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Stefan Avenarius, MD; Kathrin Föhe, MD; Hubertus Schultz, MD; Eberhard Canzler, MD; Beverly P. Wood, MD
From the Department of Neonatal and Pediatric Intensive Care, Center for Pediatrics, Medical Faculty of Otto-von-Guericke-University (Drs Avenarius and Föhe), Walter-Friedrich-Hospital (Drs Schultz and Canzler), Magdeburg, Germany; and the Department of Radiology, University of Southern California School of Medicine, Los Angeles (Dr Wood).

Arch Pediatr Adolesc Med. 1999;153:1103-1104.

DURING A ROBBERY a 19-year-old woman in her 29th week of pregnancy was stabbed in the lower abdomen. Two hours later, an emergency cesarean delivery was performed. Blood was present in the amniotic fluid. The Apgar scores were 2/5/6 at 1, 5, and 10 minutes, respectively. Above the right ear was a 2-cm-long bleeding wound. The neonate had stable respiratory and hemodynamic functions. The cerebral sonogram showed an extensive intracerebral hemorrhage in the region of the right thalamus and temporal lobe with a visible 5- to 6-cm-long incision channel (Figure 1) stretching about 1 cm beyond the midline. A large, right-sided subdural hematoma near the laceration site and intraventricular bleeding had occurred.

Figure 1.

A cranial computed tomographic scan confirmed the incision channel and fresh bleeding (Figure 2). Surgical evacuation of a subdural hematoma was undertaken. Serial cranial sonography revealed right hydrocephalus and absence of the right thalamus and a small right choroid plexus, apparently excised by the knife (Figure 3). After age 6 months, left spastic hemiparesis, an abducted position of the left leg, and external rotation of the left hand developed.

Figure 2.

Figure 3.

Denouement and Discussion: Intrauterine Stab Wound to the Head of a 29-Week Fetus

Figure 1. Cranial sonographic scan on day 1 of life. The coronary section reveals a right intracerebral hemorrhage with a clearly visible incision channel (about 5-6 cm) stretching as far as 1 cm beyond the falx cerebri and a subdural hematoma on the right.

Figure 2. Cranial sonographic scan on day 55 of life. The sagittal section shows the right choroid plexus nearly completely cut off by the knife.

Figure 3. Cranial computed tomographic scan on day 1 of life. Hyperdensity is seen in the bleeding zone, with the incision channel from the right and a subdural hematoma.

To our knowledge, this is the first case of infant survival after an intrauterine stab injury. After cesarean delivery, aggressive management prevented severe asphyxia. An intraventricular hemorrhage resulted from the penetrating injury; compression of the hematoma may have prevented secondary damage.

Intrauterine gunshot wounds reported by Buchsbaum and coworkers^1-4 and Edner et al⁵ did not result in extensive intracranial hemorrhage. Martin and Gussack⁶ reported on penetrating craniocerebral injuries with ventricular system involvement. All infants consequently showed neurologic defects. Hiebsch et al⁷ found a poor prognosis in infants with intraventricular hemorrhage.

In our patient the first neurologic deficit was noted at 8 months as a slowly increasing contralateral hemiparesis and hemihypsarrhythmia observed on electroencephalogram (without clinical convulsions).

This case demonstrates (1) how an intrauterine intracranial injury in a premature neonate at 29 weeks' gestation can be cared for through intensive neonatal treatment and (2) the importance of performing cranial sonography in the follow-up of neurologic defects in infancy. Sonography is the imaging modality of choice in infants with injuries or diseases of the central nervous system as it determines localization, size, and change in the process and improves early recognition and therapy for complications such as subdural hematoma and hydrocephalus.

AUTHOR INFORMATION
Accepted for publication April 20, 1998.

Corresponding author: Beverly P. Wood, MD, KAM 211, University of Southern California School of Medicine, 1975 Zonal Ave, Los Angeles, CA 90033.

REFERENCES
1. Buchsbaum HJ. Accidental injury complicating pregnancy. Am J Obstet Gynecol. 1968;102:752-769. PUBMED 2. Buchsbaum HJ, Caruso PA. Gunshot wound of the pregnant uterus. Obstet Gynecol. 1969;33:673-676. FREE FULL TEXT 3. Buchsbaum HJ. Diagnosis and management of abdominal gunshot wounds during pregnancy. J Trauma. 1975;15:425-430. ISI | PUBMED 4. Iliya FA, Haji SN, Buchsbaum HJ. Gunshot wound of the pregnant uterus: report of two cases. J Trauma. 1980;20:90-92. ISI | PUBMED 5. Edner G, Erasmie U, Gentz J, Lundell B, Schiller B. Intrauterine cranial gunshot wound in a 32-week fetus. J Trauma. 1988;28:1605-1606. PUBMED 6. Martin WS, Gussack GS. Pediatric penetrating head and neck trauma. Laryngoscope. 1990;100:1288-1291. PUBMED 7. Hiebsch W, Geissler W, Haltrich E, Konzag I, Thiemann HH. Zur Früh- und Spätprognose der Hirnblutungen beim Neugeborenen. Z Klin Med. 1991;46:1643-1645.

SECTION EDITOR: BEVERLY P. WOOD, MD