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 CNS. Birth trauma of spinal cord and peripheral nervous Birth trauma of spinal cord and peripheral nervous

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

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

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

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

Birth trauma of CNS(intracranial hemorrhage)

Types of intracranial hemorrhagesTypes of intracranial hemorrhages::

1.1. - Intraventricular hemorrhage (peri- and - Intraventricular hemorrhage (peri- and intraventricular)intraventricular)

2.2. - Subarachnoidal hemorrhages- Subarachnoidal hemorrhages

3.3. - Subdural hemorrhages- Subdural hemorrhages

4.4. - Epidural hemorrhages- Epidural hemorrhages

5.5. - Parenchymatous hemorrhages- Parenchymatous hemorrhages

6.6. - Cerebella hemorrhages- Cerebella hemorrhages

Birth trauma of CNS (intracranial hemorrhage)Etiology and pathogenesis

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

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

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

obstetric tongs)obstetric tongs)

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

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

Child, that had chronic antenatal hypoxia in past, can have ICH even at the normal birth 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. 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. 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 More frequently intraventricular hemorrhages of the I-II stages and petechial hemorrhages into the gray matter have hypoxic genesis.the gray matter have hypoxic genesis.

Birth trauma of CNS (intracranial hemorrhage)

Etiology and pathogenesis    Perinatal features of coagulative and thrombocytal hemostasis Perinatal features of coagulative and thrombocytal hemostasis

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

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

    Prematurity and morphological-functional immaturityPrematurity 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 infectionsPrenatal infections (defeats of vascular wall) (defeats of vascular wall)

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

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

Birth trauma of CNS(intracranial hemorrhage)

Typical clinical manifestationsTypical clinical manifestations::                      Sudden worsening of the general stateSudden worsening of the general state                      Change of scream character (“cerebral scream”)Change of scream character (“cerebral scream”)                      Bulging of the large fontanel Bulging of the large fontanel                       Local eye symptomsLocal eye symptoms                      Violations of thermoregulationViolations of thermoregulation                      Vegeto-visceral and pseudobulbar disordersVegeto-visceral and pseudobulbar disorders                      Motive disordersMotive disorders                      CrampsCramps                      Disorders of muscle toneDisorders of muscle tone                      Posthemorragic anaemiaPosthemorragic anaemia                      Metabolic violationsMetabolic violations Addition of somatic diseasesAddition of somatic diseases

Intraventricular hemorrhages

Clinics:Clinics:

                  Flaccidity, adynamyFlaccidity, adynamy

                  Bulging of the large fontanel Bulging of the large fontanel

                  Decrease of the muscle toneDecrease of the muscle tone

                  Disappearance of the sucking and swallowing reflexesDisappearance of the sucking and swallowing reflexes

                  Attacks of Attacks of ааpnoe, respiratory disturbancepnoe, respiratory disturbance

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

Arterial pressure and tachycardia decreaseArterial pressure and tachycardia decrease

Intraventricular hemorrhagesDiagnosticsDiagnostics::

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

NeurosonographyNeurosonography::PVH of the I stage - subepindemal hemorrhage in the germinal PVH of the I stage - subepindemal hemorrhage in the germinal

matrixmatrixPVH of the II stage - breach of hemorrhage in the cerebral ventricles PVH of the II stage - breach of hemorrhage in the cerebral ventricles

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

dilatationdilatationPVH of the IV stage– intraventricular and parenchymatous PVH of the IV stage– intraventricular and parenchymatous

hemorrhageshemorrhages Doppler: bloodstream fluctuationDoppler: bloodstream fluctuation ECG: focal changes, paroxysmal activityECG: focal changes, paroxysmal activity

Subarachnoidal hemorrhages

ClinicsClinics::1.1. Hyperexcitability ( anxiety, cerebral scream, Hyperexcitability ( anxiety, cerebral scream,

inversion of sleep, increase of motive activity, inversion of sleep, increase of motive activity, hypertension, increase of muscle tone).hypertension, increase of muscle tone).

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

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

Subarachnoidal hemorrhages

Diagnostics:

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

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

Subdural hemorrhagesClinics of supratentorial hemorrhagesClinics of supratentorial hemorrhages::

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

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

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

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

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

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

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

Subdural hemorrhages

DiagnosticsDiagnostics::

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

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

compression of lateral ventricles.compression of lateral ventricles.

Epidural hemorrhagesClinics:Clinics:

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

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

opposite sideopposite side Stagnant disks of optic nerveStagnant disks of optic nerve

Example of diagnosis of ICH:

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

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

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

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

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

4.4. In the period of rehabilitation – application of resorbtive In the period of rehabilitation – application of resorbtive therapy (lydasa) and nootrops is necessary.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 Reasons of spinal cord defeat Forced increase of distance between shoulders and skull base caused by:Forced increase of distance between shoulders and skull base caused by: Breech presentationBreech presentation Difficulties at remove of head or shoulders of a childDifficulties at remove of head or shoulders of a child Traumatic remove of head during the operation of caesarian sectionTraumatic remove of head during the operation of caesarian section Imposition of obstetric forcepsImposition of obstetric forceps Use of receptions of CovyanovUse of receptions of Covyanov Excessive compression in births along a spine.Excessive compression in births along a spine. Reasons Reasons of the peripheral nervous systemof the peripheral nervous system defeat defeat

Wrong executed obstetric manipulations, that cause the defeats of peripheral Wrong executed obstetric manipulations, that cause the defeats of peripheral

motoneuron with further violation of muscles functionmotoneuron with further violation of muscles function..

EtiologyEtiology

Birth traumas of spinal cord and peripheral nervous system

PathogenesisPathogenesis Damages of spine (distribution of the neck Damages of spine (distribution of the neck

vertebrae, compression break of vertebral body)vertebrae, compression break of vertebral body) Hemorrhage in a spinal cord and its membranesHemorrhage in a spinal cord and its membranes An ischemia in the vertebral arteries basinAn ischemia in the vertebral arteries basin Damage of intravertebral disksDamage of intravertebral disks Edema, haematomas and sprains, breaks of spinal Edema, haematomas and sprains, breaks of spinal

bone-muscle- ligamentous apparatus.bone-muscle- ligamentous apparatus.

Clinics of spinal cord birth traumas

Damage of upper neck segments (C1-C4):Damage of upper neck segments (C1-C4):

Spinal shockSpinal shock Spastic tetraparesisSpastic tetraparesis SDRSDR Vasomotoric violationsVasomotoric violations Central disorders of urinationCentral disorders of urination

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

mediastinum to a healthy side.mediastinum to a healthy side.

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

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

level level Central disorders of urinationCentral disorders of urination

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

atrophy of muscles of lower extremitiesatrophy of muscles of lower extremities..

Clinics of birth traumas of the peripheral nervous system

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

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

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

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

Clinics of birth traumas of the peripheral nervous system

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

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

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

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

defeat sidedefeat side

Clinics of birth traumas of the peripheral nervous system

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

the side of defeatthe side of defeat Pallor of the hand skin, a hand is cold to the feelPallor of the hand skin, a hand is cold to the feel Absence of pain sensitivenessAbsence of pain sensitiveness

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

Patomorphologic changes:Patomorphologic changes: Spasm of vertebral arteries, ischemia of vertebro-basilar areaSpasm of vertebral arteries, ischemia of vertebro-basilar area Edema of brainstem and cerebellumEdema of brainstem and cerebellum Ischemia-hypoxiaIschemia-hypoxia HemorrhagiesHemorrhagies Circulatory ischemic necrosisesCirculatory ischemic necrosises

Clinical syndromes of the acute period:Clinical syndromes of the acute period: Spinal shockSpinal shock SDRSDR Gross violations of haemodynamicsGross violations of haemodynamics CrampsCramps Hearth neurological symptomsHearth neurological symptoms Syndrome of suppression or excitation of CNSSyndrome of suppression or excitation of CNS

Examples of diagnoses

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

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

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

easy course, syndrome of motive violationseasy 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 extremityImmobilization of head and neck or staggered extremity Anaesthetic therapy (0,01 ml50% solution of analgin 2 times per Anaesthetic therapy (0,01 ml50% solution of analgin 2 times per

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

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

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

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

Syndromal therapy (correction of SDR, vegetovisceral violations Syndromal therapy (correction of SDR, vegetovisceral violations etc.) at a spinal trauma 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 Complexity of treatment (the joint participating in treatment of neurologist, orthopaedist, oculist, doctor treatment of neurologist, orthopaedist, oculist, doctor MPC, psychologist, speech therapist, teacher).MPC, psychologist, speech therapist, teacher).

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

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

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

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