from the moment of birth with further appearance

of symptoms of brainstem squeezing (violation of suction and swallowing, anisocoria, nistagmus, cramps). A pallor, flaccidity, disorders of breathing, bradycardia, muscle hypotonia, hyporeflexia grow in a dynamics.

Subdural hemorrhagesDiagnostics:

NSG: uneven strengthening of echogenicity of the tentorium of cerebellum, thrombus in the back cranial fossa, local

expansion and hyperechogenicity of the interhemispheric fissure, displacement of interhemispheric fissure,

compression of lateral ventricles.

Epidural hemorrhagesClinics:

Epidural hemorrhages more frequently appear in case of mature children, if there was the damage of the skull bones. Their typical location is between the pachymeninx and skull bones, they combine with cephalohematomas.

Period of “imagine prosperity” 3-6 hours Hyperexcitability, acute anxiety Cramps Mydriasis on the side of defeat, hemiparesis on an

opposite side Stagnant disks of optic nerve

Example of diagnosis of ICH:

Birth trauma of CNS: periventricular hemorrhage of the I stage, acute period, severe course, convulsive syndrome.

Main principles of treatment of ICH are similar that perinatal defeats of CNS

1. Monitoring of basic vital functions parameters (AP, pulse, BF, T of the body, diuresis, body weight, amount of entered liquid, transcutaeus pulsoxymetry, biochemical indexes).

2. Haemostatic therapy – indicated to all new-born with ICH.

3. The usage of preparations of complex action is obligatory (actovegin i/vdroplet or i/m of 1 ml 1 time a day).

4. In the period of rehabilitation – application of resorbtive therapy (lydasa) and nootrops is necessary.

Features of the ICH treatment

Birth traumas of spinal cord and peripheral nervous system

Reasons of spinal cord defeat Forced increase of distance between shoulders and skull base caused by: Breech presentation Difficulties at remove of head or shoulders of a child Traumatic remove of head during the operation of caesarian section Imposition of obstetric forceps Use of receptions of Covyanov Excessive compression in births along a spine.

Reasons of the peripheral nervous system defeat

Wrong executed obstetric manipulations, that cause the defeats of peripheral

motoneuron with further violation of muscles function.

EtiologyEtiology

Birth traumas of spinal cord and peripheral nervous system

Pathogenesis Damages of spine (distribution of the neck vertebrae, compression

break of vertebral body) Hemorrhage in a spinal cord and its membranes An ischemia in the vertebral arteries basin Damage of intravertebral disks Edema, haematomas and sprains, breaks of spinal bone-muscle-

ligamentous apparatus.

Clinics of spinal cord birth traumasDamage of upper neck segments (C1-C4):

Spinal shock Spastic tetraparesis SDR Vasomotoric violations Central disorders of urination

Diaphragm paresis (C3-C4): Dyspnea, paradoxical breathing Attacks of cyanosys Skewness of thorax, lag in the act of breathing of the staggered half of thorax. At auscultation – diminished breath sounds on the side of paresis At Rö-research– a high location of diaphragm dome, displacement of

mediastinum to a healthy side.

Clinics of spinal cord birth traumas Damage of thorax (T1-T12):

Thorax falls back during inhalation Respiratory insufficiency Spastic paresis of lower extremities The loss of all types of sensitiveness below the defeat

level Central disorders of urination

Damage of lumbosacral area: Flaccid paresis of lower extremities Violations of the pelvic organs functions In the sequel –the wrong forming of gluteus muscles,

atrophy of muscles of lower extremities.

Clinics of birth traumas of the peripheral nervous system

Upper paralysis of Erb: Typical position of extremity (a hand is clasped to the

trunk, turned inward in a shoulder, pronated in a forearm, manus in a state of palm's bending, shoulder is dropped, a head is inclined to the damaged shoulder)

Impossibility of abduction of shoulder Absence of spontaneous motions in humeral and elbow

joints Impossibility of bending of forearm Absence of Moro reflex on the defeat side Hypotonia of the hand muscles Symptom of “doll’s hand”

Clinics of birth traumas of the peripheral nervous system

Lower paralysis of Klumpke: Typical position of manus (a manus hangs down or is in

position of clawhand (griffin claw) – in case of the defeat of radial nerve, “seal paw” - at the defeat of elbow nerve)

Absence of motions in an elbow and radiocarpal joints Motions in a humeral joint are saved Limitation of reflex of Moro on the side of defeat,

absence of reflex of Babkin, grasping reflex Edema of the manus, a manus is cold to the feel. Symptom of Horner (ptosis, miosis, enophtalmus) on the

defeat side

Clinics of birth traumas of the peripheral nervous system

Total obstetric paralysis of upper extremity: Hypotonia of the hand muscles Hand hanging down along a trunk Absence of spontaneous motions Absence of Moro’s, Babkin’s, grasping reflexes on the side of

defeat Pallor of the hand skin, a hand is cold to the feel Absence of pain sensitiveness

Craniospinal birth trauma Combined trauma of brain (ICH) and spinal brain, caused by the action of the force vector to the turnings around the spine axis.

Patomorphologic changes: Spasm of vertebral arteries, ischemia of vertebro-basilar area Edema of brainstem and cerebellum Ischemia-hypoxia Hemorrhagies Circulatory ischemic necrosises

Clinical syndromes of the acute period: Spinal shock SDR Gross violations of haemodynamics Cramps Hearth neurological symptoms Syndrome of suppression or excitation of CNS

Examples of diagnoses

Craniospinal birth trauma: birth trauma of CNS, PVH of the II stage, spinal birth trauma, damage of upper neck segments (C1-C4), acute period, severe course, syndrome of vegetovisceral disorders, spastic tetraparesis.

Birth trauma of thorax (T1-T12) of spinal cord, acute period, moderate severety, spastic paresis of lower extremities

Birth trauma of the peripheral nervous system, lower paralysis of Dezherin-Klyumpke, period of rehabilitation,

easy course, syndrome of motive violations

Treatment of spinal birth trauma and trauma of the peripheral nervous system in the acute period

Immobilization of head and neck or staggered extremity Anaesthetic therapy (0,01 ml50% solution of analgin 2 times per

day intramuscular, 0,1 mgs/kg 0,25% solution of droperidol 2 times per day intravenously slowly, 1 ml/kg 0,25% solution of novocaine 2 times per day intravenously slowly)

Oxygen therapy Correction of muscle hypotonia (0,5% solution of galantamin

0,18 mgs/kg hypodermic 1 time a day, 0,05% solution of proserinum 0,009 mgs/kg intramuscular 1 time a day)

Improvement of processes of myelinization (vitamins V1, V6, 5 mgs/kg intramuscular 1 time a day)

Syndromal therapy (correction of SDR, vegetovisceral violations etc.) at a spinal trauma

Treatment of perinatal defeat of CNS and birth trauma in a period of rehabilitation

Complexity of treatment (the joint participating in treatment of neurologist, orthopaedist, oculist, doctor MPC, psychologist, speech therapist, teacher).

Orthopaedic measures warns the development of anomalous poses, contractures in the child’s organism.

Medical gymnastics and massage. Stimulation of psychical and vocal development. Physical therapy treatment: electrophoresis with

anticholiesterasis preparations (galantamin, proserin), preparations, that improve bloodcirculation in the vertebrobasilar system ( nicotine acid, aminophylline), resolving preparations (lidasa, aloe), hydrotherapy, paraffin-, ozoceritotherapy, hot woolen wrappings.

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