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N.G. Andersson et al.
CS in 293 (31.6%). Sixty-two (6.7%) of the included patients were preterm. For more detailed information on cohort demographics see Table 1.
Intracranial hemorrhages and major bleeds
Twenty ICH (2.2%) and 44 other major bleeds (4.8%) were recorded in the 926 children. The majority of major bleeds were soft tissue bleeds (n=14), followed by muscle bleeds (n=7) and mucous membrane bleeds (n=3). One patient each suffered from a shoulder bleed, subgaleal bleed, scalp bleed, cephalohematoma, hematemesis, and a hepatic bleed; in 14 patients the bleeds were not further defined. No significant difference was observed in the fre- quency of bleeds when comparing HA to HB or moderate to severe hemophilia.
In the whole cohort, major bleeds occurred at a frequen- cy of 4.3% (27 of 633) after all vaginal deliveries and 5.8% (17 of 293) after CS (P=0.32). The frequencies of ICH after all vaginal deliveries was 2.4% (15 of 633), compared to 1.7% after CS (5 of 293), with no significance (P=0.631).
Term and preterm neonates
Data on gestational age was available in 849 of 926 neonates. When comparing major bleeds in term and preterm deliveries, major bleeds occurred in 5.2% (41 of 787) of term and in 6.4% (3 of 62) of preterm babies with no significant statistical difference between the groups (P=1.0). The frequency of ICH in the term delivery group was 2.5% (20 of 787) and no cases of ICH was reported in the preterm delivery group (n=62). In the preterm group, neonates were born at a median of 35 gestational weeks (range 26-36 weeks) and only 11 of 62 (17.7%) neonates were very or extremely preterm (born before the 33rd ges- tational week). Unfortunately, in 77 cases, gestation at delivery was not recorded, but no major bleeds were reported in this group (Table 2). Because there was no dif- ference between the groups based on gestational age, all further analysis was carried out on the whole cohort.
Mode of delivery
In 813 of 926 patients, more information about the mode of delivery was available and further subgroups could be defined: non-instrumental vaginal delivery (n=541), vaginal with instruments, e.g. forceps or vacuum extraction (n=68), CS prior to labor (n=125), and CS dur- ing labor (n=79). The frequencies for ICH were 1.5% (8 of 541) for non-instrumental vaginal delivery, 10.2% (7 of 68) for instrumental vaginal delivery, 1.6% (2 of 125) CS prior labor, and 2.5% (2 of 79) during labor. Regarding major bleeds, the frequencies showed 2.6% (14 of 541) for non- instrumental vaginal delivery, 19.1% (13 of 68) for instru- mental vaginal delivery, 4.0% (5 of 125) CS prior to labor, and 8.9% (7 of 79) for CS during labor. The results identify vaginal instrumental delivery as a significant risk factor in comparison to vaginal delivery without instruments and CS prior to labor for both major bleeds and ICH: the Relative Risk (RR) for ICH was 6.96 (95%CI: 2.61-18.6; P=0.0005) and the RR for major bleeds was 7.39 (95%CI: 3.63-15.05; P<0.0001) for comparison with vaginal deliv- ery without instruments; compared to CS prior to labor the RR was 6.43 (95%CI: 1.37-30.12; P=0.010) for ICH and 4.78 (95%CI: 1.78-12.84; P=0.0012) for major bleeds. Regarding major bleeds only at a significance level of P<0.05, vaginal delivery without instruments was signifi- cantly safer than CS during labor (P=0.011; RR 3.42, 95%CI: 1.43, 8.22) but no difference for ICH could be seen (P=0.37). All other groups showed no significances in comparison; there was no significant difference in the rate of ICH or major bleeds when comparing instrumental vaginal delivery with CS during labor. For more details see Tables 3 and 4.
A subanalysis of moderate versus severe hemophilia was made showing similar results regarding ICH: 2.14% (3 of 140) ICH for moderate and 2.16% (17 of 786) for severe hemophilia without statistical significance. However, major bleeds were significantly more often reported in severe hemophilia 5.5% (43 of 786) than in moderate
Table 2. Major bleed and intracranial hemorrhage (ICH) in term or preterm delivery in the first 28 days.
Table 1. Basic characteristics of study group. Type and severity of hemophilia
Moderate hemophilia A Severe hemophilia A Moderate hemophilia B Severe hemophilia B
Family history of hemophilia
No known family history Known family history
No data on family history
Mode of delivery Vaginal delivery Cesarean section
Gestational age
Born term
Born preterm
No data term/preterm
Total
n(%)
110 (11.9) 693 (74.8) 30 (3.2) 93 (10.0)
445 (48.1) 466 (50.3) 15 (1.6)
633 (68.4) 293 (31.6)
787 (85.0) 62 (6.7) 77 (8.3) 926
Term
Preterm
Missing data term/preterm Total
All Major bleed n (%)
787 41 (5.2)
62 3 (6.4) 77 0 (0)
926 44
ICH n (%)
20(2.5)
0 (0) 0 (0) 20
Table 3. Intracranial hemorrhage (ICH) and major bleeds and mode of delivery.
All ICH Major bleeds n n(%) n(%)
Vaginal delivery without 541
instruments
Vaginal instrumental 68
Cesarean prior to labor 125
Cesarean during labor 79
No detailed information on MOD 113
Total 926
8 (1.5)
7 (10.2) 2 (1.6) 2 (2.5) 1 (0.8) 20
14 (2.6)
13 (19.1) 5 (4.0) 7 (8.9) 5 (4.4) 44
MOD: mode of delivery.
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haematologica | 2019; 104(10)