Fetal intracranial hemorrhage associated with maternal coagulopathy and vitamin K deficiency after biliary drain placement: A case report and literature review

Abstract

Introduction Fetal intracranial hemorrhage (ICH) is a rare but serious prenatal diagnosis. Predisposing factors include maternal trauma and fetal coagulation dysfunction. Maternal vitamin K deficiency has been described as an etiology. We present a case of maternal vitamin K deficiency associated with fetal ICH after percutaneous biliary drain (PBD) placement in a complicated cholecystectomy with injury to the common bile duct. Case presentation A 21-year-old woman, G2P1, presented at 23 weeks and 3 days of gestation with epigastric pain, nausea and vomiting. Right upper quadrant ultrasound diagnosed cholelithiasis. The patient was managed conservatively and discharged. She returned four days later, at 24 weeks of gestation, with worsening symptoms and ultrasound showing acute cholecystitis. She underwent laparoscopic cholecystectomy. Increasing bilirubin and imaging showed a transected biliary duct that required percutaneous biliary drain (PBD) placement. The patient was discharged and followed up at a high-risk obstetric clinic. Prenatal ultrasound showed bilateral ventriculomegaly with features of ICH. Maternal vitamin K deficiency was confirmed with PIVKA-II testing. The patient received vitamin K supplementation with normalization of the coagulopathy. Delivery occurred at 36 weeks of gestation via cesarean delivery after preterm premature rupture of membranes for fetal macrocrania. The neonate was discharged to a hospice. Discussion Maternal and neonatal etiologies for ICH include malabsorption and coagulopathy. Maternal vitamin K deficiency should be considered when coagulopathy is present. This case highlights that maternal vitamin K deficiency due to biliary diversion and malabsorption increases the risk of fetal ICH, which impacts pregnancy and neonatal outcomes.

Fetal intracranial hemorrhage and maternal vitamin K deficiency induced by total parenteral nutrition

“…In previous reports, deliveries were performed at least a few days or weeks after confirming fetal intracranial hemorrhage, and usually in the third trimester of pregnancy. [1][2][3]11] In this case, the patient complained of decreased fetal movement and immediate diagnosis of fetal intracranial hemorrhage through abdominal ultrasonography, and decreased fetal variability was observed through NST. In serial monitoring, the amount of hemorrhage in the fetus increased rapidly in a matter of hours, and the pattern of fetal variability in NST showed unguaranteed fetal well-being and absent diastolic flow of umbilical artery Doppler findings.…”

“…[ 1 , 4 ] It is devastating for both parents and fetuses, either with intrauterine death or severe neurodevelopmental complications in surviving children. [ 1 , 2 ] According to previous reports, the causes of fetal brain hemorrhage may be trauma, coagulopathy, infection, drug use, febrile illness, and cholestasis of pregnancy as maternal factors, and thrombocytopenia, congenital factor X, factor V deficiency, vascular malformations, and monochorionic twin complications as fetal factors. [ 4 ] In addition, placenta and umbilical problems, or vitamin K deficiency, can also cause fetal hemorrhage.…”

“…Fetal brain hemorrhage occurs in approximately 1 in 10,000 pregnancies, most commonly in the third trimester of pregnancy, arising from germinal matrix hemorrhage [1,4] . It is devastating for both parents and fetuses, either with intrauterine death or severe neurodevelopmental complications in surviving children [1,2] . According to previous reports, the causes of fetal brain hemorrhage may be trauma, coagulopathy, infection, drug use, febrile illness, and cholestasis of pregnancy as maternal factors, and thrombocytopenia, congenital factor X, factor V deficiency, vascular malformations, and monochorionic twin complications as fetal factors [4] .…”

“…Previous studies have reported that diseases such as hyperemesis gravidarum, eating disorders, and Crohn disease cause vitamin K deficiency during pregnancy, resulting in fetal brain hemorrhage. [2,3,10,11] In most cases, a relatively prolonged period of an eating disorder or intestinal absorptive disorder caused vitamin K deficiency, and recommendations included vitamin K supplementation for pregnant women with more than 3 weeks of TPN or more than 36 weeks of pregnancy impending delivery. [3] In the present case, the patient developed an intestinal obstruction during the second trimester of pregnancy, leading to sudden and fatal brain hemorrhage of the fetus in the absence of maternal bleeding tendency.…”

“…[ 1 ] Fetal brain hemorrhage occurs in approximately 0.01% of pregnancies. [ 1 , 2 ] The major causes of fetal brain hemorrhage are maternal trauma history or fetal coagulation disorder, but unknown causes have also been reported in about half of all cases. In addition, intrauterine hypoxia and fetal anemia caused by Rh alloimmunization or maternal vitamin K deficiency have been reported to cause fetal brain hemorrhage.…”