A C T A O P H T H A L M O L O G I C A V O L . 5 2 1 9 7 4

Department of Ophthalmology (Heads: Viggo A . Jensen azd Nic!s E!ilers), Arhus Kommunehospital, and

Department of Obstetrics (Heads: Mogens Ingerslev and Otto Resen Steenstr::{ij Fodselsanstalten i Jylland, Arhus, Denmark

RETINAL HAEMORRHAGES IN THE NEWBORN

Comparison of delivery by forceps and by vacuum extractor

BY

NIELS EHLERS, IB KRARUP JENSEN and KARL BROGARD HANSEN

Retinal haemorrhages were studied in a consecutive series of 99 babies delivered by forceps, 94 delivered by vacuum extractor and 207 delivered spontaneously.

The incidence of haemorrhages for spontaneously delivered was 27.5 O/o,

for those delivered by forceps 38"/0, and for those delivered by vacuum extractor 64O/o. The incidence of haemorrhages in the group of vacuum extractions was significantly higher than among either the group of for- ceps extractions or the spontaneous deliveries. In addition, more severe haemorrhages were found in the group of vacuum extractions. Influence on the incidence of haemorrhages by factors other than type of delivery could not be verified statistically.

Key words: retina - retinal haemorrhages - newborns - artificial delivery.

Retinal haemorrhages, which occur fairly frequently in the newborn, have been the object of several studies since the first descriptions of a century ago. In the Department of Obstetrics, Fsdselsanstalten, Arhus a comparative study of deliveries by means of forceps or vacuum extractor was planned, and an assessment of the incidence of retinal haemorrhages was a natural part of

Received 16 August, 1973

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Niels Ehlers, Ib Krarup Jensen and Karl Brogird Hansen

99 deliveries by forceps

this. A consecutive series of deliveries was studied. Extraction by forceps was performed on uneven dates, vacuum extraction on even dates. A full descrip- tion of this study is given elsewhere (BrogPrd et al. to be published). Below, a report is given on the ophthalmological findings and how they are influenced by some obstetrical factors.

94 deliveries by vacuum extractor

Material

The ophthalmological study comprised 413 newborns, 221 males and 192 fe- males. Ninety-nine babies were delivered by forceps, 94 by vacuum extractor, while in 13 cases a failed vacuum extraction was followed by forceps deli- very. In order to have a group of normal deliveries for comparison, the first baby weighing more than 2500 g to be delivered spontaneously after each artifical delivery was examined. This group comprised 207 children. The comparability of the groups delivered by forceps and by vacuum extractor is demonstrated by Table I.

Table I . Characteristics of consecutive, random selected series of delivery by forceps or by

vacuum extractor.

Second stage labour > 1 min

Pathologic position of foetus

Reduced Apgar score

70 O/o 68 O/o

23 010 23 O/o

29 010 16 O/o

Maternal disease

before pregnancy 9 010 6 Olu

during pregnancy 21 010 18 010

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Retinal Haemorrhages in the Newborn

Fig. 1. Examples of retinal haemorrhages. In the right eye few scattered haemorrhages, in

the left numerous retinal haemorrhages and a macular haemorrhage.

Ocular examination. Tropicamide (0.5 O/O) and metaoxedrine (10 O/o) were instilled twice, with an interval of 15 min. Direct ophthalmoscopy through a Richardson lens was performed 1-2 hours later, within 30 hours after deli- very. The findings were recorded in a diagram (Fig. l), and grouped as (1) No haemorrhages, (2) Few scattered, retinal haemorrhages, (3) Numerous reti- nal haemorrhages, (4) Macular haemorrhages, or ( 5 ) Prepapillar haemorrhages. When haemorrhages were found the examination was repeated on the seventh day. Haemorrhages present at the second examination were followed until they had disappeared.

Results

Incidence of retinal haemorrhages. Of the 413 children examined, 165 had retinal haemorrhages (39.9 O/O). Thirty-eight of the 99 children delivered by forceps (380/0) showed haemorrhages, while 60 of the 94 children delivered by vacuum extraction (640/0) showed haemorrhages. Nine of 13 children in whom a failed vacuum extraction was followed by forceps delivery had retinal haemorrhages. In the group of control children, 57 of 207 (27.50/0) revealea this pathology. Statistical calculations by means of the Xz-test showed that significantly more haemorrhages occurred among the vacuum extractions (2' < 0.0005) than among either controls or forceps extractions. The difference between newborns delivered by forceps extractions and spontaneously delivered was not statistically significant (0.05 < P < 0.1).

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Niels Ehlers, Ib Krarufi Jensen and Karl BrogGrd Hansen

Spontaneous delivery

1st day 7th day

Appearance, localization and fate of retinal haemorrhages. Usually a limited number of flame-shaped or rounded intraretinal haemorrhages occurred local- ized peripapillarily or scattered over the posterior part of the fundus (Fig. 1 ) . Occasionally the number of haemorrhages was very large, the entire posterior fundus being covered. The vessels always looked normal an exudates were never seen. Special localizations were macular and prepapillar. In a few cases peripheral choroidal haemorrhages were noted.

The findings in the studied series, grouped according to the classification mentioned, are shown in Table I1 which also includes the findings at the examination on the seventh day. While the scattered retinal haemorrhages have mainly disappeared after 6 days, the macular and prepapillar haemorr- hages persist. These haemorrhages were followed up, and they all disappeared within a few months, leaving no permanent visible damage. One of the pre- papillar haemorrhages, in a child delivered by vacuum extraction, was of the type described by Braendstrup (1969), localized to the primary vitreous.

Table I11 shows how the time of examination after delivery influences the frequency of haemorrhages. No statistically significant differences were found between the frequency of haemorrhages observed in less than 12 hours, 12 to 24 hours and 24-30 hours after delivery.

Influence of birth weight and sex. Fig. 2 shows the material grouped according to birth weight. In none of the three groups was there any statistically signifi- cant correlation between birth weight and frequency of haemorrhages. In

Delivery Vacuum by forceps extraction

1st day 7th day 1st day 7th day

Table I I . Localization of retinal haemorrhages.

The four groups of haemorrhages are not mutually exclusive.

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Retinal Haemorrhages in the Newborn

Delivery by forceps

SPONTANEOUS DELIVERY

Vacuum extraction

FORCEPS DELIVERY VACUUM EXTRACTION

A , 3 4 33

Retinal haemorrhages and birth Fig. 2.

weight. White columns total number, black columns number with retinal haemorrhages. Birth weight in grams. In none of the three groups was there any statistically significant correlation between birth weight and frequency

of haemorrhages ($tests).

Fig. 3 the series are divided according to sex. In each sex, more haemorrhages occurred after vacuum extraction (P < 0.001). There were no differences be- tween the frequency of haemorrhages in female and males.

Parameters related to labour. In 69 of the 99 cases delivered by forceps, more than one pull was needed. Among these 69 cases, haemorrhages were found in

Table 111. Influence of period of time between delivery and examination.

Time of observation

(hours)

Spontaneous delivery

Total no. No of Total no. No. of o,o examined I haem ' . 1 lexaminedl haem. I

< 12 56 14 25 28 8 29 1 7 10 59

12-24 119 30 25 56 25 45 63 40 64

> 24 33 13 39 15 5 33 14 10 7 1

Total 208 57 27.5 99 38 38 94 60 64

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Niels Ehlers, Ib Krarul Jensen azd Karl Brogdrd Hansen

!!

C F V C F V

F i g . 3. Retinal haemorrhages and sex. White columns total number, black columns number with retinal haemorrhages. C control = spontaneous delivery, F forceps delivery, V vacuum extraction. In both sexes more haemorrhages occurred after vacuum extrac- tion (P < 0.001). No differences between frequency of haemorrhages in females

and males.

26 (380/0). In 84 of the 94 vacuum extractions, the time of pull was longer than 1 min. Among these 84 cases, haemorrhages were found in 53 cases (630/0). As already mentioned, 9 of the 13 cases in which a failed vacuum extraction was followed by forceps showed retinal haemorrhages (69 O/o) .

The Apgar score of the newborn was noted in the forceps and the vacuum groups. Among the forceps delivered, where 38 O/O had retinal haemorrhages, 29 had an Apgar score under 10. Of these 29 children, 15 (520/0) had reti- nal haemorrhages. This frequency does not differ statistically significantly from that of the entire forceps group (0.05 < P(O.1). Among the 94 va- cuum extractions, 15 had an Apgar score under 10. Nine of these had retinal haemorrhages (60 O/o), a frequency corresponding to that for the entire group of vacuum extractions (60 of 94, 64 O/O).

The duration of labour, the position and the presentation of the foetus had no relation to the incidence of haemorrhages.

Maternal diseases, age of mother, previous deliveries. The material has been analysed with respect to major diseases before pregnancy and to major com- plications during the pregnancy. The number of cases was small but neither condition appeared to influence the incidence of haemorrhages in any of the groups mentioned. Fig. 4 shows the material grouped according to the age of

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Retinal Haemorrhages in the Newborn

SPONTANEOUS DELIVERY FORCEPS DELIVERY VACUUM EXTRACTION

I I I I I , , , , , I ) I O I I I I

2 a 3 x R 8 2 : R R R R S 2 E i R R R 8

Fig. 4. Retinal haemorrhages and age of mother. White columns total number, black columns number with retinal haemorrhages. In none of the three groups could any heterogeneity

be demonstrated by the X2-test.

the mother. In none of the three groups could any heterogeneity be demon- strated by the Xz-test. The material contained 259 first born babies, of which 110 showed haemorrhages (42.4 O / o ) . Among 141 subsequent babies, 47 showed haemorrhages (33.4 O/O). The difference between first and subsequent babies is not statistically significant (0.05 < P < 0.1). Fig. 5 shows the material divided into first born a n d subsequent babies.

C F V C F V

Fig. 5 . Retinal haemorrhages and parity. White columns total number, black columns number with retinal haemorrhages. C control = spontaneous delivery, F forceps delivery, V vacuum extraction. No differences between first and subsequent babies could be

demonstrated.

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Niels Ehlers, Ib Krarup Jensen and Karl Brogdrd Hansen

Discussion

The problem of retinal haemorrhages in the newborn has been the subject of numerous investigations during the last century. The earlier literature has been excellently reviewed by Sanchez Ibanez et al. (1963). Recent studies have been published by Krauer-Mayer (1965), Krebs & Jager (1966), Schenker & Gombos (1966), Neuweiler & Onwudiwe (1967), Sezen (1970), Weiden (1970), Baum & Bulpitt (1970), Planten & Schaaf (1971) and Pommer (1972). In the Scandinavian literature the subject has been studied by Bjerrum (1884), Wille (1944) and Braendstrup (1969).

Various authors have reported overall incidences of retinal haemorrhages to vary between a few and more than 400/0. Recent larger series agree upon an incidence of about 30 O/O. The large variation may be partly due to different observation times, as all authors agree that most of the haemorrhages disap- pear within a few days (Table 11). In agreement with Weiden's results no correlation could be demonstrated in our series between incidence of haemor- rhages and time of observation within the first 30 hours.

Classifications of haemorrhages according to morphology have been nume- rous. However, the clinical significance seems to have more connection with the rate of disappearance, probably corresponding to a localization in or in front of the retina.

General agreement exists on there being a higher incidence of haemorrhages after delivery by vacuum extraction (Sanchez Ibanez 1963, Krauer-Mayer 1965, Krebs & Jager 1966, Schenker & Gombos 1966, Neuweiler & Onwudiwe 1969. Weiden 1970), about 60 o/o. After delivery by f,orceps the incidence is generally reported to be slightly higher than after spontaneous delivery, although in some series no difference is found. The figures of the present series correspond to those of the literature: after spontaneous delivery, 27.5 O/O haemorrhages; after forceps, 38 "0; after vacuum extraction, 64 O/O. It is emphasized that the present series of deliveries by forceps or by vacuum extractor is the only one in which the two groups are directly comparable (consecutive, randomly select- ed). Statistical significance can be demonstrated for the difference between delivery by vacuum extraction versus forceps or spontaneous delivery, but not for the difference between delivery by forceps and spontaneous delivery. Furthermore, a relatively large part of the haemorrhages seen after delivery by vacuum extraction was of the preretinal type, a tendency also noted by others. If late sequelae can be expected it should be after this type of haemorr- hage.

Several authors have reported a correlation between incidence of haemorr- hages and various obstetrical factors, such as birth weight and sex, duration

80

Retinal Haemorrhages in the Ncwborn

and severity of labour, complications of delivery, Apgar score of the newborn, and first and subsequent births. In this series no such correlations have been statistically verified, which is in close agreement with the results of Weiden (1970).

Numerous attempts have been made to explain the pathogenesis of retinal haemorrhages in the newborn. A generalized haemorrhagic tendency has been supposed, but seems to be of little or no significance (Planten & Schaaf 1971). Several authors have stressed the importance of haemostatic or -dynamic factors. The incidence of retinal haemorrhages is low after Caesarean section or breech delivery. This suggests that pressure on the head during delivery or compression of the thorax, when the head has been delivered, may be of importance. Retinal stasis by thorax compressions seems to be the most direct explanation, the mechanism resembling that of retinal haemorrhages after thorax compressions in adults and after pressure reducing ocular surgery. In the literature no single theory has been adopted.

The prognostic significance of retinal haemorrhages remains an open ques- tion. From the literature there appears to be no association between retinal haemorrhages and brain damage, but it is still possible that sub-clinical alte- rations in the central nervous system occur in children with retinal haemorr- hages. The possible role of macular haemorrhages in the development of amblyopia has been studied in only a few series. I t is intended to follow up the children in the present series who had macular haemorrhages.

References

Baum, J. D. & Bulpitt, C. J. (1970) Retinal and conjunctival haemorrhage in the new-

Brogird, Karl Hansen et al. To be published. Braendstrup, P. (1969) Vitreous haemorrhage in the newborn. A rare type of neonatal

intraocular haemorrhage. Acta ophthal. ( K b h . ) 47, 502-513. Krauer-Mayer, B (1965) Retinahaemorrhagien beim Neugeborenen. Vergleichende

Untersuchungen nach Spontangeburten, Vakuumextractionen und Forceps. Ann. pae- &at. 204, 168-176.

Krebs, W. & Jager, G. (1966) Netzhausblutungen bei Neugeborenen und Geburtsver- lauf. Kl in . M b l . Augenheilk. 148, 483-490.

Neuweiler, W. & Onwudiwe, E. U. (1967) Retinahamorrhagien beim Neugeborenen. Gynaecologia 163, 27-42.

Planten, J. T. & Schaaf, P. C. v. d. (1971) Retinal haemorrhage in the newborn. An attempt to indicate and explain its cause and significance. Ophthalmologica (Basel)

born. Arch. Dis. Childh. 45, 344-349.

162, 213-222.

81 Acta ophthal. 52, I b

Niels Ehlers, Ib Krarup Jensen and Karl Brogdrd Hansen

Pommer, H. (1972) Die Geburt als Ursache von kindlichen Netzhautblutungen. Klin. Mbl. Augenheilk. 160, 203-206.

Sanchez Ibanes, J. M., Belmonte Gonzales, N. & Navarro Martinez, A. (1963) Retina- Hamorrhagien beim Neugeborenen und Vakuum-Extraction. Gynaecologia 156,

Sezen, F. (1970) Retinal haemorrhages in ncwborn infants. Brit. J . Oplithal. 55,

Schenker, J. G. & Gombos, G. M. (1966) Retinal hemorrhage in the newborn. Obstet.

Weiden, H. (1970) Uber Netzhautblutungen bei Neugeborenen mit unterschiedlichen

Wille, H. (1944) Investigations in the influence of K avitaminosis on the occurrence

172-186.

248-253.

Gynec. 27, 521-524.

Geburtsablauf. Klin. Mbl. Augenheilk. 156, 363-37 1.

of retinal hemorrhages in the newborn. Acta ophthal. (Kbh). 22, 261-269.

Author’s address: Niels Ehlers, M. D., Dept. of Ophthalmology, Arhus Kommunehospital, DK-8000 Arhus C, Denmark.

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