|Year : 2018 | Volume
| Issue : 1 | Page : 8-11
Retinal hemorrhages in term newborns – Our experience at tertiary centre
Vidya Hegde, Soni Soman, Rashmi Jain, Anupama Bappal, Rashmi Shambhu
Department of Ophthalmology, Yenepoya Medical College, Deralakatte, Mangalore, Karnataka, India
|Date of Web Publication||18-Jan-2018|
Department of Ophthalmology, Yenepoya Medical College, Deralakatte, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
Background: There are very few previous studies regarding ocular screening done in term neonates. Retinal hemorrhages can occur in babies during delivery. Aims: To evaluate the correlation of retinal findings with the duration of second stage of labor in term neonates and mode of delivery. Settings and Design: This was a cross-sectional, observational study done on term newborns in a tertiary care centre. Convenience sampling was done. Subjects and Methods: Neonates were examined in the postnatal ward using handheld slit lamp and indirect ophthalmoscope. Fundus examination was done after dilating the pupils with 0.5% tropicamide and 2.5% phenylephrine eyedrops. Second stage of labor and mode of delivery were noted. Chi-square test and independent sample t-test were used to analyze the data. Results: One hundred and fifty infants were screened, of which 75 (50%) had retinal hemorrhages. Chi-square test showed statistical significance with duration of second stage of labor and occurrence of retinal hemorrhages (P < 0.001). Patients with second stage of labor shorter than 30 minutes of duration were found to have more chances of having retinal hemorrhages. Independent sample t-test used for association between mode of delivery and retinal hemorrhages showed patients born of normal vaginal delivery to have more chances of having hemorrhages (P = 0.006). Chi-square test showed statistical significant association with the presence of hemorrhages and day of evaluation (P < 0.001). Conclusion: Retinal hemorrhages were found to be common in full-term babies whose second stage of delivery was shorter than 30 minutes of duration.
Keywords: Mode of delivery, retinal hemorrhages, screening, second stage of labor duration, term newborn
|How to cite this article:|
Hegde V, Soman S, Jain R, Bappal A, Shambhu R. Retinal hemorrhages in term newborns – Our experience at tertiary centre. J Clin Ophthalmol Res 2018;6:8-11
|How to cite this URL:|
Hegde V, Soman S, Jain R, Bappal A, Shambhu R. Retinal hemorrhages in term newborns – Our experience at tertiary centre. J Clin Ophthalmol Res [serial online] 2018 [cited 2018 Jun 25];6:8-11. Available from: http://www.jcor.in/text.asp?2018/6/1/8/223569
Comprehensive neonatal examination done by pediatricians includes ocular examination. A significant number of ocular conditions may go undetected. Screening of ocular conditions at birth is being recommended as this would help in early detection of vision and life-threatening conditions like retinoblastoma. But in India, this is restricted to screening of retinopathy of prematurity. Recently, the government of India has launched the “Rashtriya Bal Swasthya Karyakram” under the National Rural Health Mission (Ministry of Health and Family Welfare 2013) to detect more than thirty conditions in the 0–16 years' age population. Studies done on ocular screening of neonates have detected ocular conditions such as retinoblastoma, familial exudative vitreoretinopathy, subconjunctival hemorrhages, congenital cataracts, congenital ptosis, neonatal dacryocystitis, optic disc anomalies, and retinal hemorrhages., Retinal hemorrhages can occur in babies during delivery. The reported incidence of retinal hemorrhages in newborn infants varies from 2.6% to 50%., However, most of these hemorrhages resolve spontaneously. Giles demonstrated that the incidence reduced from 40% at 1 hour postdelivery to 20% at 72 hours. The incidence varies with the mode of delivery. They occur most frequently in those delivered by vacuum extraction (75%), 33% in those delivered by spontaneous vaginal delivery, and 6.7% in those delivered by cesarean section. There are few previous studies looking at the incidence of retinal hemorrhages in healthy full-term newborns. A study done in India showed that retinal hemorrhages were the most common ophthalmologic findings seen in term neonates (52.1%). Very short or very prolonged labor is considered as the risk factor for the occurrence of retinal hemorrhages. This study was aimed to evaluate the correlation of retinal findings with the duration of second stage of labor in term neonates and mode of delivery.
| Subjects and Methods|| |
The study was a cross-sectional observation study done in term newborns (≥36 and <40 weeks) in the postnatal ward in the Department of Pediatrics in a medical college hospital for a period of 1 year from August 2014 to April 2015. It was done after obtaining ethical clearance from the Institutional Ethics Committee. The study excluded neonates with critical illnesses and systemic infectious diseases and those on ventilator or continuous positive airway pressure.
Informed consent was taken from the parents of the newborn. The babies were examined within 5 days of delivery. Detailed antenatal, perinatal, and immediate neonatal history was obtained from the mothers. Details regarding the mode of delivery and duration of second stage of labor in normal and assisted delivery along with Apgar score and new Ballard score were obtained from the pediatrician. Ocular examination of the newborns was done by the ophthalmologist, assisted by a nurse. Neonates were examined using handheld slit lamp. Fundus examination was done after dilating the pupils with 0.5% tropicamide and 2.5% phenylephrine eyedrops using an indirect ophthalmoscope with +20 D condensing lens and also with the help of a pediatric eye speculum and wire vectis.
Chi-square test was used to find the association between the duration of second stage and occurrence of retinal hemorrhages and also to find the association between the day of ocular evaluation and occurrence of retinal hemorrhages. Independent sample t-test was used to show the association of occurrences of retinal hemorrhages with the mode of delivery and gestational age. P < 0.05 was considered significant.
| Results|| |
In the study, 150 infants were screened, of which 75 (50%) had retinal hemorrhages. Of the newborns examined, 72 newborns were males and 78 were females. We followed the grading of retinal hemorrhages described by Egge as Grade 1, Grade 2, and Grade 3. Grade 1 is a small retinal hemorrhage confined to the area around the optic nerve head, associated with dot or fine linear bleeding. Grade 2 is a patchy, dot, blot, or flame-shaped hemorrhage, the size of which does not exceed the optic disc diameter. Grade 3 Retinal haemorrhages are retinal hemorrhages more than the diameter of the optic disc area or a line of flame-shaped haemorrhage along vessels or macular haemorrhage Of the 150 infants screened, Grade 1 hemorrhages were seen in 66 cases (44%), Grade 2 in 8 cases (5.3%), and Grade 3 without the involvement of macula in only 1 case (0.7%). Retinal hemorrhages were seen bilaterally in 41 cases (27.33%) and unilaterally in 34 (22.67%) cases. All retinal hemorrhages were intraretinal in nature.
Among the newborns screened, 74.7% of babies were delivered by normal vaginal delivery, 22.7% by cesarean section, and 2.7% by assisted labor (vacuum extraction). Chi-square test used for the association between the mode of delivery and retinal hemorrhages showed patients born of normal vaginal delivery to have more chances of having hemorrhages (P = 0.006) as shown in [Table 1].
|Table 1: Association between mode of delivery and occurrence of retinal hemorrhages|
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Duration of second stage of labor varied from 10 to 100 minutes. The mean duration of the second stage of labor in patients without retinal hemorrhages was 63.2 minutes and in those with hemorrhages was 17.5 minutes. Independent sample t-test showed statistical significance with the duration of second stage of labor and occurrences of retinal hemorrhage (P < 0.001). Patients with second stage of labor shorter than 30 min of duration were found to have more chances of having retinal hemorrhages as shown in [Table 2].
|Table 2: Correlation between duration of second stage of labor and occurrence of retinal hemorrhages|
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The days of evaluation varied between 1 and 5 days. Majority of the newborns were examined on day 2 (n = 36). [Table 3] shows the occurrence of retinal hemorrhages and day of evaluation. Chi-square test showed a statistically significant association with the presence of hemorrhages and day of evaluation (P < 0.001). Earlier the day of evaluation, the more the chances of occurrence of retinal hemorrhages. The gestational age of newborns ranged from 36 to 40 weeks. In the study, 64% of babies with retinal hemorrhages had gestational age of 39 weeks. Independent sample t-test showed no statistical significance with occurrences of retinal hemorrhages and gestational age (P = 0.807). With regard to parity, 78.7% of newborns with retinal hemorrhages were born to multigravida and 21.3% of babies with retinal hemorrhages were born to primigravida.
| Discussion|| |
Retinal hemorrhages are known to occur in newborns, and most of these resolve over a period of time. The incidence varies with the mode of delivery. The greater incidence of hemorrhages in babies born from vacuum-assisted vaginal delivery may be due to the mechanical effect on retinal vessels during passage through the birth canal, perhaps by direct compression on the globe. Maternal and fetal hemodynamic and rheologic changes during labor and delivery may also be responsible in the genesis of retinal hemorrhages, as these hemorrhages are seen in babies born by cesarean section. Retinal hemorrhages if unresolved could limit the function of the visual pathway and can affect the normal development of visual function., Grade 1 and Grade 2 retinal hemorrhages can dissipate quickly and get absorbed without leaving a trace, causing no discernible effect on visual development. However, Grade 3 macular hemorrhage can leave a long-term impact on vision. In our study, 50% of the newborns had retinal hemorrhages. Forty-four percent of retinal hemorrhages in the newborns were Grade 1. Only one case was Grade 3 but did not involve the macula. A study by Li et al. reported retinal hemorrhages in 21.53% of newborns of the 3573 healthy full-term newborns screened and occurrence of Grade 3 hemorrhages in 6%. Hughes et al. in their prospective study on birth-related retinal hemorrhages have reported the incidence to be 34%. Vinekar et al. in their study on ocular screening of term infants using wide-field digital imaging found the presence of retinal hemorrhages in 52% of the 1021 term newborns screened and 24% were macular hemorrhages.
A systematic review study on newborn retinal hemorrhages done by Watts et al. showed the presence of retinal hemorrhages in 25.6% after spontaneous vaginal delivery, 42.6% by vacuum extraction, and 52% by double-instrument deliveries. In our study, out of the 150 infants screened, the presence of retinal hemorrhages was seen in 42% of the newborns after normal vaginal delivery, 2% after assisted delivery (vacuum extraction), and 6% after cesarean section. Emerson et al. found no difference between the total duration of second stage of labor and occurrence of retinal hemorrhages. Williams et al. found a significant association between a short (<30 minutes) second stage of labor and the presence of moderate-to-severe retinal hemorrhages (P < 0.006). Our study also showed statistical significance with the duration of second stage of labor and occurrences of retinal hemorrhages (P < 0.001). Probably, the short second stage of labor results in compression of fetal cranium with sudden decrease of venous pressure that leads to retinal hemorrhages.
In a study done by Sezen, the incidence of retinal hemorrhages varied according to the time of examination. Those term newborns examined within the first 24 hours revealed the presence of hemorrhages in 18.9% and 2.6% in those between the third and fifth days, respectively. The study concluded that later the time of fundus examination, less the incidence of retinal hemorrhages found. Watts et al., in their systematic review on newborn retinal hemorrhages have found that investigators examining infants up to 48 hours or more found a lower prevalence of retinal hemorrhages (26%) than those examining all infants within 30 hours (39%). They also found that the retinal hemorrhages were commonly bilateral. In our study, we found bilateral occurrence of retinal hemorrhages in 27.33%, and there was a significant statistical association between the day of examination and occurrence of retinal hemorrhages.
However, this study did not show any significant statistical association between retinal hemorrhages and gestational age and parity. A similar finding was seen in a systematic review study on newborn retinal hemorrhages done by Watts et al.
Limitations of our study
The newborns underwent ophthalmic evaluation within 5 days of birth, and the examination was done only once with no further follow-up of these babies. We were not able to know the course of the retinal hemorrhages over a period of time. Hence, it is needed to do a longitudinal study to know their natural history. The pattern of resolution of these hemorrhages has important implications when considering a differential diagnosis of nonaccidental injury or shaken baby syndrome. Also not all newborns were examined on the same day after birth and we did not include maternal and fetal hemodynamic factors that may be responsible for the occurrence of retinal hemorrhages.
| Conclusion|| |
The study found that half of the neonates screened had retinal hemorrhages. This was statistically associated with short second stage of labor and the day of evaluation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Vinekar A, Govindaraj I, Jayadev C, Kumar AK, Sharma P, Mangalesh S, et al.
Universal ocular screening of 1021 term infants using wide-field digital imaging in a single public hospital in India - A pilot study. Acta Ophthalmol 2015;93:e372-6.
Li LH, Li N, Zhao JY, Fei P, Zhang GM, Mao JB, et al.
Findings of perinatal ocular examination performed on 3573, healthy full-term newborns. Br J Ophthalmol 2013;97:588-91.
Nie WY, Wu HR, Qi YS, Zhang M, Hou Q, Yang HX, et al.
A pilot study of ocular diseases screening for neonates in China. Zhonghua Yan Ke Za Zhi 2008;44:497-502.
Kaur B, Taylor D. Fundus hemorrhages in infancy. Surv Ophthalmol 1992;37:1-17.
Emerson MV, Pieramici DJ, Stoessel KM, Berreen JP, Gariano RF. Incidence and rate of disappearance of retinal hemorrhage in newborns. Ophthalmology 2001;108:36-9.
Giles CL. Retinal hemorrhages in the newborn. Am J Ophthalmol 1960;49:1005-11.
Sezen F. Retinal haemorrhages in newborn infants. Br J Ophthalmol 1971;55:248-53.
Egge K, Lyng G, Maltau JM. Retinal haemorrhages in the newborn. Acta Ophthalmol (Copenh) 1980;58:231-6.
Egge K, Lyng G, Maltau JM. Effect of instrumental delivery on the frequency and severity of retinal hemorrhages in the newborn. Acta Obstet Gynecol Scand 1981;60:153-5.
Hughes LA, May K, Talbot JF, Parsons MA. Incidence, distribution, and duration of birth-related retinal hemorrhages: A prospective study. J AAPOS 2006;10:102-6.
Watts P, Maguire S, Kwok T, Talabani B, Mann M, Wiener J, et al.
Newborn retinal hemorrhages: A systematic review. J AAPOS 2013;17:70-8.
Williams MC, Knuppel RA, O'Brien WF, Weiss A, Spellacy WN, Pietrantoni M. Obstetric correlates of neonatal retinal hemorrhage. Obstet Gynecol 1993;81(5(Pt 1)):688-94.
[Table 1], [Table 2], [Table 3]