Delivering a Hemophilic Newborn with No Intracranial Hemorrhage: Is Caesarian Section the Answer?

Birth is not only considered the first hemostatic challenge for a child with hemophilia A, but also it can result in one of the most devastating and often preventable type of bleeding in hemophilic newborns. Three to four percent of infants with hemophilia experience a head bleed at delivery. The optimal mode of delivery of the hemophilic carrier expecting an affected child is still a matter of uncertainty and debate.

The aim of this study was to evaluate the frequency of major bleeding in the neonatal period and to examine the association between mode of delivery and neonatal intracranial hemorrhage (ICH) in an Arab cohort of infants with hemophilia A.

Subjects and methods:

A retrospective multi-center study of children with severe hemophilia A (age 0-18 years) was conducted. Five hemophilia treatment centers distributed across four Arabian Gulf countries participated in the study. Two centers from Oman and one center of each of KSA, UAE and Kuwait were included.

The collected data were date of birth, maternal parity, mode of delivery, duration of labor, admission to neonatal intensive care unit, symptomatic ICH, and other bleeding episodes. Review of electronic patient record along with telephone interviews when needed were the tools used for data collection.

Results:

A total of 153 patients were found. Most of them were born through spontaneous vaginal delivery (SVD) (125 patients; 82 %). Vacuum extraction was adopted in six patients (4%), while twenty two patients were offered caesarian section (CS) (14%).

ICH was reported in a total of four patients (2.6%). All of them were full term babies with variable time interval between the onset of the bleed and birth. One patient presented at birth, another presented at the age of 4 weeks while the remaining two had the bleed at the age of 2 weeks.

Vacuum extraction was associated with the highest risk of ICH (two patients; 33 %).The other two patients were born by SVD (1.6 %). CS was not associated with ICH.

Conclusions:

Normal vaginal delivery is still considered a safe journey through the birth canal for hemophilic newborns. Larger prospective studies are needed to define an evidence-based optimal mode of delivery for the hemophilia carrier expecting an affected child.