Fetal Subdural Hematoma –? Aspirin induced or Idiopathic – A case report

Fetal Subdural Hematoma –? Aspirin induced or Idiopathic – A case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Fetal Subdural Hematoma –? Aspirin induced or Idiopathic – A case report Shruti Thakur, Charu Smita Thakur, Abhinash Sharma, Sushma Makhaik This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5013088/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Dec, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 4 You are reading this latest preprint version Abstract Background Fetal intracranial haemorrhage (ICH) is a rare antenatal complication that increases perinatal morbidity and mortality and may cause neurodevelopmental delay in surviving babies. Even though the majority of cases are idiopathic, there are many maternal and fetal factors predisposing to ICH. Low dose aspirin has a proven efficacy in secondary preeclampsia, however, with a daily dosage of > 100mg, its safety is not well established and sporadic cases of fetal hemorrhagic complications have been reported. As fetal ICH has prognostic implications for the current and potentially for future pregnancies, in utero diagnosis is of utmost importance. Case Presentation A 34- year- old primigravida was diagnosed with fetal subdural hematoma (SDH) on her routine third trimester ultrasound (USG). There were no predisposing factors except that the patient was on low dose aspirin from 12 th week of gestation. On serial USG, the SDH reduced in size. She delivered a healthy baby who was followed till 6 months of age and showed normal neurodevelopment. Conclusions As the number of reported cases of fetal ICH are limited with even rarer SDH, meaningful etiological and prognostic criteria cannot be inferred and parental counseling is challenging. fetal subdural hematoma ultrasound magnetic resonance imaging aspirin idiopathic perinatal mortality neurodevelopmental delay Figures Figure 1 Figure 2 Background Fetal subdural hematoma (SDH) is an unusual antenatal complication with an uncertain reported incidence of 1 in 1000 to 1 in 100,000 pregnancies [ 1 , 2 , 3 ]. It not only has an adverse effect on perinatal outcome causing preterm births, growth restriction, stillbirths and neonatal deaths but also may cause long term neurological sequalae [ 2 , 3 , 4 ]. Most of the cases have no obvious cause or predisposing factor for SDH. Here we present a case of fetal SDH diagnosed during the third trimester in which no maternal or fetal risk factors could be identified except that the mother was on low dose aspirin (150 mg/ day) from 12th week of gestation onwards. Case Presentation A 34- year- old primigravida was a booked case and had her regular antenatal checkups. She had no significant personal history. As for her family history, her mother was hypertensive so she was taken as a moderate-risk case for pre-eclampsia and was started on low dose aspirin (150mg/day) from 12th week of gestation onwards. All her routine blood investigations were unremarkable. Her first trimester and second trimester ultrasound scans were normal. The third ultrasound scan done at 32nd week of gestation showed normal fetal biometry and Doppler imaging with a normal peak systolic velocity (PSV) of middle cerebral artery (MCA). However, the third trimester ultrasound also showed a left sided subdural hematoma/ collection along frontoparietal region measuring 8 mm in maximum thickness and 6.7 cm in anteroposterior dimension (Fig. 1 ). Fetal magnetic resonance imaging (MRI) was further done that revealed subdural hematoma along left frontoparietal lobe which was hypointense on T1 weighted images and heterogeneously hyperintense on T2 weighted images with blooming on inner border of collection seen on SWI signifying hemosiderin deposition. There was no significant midline shift of the cerebrum (Fig. 2 ). The mother was then extensively worked up for eliciting any possible cause of fetal SDH that included tests for TORCH (toxoplasmosis, rubella, cytomegalovirus, herpes), parvovirus 19 infections, platelet count, prothrombin time, partial thromboplastin time, assays for isoimmune and alloimmune thrombocytopenia, plasminogen, von Willebrand factor, factor V Leiden, anticoagulant protein S and activated protein C, all of which were normal. Also, there was no history of maternal trauma or any illicit drug abuse. After taking neonatologist and pediatric neurologist consultation, the couple decided to continue the pregnancy. The maternal aspirin was stopped at this gestational age for the fear of deteriorating intracranial bleed in the fetus. The fetus was followed by serial ultrasounds every 2 weeks that showed progressively reducing SDH and at 38 weeks of gestation, the hematoma measured 5mm in thickness. The PSV of MCA was within normal limits during each scan ruling out fetal anemia. The mother underwent a normal full term vaginal delivery and gave birth to a baby boy with a birth weight of 3.3 Kg. All the relevant neonatal blood investigations including the coagulation profile were normal. The neonate underwent neurosonography at 2 weeks of age that showed complete resolution of the subdural hematoma. He was followed till 6 months of age for neurodevelopment which was normal. The genetic analysis could not be done as the infant was gaining developmental milestones normally and neither the treating pediatric neurologist nor the parents felt any need for this test. So, a definitive cause of SDH in this case could not be ascertained. The majority of fetal SDH are idiopathic but there are a few sporadic cases of aspirin induced fetal intracranial hemorrhage (ICH) especially when the daily dosage is more than 100mg [ 5 ] as was also seen in our case. Although, the etiology of fetal SDH in our case was not clear but the silver lining is that the infant is having a normal neurodevelopment till now. Discussion Fetal intracranial haemorrhage (ICH) is a rare antenatal complication that increases perinatal morbidity and mortality and may cause neurodevelopmental delay in surviving babies [ 2 , 4 ]. Fetal ICH may be intraaxial or extraaxial and can be subdivided into five types- intraventricular haemorrhage (IVH), cerebellar haemorrhage, subdural hematoma (SDH), subarachnoid haemorrhage (SAH) and intraparenchymal haemorrhage [ 1 ]. Out of these, IVH is the most common type. The prognostic outcome is related to the severity of the bleeding and associated brain injury with a grave prognosis seen in higher grades of IVH [ 2 , 3 , 6 ]. SDH in asymptomatic neonates have a peculiar distribution along occipital lobes, tentorium cerebelli and posterior fossa [ 7 ]. Better prognosis is seen in SDH when the underlying etiology is identifiable [ 4 ]. But unfortunately, the majority of cases are idiopathic [ 8 ]. The two most common risk factors for fetal ICH are maternal trauma and fetal coagulopathy [ 3 ]. However, there is a long list of predisposing factors that may be responsible for fetal ICH. The maternal factors include trauma, advanced maternal age, hypertension, preeclampsia or eclampsia, coagulopathy, alloimmune thrombocytopenia, seizures, viral or bacterial infection (TORCH, parvovirus B -19 etc.), amniocentesis, medications (warfarin or cholestyramine) and illicit drugs (cocaine2). The fetal factors responsible for ICH are congenital coagulopathy with factor V and factor X deficiency, haemorrhage into a congenital tumour, twin–twin transfusion syndrome, demise of a co-twin, and alterations in maternal or fetal blood pressure [ 1 , 2 , 6 , 8 ]. Apart from these, genetic factors like disruption in COL4A1, COL4A2, F11, F7, FGA, VWF, GP1BA, JAM3 and X-linked GATA1 genes have also been implicated [ 1 ]. The exact pathophysiology of fetal ICH is not clear. It is postulated that IVH in preterm infants may be because of hypoperfusion–reperfusion cycle. Around 80% of upper body blood flow goes to the brain, so when superior vena cava flow is low, the cerebral blood flow may also be low causing ischemic insult especially to germinal matrix which is the watershed area and vulnerable. So, this early low cerebral flow may be a predisposing factor for IVH [ 8 ]. There is a reported increased rate of left-side hemispheric involvement as was also seen in our case. This may be due to an inherent susceptibility of the blood vessels in the left hemisphere to rupture or to a better right carotid blood supply in fetal hypotensive situations [ 8 ]. The fetal ICH cases are mostly identified during the third trimester, again also seen in our case. The plausible explanation for this may be that there is a high brain to fluid ratio in fetus resulting in increased mobility of the fetal brain. As the pregnancy advances, the fetal head gets nearer to uterine wall and maternal abdomen and by apparently minor direct trauma to the maternal abdomen, the chances of tearing of cerebral bridging veins rises, leading to SDH [ 2 , 4 ]. As the routine third trimester ultrasound scan in not done in many countries in the absence of risk factors, the number of fetal ICH cases may be underestimated. Obstetric ultrasound can diagnose fetal ICH given various sonographic features such as loss of normal cerebral landmarks, intracranial echogenicity, lateral ventriculomegaly, avascular intracranial mass, hyperechoic acute clot adherent to nodular choroid plexus, hyperechoic clot outlining cerebral cortex, hyperechoic nodular ependyma, increased periventricular white matter echogenicity, porencephaly, hydranencephaly, macrocephaly, midline deviation of cerebral falx, and intracranial fluid collection [ 4 , 6 ]. Echogenic bowel, hydrops fetalis and Doppler parameters like reversed diastolic flow in the MCA and elevated PSV of MCA which are indicative of fetal anaemia may also be seen, albeit in lesser number of cases [ 4 ]. Acute SDH is seen as echogenic collection in the intracranial subdural region while chronic SDH looks like cerebrospinal fluid only. If the SDH is showing mixed echogenicity, it is either in the transitional phase or there is acute bleeding in chronic hemorrhage [ 4 ]. Ultrasound has a low sensitivity in diagnosis of fetal ICH particularly in late gestation when it is most likely to occur. The factors like maternal obesity, overlapping fetal parts, challenging fetal position, ossified skull and multiple pregnancies may further hinder sonographic information. Fetal MRI can overcome all these sonographic limitations and can act as a problem-solving imaging modality [ 6 ]. So, in case the sonographic findings are suspicious for ICH, fetal MRI should be considered for confirmation of the diagnosis and to age hemorrhage. A complete genetic analysis including whole exome sequencing may be required to elucidate a genetic cause of fetal ICH that may be important for parental counselling so that at risk future pregnancies may be foreseen [ 1 ]. Aspirin with its first obstetric usage in 1985 [ 5 , 9 ], is being extensively prescribed worldwide in pregnant females having high risk of developing preeclampsia. Preeclampsia is defined as hypertension and proteinuria diagnosed after 20 weeks of gestation [ 5 ]. The pregnant women with pre-eclampsia have escalated platelet activation as indicated by shortened APTT and hypercoagulable state. Aspirin is a cyclooxygenase inhibitor and reduces the thromboxane A2 (TXA2) to prostacyclin (PGI2) ratio. TXA2 is a vasoconstrictor, promotes platelet aggregation and causes thrombus formation. While PGI2 has a reciprocal effect, it is a vasodilator and the most effective endogenous inhibitor of platelet aggregation. Aspirin is considered low dose if taken less than 300mg/day [ 10 ]. Low dose aspirin (LDA) selectively inhibits the secretion of TXA2 and does not change the secretion of PGI2 by endothelial cells with an overall effect of dilatation of blood vessels and lowering blood pressure. Moreover, it also prevents platelet aggregation thereby inhibiting formation of small thrombi thus preventing pre-eclampsia [ 5 , 9 ]. The guidelines for screening modalities, target population, gestational period and dosage of aspirin administration for preeclampsia varies considerably from country to country. The general recommended daily dosage is between 80 -150mg. The efficacy of aspirin increases with the increasing dose. However, the safety with a daily dosage of > 100mg is not well established [ 5 , 9 ]. According to the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal – Fetal Medicine (SMFM) guidelines 2018, prophylactic aspirin should be started at 81 mg/ day between 12 to 28 weeks, preferably before 16 weeks of gestation till delivery [ 11 ]. But some studies advocate the treatment to be initiated at 8–16weeks’ gestation to reduce the risk of the severe and preterm forms of preeclampsia and risk of fetal growth restriction (FGR), preterm birth and perinatal death as well. This metanalysis also concluded that aspirin was best avoided in the last month of pregnancy and should be stopped at 36 weeks of gestation to prevent fetal ICH, although the chances are rare if dosage is below 100mg/day [ 10 ]. The indications to start LDA are presence of one high risk factor or presence of two or more moderate risk factors for preeclampsia in the pregnant female. LDA has a proven efficacy and unquestionable benefit in reducing cases of secondary eclampsia [ 5 , 9 , 11 ]. However, as far as the still births, FGR, preterm births and early pregnancy loss are concerned, it has conflicting results [ 11 ]. LDA is not usually associated with increased risk of haemorrhagic complication, placental abruption, post-partum haemorrhage, congenital anomalies, early ductal closure with persistent pulmonary hypertension or fetal ICH. But a few studies have shown increased incidence of gastroschisis [ 11 ]. The teratogenic effect of aspirin in the form of cardiopathies and limb anomalies are seen only at a high dose of 650 to 2600mg per day [ 5 ]. Rare cases of high fetal bleeding tendencies have also been reported as the aspirin crosses placental barrier and hinders fetal platelet aggregation [ 5 , 9 ]. The inhibition of platelet thromboxane A2 formation has been observed in the neonates of women taking 100 mg of aspirin daily [ 10 ]. The reported maternal side effect of aspirin is mainly gastrointestinal discomfort seen in 10% of cases [ 5 ]. A detailed history, blood tests and genetic analysis are vital to elucidate the underlying cause of ICH. The pregnant woman should be cautioned about the dilemma in predicting perinatal outcomes based on ultrasonographic findings alone. Termination of pregnancy is an option in view of the potential significant neurological deficit. If she chooses to continue the pregnancy, serial sonography is required to follow the size of SDH and monitor the PSV of MCA. There are no specific guidelines for the mode of delivery; whether vaginal or by caesarean section which has to be individualized. Blood tests are required in neonatal period to rule out anaemia and coagulopathy [ 4 ]. The risk with regards to potential fetal haemorrhagic complications is low with LDA, but cases of such adverse effects may rise in number with inadvertent and widespread use of aspirin in pregnancy. With the broadening of indications, there is routine and extensive prescription of LDA. Hence, patient selection should be optimized for a favorable benefit to risk ratio and the needless exposure of pregnant females to aspirin should be avoided. However, due to rarity of fetal ICH, multicentred, large scale studies are required to collect high quality data to reach a robust conclusion. Conclusions Fetal SDH is a complication rarely encountered during antenatal sonography and the diagnosis is complemented by fetal MRI. Recognition of etiology is crucial as there may a possibility of recurrence in future pregnancies in conditions such as alloimmune thrombocytopenia or if genetic cause is identified. This case highlights the importance of a meticulous antenatal sonographic examination and to judiciously follow standard guidelines for drug usage. Whenever fetal ICH is diagnosed, parental counseling and discussion with pediatric neurologist and neonatologist is required for individualized case management. Abbreviations ICH Fetal Intracranial Haemorrhage SDH Subdural Hematoma USG Ultrasound PSV Peak Systolic Velocity MCA Middle Cerebral Artery MRI Magnetic Resonance Imaging TORCH Toxoplasmosis, Rubella, Cytomegalovirus, Herpes IVH Intraventricular Haemorrhage SAH Subarachnoid Haemorrhage LDA Low Dose Aspirin ACOG American College of Obstetricians and Gynecologists SMFM Society for Maternal-Fetal Medicine FGR Fetal Growth Restriction Declarations Ethics approval and consent to participate – Ethical approval was waived off as the index case was de-identified. An informed consent was taken from the parents. Consent for publication – Yes. Availability of data and material – Available in PACS of the institution. Competing interests - The authors declare that they have no competing interests. Funding - NONE Authors' contributions Study concept and design: S T Data acquisition: C T Data analysis: ST Drafting of manuscript: S T, A S Critical revision of the manuscript: S M Acknowledgements - Nil References Xu M, Jin P, Huang Y, Qian Y, Lin M, Zuo J, Zhu J, Li Z and Dong M (2022), Case report: Prenatal diagnosis of fetal intracranial hemorrhage due to compound mutations in the JAM3 gene. Front. Genet. 13:1036231. doi: 10.3389/fgene.2022.1036231 Sileo FG, Zöllner J, D'Antonio F, Islam S, Papageorghiou AT, Khalil A. Perinatal and long‐term outcome of fetal intracranial hemorrhage: systematic review and meta‐analysis. Ultrasound in Obstetrics & Gynecology. 2022 May;59(5):585-95. Gao B, Zhang L, Wei Q. An unexplained fetal intracranial hemorrhage with extensive and multifocal hemorrhagic lesions: A case report. Medicine. 2022 Jun 24;101(25): e29335. Cheung KW, Tan LN, Seto MT, Moholkar S, Masson G, Kilby MD. Prenatal diagnosis, management, and outcome of fetal subdural haematoma: a case report and systematic review. Fetal Diagnosis and Therapy. 2019 Nov 13;46(5):285-95. Atallah A, Lecarpentier E, Goffinet F, Doret-Dion M, Gaucherand P, Tsatsaris V. Aspirin for prevention of preeclampsia. Drugs. 2017 Nov; 77:1819-31. Putbrese B, Kennedy A. Findings and differential diagnosis of fetal intracranial haemorrhage and fetal ischaemic brain injury: what is the role of fetal MRI? The British journal of radiology. 2017 Feb 1;90(1070):20160253. Zamora C, Sams C, Cornea EA, Yuan Z, Smith JK, Gilmore JH. Subdural hemorrhage in asymptomatic neonates: Neurodevelopmental outcomes and MRI findings at 2 years. Radiology. 2021 Jan;298(1):173-9. Elchalal U, Yagel S, Gomori JM, Porat S, Beni‐Adani L, Yanai N, Nadjari M. Fetal intracranial hemorrhage (fetal stroke): does grade matter? Ultrasound in Obstetrics and Gynecology: The Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology. 2005 Sep;26(3):233-43. Ren Y, Zhao Y, Yang X, Shen C, Luo H. Application of low dose aspirin in pre-eclampsia. Frontiers in Medicine. 2023 Mar 8; 10:1111371. Bujold E, Roberge S, Nicolaides KH. Low‐dose aspirin for prevention of adverse outcomes related to abnormal placentation. Prenatal diagnosis. 2014 Jul;34(7):642-8. ACOG committee opinion. Low dose aspirin during pregnancy. E44 vol 132, no 1, July 2018 obstetrics and gynaecology. Additional Declarations No competing interests reported. Supplementary Files CAREchecklist2013SDH2.docx Cite Share Download PDF Status: Published Journal Publication published 30 Dec, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 05 Sep, 2024 Editor assigned by journal 04 Sep, 2024 Submission checks completed at journal 04 Sep, 2024 First submitted to journal 01 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5013088","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":349844263,"identity":"b5116420-42ce-47f9-9c99-a5dc7c25888c","order_by":0,"name":"Shruti Thakur","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYFACHhAhIWd/vPkAA2MDkM1MUANIS4KEMcOZYwkkaWFIbLiRYwDRQgjY85899pn3h4UxY8+ZbxI/d9jIMbDzHsBvi0Re8myeBAk5ZvbebZK9Z9KMGZj5Egho4TFmBmoxZuM5u02Ct+1wYgMzjwF+LfxnwFoSeyRynkn+JUoLQw5EywyJHDZp4my5kWPMOCdNwtiA55ixtWxbmjEbIS3s/WeMGd7Y1MkZsDc/vPm2zUaOn/8Mfi3IgEUCRLIRrR4ImD+QonoUjIJRMApGDgAAYxk6pKGtn8AAAAAASUVORK5CYII=","orcid":"","institution":"Indira Gandhi Government Medical College \u0026 Hospital","correspondingAuthor":true,"prefix":"","firstName":"Shruti","middleName":"","lastName":"Thakur","suffix":""},{"id":349844264,"identity":"dca1db36-23a6-41a8-b375-350a079ad05e","order_by":1,"name":"Charu Smita Thakur","email":"","orcid":"","institution":"Indira Gandhi Government Medical College \u0026 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Charu","middleName":"Smita","lastName":"Thakur","suffix":""},{"id":349844265,"identity":"8ee169cd-a098-49f1-bd88-448f995ca84e","order_by":2,"name":"Abhinash Sharma","email":"","orcid":"","institution":"Indira Gandhi Government Medical College \u0026 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Abhinash","middleName":"","lastName":"Sharma","suffix":""},{"id":349844266,"identity":"ca194000-37d0-49f5-bde1-f7f81b801a5b","order_by":3,"name":"Sushma Makhaik","email":"","orcid":"","institution":"Indira Gandhi Government Medical College \u0026 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sushma","middleName":"","lastName":"Makhaik","suffix":""}],"badges":[],"createdAt":"2024-09-01 13:23:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5013088/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5013088/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-025-08469-0","type":"published","date":"2025-12-30T15:57:54+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":67111186,"identity":"893b128a-2802-4cc9-888a-3f758392513c","added_by":"auto","created_at":"2024-10-21 09:42:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":90974,"visible":true,"origin":"","legend":"\u003cp\u003eA 34- year- old primigravida at 32 weeks of gestation. Ultrasound axial image of fetal brain shows a subdural collection (arrow) along far cranium with no significant midline shift.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5013088/v1/f3c8d25eed113eda5e844405.png"},{"id":67111188,"identity":"1e46474d-1652-4699-b3cc-b74fe85b76b2","added_by":"auto","created_at":"2024-10-21 09:42:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":147681,"visible":true,"origin":"","legend":"\u003cp\u003eFetal brain MRI done at 32 weeks of gestation shows a chronic subdural hematoma (arrow) which is heterogeneously hyperintense on T2 WI coronal (a) and axial image (b) and hypointense of T1 WI (c) and showing hypointense blooming (arrowhead) suggestive of hemosiderin deposition along inner border on SWI (d).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5013088/v1/551c9c2305e5d0aceea0c7f2.png"},{"id":99545626,"identity":"b80b7228-541b-4b3b-8f69-280db681ebe8","added_by":"auto","created_at":"2026-01-05 16:09:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":712948,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5013088/v1/8f45dde7-a6ce-44fb-918a-9a0fa935a8d7.pdf"},{"id":67111189,"identity":"451c9c49-67ca-47b3-b723-033b8186d605","added_by":"auto","created_at":"2024-10-21 09:42:19","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":145911,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklist2013SDH2.docx","url":"https://assets-eu.researchsquare.com/files/rs-5013088/v1/4fb4dc0b43f41911ef81c27c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Fetal Subdural Hematoma –? Aspirin induced or Idiopathic – A case report","fulltext":[{"header":"Background","content":"\u003cp\u003eFetal subdural hematoma (SDH) is an unusual antenatal complication with an uncertain reported incidence of 1 in 1000 to 1 in 100,000 pregnancies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It not only has an adverse effect on perinatal outcome causing preterm births, growth restriction, stillbirths and neonatal deaths but also may cause long term neurological sequalae [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Most of the cases have no obvious cause or predisposing factor for SDH. Here we present a case of fetal SDH diagnosed during the third trimester in which no maternal or fetal risk factors could be identified except that the mother was on low dose aspirin (150 mg/ day) from 12th week of gestation onwards.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 34- year- old primigravida was a booked case and had her regular antenatal checkups. She had no significant personal history. As for her family history, her mother was hypertensive so she was taken as a moderate-risk case for pre-eclampsia and was started on low dose aspirin (150mg/day) from 12th week of gestation onwards. All her routine blood investigations were unremarkable. Her first trimester and second trimester ultrasound scans were normal. The third ultrasound scan done at 32nd week of gestation showed normal fetal biometry and Doppler imaging with a normal peak systolic velocity (PSV) of middle cerebral artery (MCA). However, the third trimester ultrasound also showed a left sided subdural hematoma/ collection along frontoparietal region measuring 8 mm in maximum thickness and 6.7 cm in anteroposterior dimension (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Fetal magnetic resonance imaging (MRI) was further done that revealed subdural hematoma along left frontoparietal lobe which was hypointense on T1 weighted images and heterogeneously hyperintense on T2 weighted images with blooming on inner border of collection seen on SWI signifying hemosiderin deposition. There was no significant midline shift of the cerebrum (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The mother was then extensively worked up for eliciting any possible cause of fetal SDH that included tests for TORCH (toxoplasmosis, rubella, cytomegalovirus, herpes), parvovirus 19 infections, platelet count, prothrombin time, partial thromboplastin time, assays for isoimmune and alloimmune thrombocytopenia, plasminogen, von Willebrand factor, factor V Leiden, anticoagulant protein S and activated protein C, all of which were normal. Also, there was no history of maternal trauma or any illicit drug abuse. After taking neonatologist and pediatric neurologist consultation, the couple decided to continue the pregnancy. The maternal aspirin was stopped at this gestational age for the fear of deteriorating intracranial bleed in the fetus. The fetus was followed by serial ultrasounds every 2 weeks that showed progressively reducing SDH and at 38 weeks of gestation, the hematoma measured 5mm in thickness. The PSV of MCA was within normal limits during each scan ruling out fetal anemia. The mother underwent a normal full term vaginal delivery and gave birth to a baby boy with a birth weight of 3.3 Kg. All the relevant neonatal blood investigations including the coagulation profile were normal. The neonate underwent neurosonography at 2 weeks of age that showed complete resolution of the subdural hematoma. He was followed till 6 months of age for neurodevelopment which was normal. The genetic analysis could not be done as the infant was gaining developmental milestones normally and neither the treating pediatric neurologist nor the parents felt any need for this test. So, a definitive cause of SDH in this case could not be ascertained. The majority of fetal SDH are idiopathic but there are a few sporadic cases of aspirin induced fetal intracranial hemorrhage (ICH) especially when the daily dosage is more than 100mg [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] as was also seen in our case. Although, the etiology of fetal SDH in our case was not clear but the silver lining is that the infant is having a normal neurodevelopment till now.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eFetal intracranial haemorrhage (ICH) is a rare antenatal complication that increases perinatal morbidity and mortality and may cause neurodevelopmental delay in surviving babies [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Fetal ICH may be intraaxial or extraaxial and can be subdivided into five types- intraventricular haemorrhage (IVH), cerebellar haemorrhage, subdural hematoma (SDH), subarachnoid haemorrhage (SAH) and intraparenchymal haemorrhage [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Out of these, IVH is the most common type. The prognostic outcome is related to the severity of the bleeding and associated brain injury with a grave prognosis seen in higher grades of IVH [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. SDH in asymptomatic neonates have a peculiar distribution along occipital lobes, tentorium cerebelli and posterior fossa [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Better prognosis is seen in SDH when the underlying etiology is identifiable [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. But unfortunately, the majority of cases are idiopathic [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The two most common risk factors for fetal ICH are maternal trauma and fetal coagulopathy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, there is a long list of predisposing factors that may be responsible for fetal ICH. The maternal factors include trauma, advanced maternal age, hypertension, preeclampsia or eclampsia, coagulopathy, alloimmune thrombocytopenia, seizures, viral or bacterial infection (TORCH, parvovirus B -19 etc.), amniocentesis, medications (warfarin or cholestyramine) and illicit drugs (cocaine2). The fetal factors responsible for ICH are congenital coagulopathy with factor V and factor X deficiency, haemorrhage into a congenital tumour, twin\u0026ndash;twin transfusion syndrome, demise of a co-twin, and alterations in maternal or fetal blood pressure [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Apart from these, genetic factors like disruption in COL4A1, COL4A2, F11, F7, FGA, VWF, GP1BA, JAM3 and X-linked GATA1 genes have also been implicated [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe exact pathophysiology of fetal ICH is not clear. It is postulated that IVH in preterm infants may be because of hypoperfusion\u0026ndash;reperfusion cycle. Around 80% of upper body blood flow goes to the brain, so when superior vena cava flow is low, the cerebral blood flow may also be low causing ischemic insult especially to germinal matrix which is the watershed area and vulnerable. So, this early low cerebral flow may be a predisposing factor for IVH [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere is a reported increased rate of left-side hemispheric involvement as was also seen in our case. This may be due to an inherent susceptibility of the blood vessels in the left hemisphere to rupture or to a better right carotid blood supply in fetal hypotensive situations [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The fetal ICH cases are mostly identified during the third trimester, again also seen in our case. The plausible explanation for this may be that there is a high brain to fluid ratio in fetus resulting in increased mobility of the fetal brain. As the pregnancy advances, the fetal head gets nearer to uterine wall and maternal abdomen and by apparently minor direct trauma to the maternal abdomen, the chances of tearing of cerebral bridging veins rises, leading to SDH [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. As the routine third trimester ultrasound scan in not done in many countries in the absence of risk factors, the number of fetal ICH cases may be underestimated.\u003c/p\u003e \u003cp\u003eObstetric ultrasound can diagnose fetal ICH given various sonographic features such as loss of normal cerebral landmarks, intracranial echogenicity, lateral ventriculomegaly, avascular intracranial mass, hyperechoic acute clot adherent to nodular choroid plexus, hyperechoic clot outlining cerebral cortex, hyperechoic nodular ependyma, increased periventricular white matter echogenicity, porencephaly, hydranencephaly, macrocephaly, midline deviation of cerebral falx, and intracranial fluid collection [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Echogenic bowel, hydrops fetalis and Doppler parameters like reversed diastolic flow in the MCA and elevated PSV of MCA which are indicative of fetal anaemia may also be seen, albeit in lesser number of cases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Acute SDH is seen as echogenic collection in the intracranial subdural region while chronic SDH looks like cerebrospinal fluid only. If the SDH is showing mixed echogenicity, it is either in the transitional phase or there is acute bleeding in chronic hemorrhage [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Ultrasound has a low sensitivity in diagnosis of fetal ICH particularly in late gestation when it is most likely to occur. The factors like maternal obesity, overlapping fetal parts, challenging fetal position, ossified skull and multiple pregnancies may further hinder sonographic information. Fetal MRI can overcome all these sonographic limitations and can act as a problem-solving imaging modality [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. So, in case the sonographic findings are suspicious for ICH, fetal MRI should be considered for confirmation of the diagnosis and to age hemorrhage. A complete genetic analysis including whole exome sequencing may be required to elucidate a genetic cause of fetal ICH that may be important for parental counselling so that at risk future pregnancies may be foreseen [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAspirin with its first obstetric usage in 1985 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], is being extensively prescribed worldwide in pregnant females having high risk of developing preeclampsia. Preeclampsia is defined as hypertension and proteinuria diagnosed after 20 weeks of gestation [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The pregnant women with pre-eclampsia have escalated platelet activation as indicated by shortened APTT and hypercoagulable state. Aspirin is a cyclooxygenase inhibitor and reduces the thromboxane A2 (TXA2) to prostacyclin (PGI2) ratio. TXA2 is a vasoconstrictor, promotes platelet aggregation and causes thrombus formation. While PGI2 has a reciprocal effect, it is a vasodilator and the most effective endogenous inhibitor of platelet aggregation. Aspirin is considered low dose if taken less than 300mg/day [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Low dose aspirin (LDA) selectively inhibits the secretion of TXA2 and does not change the secretion of PGI2 by endothelial cells with an overall effect of dilatation of blood vessels and lowering blood pressure. Moreover, it also prevents platelet aggregation thereby inhibiting formation of small thrombi thus preventing pre-eclampsia [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe guidelines for screening modalities, target population, gestational period and dosage of aspirin administration for preeclampsia varies considerably from country to country. The general recommended daily dosage is between 80 -150mg. The efficacy of aspirin increases with the increasing dose. However, the safety with a daily dosage of \u0026gt;\u0026thinsp;100mg is not well established [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. According to the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal \u0026ndash; Fetal Medicine (SMFM) guidelines 2018, prophylactic aspirin should be started at 81 mg/ day between 12 to 28 weeks, preferably before 16 weeks of gestation till delivery [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. But some studies advocate the treatment to be initiated at 8\u0026ndash;16weeks\u0026rsquo; gestation to reduce the risk of the severe and preterm forms of preeclampsia and risk of fetal growth restriction (FGR), preterm birth and perinatal death as well. This metanalysis also concluded that aspirin was best avoided in the last month of pregnancy and should be stopped at 36 weeks of gestation to prevent fetal ICH, although the chances are rare if dosage is below 100mg/day [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The indications to start LDA are presence of one high risk factor or presence of two or more moderate risk factors for preeclampsia in the pregnant female. LDA has a proven efficacy and unquestionable benefit in reducing cases of secondary eclampsia [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, as far as the still births, FGR, preterm births and early pregnancy loss are concerned, it has conflicting results [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. LDA is not usually associated with increased risk of haemorrhagic complication, placental abruption, post-partum haemorrhage, congenital anomalies, early ductal closure with persistent pulmonary hypertension or fetal ICH. But a few studies have shown increased incidence of gastroschisis [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The teratogenic effect of aspirin in the form of cardiopathies and limb anomalies are seen only at a high dose of 650 to 2600mg per day [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Rare cases of high fetal bleeding tendencies have also been reported as the aspirin crosses placental barrier and hinders fetal platelet aggregation [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The inhibition of platelet thromboxane A2 formation has been observed in the neonates of women taking 100 mg of aspirin daily [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The reported maternal side effect of aspirin is mainly gastrointestinal discomfort seen in 10% of cases [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA detailed history, blood tests and genetic analysis are vital to elucidate the underlying cause of ICH. The pregnant woman should be cautioned about the dilemma in predicting perinatal outcomes based on ultrasonographic findings alone. Termination of pregnancy is an option in view of the potential significant neurological deficit. If she chooses to continue the pregnancy, serial sonography is required to follow the size of SDH and monitor the PSV of MCA. There are no specific guidelines for the mode of delivery; whether vaginal or by caesarean section which has to be individualized. Blood tests are required in neonatal period to rule out anaemia and coagulopathy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe risk with regards to potential fetal haemorrhagic complications is low with LDA, but cases of such adverse effects may rise in number with inadvertent and widespread use of aspirin in pregnancy. With the broadening of indications, there is routine and extensive prescription of LDA. Hence, patient selection should be optimized for a favorable benefit to risk ratio and the needless exposure of pregnant females to aspirin should be avoided. However, due to rarity of fetal ICH, multicentred, large scale studies are required to collect high quality data to reach a robust conclusion.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eFetal SDH is a complication rarely encountered during antenatal sonography and the diagnosis is complemented by fetal MRI. Recognition of etiology is crucial as there may a possibility of recurrence in future pregnancies in conditions such as alloimmune thrombocytopenia or if genetic cause is identified. This case highlights the importance of a meticulous antenatal sonographic examination and to judiciously follow standard guidelines for drug usage. Whenever fetal ICH is diagnosed, parental counseling and discussion with pediatric neurologist and neonatologist is required for individualized case management.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFetal Intracranial Haemorrhage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSDH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSubdural Hematoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUSG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUltrasound\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePSV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePeak Systolic Velocity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMCA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMiddle Cerebral Artery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic Resonance Imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTORCH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eToxoplasmosis, Rubella, Cytomegalovirus, Herpes\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIVH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntraventricular Haemorrhage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSAH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSubarachnoid Haemorrhage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLDA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow Dose Aspirin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eACOG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican College of Obstetricians and Gynecologists\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSMFM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSociety for Maternal-Fetal Medicine\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFGR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFetal Growth Restriction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e– Ethical approval was waived off as the index case was de-identified. An informed consent was taken from the parents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication –\u0026nbsp;\u003c/strong\u003eYes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material –\u0026nbsp;\u003c/strong\u003eAvailable in PACS of the institution.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests -\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding -\u0026nbsp;\u003c/strong\u003eNONE\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy concept and design: S T\u003c/p\u003e\n\u003cp\u003eData acquisition: C T\u003c/p\u003e\n\u003cp\u003eData analysis: \u0026nbsp; ST\u003c/p\u003e\n\u003cp\u003eDrafting of manuscript: \u0026nbsp;S T, A S\u003c/p\u003e\n\u003cp\u003eCritical revision of the manuscript: \u0026nbsp;S M\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements -\u003c/strong\u003e Nil\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eXu M, Jin P, Huang Y, Qian Y, Lin M, Zuo J, Zhu J, Li Z and Dong M (2022), Case report: Prenatal diagnosis of fetal intracranial hemorrhage due to compound mutations in the JAM3 gene. Front. Genet. 13:1036231. doi: 10.3389/fgene.2022.1036231\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSileo FG, Z\u0026ouml;llner J, D\u0026apos;Antonio F, Islam S, Papageorghiou AT, Khalil A. Perinatal and long‐term outcome of fetal intracranial hemorrhage: systematic review and meta‐analysis. Ultrasound in Obstetrics \u0026amp; Gynecology. 2022 May;59(5):585-95.\u003c/li\u003e\n \u003cli\u003eGao B, Zhang L, Wei Q. An unexplained fetal intracranial hemorrhage with extensive and multifocal hemorrhagic lesions: A case report. Medicine. 2022 Jun 24;101(25): e29335.\u003c/li\u003e\n \u003cli\u003eCheung KW, Tan LN, Seto MT, Moholkar S, Masson G, Kilby MD. Prenatal diagnosis, management, and outcome of fetal subdural haematoma: a case report and systematic review. Fetal Diagnosis and Therapy. 2019 Nov 13;46(5):285-95.\u003c/li\u003e\n \u003cli\u003eAtallah A, Lecarpentier E, Goffinet F, Doret-Dion M, Gaucherand P, Tsatsaris V. Aspirin for prevention of preeclampsia. Drugs. 2017 Nov; 77:1819-31.\u003c/li\u003e\n \u003cli\u003ePutbrese B, Kennedy A. Findings and differential diagnosis of fetal intracranial haemorrhage and fetal ischaemic brain injury: what is the role of fetal MRI? The British journal of radiology. 2017 Feb 1;90(1070):20160253.\u003c/li\u003e\n \u003cli\u003eZamora C, Sams C, Cornea EA, Yuan Z, Smith JK, Gilmore JH. Subdural hemorrhage in asymptomatic neonates: Neurodevelopmental outcomes and MRI findings at 2 years. Radiology. 2021 Jan;298(1):173-9.\u003c/li\u003e\n \u003cli\u003eElchalal U, Yagel S, Gomori JM, Porat S, Beni‐Adani L, Yanai N, Nadjari M. Fetal intracranial hemorrhage (fetal stroke): does grade matter? Ultrasound in Obstetrics and Gynecology: The Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology. 2005 Sep;26(3):233-43.\u003c/li\u003e\n \u003cli\u003eRen Y, Zhao Y, Yang X, Shen C, Luo H. Application of low dose aspirin in pre-eclampsia. Frontiers in Medicine. 2023 Mar 8; 10:1111371.\u003c/li\u003e\n \u003cli\u003eBujold E, Roberge S, Nicolaides KH. Low‐dose aspirin for prevention of adverse outcomes related to abnormal placentation. Prenatal diagnosis. 2014 Jul;34(7):642-8.\u003c/li\u003e\n \u003cli\u003eACOG committee opinion. Low dose aspirin during pregnancy. \u0026nbsp;E44 vol 132, no 1, July 2018 obstetrics and gynaecology.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"fetal subdural hematoma, ultrasound, magnetic resonance imaging, aspirin, idiopathic, perinatal mortality, neurodevelopmental delay","lastPublishedDoi":"10.21203/rs.3.rs-5013088/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5013088/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFetal intracranial haemorrhage (ICH) is a rare antenatal complication that increases perinatal morbidity and mortality and may cause neurodevelopmental delay in surviving babies. Even though the majority of cases are idiopathic, there are many maternal and fetal factors predisposing to ICH. Low dose aspirin has a proven efficacy in secondary preeclampsia, however, with a daily dosage of \u0026gt; 100mg, its safety is not well established and sporadic cases of fetal hemorrhagic complications have been reported. As fetal ICH has prognostic implications for the current and potentially for future pregnancies, in utero diagnosis is of utmost importance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 34- year- old primigravida was diagnosed with fetal subdural hematoma (SDH) on her routine third trimester ultrasound (USG). There were no predisposing factors except that the patient was on low dose aspirin from 12\u003csup\u003eth\u003c/sup\u003e week of gestation. On serial USG, the SDH reduced in size. She delivered a healthy baby who was followed till 6 months of age and showed normal neurodevelopment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs the number of reported cases of fetal ICH are limited with even rarer SDH, meaningful etiological and prognostic criteria cannot be inferred and parental counseling is challenging.\u003c/p\u003e","manuscriptTitle":"Fetal Subdural Hematoma –? Aspirin induced or Idiopathic – A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-21 09:42:14","doi":"10.21203/rs.3.rs-5013088/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-05T07:08:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-04T08:31:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-04T08:29:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-09-01T13:22:09+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5aa52e87-1e3c-42fa-bf72-f7d35a6d0d63","owner":[],"postedDate":"October 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-05T16:07:34+00:00","versionOfRecord":{"articleIdentity":"rs-5013088","link":"https://doi.org/10.1186/s12884-025-08469-0","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2025-12-30 15:57:54","publishedOnDateReadable":"December 30th, 2025"},"versionCreatedAt":"2024-10-21 09:42:14","video":"","vorDoi":"10.1186/s12884-025-08469-0","vorDoiUrl":"https://doi.org/10.1186/s12884-025-08469-0","workflowStages":[]},"version":"v1","identity":"rs-5013088","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5013088","identity":"rs-5013088","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}