Mode of delivery and cranial bleeding in newborns with haemophilia: a systematic review and meta-analysis of the literature

Objectives: Cranial bleeding at birth can result in significant neurological morbidity in newborns with haemophilia. The optimum mode of delivery (MOD) of a potentially affected foetus remains controversial. Aim: The aim of this review is to ascertain overall incidence of cranial bleeding in newborns with haemophilia compared to the general population and the impact of MOD on rates of intracranial haemorrhage (ICH). Method: An EMBASE/MEDLINE search using key terms revealed the relevant studies. Studies included report the incidence of cranial bleeding by MOD within a newborn population. The heterogenicity across studies was assessed using Cochrane's Q test and I-2 statistic and studies were assigned appropriate weight based on a fixed-effect model. Odds ratio (OR) is the primary effect measure. Results: Newborns with haemophilia are 44 times (95% CI: 34.7-57.1, P < 0.01) more likely to experience symptomatic ICH, and 8 times (95% CI: 5.38-12.6, P < 0.01) more likely to experience extracranial haemorrhage at birth, compared to the general population. In newborns with haemophilia the OR of experiencing ICH are 4.4 (95% CI: 1.46-13.7, P = 0.008) following an assisted vaginal delivery (AVD) and 0.34 (95% CI: 0.14-0.83, P = 0.018) following caesarean section (CS), compared to vaginal delivery. Conclusion: Cranial bleeding occurs with a significantly higher frequency in newborns with haemophilia compared to the general population. In newborns with haemophilia, delivery by a CS is associated with the lowest risk of ICH. AVD significantly increases the risk of ICH and should be avoided.