Subdural Hemorrhage

SUBDURAL HEMORRHAGE

This rarely occurs in the fetus; most are related to trauma during the perinatal period (1-11). In the fetus they have been reported as a result of:

· Trauma (motor vehicle accidents). Abdominal massage has been reported in some women from the Pacific Islands (2).

· Maternal warfarin ingestion.

· Maternal pancreatitis.

· Coagulation factor deficiency.

· Fetal thrombocytopenia.

· Premature closure of foramen ovale complicated by cardiac and hepatic failure due to DIC-type hemostasis disorders (without thrombocytopenia) (3).

· Severe pre-eclampsia (7).

· Cerebral malformation (8).

· Idiopathic.

ULTRASOUND

Initially very echogenic but may gradually become echolucent with echogenic areas (4). At this stage it may be difficult to distinguish from a subarachnoid cyst or hygroma. Monitoring fetuses at risk for hemorrhage with doppler studies has been suggested to detect indicators of a worsening prognosis (9).

Post-traumatic inter-hemispheric subdural hematoma.

There is an avascular collection of fluid situated centrally between the falx (**).

Note the anhydramnios that is present due to co-existent rupture of membranes.

The post delivery CT scan demonstrates the interhemispheric collection of blood,

with an area of acute hemorrhage posteriorly between the layers of the falx.

Ultrasound at 31 weeks of gestation

CT scan on day 1 of life

Video clip of interhemispheric subdural hematoma

PROGNOSIS

Prognosis is generally poor when compared to prenatal intraventricular hemorrhage. 50% die in utero with the surviving 50% demonstrating post-natal neurological sequelae.

There is no standard antenatal management. Treatment of the underlying disorder is vital. Vaginal delivery does not appear to be contra-indicated if there are no other obstetric contra-indication.

REFERENCES

1. Kawabata I, Iami A, Tamaya T. Antenatal subdural hemorrhage causing fetal death before labor. Int J Gynecol Obstet 1993;43:57-60.

2. Gunn TR, Mok PM, Bencroft DMO. Subdural hemorrhage in utero. Pediatrics 1985;76:605-609.

3. Hanigan WC, Ali MB, Cusak TJ et.al. Diagnosis of subdural hemorrhage in utero. J Neurosurg 1985;63:977-979.

4. Rotmensch S, Grannum PA, Nores JA et.al. In utero diagnosis and management of fetal subdural hematoma. Am J Obstet Gynecol 1991;164:1246-1248.

5. Demir RH, Gleicher N, Myers SA. Atraumatic antepartum subdural hematoma causing fetal death. Am J Obstet Gynecol 1989;160:619-620.

6. deSousa CD, Clark T, Bradshaw A. Antenatally diagnosed subdural hemorrhage in congenital factor X deficiency. Arch Dis Child 1988;63:1168-1170.

7. Bondurant S, Boehm FH, Fleisher AC et.al. Antepartum diagnosis of fetal intracranial hemorrhage by ultrasound. Obstet Gynecol 1994;63:S25-S27.

8. Sodha S, Hamada H, Takanami Y et.al. Prenatal diagnosis of fetal subdural hematomas. Br J Obstet Gynaecol 1996;103:89-90.

9. De Spirlet M, Goffinet F, Philippe HJ et.al. Prenatal diagnosis of a subdural hematoma associated with reverse flow in the middle cerebral artery: case report and literature review. Ultrasound Obstet Gynecol 2000;16:72-76.