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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 60  |  Issue : 1  |  Page : 11-14

Incidence of retinal hemorrhages in full-term newborn babies in a tertiary care hospital in India


1 Department of Ophthalmology, ESIC MC and PGIMSR, Chennai, Tamil Nadu, India
2 Department of Preventive and Social Medicine, ESIC MC and PGIMSR, Chennai, Tamil Nadu, India
3 Department of Ophthalmology, SRM Medical College Hospital, Chengalpattu, Tamil Nadu, India

Date of Submission05-Sep-2021
Date of Decision07-Oct-2021
Date of Acceptance07-Oct-2021
Date of Web Publication22-Mar-2022

Correspondence Address:
Dr. V K Malathi
Plot No. 76, Door No. 14, Balakrishnapuram 4th Street, Adambakkam, Chennai - 600 088, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_136_21

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  Abstract 


Context: Neonatal retinal hemorrhage (RH) is a condition occurring in newborns within 1 month of birth. Long-standing, dense hemorrhages obscuring the macula may lead to severe vision deprivation amblyopia. Aims: This study aimed to estimate the incidence of retinal hemorrhages (RHs) in full-term newborn babies in a medical college tertiary care hospital over a period of 1 year and to determine the association between RH and the mode of delivery. Settings and Design: This was a prospective observational study. Subjects and Methods: Screening was done in 469 full-term newborn babies within a week of delivery. Pupils were dilated with 0.4% tropicamide and 2.5% phenylephrine. Retinal evaluation was done with indirect ophthalmoscope and 20D lens. Statistical Analysis Used: Data analysis was done using SPSS software version 21. Chi-square test was used to assess the association between sex of the baby, mode of delivery, birth weight, and RH. P < 0.05 was considered statistically significant. Results: Out of 469 babies screened, 27 had RH on fundus examination. Of the 266 babies who were born spontaneously through vaginal route, 20 babies had RH. Eleven babies were delivered through vacuum-assisted vaginal delivery, of which 5 had RH. Babies weighing >2.5 kg had a higher incidence of RH (6.3%). There was no significant association between sex and RH. Conclusion: The incidence of RH in newborn babies was found to be 5.8%. Incidence of RH was found to be high among vacuum-assisted delivery followed by spontaneous vaginal delivery. Babies weighing >2.5 kg had a higher incidence of RH. By 2 weeks after birth, RH resolved in 96.29% of eyes.

Keywords: Full-term newborn, mode of delivery, retinal hemorrhage


How to cite this article:
Malathi V K, Elangovan S, Anuradha R, Senthamarai G, Kumar T S. Incidence of retinal hemorrhages in full-term newborn babies in a tertiary care hospital in India. TNOA J Ophthalmic Sci Res 2022;60:11-4

How to cite this URL:
Malathi V K, Elangovan S, Anuradha R, Senthamarai G, Kumar T S. Incidence of retinal hemorrhages in full-term newborn babies in a tertiary care hospital in India. TNOA J Ophthalmic Sci Res [serial online] 2022 [cited 2022 May 29];60:11-4. Available from: https://www.tnoajosr.com/text.asp?2022/60/1/11/340350




  Introduction Top


Neonatal RH is a condition occurring in newborns within 1 month of birth. Long-standing, dense hemorrhages obscuring the macula may lead to severe vision deprivation amblyopia.[1],[2] Most RHs resolve within 2 weeks. RH is considered to be a component of normal birth process wherein the head of the baby is delivered through the mother's birth canal.[3] Postulates related to birth-related RH include instrumental (forceps/vacuum) delivery and spastic contraction of the lower segment of uterus.[4]

The types of RH have been described by Schenker and Gombos (I966).[5] They were classified into (a) flame shaped; (b) more or less circular in the deeper layers of the retina; (c) sharply circumscribed, perfectly round, and deep red; and (d) subhyaloid. They were predominantly intraretinal, posterior, resolved rapidly, and rarely persisted beyond 6 weeks.[4]

The objective of the study is to estimate the incidence of retinal hemorrhages (RH) in full-term newborn babies in a medical college tertiary care hospital over a period of 1 year (November 2019 to November 2020) and to determine the association between the RH and the mode of delivery. This study will be useful in deciding whether to incorporate routine fundus screening protocol for newborn babies, especially in those with perinatal distress so that stimulus deprivation amblyopia can be prevented.


  Subjects and Methods Top


Institutional ethics committee clearance was obtained. Consent was obtained from the parents. A total of 469 full-term newborn babies were screened. Babies with severe systemic diseases such as cardiac anomalies, metabolic disorders, storage disorders, and congenital ocular disorders were excluded from the study.

Data collection

Birth history was recorded which included mode of delivery, gestational age, gender, perinatal complications, and birth weight. The obstetric parameters include spontaneous vaginal delivery, forceps-assisted vaginal delivery, vacuum-assisted vaginal delivery, elective C-section, and emergency C-section. Eye examination was done within a week of delivery. Anterior segment of the eye was examined using torchlight. Retinal screening was performed by ophthalmologists experienced in retinal evaluation using an indirect ophthalmoscope. Pupils were dilated with 0.4% tropicamide and 2.5% phenylephrine (half dilution of tropicamide plus phenylephrine eye drops). Clinical evaluation was done with indirect ophthalmoscope and 20D lens. The fundus findings were recorded in the register. All babies with RH were followed up every week until the RH was resolved. The absence of RH in the 1st week after birth excludes birth-related RH; hence, babies without RH were examined only once.


  Results Top


Totally, 469 full-term babies were screened within 1 week of their birth. Distribution of characteristics of study participants is given in [Table 1]. Out of 469 babies screened, 27 (5.8%) had RH on fundus examination [Table 2]. Types of RH are presented in [Table 3]. Majority of the hemorrhages were flame shaped (77.7%). The other types of nonocular hemorrhages observed in the study are given in [Table 4]. RH resolved in 96.3% of eyes. One baby had persistent superficial flame-shaped hemorrhage for 2 months which eventually resolved [Table 5]. Of the 246 babies who were born spontaneously through the vaginal route, 20 babies (7.5%) had RH. Among the 11 babies delivered through vacuum-assisted vaginal delivery, five babies (45.5%) had retinal hemorrhages. Highly significant association was found between mode of delivery and RH [Table 6]. There was no significant association between sex and RH [Table 7]. Babies weighing >2.5 kg had higher incidence of RH (6.3%) when compared to babies weighing <2.5 kgs (4.6%). However, there was no significant association between birth weight and RH [Table 8].
Table 1: Distribution of characteristics of study participants (n=469)

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Table 2: Incidence of retinal hemorrhage (n=469)

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Table 3: Types of retinal hemorrhage (n=27)

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Table 4: Other types of hemorrhages in full-term newborn babies

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Table 5: Time taken for spontaneous resolution (n=27)

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Table 6: Association between mode of delivery and retinal hemorrhage

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Table 7: Association between sex and retinal hemorrhage

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Table 8: Association between birth weight and retinal hemorrhage

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  Discussion Top


In our study, not only the incidence of RH in term newborn babies has been estimated but also the association between the various modes of deliveries such as spontaneous vaginal delivery, forceps-assisted vaginal delivery, vacuum-assisted vaginal delivery, elective lower segment cesarian section (LSCS), and emergency LSCS has been determined. In this study, the gender predilection for retinal hemorrhages (RH) and association of RHs with respect to weight of the babies have been analyzed. Donahue et al. revealed that approximately 25.6% of newborns via spontaneous vaginal deliveries had RH.[3] In our study, 7.5% of newborns via spontaneous vaginal deliveries had RH. Most RHs in newborns resolve within 2 weeks. RH is considered to be a component of normal birth process wherein the head of the baby is delivered through the mother's birth canal.[3] Birth-related RHs in infants occur in one-quarter of normal deliveries and are more common after instrumental deliveries.[3] In our study, the percentage of RHs in vacuum-assisted deliveries is 45.5%. According to Al-Khamees and Al-Amro, intra-RH was present in 34% of newborns and varied from a single dot hemorrhage in one eye to bilateral widespread hemorrhages, occasionally with white centers. The incidence of hemorrhage was higher for vacuum assisted (75%) than for spontaneous vaginal deliveries (33%) and was least for infants delivered by cesarean section (7%). By 2 weeks after birth, RH resolved in 86% of eyes, and at 4 weeks, no intraretinal hemorrhage was detected, although a single sub-RH persisted until 6 weeks after birth.[6] In our study, hemorrhages, in all except one, resolved within 3 weeks. One baby had persistent extramacular RHs for 2 months and eventually resolved. Intervention was not required because of extramacular retinal hemorrhage. These findings may help in differential diagnosis of shaken baby syndrome in which case the hemorrhages may persist or recur. Extramacular hemorrhages are more common than macular hemorrhages. If RH persists for more than a month, the baby should be closely observed. If there is intravitreal bleed persisting for more than 4 weeks, a vitrectomy should be planned. RH in infants older than 1 month should heighten suspicion that the hemorrhage is associated with factors other than birth.[6],[7] In our study, the incidence of intraretinal hemorrhages was common in babies weighing more than 2.5 kg, delivered through vaginal route with or without instrument assistance. This could be due to the prolonged 2nd stage of labor due to the large size of the baby. Our study showed results similar to Laghmari et al. According to Laghmari et al., 31.8% of newborns exhibited RHs. About 72.6% of hemorrhages were bilateral. They tended to be localized around the optic discs, and in the posterior pole, but their distribution was variable. RHs were of variable shapes. The prevalence of RHs was higher in newborns delivered with vacuum-assisted extraction (38%, P < 0.001), intermediate during normal vaginal delivery (32.6%, P < 0.001), and lower with caesarean section (20.8%). Comparative analysis between elective cesarean section and emergency cesarean showed a higher incidence of RHs in the emergency cesarean group (P = 0.006). On multivariate analysis, vacuum-assisted delivery was the only factor associated with a higher prevalence of RHs in newborns (P = 0.045). Two-third of hemorrhages had disappeared by 1 week after birth. RHs had resolved in all newborns within 4 weeks.[8] Similar to our study, Schenker and Gombos (1966) noted a relationship between retinal hemorrhages and the mode of delivery-0% with cesarian section 8%, 3% with breech, 31% with forceps, and 52% with vacuum extraction.[9]


  Conclusion Top


The incidence of RH in newborn babies was found to be 5.8%. Incidence of RH was found to be high among vacuum-assisted delivery followed by spontaneous vaginal delivery. Babies weighing >2.5 kg had a higher incidence of RH. By 2 weeks after birth, RH resolved in 96.29% of eyes.

Key message

Neonatal RH is a condition occurring in new-borns within 1 month of birth. Long-standing, dense hemorrhages obscuring the macula may lead to severe vision deprivation amblyopia. Hence, it is essential to incorporate routine fundus screening protocol for newborn babies, especially in those with perinatal distress.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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.  Back to cited text no. 1
    
2.
Choi YJ, Jung MS, Kim SY. Retinal hemorrhage associated with perinatal distress in newborns. Korean J Ophthalmol 2011;25:311-6.  Back to cited text no. 2
    
3.
Donahue SP, Arthur B, Neely DE, Arnold RW, Silbert D, Ruben JB, et al. Guidelines for automated preschool vision screening: A 10-year, evidence-based update. J AAPOS 2013;17:4-8.  Back to cited text no. 3
    
4.
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.  Back to cited text no. 4
    
5.
Schenker JG and Gombos GM: Retinal haemorrhage in the newborn. Obstetrics and Gynaecology. Vol. 27:521-254;1966.  Back to cited text no. 5
    
6.
Al-Khamees F, Al-Amro SA. Deep deprivation amblyopia resulting from labor-induced neonatal vitreous hemorrhage: A need for screening. Ann Ophthalmol 2000;32:328-30.  Back to cited text no. 6
    
7.
Giles CL. Retinal hemorrhages in the newborn. Am J Ophthalmol 1960;49:1005-11.  Back to cited text no. 7
    
8.
Laghmari M, Skiker H, Handor H, Mansouri B, Ouazzani Chahdi K, Lachkar R, et al. Hémorragies rétiniennes liées à l'accouchement chez le nouveau-né: fréquence et relation avec les facteurs maternels, néonataux et obstétricaux. Étude prospective de 2031 cas [Birth-related retinal hemorrhages in the newborn: incidence and relationship with maternal, obstetric and neonatal factors. Prospective study of 2,031 cases]. J Fr Ophtalmol. 2014 Apr;37(4):313-9. French. doi: 10.1016/j.jfo.2013.06.005. Epub 2014 Feb 24. PMID: 24576566.  Back to cited text no. 8
    
9.
Critchley EM. Observations on retinal haemorrhages in the newborn. J Neurol Neurosurg Psychiatry 1968;31:259-62.  Back to cited text no. 9
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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