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ARTICLES |
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Year : 1978 | Volume
: 26
| Issue : 1 | Page : 12-16 |
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Retinal haemorrhage in the newborn (an autopsy study)
K Jayanthi, AL Aurora
Department of Pathology, JIPMER, Pondicherry-605006, India
Correspondence Address: A L Aurora Department of Pathology, JIPMER, Pondicherry-605006 India
Source of Support: None, Conflict of Interest: None | Check |
PMID: 711269
How to cite this article: Jayanthi K, Aurora A L. Retinal haemorrhage in the newborn (an autopsy study). Indian J Ophthalmol 1978;26:12-6 |
The presence of retinal haemorrhage in the newborn has been subject of interest ever since its first description shortly after the invention of the ophthalmoscope. Their presence and location has been substantiated by funduscopic studies by various authors[1],[2],[5] and a correlation has been sought with several parameters including the parity of the mother, mode of delivery, instrumentation employed during delivery, duration of labour and Vit. K therapy to the mother'. Definite correlation between the increased incidence of haemorrhage in the newborn following obstetrical maneuvers using forceps and vacuum extractor has been established[5]. However no detailed autopsy studies are available giving the extent and incidence of retinal haemorrhage. The present study was undertaken with this object.
Materials and Methods | | |
The material for the study was obtained from 100 random paediatric autopsies carried out between September 1973 and October 1976.
The 100 cases studied included premature babies, mature babies, eight infants and 3 children. Clinical data regarding the parity of the mother and relevant points were obtained from the case records. Three mothers of the three cases which showed retinal haemorrhages had spontaneous vaginal delivery. In one of these there was cord prolapse leading to intrauterine death of the fetus. In two other mothers, caesarean section was done for obstructed labour in one case and fetal distress in the other. Two babies were delivered with the help of forceps in two mothers. In one of them mother had severe anaemia while the other was a case of pre-eclamptic toxanemia. In two mothers there was rupture of the uterus leading to foetal death.
The eye balls removed from the autopsy cases were processed, grossed and sectioned as already described by us. The sections were stained with haematoxylin and eosin, Masson trichrome, Verhoeff's elastic tissue stain (Manual of histologic and special staining techniques, 1960)[1] and alcian-blue (pH 2.5) periodic acid Schiff combined stains according to the standard procedure.
The histologic sections were studied and a semi. quantitative scoring of the entire retina was done to assess the extent and severity of the haemorrhages. To accomplish this, the retina on the nasal and temporal sides was arbitrarily divided into three parts viz. the anterior one third, middle one third and posterior one third. Likewise the thickness of the retina from the vitreal surface upto the pigment epithelium was divided into three zones the first zone consisted of the nerve fibre and ganglion cell layers, the second zone included the inner nuclear and inner plexiform layers and third zone comprised of the outer plexiform, outer nuclear layer and the layer of rods and cones. A single " + " score was marked for a lesion which occupied the entire high power field (HPF) in any part or zone of the retina Correspondingly half - or quarter + score was given for smaller lesions occupying half or less than half high power field respectively. A lesion occupying three. fourth or more of the field was given + score. The to-al number of scores were recorded for the temporal side and nasal side of each section of the eyeball, an example of which is given in [Table - 1]. In this particular case right eye showed the highest score in the posterior one-third in the ganglion and nerve fibre lavers. However in the left eye the haemorrhages were chiefly confined to the anterior one-third in the same lavers as in the right eye. Taking both the eyes together the score were highest in the anterior one-third of the retina in the ganglion and nerve fibre lasers.
Results | | |
Nine cases out of a total number of 100 autopsies showed retinal haemorrhages [Table - 2]. Four cases showed bilateral lesions. The haemorrhages were located throughout the retina, particularly involving the anterior and middle one third portions. Similarly the haemorrhages were mostly situated in the inner four layers. The Lange's fold was particularly the site of haemorrhages. In the two cases with prolonged intrauterine asphyxia associated with rupture of uterus due to prolonged labour, the haemorrhages were extensive. One case which was delivered spontaneously showed extensive haemorrhages, but this case had prolapse of the cord. Two cases delivered by Caesarean section and two other cases delivered spontaneously showed minimal haemorrhages. Two cases delivered with the assistance of forceps showed moderate haemorrhage.
Discussion | | |
Retinal haemorrhages in the newborn is a fairly common finding. Its presence has been correlated with and explained with the help of various parameters. The most interesting aspect of it has been the variable incidence quoted by several authors[1],[2],[5]. This could be a result of difference in the time of examination of the eyes since these haemorrhages tend to be absorbed soon after birth .
Higher incidence of retinal haemorrhage has been noted in infants subjected to instrumental delivery (forceps and vacuum extractor) in contrast to those delivered by caesarean section or delivered spontaneously. Thus ophthalmoscopic examination carried out on 773 full term babies in the total series of 839 infants by Chance showed retinal haemorrhage in 2.6 percent of the cases. The remaining 66 infants were premature babies and 4.5 percent of these had retinal haemorrhages. The haemorrhages were flame shaped in 16 infants, were multiple and found adjacent to the vessels near the optic disc. Pinpoint haemorrhages were seen in 6 cases. The incidence was higher in those cases examined within the first 3 days of birth (4.5%) than those examined later (1.4%). Obstetric trauma is felt to be the most probable cause of retinal haemorrhages in the newborn babies.
Funduscopic examination of the newborn has thrown light on the location and their distributions,[1],[5] Haemorrhages were noted in the periphery and around the larger vessels near and at the optic disc. In more severe cases dark ted haemorrhages was found scattered throughout the fundus particularly in the macular area and at the fovea. These were not directly connected with the blood vessels and were associated with white exudates. In the most severe cases there was extensive haemorrhage amounting to infraction.[5] A study undertaken by these authors on 329 infants showed an incidence of 5 percent of retinal haemorrhages in those delivered spontaneously, 4 percent in those delivered by forceps, 3 percent in those delivered by caesarean section and 14 percent in those delivered by vacuum extraction and zero percent in those delivered after version and extraction.
Vit. K administration given to the mother during the later part of the labour was found to lower the incidence of retinal haemorrhages in the newborn but Falls and Furrow in 1946 (quoted by Giles, 1960)2 concluded that there was no such effect.
In the present study, the cases which showed most severe haemorrhages were those subjected to prolonged labour and were asphyxiated. The haemorrhages were situated in the anterior and middle thirds of the retina and involved the inner layers. Two cases delivered spontaneously and 2 cases by caesarean section showed least haemorrhages. Two cases delivered by forceps showed moderate haemorrhages. The findings support those quoted by some authors, but the location of haemorrhages in our series was different from that observed by others in their material. Whether any nutritional, racial or geographical factors are responsible for these differences is difficult to say at this stage. Further work on larger number of autopsies is certainly indicated.
References | | |
1. | Chace, R.R.. Merrit, K.K. and Bellows. M., 1950, Arch. Ophthal., 44, 236. |
2. | Giles, C.L., 1960, Amer. J. Ophthal., 49, 1005. |
3. | Luna, C.G., 1968. Manual of histologic staining methods or the Armed Forces Institute of Patho. logy, 3rd edition, McGraw-Hill Rook Company, New York. |
4. | Manual of histologic staining methods of the Armed Forces Institute of Pathology, 2nd edi. tion, 1960. McGraw-Hill Book Company, New York. |
5. | Planten, J.Th. and P.C.V.d. Schaaf*, 1971, Ophthalmological_ 162, 213. |
[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1], [Table - 2]
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