Eur J Pediatr (1998) 157: 663±665

Ó Springer-Verlag 1998

NEONATOLOGY

P. Renzulli á P. Tuchschmid á G. Eich á S. Fanconi á M. G. SchwoÈbel

Early vitamin K de®ciency bleeding after maternal
phenobarbital intake: management of massive
intracranial haemorrhage by minimal surgical
intervention
Received: 4 July 1997 and in revised form: 30 October 1997 / Accepted: 7 November 1997

Abstract Vitamin K de®ciency bleeding within the ®rst 24 h of life is caused in most cases
by maternal drug intake (e.g. coumarins, anticonvulsants, tuberculostatics) during
pregnancy. Haemorrhage is often life-threatening and usually not prevented by vitamin K
prophylaxis at birth. We report a case of severe intracranial bleeding at birth secondary to
phenobarbital-induced vitamin K de®ciency and traumatic delivery. Burr hole trepanations of the skull were performed and the subdural haematoma was evacuated. Despite
the severe prognosis, the infant showed an unexpected good recovery. At the age of 3
years, neurological examinations were normal as was the EEG at the age of 9 months. CT
showed close to normal intracranial structures.
Conclusion This case report stresses the importance of antenatal vitamin K prophylaxis
and the consideration of a primary Caesarean section in maternal vitamin K de®ciency
states and demonstrates the successful management of massive subdural haemorrhage
by a limited surgical approach.
Key Words Vitamin K de®ciency bleeding á Phenobarbital á Cerebral haemorrhage á
Surgery
Abbreviation VKDB vitamin K de®ciency bleeding
Introduction

Maternal phenobarbital intake during pregnancy causes
liver enzyme induction in the fetus which increases the
catabolism of vitamin K and results in vitamin K de®ciency related coagulation disorders. The following case
report describes the surgical management and the clinical outcome of a neonate with early vitamin K de®ciency
bleeding (VKDB) and stresses the necessity of antenatal

M. G. SchwoÈbel (&)
Department of Surgery, University Children's Hospital,
Steinwiesstrasse 75,
CH-8032 ZuÈrich, Switzerland,
Tel.: 0041/1/266 71 11, Fax.: 0041/1/266 71 71
G. Eich
Department of Paediatric Radiology,
University Children's Hospital, Zurich, Switzerland

vitamin K prophylaxis and the consideration of a Caesarean section in maternal vitamin K de®ciency states.

Case report
A female newborn (3330 g) was delivered by vacuum extraction
after 42 1/7 weeks of gestation to a 39-year-old mother (gravida I,
para I) in a regional hospital. The mother was treated for generalized epilepsy with phenobarbital 100 mg daily. This medication

S. Fanconi
Department of Paediatrics, Intensive Care Unit,
University Children's Hospital, Zurich, Switzerland
P. Renzulli
Department of Paediatric Surgery,
University Children's Hospital, Zurich, Switzerland
P. Tuchschmid
Department of Paediatrics, Section of Paediatric Haematology,
University Children's Hospital, Zurich, Switzerland

664
Fig. 1 Unenhanced CT scan of
the head at initial presentation:
note extensive left hemispheric
subdural haemorrhage extending along the tentorium and
into the posterior fossa. Midline
structures are deviated to the
right and herniation of the left
medial temporal lobe towards
the brainstem is seen (arrow)
Fig. 2 Unenhanced CT scan of
the head at the age of 3 months:
there is mild atrophy of the left
temporal and occipital lobes
with widening of the extracerebral cerebrospinal ¯uid spaces

was continued unchanged during pregnancy. No antenatal vitamin
K prophylaxis was given and no clotting studies were performed
during pregnancy. Apgar score was 8/9/9 and a cleft lip was found.
Oral vitamin K (2 mg) was given within 1 h after birth. After 20 h,
the infant became increasingly pale and showed a decreased muscle
tone. It was transferred to our neonatal Intensive Care Unit 28 h
after birth. Coagulation data at that time were as follows (normal
values): prothrombin time 16% (>60%), partial thromboplastin
time 50 s (<42 s), ®brinogen 2.1 g/l (>1.5 g/l), no ®brinogen split
products were detected. Fresh frozen plasma (65 ml) and 1 mg
vitamin K (Konakion) were given intravenously. Despite a rapid
normalisation of prothrombin and partial thromboplastin times,
respiratory arrest necessitated emergency endotracheal intubation
and assisted ventilation. Cranial ultrasound and CT disclosed a
large left hemispheric subdural haematoma. There was a considerable mass e€ect with midline shift to the right and evidence for
transtentorial herniation of the left medial temporal lobe (Fig. 1).
A burr hole trepanation was performed in the left parieto-occipital
region, approx. 20 ml of haematoma were evacuated and an intracranial pressure probe implanted. The intracranial pressure fell
initially from 25 mmHg to 15 mmHg and remained at this level for
the next 12 h. Therefore, the CT scan was repeated and showed a
residual subdural haematoma in the occipital region. A second burr
hole trepanation was performed and the residual haematoma was
evacuated. Postoperatively, the intracranial pressure remained below 15 mmHg and extubation took place 8 days later. The infant
was mainly breast-fed and the clotting analysis remained normal
without additional vitamin K supplementation. CT scan examination at the age of 3 months showed no residual haemorrhage but
mild atrophy of the left temporal and occipital lobes (Fig. 2). EEG
at the age of 9 months was completely normal as was an expert
neurological examination at the age of 3 years.

Discussion

Early VKDB occurs within the ®rst 24 h of life and often
presents with acute life-threatening intracranial bleeding. A history of maternal drug intake during pregnancy

interacting with vitamin K (e.g. coumarins, tuberculostatics, anticonvulsants) is disclosed in almost all cases.
Fatal neonatal haemorrhage secondary to anticonvulsant drug treatment of the mother was ®rst described
more than 20 years ago [2]. Subsequently, a range of
di€erent measures have been proposed to prevent early
VKDB. A Caesarean section should always be considered if a traumatic delivery is anticipated [4]. An oral
dose of 20 mg vitamin K taken by the mother during the
last 1±2 weeks of pregnancy [3] has been proposed and
proven e€ective [5] in the prevention of early VKDB.
Immediate parenteral vitamin K administration at birth
as well as blood sampling for clotting studies should
further be performed. Fully breast-fed infants of mothers under anticonvulsive treatment should receive 1 mg
vitamin K orally once a week or regular clotting studies [7].
A conventional operation was rejected due to the
child's instable condition. Therefore, a limited surgical
approach was chosen, the haematoma was evacuated by
needle aspiration via a burr hole trepanation and an
epidural transducer was implanted. The burr hole technique is a well known therapy in adults for non-acute
subdural haematoma [1]. Recently, needle aspiration
was used in four infants su€ering from acute subdural
haematoma with good results [6]. The technique helps to
avoid intracerebral haemorrhage after rapid evacuation
of the haematoma [8]. The epidural probe allows the
monitoring of intracranial pressure during the treatment
in the ICU. Given the massive intracranial haematoma,
the initial prognosis of the infant was extremely poor.
Our treatment with staged evacuation of the acute haematoma by aspiration was successful and the infant
recovered completely without sequelae at 3.5 years of age.

665

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