Prenatal Diagnosis, Management, and Outcome of Fetal Subdural Haematoma: A Case Report and Systematic Review

Abstract

<b><i>Background:</i></b> Fetal subdural haematoma (SDH) is associated with poor prognosis. <b><i>Objective:</i></b> The conflicting evidence from the literature presents a challenge in prenatal counselling. We present a case study and systematic review of the literature for the management and outcome of fetal SDH. <b><i>Methods:</i></b> Systematic search of electronic database. <b><i>Results:</i></b> A total 45 cases were extracted from 39 papers. Prenatal ultrasonographic features were intracranial echogenicity (42%), lateral ventriculomegaly (38%), presence of an intracranial mass (31%), macrocephaly (24%), midline deviation of cerebral falx (20%), and intracranial fluid collection (11%). Further secondary features were noted including reversed diastolic flow in the middle cerebral artery (11%), echogenic bowel (4%), hydrops fetalis (2%), and elevated middle cerebral artery peak systolic velocity (2%) (all highly likely to be associated with fetal anaemia). The rates of termination of pregnancy, stillbirth, and neonatal death were 18% (8/45), 16% (7/45), and 11% (5/45), respectively. Overall, therefore, the fetal and perinatal mortality was 32% (12/37). Amongst the 24 survivors with available neurological outcome, 42% (10/24) and 58% (14/24) had abnormal and normal neurological outcome, respectively. Underlying aetiology of fetal SDH was not identified in 47% (21/45). Fetal SDH with an identifiable underlying aetiology was the only factor associated with a higher chance of normal neurological outcome when compared to fetal SDH without a detectable cause (78.5 vs. 21.4%, <i>p</i> = 0.035). <b><i>Conclusions:</i></b> Stillbirth and neonatal death occurred in a significant proportion of fetal SDH. 58% of survivors had normal neurological outcome, and better prognosis was seen in SDH with identifiable underlying aetiology.

Persistent reversed end‐diastolic flow of the middle cerebral artery: A rare and concerning finding

“…So far, only a few reports are similar to our case. 2,6,8,12,15 This reversed flow has been reported as a rare finding related to pathological fetal conditions, such as fetal growth restriction, 3,4,7,10,11,13 fetomaternal hemorrhage, 1,5,9 and congenital hydrocephalus. 14 Some cases had a transient period of reversed flow, which was possibly from temporary extracranial compression such as increased transducer compression or anhydramnios/oligohydramnios.…”

“…1 The majority of cases ultimately resulted in fetal or neonatal death. 1,2,4,[6][7][8]10,12,14,15 However, some studies reported that fetuses survived and subsequently required neurological follow-up; however, no study reported long-term neurological outcomes. 3,5,9,11,[13][14][15] A wide range of intervals between the diagnosis of reversed end-diastolic flow of the MCA and adverse event or delivery were reported.…”

“…1,2,4,[6][7][8]10,12,14,15 However, some studies reported that fetuses survived and subsequently required neurological follow-up; however, no study reported long-term neurological outcomes. 3,5,9,11,[13][14][15] A wide range of intervals between the diagnosis of reversed end-diastolic flow of the MCA and adverse event or delivery were reported. [4][5][6][7][8][9]11,12,[14][15][16][17] In healthy fetuses, there is a high resistance of cerebral blood flow with a continuous forward flow of the MCA.…”

“…3,5,9,11,[13][14][15] A wide range of intervals between the diagnosis of reversed end-diastolic flow of the MCA and adverse event or delivery were reported. [4][5][6][7][8][9]11,12,[14][15][16][17] In healthy fetuses, there is a high resistance of cerebral blood flow with a continuous forward flow of the MCA. However, specific fetal conditions relating to an increased intracranial pressure can cause persistent reversed end-diastolic flow of the MCA.…”

“…16,18 The bleeding volume from intracranial hemorrhage causes increased intracranial pressure which interferes with the normal cerebral blood flow and the resistance in turn leads to reversed end-diastolic flow of the MCA. 15 In congenital hydrocephalus, excessive accumulation of cerebrospinal fluid also causes increased intracranial pressure that leads to reversed flow of the MCA. 14 Finally, fetomaternal hemorrhage causes fetal anemia that precipitates cerebral ischemia or hemorrhage, or both, resulting in cerebral edema.…”