Perinatal and long-term outcomes of fetal intracranial hemorrhage: systematic review and meta-analysis.

Objective Fetal intracranial hemorrhage is associated with increased risk of perinatal mortality and morbidity. Healthcare professionals often find it challenging to counsel parents due to its rarity and diverse presentation. The aim of this systematic review and meta-analysis was to investigate the perinatal outcomes of fetuses with intracranial hemorrhage. Methods Medline, Embase, Clinicaltrials.gov and Cochrane Library databases were searched. Inclusion criteria were studies reporting the outcomes of fetuses diagnosed with intracranial hemorrhage. The primary outcome was perinatal death (PND) defined as the sum of intra-uterine (IUD) and neonatal death (NND). The secondary outcomes were stillbirth, NND, termination of pregnancy, need for surgery/shunting at birth, cerebral palsy, defined according to the European Cerebral Palsy Network and classified as diplegia, hemiplegia, quadriplegia, dyskinetic, or mixed, neurodevelopmental delay, and intact survival. All these outcomes were explored in the overall population of fetuses with intracranial hemorrhage. A subgroup analysis according to the location of the hemorrhage (intra-axial and extra-axial) was also planned. Meta-analyses of proportions were used to combine data and reported pooled proportion and their 95% confidence intervals (CI). Results Sixteen studies (193 fetuses) were included in the analysis. PND occurred in 14.6% (95% CI 7.3-24.0), of fetuses with intracranial hemorrhage. Of those liveborn, 27.6% (95% CI 12.5-45.9) required shunt placement after birth and 32.0% (95% CI 22.2-42.6) had cerebral palsy. 16.7% of children had signs of mild neurodevelopmental delay, while 31.1% (95% CI 19-44.7) experienced severe adverse neurodevelopmental outcome. A normal outcome was reported in 53.6% of the fetuses. Subgroup analysis according to the location of the intracranial hemorrhage showed that PND occurred in 13.3% (95% CI 5.7-23.4) of fetuses with intra-axial and in 26.7% (95% CI 5.3-56.8) with extra-axial bleeding. In fetuses with intra-axial hemorrhage 24.7% (95% CI 11-41.2) required shunt placement after birth and 27.1% (95% CI 17.1-38.4) experienced cerebral palsy. Mild and severe neurodevelopmental delay were observed in 15% (95% CI 6.9-25.6) and 32.3% (95% CI 19.7-46.3) of cases, respectively, while 51.9% (95% CI 36-67.4) experienced a normal neurodevelopmental outcome. Robust evidence on the incidence of mortality and postnatal outcome in fetuses with extra-axial hemorrhage could not be extrapolated due to the small number of cases. Conclusions Fetuses with a prenatal diagnosis of intracranial hemorrhage are at high risk of perinatal morality and impaired neurodevelopmental outcome. Postnatal shunt placement was performed in 28% and cerebral palsy was diagnosed in approximately one third of these infants. This article is protected by copyright. All rights reserved.