|Year : 1987 | Volume
| Issue : 3 | Page : 117-120
Retinal haemorrhages in vacuum extraction deliveries
Mostafa M Bahgat
Lecturer in Ophthalmology, Faculty of Medicine, Cairo University, Egypt
Mostafa M Bahgat
Lecturer in Ophthalmology, Faculty of Medicine, Cairo University
Source of Support: None, Conflict of Interest: None
Two hundred and thirty eight newly born infants were subjected to fundus examination in the first 5 hours of labour then daily till discharge from the hospital then weekly till complete absorption of retinal haemorrhages
The 238 infants were 23 delivered by caesarean section, 90 with spontaneous vaginal delivery,45 babies (over3.5 kgm) delivered vaginallyand80 delivered by vacuum extraction.
It was found that 37.39% of the newborns had retinal haemorrhages. The incidence, type and severity of retinal haemorrhages were related to the extent of obstetric trauma during birth. They were least with caesarean section. (4.35%), more in babies with spontaneous vaginal delivery (20%), more higher in infants over 3.5 kgm birth weight (33.33%) and maximum in vacuum extraction deliveries (68.75%). A good correlation was made between the site and duration of cup application, level and rate of increase of negative pressure, the presence and size of cephalhematoma and the incidence and severity of retinal haemorrhages
A good choice of cases as well as good control of the technique of vacuum extraction will minimize the incidence and severity of retinal haemorrhages in the new born.
|How to cite this article:|
Bahgat MM. Retinal haemorrhages in vacuum extraction deliveries. Indian J Ophthalmol 1987;35:117-20
| Introduction|| |
The appearance of haemorrhage in the retina of the newly born infants has been a well-known observation for over 100 year. Studies still speculate, however as to the incidence, aeteology and fate of these haemorrhages.
The frequency of retinal haemorrhages in the newly born infants has been reported to be between 2.6% (1) and 50% (2). Retinal haemorrhages in the new boms are caused by foetal and maternal factors Foetal factors include high pressure of the cavernous sinus and increased intracranial pressure , asphyxia (4)"denied by Giles (4)", presentation (6), increased blood pressure due to obstruction of foetal circulation (4) and obstetric trauma (3). Maternal factors include duration of first and second stages of labour (6), time between rupture of membranes and delivery (7), type of delivery much more with vaginal than caesarean (6), age and parity of the mother although reported by previous workers but denied by Giles (5).
The vacuum extractor is used by applying traction on a metal cup which holds on the foetal head by suction and creates an artificial caput In spite of early enthusiasm for the instrument the vacuum extractor is not used extensively because of reports of foetal damage such as abrasions and lacerations of the scalp, cephalhematoma, intracranial haemorrhage and foetal death (8). In contra-distinction to them, there is an enthusiastic acceptance of the ventose in other reports (9).
Retinal haemorrhages in the newly born infants can be classified into three principal types ,, the most common are small, superficial and flame shaped haemorrhages they are mainly confined to the posterior pole of the eye. Less common are thin, sheetlike haemorrhages in the nerve fiber layer and spread out from the optic disc towards the equator. The least common are dull red, dense and diffusely round haemorrhages They are usually found about the macular region.
The significant of retinal haemorrhages in the newly born is not yet known. It is the opinion of many that some correlation may exist between brain damage and retinal haemorrhages The evidence for such a relationship is the appearance in the fundus of manifestations of brain damage in some cases of Cameron . However, Schenker and Combos (11) discarded this theory, since they had not observed any such relationship in their cases Also, the absorption of central retinal haemorrhages may lead to late granular macular changes that may affect the visual acuity 11 % of the cases of Pajor .
| Material and Methods|| |
The material of this work consisted of 238 newly born infants They included those delivered by caesarean section, spontaneous vaginal -deliveries, vaginal deliveries of babies over 3.5 kgm (more liable to prolonged or difficult labour) and those delivered by vacuum extraction
The eyes of the neonates were subjected to full fundus examination in the first 5 hours of labour, after pupillary dilation with tropicamide drops 1 %. The eyelids were held open with a Barraquer wire speculum. A diagram was drawn of the fundus of those with retinal haemorrhages Follow up fundus examination was performed daily till the discharge of the baby then every week till complete absorption of retinal haemorrhages
| Results|| |
Two hundred fifteen infants were delivered vaginally and 23 by caesarean section. Vaginal deliveries were 90 spontaneous, 45 of babies over 3.5 kgm and 80 delivered by vacuum extraction
Out of the 238 infants examined, 104 (43.69%) showed retinal haemorrhages Those delivered by caesarean section had the least incidence of retinal haemorrhages (4.35%) followed by new born with spontaneous vaginal delivery (20.00%) then babies over 3.5 kgm and delivered vaginally while infants delivered by ventose had the highest incidence of retinal haemorrhages (68.75%) "see the table".
It was noticed that the retinal haemorrhages were mainly central, rarely at the mid periphery, very rarely at the extreme periphery but not in the vitreous Moderate retinal venous congestion was found in most of the cases but the optic disc as well as the macular area were normal in all the babies
The most frequently seen type of retinal haemorrhage was flame-shaped which seemed to follow the direction of the retinal vessels and as if radiating from the optic disc. They appeared to be superficial to the retinal vessels above and below the optic disc. Subsequent fundus examination showed that they were usually absorbed within 5 days. A less common type was sheetlike superficial haemorrhages with ill-defined margins and orange-red in colour. They were variable in size and number and some of them appeared to lie deeper to the retinal vessels. Small white dots were seen at the middle of some of the big haemorrhages only (one dot in each spot of haemorrhage). None of these dots could be found in the retina without surrounding haemorrhage. These white dots may be similar to Roth's spots which occur in septic retinitis or the white center of boot-shaped haemorrhage which occur in anaemia and leukemia. The big retinal haemorrhages and the white dots disappeared within 710 days The least common type was small, globular, dark-red retinal haemorrhages with light reflex on its surface. They were mainly at the macular are and they seemed to be preretinal in level. These haemorrhages took a longer period of absorb (2-3 weeks).
All babies (irrespective of the term or weight at birth) delivered by caesarean section had normal fundi except one with a history of failed trial for ventose delivery. This means that neither the weight of the baby nor the term had a role in producing retinal haemorrhage so long vaginal delivery is avoided. Fundus examination of the baby with retinal haemorrhage showed bilateral, few, superficial faintly red haemorrhages which disappeared in one week time
Eighteen out of the 90 babies delivered spontaneously through the vagina had retinal haemorrhages. Thirteen of them were bilateral while the remaining 5 had haemorrhages in one eye only. Most of the haemorrhages were flame-shaped and took 2-5 days to absorb. The number of primipara delivered spontaneously through the vagina was 50, 24% out of their babies showed retinal haemorrhages, while the multipara were 40 and 15% of their infants revealed retinal haemorrhages
Fifteen out of the 45 infants with birth weight over 3.5 kgm revealed retinal haemorrhages Thirteen out of them were bilateral without significant difference between the two eyes All types of haemorrhages were found in these babies without a relation between the type of haemorrhage and the weight of the baby.
Vacuum extraction was used in 80 cases. Its main indication was prolonged second stage of labour and foetal distress in few cases.
All ventose deliveries were done in the second; tape of labour. Fifty five out of the 80 deliveries showed retinal haemorrhages. It was noticed that the incidence and severity of retinal haemorrhages wore related to the duration of cup application, rate of increase and level of negative pressure used for extraction. Another finding was the increased frequency and extent of retinal haemorrhages with the presence and size of cephalhematoma. The site of cup application had a determining role on the side of retinal haemorrhages The haemorrhages were bilateral with centrally applied up and more apparent on the side of cup placing (if it is applied on one side). In 3 cases, the retinal haemorrhages were only unilateral on the same side of cup application. The retinal haemorrhages associated with ventose delivery were mainly rounded (big orange-red with central white dots and small dark red) with few flame-shaped haemorrhages The number of primipara delivered by vacuum extraction was 52 with 61.53% retinal haemorrhages in their new born while the multipara were 28 with retinal haemorrhages in 46.43% of their infants
| Discussion|| |
It is clear from this study that the obstetric trauma is one of the main causes of retinal haemorrhages in the newly born infants It is assumed by many workers that the trauma involved in the delivery of a primipara is greater than that in the delivery of a multiparous patient so the incidence of retinal haemorrhages is expected to be more in primipara than in multiparas deliveries and that was observed in our series
The role of obstetric trauma is well seen if we compare the incidence of retinal haemorrhages in newly born infants delivered by caesarean section with least trauma (4.35%) to those of spontaneous vaginal delivery with more obstetric trauma (20.0%). The incidence is still higher (33.33%) in new borns with birth weight over 3.5 kgm who were liable to more trauma and longer duration of labour. 'The highest incidence (68.75%) was found in babies delivered with vacuum extraction.
It was found that the site and duration of cup application, the rate of creation and level of negative pressure had a role in increasing the incidence of retinal haemorrhages being more with longer duration, rapid increase and higher level of negative pressure and on the same side of cup application. It was also found that the retinal haemorrhages were more severe if cephalhematoma was present at the site of cup application.
The role of ventose in retinal haemorrhage formation is not clear. It may be due to venous stasis as a result of high negative pressure applied on the scalp. This will lead to venous stasis and engorgement of retinal vessels and subsequently retinal haemorrhages Rapid delivery of the foetal head with the ventose in addition to sudden release of the high intracranial pressure may also an adding role.
The presence of small white dots at the center of the big retinal haemorrhages was a constant finding in this work Only one dot was found at the center of each spot of harmorrhage. None. of these dots could be found in the retina without surrounding haemorrhage. The aeteology of these white dots was not found in the previous literature about the subject It is interesting to know that the haemorrhages with white dots at their centers were found in the fundus drawing of Mc Keown  but he did not comment on these spots in his article. The aeteology of these spots in our mind may be linked eo either infarcts of the nerve fiber layer of the retina or accumulations of degenerated cells.
Although all retinal haemorrhages in this study were absorbed within 2-3 weeks, yet the importance of these haemorrhages was related to two things : the association of cerebral haemorrhage its sequelae and secondly the possible late visual disorders from already absorbed macular haemorrhages.
Although vacuum extraction has its own indications in some labours, yet good choice of cases and better control of the technique may minimize the occurrence of retinal haemorrhages.
| References|| |
Chace RR, Merit KK and Bellows M 1950, Ocular findings in the new born infant Arch Ophthalmol. 44: 236-242.
Touloukian, R.J. 1978 Pediatric trauma p. 149. John Wiley and Sons, New York
Edgerton, Ae 1934, Ocular observation and studies of the new born Arch. OphthalmoL 11.839.
Wolff, B, 1907 Injury to the eyes of the child during labour. Ophthalmoscope 5 : 484.
Giles, CL : 1960 Retinal haemorrhages in the new born Am. J. Ophthalmol 49:1005.
Mc Keown, MS : 1941 Retinal haemorrhages in the new born Arch. OphthalmoL 26: 25.
Kauffman, ML.: 1958 Retinal haemorrhages in the new born. Am J. OphthalmoL 46: 658.
Plauche, W.C 1978 Vaccum extraction use in community hospital setting. Obstet Gynecol 52; 289:
Patel N. 1980 Williams obstetrics 16th edn, Appleton-century Crofts 292 Madison Avenue New York N.Y. p. 1059.
Cameron HC. 1923 Intracranial birth injuries Lancet 2 : 1292.
Schenker, J.Q and Gombos, G.M. 1966. Retinal haemorrhages in the new born Obstet Gynecot 27: 521-524.
Pajor, R. Szabo, Z and Puskas E 1964 Control examination at 3 years of age in 227 infants with retinal haemorrhages at birth Orv Hetil 105:781.
[Figure - 1], [Figure - 2]
[Table - 1]