Physical trauma is common in pregnancy, affecting 1 in 12 pregnant women [
A 23-year-old gravida 2 para 1 woman at 27-week gestation was admitted following a high-speed motor vehicle accident. She was a restrained front seat passenger in a car that rear-ended a parked vehicle at 70 miles per hour. Injuries included a left hip dislocation and multiple closed pelvic fractures involving the bilateral hips and the bilateral pubic rami. She was alert and normotensive on admission. Fetal heart tones were noted to have a baseline of 140 beats per minute with minimal variability and no accelerations or decelerations (Figure
Fetal heart rate and evolving ultrasound findings following fetal intracranial injury. (a) Fetal heart rate showed a normal baseline with persistent minimal variability and no accelerations or decelerations (b) 34 hours after trauma: fetal intracranial anatomy largely unremarkable as demonstrated by this transverse view at the level of the lateral ventricle. (c) 62 hours after trauma: a large hyperechoic lesion in the frontal lobe is visualized (
She received a course of betamethasone. An ultrasound done approximately 34 hours into admission showed unremarkable intracranial anatomy (Figure
In the subsequent days of admission the fetal heart tones demonstrated persistent minimal variability without accelerations or decelerations. The patient was receiving fentanyl and it was speculated that narcotics were contributing to the decreased variability. Approximately 62 hours into admission a biophysical profile (BPP) was performed. The BPP returned 6 of 8 (off 2 points for absent breathing). However at this time a hyperechoic lesion in the left frontal cortex was noted, extending to the left lateral ventricle with an additional fluid collection concerning for a left subdural hematoma (Figure
She presented for follow-up ultrasound at 30-week gestation. A left subdural hypoechogenic lesion and mild left ventriculomegaly were present. In addition, there was no interval head growth (BPD 67 mm, HC 269 mm). Follow-up ultrasound at 35 weeks again showed mild left ventriculomegaly (Figure
Fetal intracranial imaging and postnatal follow-up. (a) Ultrasound at 35-week gestation demonstrates unilateral ventriculomegaly. (b) MRI at day 4 of life shows cystic encephalomalacia of the bilateral frontal and left parietal lobes and artifact consistent with a previous intraventricular hemorrhage, hemorrhagic contusion, and subdural hematoma.
Delivery was by an uncomplicated scheduled repeat cesarean delivery at 39 weeks gestation. APGARs were 8 and 8 at 1 and 5 minutes, respectively, with umbilical artery cord pH of 7.16 and base excess of −4.3. The neonate required continuous positive airway pressure in the delivery room. Birthweight was 3033 gm, but severe microcephaly was present with a head circumference of 31.8 cm (<3%ile). Neurologic findings also included seizure-like activity, lower extremity hyperreflexia, and increased truncal tone. Brain MRI on day of life 4 was consistent with cystic encephalomalacia of the bilateral frontal lobes and left parietal lobe. There was also artifact suggestive of hemosiderin deposits, consistent with prior left intraventricular hemorrhage, hemorrhagic contusion, and subdural hematoma, but no indications of skull fracture (Figure
While fetal intracranial hemorrhage is a known potential sequelae of maternal trauma, this is among the first reported cases of the delayed appearance of such hemorrhage. The events of this case demonstrate the possibility of severe fetal intracranial injury even in the setting of unremarkable initial imaging. It also helps delineate the timing of imaging as the CNS findings at 34 hours after injury were not evident enough to be detected on a thorough fetal exam, but by 62 hours the findings were striking enough to be noted at the time of a BPP, which is not focused on the CNS. The exact timing of the intracranial bleeding cannot be determined with certainty. However, given the extent of the blunt forces and maternal pelvic injuries, as well as the decreased fetal heart rate variability upon admission, it is suspected that the fetal injury occurred at the time of the trauma with a delayed presentation. In addition, there were no subsequent maternal hypoxic or hypotensive events that would account for a later onset of fetal injury.
There are multiple potential underlying reasons for a delayed presentation. Certainly, more subtle findings of intracranial hemorrhage could have been present on the initial ultrasound and went undetected, and on retrospective review there was a hint of increased echogenicity on the first set of images. However the extent of the abnormality was significantly more pronounced on the second ultrasound. A small but ongoing bleed could also have been present, though a significant hemorrhage is unlikely in the setting of a normal middle cerebral artery Doppler. It is also well known that the appearance of an intracranial hemorrhage evolves with the formation and then breakdown of the hematoma. The initial intracranial hemorrhage is liquid with highly oxygen-saturated hemoglobin. Within hours a heterogeneous clot forms and subsequently retracts. Serum is expelled from the clot into the surrounding tissue, which also undergoes vasogenic edema. As the injury evolves, red blood cell lysis and hematoma resolution occur with hemosiderin deposition. The resolved hematoma may present as a cystic or collapsed brain defect [
Strigini et al. described two cases of fetal intracranial hemorrhage following minor maternal trauma in which an ultrasound within 24 hours of the event appeared normal, but in which injury was visualized several weeks later [
Fetal intracranial hemorrhage is identified in up to 1 per 1000 births in referral centers. Intraventricular hemorrhage is the most common location of bleeding in the fetus [
The literature on fetal intracranial hemorrhage secondary to maternal trauma is limited to case reports and case series. A theorized mechanism of fetal head injury with blunt maternal trauma is fetal skull compression between the pubic symphysis and sacrum [
An obstetrical ultrasound has been recommended for all pregnant trauma patients with a viable pregnancy who are admitted for greater than 4 hours for fetal monitoring [
Abnormal fetal heart rate tracings alone in the setting of maternal trauma are poor predictors of adverse obstetrical outcomes [
Fetal intracranial injury is a rare but serious consequence of maternal trauma that may not always be apparent on initial presentation. Prenatal diagnosis of such injuries is important for optimizing delivery plans and location. Thus, serial fetal imaging should be considered following maternal trauma, particularly in the setting of an abnormal fetal heart rate tracing.
The authors declare that they have no conflicts of interest.