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Intrauterine quadriplegia associated with breech presentation and hyperextension of fetal head: A case report
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This section is suitable for reporting results of therapeutic trials, descriptions of new procedures or instruments, and case reports which illustrate a principle. Reports should be limited to seven hundred words and two references. Use of an illustration or table requires a proportionate reduction in total words.
Intrauterine quadriplegia associated with breech presentation and hyperextension of fetal head: A case report GEETHA
R.
CATTAMANCHI,
T.
EGEL,
VASUNDHARA ROBERT RAMA
TAMASKAR, M.D.
S. YRAPSIS, PATEL,
MANOHAR
M.D.
M.D..
RATHI,
Perinatal Medicine Oak Lawn, Illinois
M.D.
M.D.
S. SINGH,
NICHOLAS VINOD
M.D.
M.D.
and Division
of Neurology,
Christ Hospital,
INTRAUTERINEHYPEREXTENSION ofthefetalhead in the breech presentation is not an uncommon finding. The etiology of this condition is obscure although factors like uterine and fetal anomalies, special locations of the placenta, and spasm of the fetal musculature have been implicated. Review of the literature indicates a high risk of cord damage following vaginal delivery in these cases. A cesarean section is recommended in all cases of breech presentation with radiologic evidence of persistent hyperextension of fetal head after the onset of labor.‘. * The following case report illustrates spinal cord damage in an infant delivered by cesarean section. The roentgenogram demonstrated breech presentation with hyperextension of the fetal head prior to onset of labor and flexion after the onset of labor.
A 22-year-old primigravid admitted
to Christ
Reprint Hospital,
requests: Oak Lawn,
Hospital
patient at term pregnancy was on September
M. Rathi, Perinatal Illinois 60453.
0002-9378/81/150831+03$00.30/0~
1981The
20, 1980, in active Medicine,
C.V.MosbyCo.
Christ
labor. Her pregnancy was uncomplicated except for an accidental fall in the shower 2 weeks prior to delivery. No fetal abnormalities were detected except for clinical evidence of breech presentation in a routine prenatal examination by her obstetrician 1 week prior to delivery. An x-ray film of the abdomen obtained at that time demonstrated a breech presentation with extreme hyperextension of the fetal head (Fig. 1). She reported having fetal movements until 2 days prior to delivery. Examination at the time of admission revealed a breech presentation with 5 to 6 cm of cervical dilatation. The fetal heart rate was 140 bpm. An x-ray film of the abdomen revealed a breech presentation with Hexion of the fetal head (Fig. 2). A primary cesarean section was performed 6 hours after admission to the hospital because of cephalopelvic disproportion. The amniotic fluid was meconium stained. The baby was flaccid and cyanotic. The Apgar scores were 1 and 4 at 1 and 5 minutes, respectively. The infant was resuscitated and placed on a ventilator. No spontaneous respirations were noted and there was absence of spontaneous movements of the limbs. However, sucking, gag, and blinking reflexes were present. A spinal tap was done at about 15 hours of age. Cerebrospinal fluid was xanthochromic; red blood cell count was 7,59O/cu mm; white blood cell count was 529/cu mm (segments, 91%; bands, 6%; and lymphocytes, 3%); and protein was 1.25 gm/lOO ml. Gram stain and culture were negative. X-ray films of the skull and the cervical spine were normal. A computed tomography scan of the head showed a very small subdural hemorrhage in the left temporal region. The ventricular system appeared normal. Tomographic cuts through the upper cervical cord revealed no abnormalities. Fluoroscopic examination of the chest revealed absence of diaphragmatic movements bilaterally. An attempt to obtain a myelogram at age 9 days was unsuccessful because of failure to enter the subarachnoid space in the lumbar region. Because of respiratory problems, the myelogram could not be repeated until a week later. A cervical myelogram obtained at age 2 weeks by cisternal puncture revealed a block at the level of C5-6. A decompressive cervical and thoracic laminectomy with intradural exploration was done at age 3 weeks. Marked scarring of the arachnoid was noticed from approximately C5 down through Tl. Above C6 the cord appeared normal. Post-
831
832
Communications
in brief
Fig. 1. Breech presentation with hyperextension head to 14.5” 8 days prior to delivery.
of the fetal
operative diagnosis was lower cervical cord compression setondary to epidurai hematoma with arachnoiditis. The infant continued to need ventiiatory support although there was some return of function of the diaphragm. She became more alert and responsive. There was no cranial nerve involvement. She did not respond to pain below the C2 level. The upper extremities tremities
were showed
flaccid spastic
with areflexia and the paraparesis. The bladder
tower exwas neu-
rogenic. A repeat Ruoroscopy of the chest at age 10 weeks revealed
minimal
movements
sence of movements
of the left diaphragm
of the right
diaphragm,
and ah-
She was
transferred to another hospital at age 3 months for evaluation of phrenic nerve pacing and further management. She died of respiratory failure 2 weeks later.
Spinal cord injury has been reported to occur in 10% to 33% of newborn deaths. Epidural hemorrhage is the most frequent manifestation and can be associated with varying degrees of damage to the cord, brain stem, nerve roots, and meninges. Spinal cord and brain stem damage may occur: (1) during intrauterine life as a result of fetal malposition, (2) during labor, or (3) during the delivery. Excessive traction, torsion, and flexion during delivery leading to stretch and compression is thought to be the most important cause of neonatal spinal cord and brain stem injury. The usual site of
Fig. 2. Breech presentation the onset of labor.
with
Hexion
of rhr fetal brad
after
injury after breech delivery is in the tower cervical IXgion. while after vertex delivery it tends to br at ;I higher level. ’ Stretch injury to the spinal cord and vascular compromise can occur in cases of’ extreme dcgrees of hyperextension. In a postmortem myelogram on a term cadaver, Bresnan and Abroms,’ in 1974, demonstrated maximum angulation and narrowing at the eighth cervical vertebra with 90” of hyperextension. However, a greater degree of hyperextension can occur in utero. It has been postulated that if hyperextension develops a long time befijre birth, the dura and ligaments of the posterior side of the cord would probably be foreshortened and, hence. prone IO damage when flexion of the fetal head occurs during vaginal delivery. After a review of 58 cases of‘ persistent breech presentation with hyperextension of the fetal head, it was concluded that if the angle of extension is greater than 90”, delivery should be by cesarean section to prevent cord damage. Our case is unique in that we documented hyperextension of the fetal head 8 days prior to deliver) and flexion of the fetal head after labor was established. In spite of cesarean section, the infant sustained spinal cord injury. Possible causes of neurological damage in our infant include: (1) the extreme degree of
Volume Number
Communications
140 7
in brief
833
hyperextension of the fetal head to 145”, (2) spontaneous Hexion prior to or after the onset of labor from an extreme degree of hyperextension, and (3) sequelae of fetal trauma incurred during the mother’s accidental fall 2 weeks prior to delivery. It is difficult to assess whether any one or more than one of the above factors contributed to the total neurological deficit. A roentgenogram obtained in cases of breech presentation after the onset of labor, as suggested by many authors, will exclude neither the presence of previously existing hyperextension of the fetal head nor the possibility of previously existing spinal cord injury. It may be important to diagnose hyperextension of the fetal head by roentgenogram in cases of breech presentation before the onset of labor and to perform an elective cesarean section if the angle of extension is more than 90”. REFERENCES
1.
Bhagwani, S. G., Price, H. V., Laurence,
K. M., and Ging, B.: Risks and prevention of cervical cord injury in the management of breech presentation with hyperextension of the fetal head, AM. J. OBSTET. GYNECOL. 115:1159, 1953.
2. Bresnan, M. J., and Abroms, I. F.: Neonatal spinal cord transection secondary to intrauterine hyperextension of the neck in breech presentation, J. Pediatr. 84:734, 1974.
Fig. 1. Transverse abdominal scan demonstrating ence of a large septated mass adjacent to the fetal Arrows outline the mass contour.
In utero diagnosis of umbilical cord hematoma by ultrasonography ERNEST0
D.
THOMAS JOHN
RUVINSKY
L. WILEY, C.
PAMELA
M.D.
M.D.
MORRISON, G.
Division of MaternallFetal and Gynecology, School Medical Center, Jackson, SPONTANEOUS
M.D.
BLAKE,
R.N.,
B.S.N.
Medicine,
Department of Obstetrics Universily of Mississippi
of Medicine, Mississi#i
UMBILICAL
period
by
ultrasound
hematoma is a Currently, only 57 literature, including article. The perinatal * The diagnosis has In this case, a sponvisualized during the
CORD
rare complication of pregnancy. cases have been reported in the the 36 cases reviewed in Dipple’sr mortality rate approaches 50%.‘, previously been made post partum. taneous umbilical cord hematoma antenatal
is reported.
J. S., a 27-year-old white woman, gravida 2, para 1, received prenatal care at a local health center. She was referred at 32 Reprint requests: Ernest0 D. Ruvinsky, M.D., Department of Obstetrics and Gynecology, School of Medicine, University of Mississippi Medical Center, 2500 North State St., Jackson, Mississippi 392 16. 0002-9378/81/150833+02$~.20/0
the presabdomen.
@I 1981
The
C. V. Mosby
Co.
weeks’ gestation to the University of Mississippi Medical Center for probable fetal death. No fetal movements had been detected for 1 week, and no fetal heart tones were heard by the referring physician. There was no history of abdominal trauma. Real-time ultrasonography performed on admission revealed a biparietal diameter consistent with 32 weeks’ gestation. No fetal cardiac activity or motion was observed. Also noted on sonography was a 6 by 8 cm sonolucent, septated intrauterine mass adjacent to the fetal abdomen (Fig. 1). The diagnosis of umbilical cord hematoma was entertained. The patient underwent induction of labor with prostaglandin E, vaginal suppositories and was delivered of a 1,250 gm. stillborn female infant. The umbilical cord contained a large hematoma 2 cm from the cords attachment to the fetus. The hematoma measured 6 by 9 by 3 cm (Fig. 2), and its volume was about 100 ml. No loops, knots, or other abnormalities of the cord were noted. The length of the cord was 52 cm. Microscopic evaluation revealed rupture of the umbilical vein. Sections of the umbilical cord not adjacent to the hematoma cavity contained three vessels (two arteries and one vein) that appeared normal in size, location, and contour. The vessel walls contained no defects in these areas. Autopsy revealed no fetal malformations.
This section is suitable for reporting results of therapeutic trials, descriptions of new procedures or instruments, and case reports which illustrate a principle. Reports should be limited to seven hundred words and two references. Use of an illustration or table requires a proportionate reduction in total words.
Intrauterine quadriplegia associated with breech presentation and hyperextension of fetal head: A case report GEETHA
R.
CATTAMANCHI,
T.
EGEL,
VASUNDHARA ROBERT RAMA
TAMASKAR, M.D.
S. YRAPSIS, PATEL,
MANOHAR
M.D.
M.D..
RATHI,
Perinatal Medicine Oak Lawn, Illinois
M.D.
M.D.
S. SINGH,
NICHOLAS VINOD
M.D.
M.D.
and Division
of Neurology,
Christ Hospital,
INTRAUTERINEHYPEREXTENSION ofthefetalhead in the breech presentation is not an uncommon finding. The etiology of this condition is obscure although factors like uterine and fetal anomalies, special locations of the placenta, and spasm of the fetal musculature have been implicated. Review of the literature indicates a high risk of cord damage following vaginal delivery in these cases. A cesarean section is recommended in all cases of breech presentation with radiologic evidence of persistent hyperextension of fetal head after the onset of labor.‘. * The following case report illustrates spinal cord damage in an infant delivered by cesarean section. The roentgenogram demonstrated breech presentation with hyperextension of the fetal head prior to onset of labor and flexion after the onset of labor.
A 22-year-old primigravid admitted
to Christ
Reprint Hospital,
requests: Oak Lawn,
Hospital
patient at term pregnancy was on September
M. Rathi, Perinatal Illinois 60453.
0002-9378/81/150831+03$00.30/0~
1981The
20, 1980, in active Medicine,
C.V.MosbyCo.
Christ
labor. Her pregnancy was uncomplicated except for an accidental fall in the shower 2 weeks prior to delivery. No fetal abnormalities were detected except for clinical evidence of breech presentation in a routine prenatal examination by her obstetrician 1 week prior to delivery. An x-ray film of the abdomen obtained at that time demonstrated a breech presentation with extreme hyperextension of the fetal head (Fig. 1). She reported having fetal movements until 2 days prior to delivery. Examination at the time of admission revealed a breech presentation with 5 to 6 cm of cervical dilatation. The fetal heart rate was 140 bpm. An x-ray film of the abdomen revealed a breech presentation with Hexion of the fetal head (Fig. 2). A primary cesarean section was performed 6 hours after admission to the hospital because of cephalopelvic disproportion. The amniotic fluid was meconium stained. The baby was flaccid and cyanotic. The Apgar scores were 1 and 4 at 1 and 5 minutes, respectively. The infant was resuscitated and placed on a ventilator. No spontaneous respirations were noted and there was absence of spontaneous movements of the limbs. However, sucking, gag, and blinking reflexes were present. A spinal tap was done at about 15 hours of age. Cerebrospinal fluid was xanthochromic; red blood cell count was 7,59O/cu mm; white blood cell count was 529/cu mm (segments, 91%; bands, 6%; and lymphocytes, 3%); and protein was 1.25 gm/lOO ml. Gram stain and culture were negative. X-ray films of the skull and the cervical spine were normal. A computed tomography scan of the head showed a very small subdural hemorrhage in the left temporal region. The ventricular system appeared normal. Tomographic cuts through the upper cervical cord revealed no abnormalities. Fluoroscopic examination of the chest revealed absence of diaphragmatic movements bilaterally. An attempt to obtain a myelogram at age 9 days was unsuccessful because of failure to enter the subarachnoid space in the lumbar region. Because of respiratory problems, the myelogram could not be repeated until a week later. A cervical myelogram obtained at age 2 weeks by cisternal puncture revealed a block at the level of C5-6. A decompressive cervical and thoracic laminectomy with intradural exploration was done at age 3 weeks. Marked scarring of the arachnoid was noticed from approximately C5 down through Tl. Above C6 the cord appeared normal. Post-
831
832
Communications
in brief
Fig. 1. Breech presentation with hyperextension head to 14.5” 8 days prior to delivery.
of the fetal
operative diagnosis was lower cervical cord compression setondary to epidurai hematoma with arachnoiditis. The infant continued to need ventiiatory support although there was some return of function of the diaphragm. She became more alert and responsive. There was no cranial nerve involvement. She did not respond to pain below the C2 level. The upper extremities tremities
were showed
flaccid spastic
with areflexia and the paraparesis. The bladder
tower exwas neu-
rogenic. A repeat Ruoroscopy of the chest at age 10 weeks revealed
minimal
movements
sence of movements
of the left diaphragm
of the right
diaphragm,
and ah-
She was
transferred to another hospital at age 3 months for evaluation of phrenic nerve pacing and further management. She died of respiratory failure 2 weeks later.
Spinal cord injury has been reported to occur in 10% to 33% of newborn deaths. Epidural hemorrhage is the most frequent manifestation and can be associated with varying degrees of damage to the cord, brain stem, nerve roots, and meninges. Spinal cord and brain stem damage may occur: (1) during intrauterine life as a result of fetal malposition, (2) during labor, or (3) during the delivery. Excessive traction, torsion, and flexion during delivery leading to stretch and compression is thought to be the most important cause of neonatal spinal cord and brain stem injury. The usual site of
Fig. 2. Breech presentation the onset of labor.
with
Hexion
of rhr fetal brad
after
injury after breech delivery is in the tower cervical IXgion. while after vertex delivery it tends to br at ;I higher level. ’ Stretch injury to the spinal cord and vascular compromise can occur in cases of’ extreme dcgrees of hyperextension. In a postmortem myelogram on a term cadaver, Bresnan and Abroms,’ in 1974, demonstrated maximum angulation and narrowing at the eighth cervical vertebra with 90” of hyperextension. However, a greater degree of hyperextension can occur in utero. It has been postulated that if hyperextension develops a long time befijre birth, the dura and ligaments of the posterior side of the cord would probably be foreshortened and, hence. prone IO damage when flexion of the fetal head occurs during vaginal delivery. After a review of 58 cases of‘ persistent breech presentation with hyperextension of the fetal head, it was concluded that if the angle of extension is greater than 90”, delivery should be by cesarean section to prevent cord damage. Our case is unique in that we documented hyperextension of the fetal head 8 days prior to deliver) and flexion of the fetal head after labor was established. In spite of cesarean section, the infant sustained spinal cord injury. Possible causes of neurological damage in our infant include: (1) the extreme degree of
Volume Number
Communications
140 7
in brief
833
hyperextension of the fetal head to 145”, (2) spontaneous Hexion prior to or after the onset of labor from an extreme degree of hyperextension, and (3) sequelae of fetal trauma incurred during the mother’s accidental fall 2 weeks prior to delivery. It is difficult to assess whether any one or more than one of the above factors contributed to the total neurological deficit. A roentgenogram obtained in cases of breech presentation after the onset of labor, as suggested by many authors, will exclude neither the presence of previously existing hyperextension of the fetal head nor the possibility of previously existing spinal cord injury. It may be important to diagnose hyperextension of the fetal head by roentgenogram in cases of breech presentation before the onset of labor and to perform an elective cesarean section if the angle of extension is more than 90”. REFERENCES
1.
Bhagwani, S. G., Price, H. V., Laurence,
K. M., and Ging, B.: Risks and prevention of cervical cord injury in the management of breech presentation with hyperextension of the fetal head, AM. J. OBSTET. GYNECOL. 115:1159, 1953.
2. Bresnan, M. J., and Abroms, I. F.: Neonatal spinal cord transection secondary to intrauterine hyperextension of the neck in breech presentation, J. Pediatr. 84:734, 1974.
Fig. 1. Transverse abdominal scan demonstrating ence of a large septated mass adjacent to the fetal Arrows outline the mass contour.
In utero diagnosis of umbilical cord hematoma by ultrasonography ERNEST0
D.
THOMAS JOHN
RUVINSKY
L. WILEY, C.
PAMELA
M.D.
M.D.
MORRISON, G.
Division of MaternallFetal and Gynecology, School Medical Center, Jackson, SPONTANEOUS
M.D.
BLAKE,
R.N.,
B.S.N.
Medicine,
Department of Obstetrics Universily of Mississippi
of Medicine, Mississi#i
UMBILICAL
period
by
ultrasound
hematoma is a Currently, only 57 literature, including article. The perinatal * The diagnosis has In this case, a sponvisualized during the
CORD
rare complication of pregnancy. cases have been reported in the the 36 cases reviewed in Dipple’sr mortality rate approaches 50%.‘, previously been made post partum. taneous umbilical cord hematoma antenatal
is reported.
J. S., a 27-year-old white woman, gravida 2, para 1, received prenatal care at a local health center. She was referred at 32 Reprint requests: Ernest0 D. Ruvinsky, M.D., Department of Obstetrics and Gynecology, School of Medicine, University of Mississippi Medical Center, 2500 North State St., Jackson, Mississippi 392 16. 0002-9378/81/150833+02$~.20/0
the presabdomen.
@I 1981
The
C. V. Mosby
Co.
weeks’ gestation to the University of Mississippi Medical Center for probable fetal death. No fetal movements had been detected for 1 week, and no fetal heart tones were heard by the referring physician. There was no history of abdominal trauma. Real-time ultrasonography performed on admission revealed a biparietal diameter consistent with 32 weeks’ gestation. No fetal cardiac activity or motion was observed. Also noted on sonography was a 6 by 8 cm sonolucent, septated intrauterine mass adjacent to the fetal abdomen (Fig. 1). The diagnosis of umbilical cord hematoma was entertained. The patient underwent induction of labor with prostaglandin E, vaginal suppositories and was delivered of a 1,250 gm. stillborn female infant. The umbilical cord contained a large hematoma 2 cm from the cords attachment to the fetus. The hematoma measured 6 by 9 by 3 cm (Fig. 2), and its volume was about 100 ml. No loops, knots, or other abnormalities of the cord were noted. The length of the cord was 52 cm. Microscopic evaluation revealed rupture of the umbilical vein. Sections of the umbilical cord not adjacent to the hematoma cavity contained three vessels (two arteries and one vein) that appeared normal in size, location, and contour. The vessel walls contained no defects in these areas. Autopsy revealed no fetal malformations.