Neonatal spontaneous bilateral subdural hematoma after nontraumatic vaginal delivery

Abstract

Dear Editor: Prepartal chronic intrauterine subdural hematomas (SH) and postpartal SH after maternal trauma, instrumentally assisted vaginal delivery, and in fetuses/newborns with hematologiccoagulation disorders and head abnormalities are known in the literature [1–3] (Table 1). Spontaneous non iatrogenic bilateral subdural neonatal hematomas (SSH) after spontaneous vaginal delivery are an extremely rare clinical entity with no clear cause, mentioned in only a few case reports, so we present the case of SSH as a contribution to this rarely described, atypical, and unexpected clinical phenomenon. The 28-year-old primiparous woman was admitted to the maternity hospital in spontaneous labor in the 41st week of pregnancy. Personal and family history were neat, negative for hematological and coagulation disorders. The external and internal pelvimetry was neat. The course of the pregnancy was orderly. The fetus was eutrophic in growth and had an orderly biophysical profile, umbilical and cerebral Doppler sonography without ultrasound-detectable intracranial masses. On admission, the obstetric finding were; the cervix was fully effaced and 6 cm dilated. Through membranes the fetal head was felt in the occipital dorsoanterior presentation, spontaneous contractions were present for 3/10 minutes. Cardiotocographic (CTG) record was physiological. An amniotomy was performed. After 3 h of regular labor contractions and an orderly CTG recording with episiotomy followed by spontaneous delivery of a live female newborn, 3830/52 cm, and Apgar score 10/10, without instrumental assistance and fundal pressure. Early neonatological examination was orderly with a minor clinically insignificant caput succedaneum on the occipital portion of the skull. On the first postpartum day, 34 h after delivery, a short-term transient apnea attack with acrocyanosis occurs during breastfeeding. No clinical neurological abnormalities were found, laboratory findings of acid-base status and glycemia were in reference range, and the newborn was observed. Three hours later, there was a repeated episode of apnea and acrocyanosis, which gradually improves. An urgent neurosonographic examination was performed and bilateral frontoparietal subdural hematoma was suspected. Angiographic MRI was indicated to confirm bilateral frontoparietal subdural hematoma of 3 and 4 cm in size without skull fractures, intracerebral hemorrhages, and arteriovenous malformations. Emergency neurosurgery was indicated. Bifrontoparietal craniotomy and hematoma evacuation were performed. The surgery and postoperative course proceeded uncomplicatedly in the NICU. Hematological and coagulation laboratory findings of the newborn were completely orderly. The neuromotor development of the infant was orderly, and later neurological controls were without deviation with orderly psycholinguistic and neuromotor development until the tenth year of life. Neonatal bilateral SH described in the literature can be argued to have arisen as a consequence of traumatic/ iatrogenic or vaginally assisted delivery (Table 1) [1, 4]. In our case, delivery was spontaneous and nontraumatic, without instrumental assistance and fundal pressure. Compression of the soft parts of the delivery canal on the head of the term fetus during natural childbirth is not considered a trauma. Since it is a natural act of birth that has existed since the world existed. Whitby et al. have shown the outcomes and risks of unilateral or bilateral SH compared to obstetric factors [5]. They found a * Anis Cerovac [email protected]