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Needle puncture of fetus: A complication of second-trimester amniocentesis
FETUS, PLACENTA, AND NEWBORN
Needle puncture of fetus: A complication of second- trimester amniocentesis DIANE
12. BROOME,
MlRIAM
G.
BENNETT
M.D.
WILSON, WEISS.
RONNIE
M.D. M.D.
KEL>LO(:G,
P.H.N.
Needle puncture of the fetus has rarely been reported with midtrimester amniocentesis. This paper contains the report offive caSes of needle scar.7 in infants born after second-trimester amniocentesis for prenatal diagnosis of fetal genetic disorders. Since this complication may be more freq’uent than has been previously believed, there is the pos.ribility that damage to the fetus may occur. It is suggested that tk products of all abortions and all live-born and stillborn infants delivered following amniocente.G should be examin~rl .for P~&WCP qf i,njq.
ALTHO 11C;H SOMETIMES occurring in third-trimester amniocentesis, needle puncture of the fetus has rarely been reported with midtrimester amniocenteses. We are reporting needle scars in five infants born after second-trimester amniocentesis for prenatal diagnosis of fetal genetic disorders. Since this complication is apparently not rare, there is the possibility that damage to the fetus may occur. depending on which part of the body is penetrated. Four of these children (Case 5 was contributed by a neighboring institution) were seen at our medical center from 1972 to 1976 in a routine amniocentesis
From t/w Department of Pediatrics, Genetics Division, thP Departrwnt of Obstptrirs-Gynecolog?I, Los Angeles Cou~~t~-C~n,~~er.~it~ of Southern Cnlqornia Medical Cmttm. RrceivedJor ArcrptPd Reprint LaboratoT .4ngeles Mrdical Cnlif;~rn
publication Junr
June
follow-up program. The indication for amniocentesis in these cases was an increased risk for fetal chromosomal abnormality. All the amniocenteses were done by the same faculty obstetrician who had done these procedures since 1969 and who had extensive prior experience in third-trimester amniocentesis for management of erythroblastosis. Amniocentesis was done between the sixteenth and seventeenth postmenstrual weeks of pregnancy. A disposable 20 gauge, 3% inch, styleted spinal needle was used for all of these procedures. In ail instances, analysis of the cultured amniotic fluid cells showed a normal karyotype concordant with the sex of the child. All children have grown and developed normally.
and
9, 1976.
Case reports
-73. 1976.
requests: Dr. Dzanv L. Broome, Bldg. for Boric and Clinical Count?-Unlllrr.~it~ of Southern Crntrr. 1 I-39 h’. St& St., Lo.c in 90033.
Patient M. D. (Case 1). A diagnostic amniocentesis was performed at 17% weeks of pregnancy on this 35-year-old Caucasian woman who was gravida 8 and para 5 and had 2 abortions. The amniocentesis was performed easily, and a single insertion yielded at first
lG-30 General Research, Los California Angeks,
247
248
Septernhcr I.5,Isit;
Broome et al.
Am. J. Obstrt.
G\mt~d.
Fig. 1. Case 1. Depressed scar on arm.
Fig. 2.
Case
15 C.C. of clear yellow fluid followed by 25 cc. of blood-tinged fluid. The pregnancy progressed to a normal term vaginal delivery of a healthy female infant, weighing 4,876 grams. At birth, the mother asked about the scar on the infant’s arm and was told by the physicians that the infant had received no injections and there was no apparent reason for the skin lesion. The child had no limitation of arm movement, and the skin mark became less noticeable with age. A physical examination at nine months showed normal findings except for scars on the infant’s right upper arm (Fig. 1). A small depressed scar was found on the anterior aspect of the proximal upper arm and a
2. Scars on
arm.
small linear scar extended 1.5 cm. posteriorly from the depression. The circumferences of the arms were equal. A radiograph of the right upper arm revealed increased soft-tissue density consistent with subcutaneous scar formation. Patient V. D. (Case 2). A diagnostic amniocentesis was performed at the sixteenth week of pregnancy on a 23-year-old Mexican-American woman who was gravida 5 and para 3 with one abortion. The second child had Down’s syndrome. Amniocentesis in the fourth pregnancy had yielded a normal chromosome analysis. In the fifth pregnancy, amniocentesis was performed without difficulty, and 40 cc. of clear, straw-colored
Needle
Fig.
3. Case 3. Scars on right
fluid was withdrawn. Immediately afterward, the patient complained of severe cramping which soon subsided. A female infant weighing 3,284 grams was born at term by a normal vaginal delivery. The mother noted scars on the arm and chest at birth but did not bring them to the attention of a physician. The child used both arms equally. Physical examination of the infant at nine months of age showed scars on the arm and chest. The left arm had two indentations 1.5 cm. apart (Fig. 2) and two smaller indentations on the anterior chest wall 1 cm. apart. When the left arm was brought next to the chest in a simulated fetal position, the four scars were in a straight line. Radiographs revealed soft-tissue density underlying the scars on the arm. Patient J. B. (Case 3). Amniocentesis was performed on a 24-year-old Caucasian woman whdse first child had a structural chromosome anomaly (46,XX,18q-). The karyotypes of the parents were normal. The woman had had no other pregnancies. Amniocentesis at 16 weeks of pregnancy required three insertions before 40 C.C. of grossly bloody fluid was obtained. Since cell growth was inadequate in the first culture, the amniocentesis was repeated two weeks later, at which time 40 C.C. of amniotic fluid tinged with blood was obtained without difficulty. The pregnant) progressed to term. at which time a female infant weighing 3,190 grams tvas born by normal vaginal tleliverv.
On physical examination at eight and a half months the infant appeared normal. When she was seen again at three years. scars were noted on the chest and thigh. The mother said that these marks had been present
anterior
chest
Fig.
puncture
of fetus
249
wall
4. Case 3. Scar on left posterior
thi&
since birth. There were two depressions on the right anterior chest wall. One scar was lateral and the othcl was medial to the nipple (Fig. 3). There was another indentation on the left posterior thigh (Fig. 4). LVhen the child was placed in a fetal position. all three indentations were in a straight line.
250
Broome et al.
September Am. .J. Ohster.
15, 1Y’iii Gynrcol
Fig. 5. Case 4. Scar under chin.
Fig. 6. Case 4. Scar on neck. Patient M. B. (Case 4). Amniocentesis was performed in the seventeenth week of pregnancy on a 28-year-old Caucasian woman who was gravida 5 and para 3. She had had one abortion and one neonatal death. Amniocentesis was done because of a family history of Down’s syndrome. The mother’s sister had Down’s syndrome with a karyotype of 46,XXl 47,Xx,+21 and the mother’s maternal aunt had Down’s syndrome (no chromosome analysis). Karyotypes of both parents were normal. Ultrasonography was performed prior to amniocentesis. Clear yellow fluid (40 CL) was slowly withdrawn. Pregnancy progressed to a normal delivery of a 3,374 gram term female infant.
When the infant was seen at nine months, scars under the left jaw (Fig. 5) and a depressed scar just right of the midline on the posterior neck were noted (Fig. 6). These scars had been seen by the mother at birth. Case 5. Another infant with needle marks has been reported to us.* In this instance, amniocentesis was performed on a 26-year-old Caucasian woman in the sixteenth week of pregnancy. The mother had been delivered of a child with Down’s syndrome two years previously. The first amniocentesis was done without difficufty, and 39 CL. of clear yellow fluid was obtained. Because of slow cell growth, the procedure was repeated two weeks later, at which time 40 CL. of clear yellow fluid was obtained without difficulty. Ultrasonography was done prior to amniocentesis in both procedures. Pregnancy proceeded to delivery of a 2,964 gram female infant. The mother brought the child at two months of age for investigation of several scars on the buttocks and legs. Physical examination was normal except for three scars. One on the lateral right buttock was 1 mm. in depth and 2 mm. in diameter (Fig. 7). Another scar was found on the left labium majora, and a third was close by on the medial aspect of the left thigh.
Comment, Fetal injury due to midpregnancy amniocentesis has not been reported as a significant hazard,‘-x although injury to the fetus during third-trimester amniocentesis has included pneumothorax,g pneumopericardium, splenic rupture, skin scars, eye trauma,“’ and *Dr. graphs
Kenneth Dumars of this case.
provided
us with
details
and
photo-
Volume Number
12fi 2
Needle
Fig.
puncture
of fetus
251
7. Case 5. Scar on huttock
recently an arteriovenous fistula.” According to preliminary reports of a prospective study by the National Institute of Child Health and Human Development,z3 3 amniocentesis in the second trimester of pregnancy appears to be safe for mother and child. The outcome of pregnancy in 1,040 women with midpregnancy amniocentesis for prenatal diagnosis was compared to that of 992 matched control pregnancies. There were no significant differences in maternal morbidity, fetal death or abortion, prematurity, neonatal complications, or congenital defects in the infants. Specifically, there was no mention of any scars in the infants possibly resulting from needle penetrations in utero.3 We have now been able to examine about 100 infants born after amniocentesis for prenatal diagnosis. Four of these infants showed scars interpreted to represent residual scarring after needle puncture in utero.” The interpretation was based on the observation that the scars were not in the usual position of congenital sinus tracts, and in two instances multiple scars fell in a straight line when the infant was placed into a simulated fetal position. The case reported to us from a neighboring medical school further substantiated that needle puncture of the fetus may occur during a midpregnancy amniocentesis. There are previous reports of a scar on the buttocks in a child born after midpregnancy amniocentesis’ and gangrene of a fetal
REFERENCES 1. Allen, H. H., Sergovich, F., Stuart, E. M., et al.: Infants undergoing antenatal genetic diagnosis: A preliminary report, Ai: J. OBSTET.-GYNECOL. il%: 310, l-974. ’ 2. Cullicon, B. J.: Amniocentesis: HEW backs test for prenatal diagnosis of diseases, Science 190: 537, 1975. 3. Milunsky, A.: Risk of amniocentesis for prenatal diagnosis, N. Engl. J. Med. 293: 932, 1975.
limb seen in a therapeutically aborted fetus following another midpregnancy amniocentesis.’ The use of ultrasonography, which is now routinely done prior to amniocentesis in our institution, ma) reduce the likelihood of needle puncture of the fetal head, particularly if performed just before the amniocentesis and before the mother changes posture. We now include disclosure of this hazard while obtaining informed consent from the parents prior to amniocentesis. In this regard, it is noteworthy that one set of parents (Case 2) elected amniocentesis t’or the next pregnancy following the birth of‘ one of the children reported here. Needle puncture of the fetus during secondtrimester amniocentesis is a hazard of unknown magnitude. The scars in the children described here were minor and, indeed, were overlooked in the first examination of one of the children. However, the possibility exists that a vital fetal part, such as the eye or a major blood vessel, might be punctured with interference of full development of a part of the body. It is of the utmost importance that all abortions and stilllbirths occurring after amniocentesis, as well as infants born after the procedure. be carefullv examined for evidence of fetal injury. We wish to acknowledge the contributions of Drs. Kenneth Dumars, Allen Iseri, and Nan<-y Shinno.
4. Nadler, H. L., and Gerbie, A. B.: Role of amniocentesis in the intrauterine detection of genetic disorders, N. Engl. J. Med. 282: 596, 1970. 5. Creasman, W. T., Lawrence, R. A., and I‘hiede, H. A.: Fetal complications of amniocentesis, ,J. A. M. A. 204: 91, 196%. 6. Hirschhorn. K.: The role and the hazards ~)f amniocentesis. Ann. N. Y. Acad. Sci. 240: 117, 197.5
7. Robinson, trauterine
A., Bowes, W., Droegemueller, W., et al.: Indiagnosis: Potential complications, AM. J. OBSTET. GYNECOL. 116: 937. 1973. 8. Lamb, M. P.: Gangrene of a fetal limb due to amniocentesis, J. Obstet. Gynaecol. Br. Commonw. 82: 829, 1975. 9. Cook, L. N., Shott, R. J.. and Andrews, B. F.: Fetal complications of diagnostic amniocentesis: A review and report of a case with pneumothorax, Pediatrics 53: 421. 1974.
10. Cross, H. E., and Maumenee, A. E.: Ocular traulna during amniocentesis, Ophthalmologica 90: 303. 1973. 11. Gottdiener, J. S., Ellison, R. C.. and Lorenlo, R. I... Arteriovenous fistula after fetal penetration at amniocentesis. N. Engl. J. Med. 293: 1302, 1975. 12. Broome, D. L., Kellogg, B., Weiss, B. A.. and Wilson, 31. G.: Needle puncture of the fetus during amniocentesis, Lancer 2: 604. 1975.
Needle puncture of fetus: A complication of second- trimester amniocentesis DIANE
12. BROOME,
MlRIAM
G.
BENNETT
M.D.
WILSON, WEISS.
RONNIE
M.D. M.D.
KEL>LO(:G,
P.H.N.
Needle puncture of the fetus has rarely been reported with midtrimester amniocentesis. This paper contains the report offive caSes of needle scar.7 in infants born after second-trimester amniocentesis for prenatal diagnosis of fetal genetic disorders. Since this complication may be more freq’uent than has been previously believed, there is the pos.ribility that damage to the fetus may occur. It is suggested that tk products of all abortions and all live-born and stillborn infants delivered following amniocente.G should be examin~rl .for P~&WCP qf i,njq.
ALTHO 11C;H SOMETIMES occurring in third-trimester amniocentesis, needle puncture of the fetus has rarely been reported with midtrimester amniocenteses. We are reporting needle scars in five infants born after second-trimester amniocentesis for prenatal diagnosis of fetal genetic disorders. Since this complication is apparently not rare, there is the possibility that damage to the fetus may occur. depending on which part of the body is penetrated. Four of these children (Case 5 was contributed by a neighboring institution) were seen at our medical center from 1972 to 1976 in a routine amniocentesis
From t/w Department of Pediatrics, Genetics Division, thP Departrwnt of Obstptrirs-Gynecolog?I, Los Angeles Cou~~t~-C~n,~~er.~it~ of Southern Cnlqornia Medical Cmttm. RrceivedJor ArcrptPd Reprint LaboratoT .4ngeles Mrdical Cnlif;~rn
publication Junr
June
follow-up program. The indication for amniocentesis in these cases was an increased risk for fetal chromosomal abnormality. All the amniocenteses were done by the same faculty obstetrician who had done these procedures since 1969 and who had extensive prior experience in third-trimester amniocentesis for management of erythroblastosis. Amniocentesis was done between the sixteenth and seventeenth postmenstrual weeks of pregnancy. A disposable 20 gauge, 3% inch, styleted spinal needle was used for all of these procedures. In ail instances, analysis of the cultured amniotic fluid cells showed a normal karyotype concordant with the sex of the child. All children have grown and developed normally.
and
9, 1976.
Case reports
-73. 1976.
requests: Dr. Dzanv L. Broome, Bldg. for Boric and Clinical Count?-Unlllrr.~it~ of Southern Crntrr. 1 I-39 h’. St& St., Lo.c in 90033.
Patient M. D. (Case 1). A diagnostic amniocentesis was performed at 17% weeks of pregnancy on this 35-year-old Caucasian woman who was gravida 8 and para 5 and had 2 abortions. The amniocentesis was performed easily, and a single insertion yielded at first
lG-30 General Research, Los California Angeks,
247
248
Septernhcr I.5,Isit;
Broome et al.
Am. J. Obstrt.
G\mt~d.
Fig. 1. Case 1. Depressed scar on arm.
Fig. 2.
Case
15 C.C. of clear yellow fluid followed by 25 cc. of blood-tinged fluid. The pregnancy progressed to a normal term vaginal delivery of a healthy female infant, weighing 4,876 grams. At birth, the mother asked about the scar on the infant’s arm and was told by the physicians that the infant had received no injections and there was no apparent reason for the skin lesion. The child had no limitation of arm movement, and the skin mark became less noticeable with age. A physical examination at nine months showed normal findings except for scars on the infant’s right upper arm (Fig. 1). A small depressed scar was found on the anterior aspect of the proximal upper arm and a
2. Scars on
arm.
small linear scar extended 1.5 cm. posteriorly from the depression. The circumferences of the arms were equal. A radiograph of the right upper arm revealed increased soft-tissue density consistent with subcutaneous scar formation. Patient V. D. (Case 2). A diagnostic amniocentesis was performed at the sixteenth week of pregnancy on a 23-year-old Mexican-American woman who was gravida 5 and para 3 with one abortion. The second child had Down’s syndrome. Amniocentesis in the fourth pregnancy had yielded a normal chromosome analysis. In the fifth pregnancy, amniocentesis was performed without difficulty, and 40 cc. of clear, straw-colored
Needle
Fig.
3. Case 3. Scars on right
fluid was withdrawn. Immediately afterward, the patient complained of severe cramping which soon subsided. A female infant weighing 3,284 grams was born at term by a normal vaginal delivery. The mother noted scars on the arm and chest at birth but did not bring them to the attention of a physician. The child used both arms equally. Physical examination of the infant at nine months of age showed scars on the arm and chest. The left arm had two indentations 1.5 cm. apart (Fig. 2) and two smaller indentations on the anterior chest wall 1 cm. apart. When the left arm was brought next to the chest in a simulated fetal position, the four scars were in a straight line. Radiographs revealed soft-tissue density underlying the scars on the arm. Patient J. B. (Case 3). Amniocentesis was performed on a 24-year-old Caucasian woman whdse first child had a structural chromosome anomaly (46,XX,18q-). The karyotypes of the parents were normal. The woman had had no other pregnancies. Amniocentesis at 16 weeks of pregnancy required three insertions before 40 C.C. of grossly bloody fluid was obtained. Since cell growth was inadequate in the first culture, the amniocentesis was repeated two weeks later, at which time 40 C.C. of amniotic fluid tinged with blood was obtained without difficulty. The pregnant) progressed to term. at which time a female infant weighing 3,190 grams tvas born by normal vaginal tleliverv.
On physical examination at eight and a half months the infant appeared normal. When she was seen again at three years. scars were noted on the chest and thigh. The mother said that these marks had been present
anterior
chest
Fig.
puncture
of fetus
249
wall
4. Case 3. Scar on left posterior
thi&
since birth. There were two depressions on the right anterior chest wall. One scar was lateral and the othcl was medial to the nipple (Fig. 3). There was another indentation on the left posterior thigh (Fig. 4). LVhen the child was placed in a fetal position. all three indentations were in a straight line.
250
Broome et al.
September Am. .J. Ohster.
15, 1Y’iii Gynrcol
Fig. 5. Case 4. Scar under chin.
Fig. 6. Case 4. Scar on neck. Patient M. B. (Case 4). Amniocentesis was performed in the seventeenth week of pregnancy on a 28-year-old Caucasian woman who was gravida 5 and para 3. She had had one abortion and one neonatal death. Amniocentesis was done because of a family history of Down’s syndrome. The mother’s sister had Down’s syndrome with a karyotype of 46,XXl 47,Xx,+21 and the mother’s maternal aunt had Down’s syndrome (no chromosome analysis). Karyotypes of both parents were normal. Ultrasonography was performed prior to amniocentesis. Clear yellow fluid (40 CL) was slowly withdrawn. Pregnancy progressed to a normal delivery of a 3,374 gram term female infant.
When the infant was seen at nine months, scars under the left jaw (Fig. 5) and a depressed scar just right of the midline on the posterior neck were noted (Fig. 6). These scars had been seen by the mother at birth. Case 5. Another infant with needle marks has been reported to us.* In this instance, amniocentesis was performed on a 26-year-old Caucasian woman in the sixteenth week of pregnancy. The mother had been delivered of a child with Down’s syndrome two years previously. The first amniocentesis was done without difficufty, and 39 CL. of clear yellow fluid was obtained. Because of slow cell growth, the procedure was repeated two weeks later, at which time 40 CL. of clear yellow fluid was obtained without difficulty. Ultrasonography was done prior to amniocentesis in both procedures. Pregnancy proceeded to delivery of a 2,964 gram female infant. The mother brought the child at two months of age for investigation of several scars on the buttocks and legs. Physical examination was normal except for three scars. One on the lateral right buttock was 1 mm. in depth and 2 mm. in diameter (Fig. 7). Another scar was found on the left labium majora, and a third was close by on the medial aspect of the left thigh.
Comment, Fetal injury due to midpregnancy amniocentesis has not been reported as a significant hazard,‘-x although injury to the fetus during third-trimester amniocentesis has included pneumothorax,g pneumopericardium, splenic rupture, skin scars, eye trauma,“’ and *Dr. graphs
Kenneth Dumars of this case.
provided
us with
details
and
photo-
Volume Number
12fi 2
Needle
Fig.
puncture
of fetus
251
7. Case 5. Scar on huttock
recently an arteriovenous fistula.” According to preliminary reports of a prospective study by the National Institute of Child Health and Human Development,z3 3 amniocentesis in the second trimester of pregnancy appears to be safe for mother and child. The outcome of pregnancy in 1,040 women with midpregnancy amniocentesis for prenatal diagnosis was compared to that of 992 matched control pregnancies. There were no significant differences in maternal morbidity, fetal death or abortion, prematurity, neonatal complications, or congenital defects in the infants. Specifically, there was no mention of any scars in the infants possibly resulting from needle penetrations in utero.3 We have now been able to examine about 100 infants born after amniocentesis for prenatal diagnosis. Four of these infants showed scars interpreted to represent residual scarring after needle puncture in utero.” The interpretation was based on the observation that the scars were not in the usual position of congenital sinus tracts, and in two instances multiple scars fell in a straight line when the infant was placed into a simulated fetal position. The case reported to us from a neighboring medical school further substantiated that needle puncture of the fetus may occur during a midpregnancy amniocentesis. There are previous reports of a scar on the buttocks in a child born after midpregnancy amniocentesis’ and gangrene of a fetal
REFERENCES 1. Allen, H. H., Sergovich, F., Stuart, E. M., et al.: Infants undergoing antenatal genetic diagnosis: A preliminary report, Ai: J. OBSTET.-GYNECOL. il%: 310, l-974. ’ 2. Cullicon, B. J.: Amniocentesis: HEW backs test for prenatal diagnosis of diseases, Science 190: 537, 1975. 3. Milunsky, A.: Risk of amniocentesis for prenatal diagnosis, N. Engl. J. Med. 293: 932, 1975.
limb seen in a therapeutically aborted fetus following another midpregnancy amniocentesis.’ The use of ultrasonography, which is now routinely done prior to amniocentesis in our institution, ma) reduce the likelihood of needle puncture of the fetal head, particularly if performed just before the amniocentesis and before the mother changes posture. We now include disclosure of this hazard while obtaining informed consent from the parents prior to amniocentesis. In this regard, it is noteworthy that one set of parents (Case 2) elected amniocentesis t’or the next pregnancy following the birth of‘ one of the children reported here. Needle puncture of the fetus during secondtrimester amniocentesis is a hazard of unknown magnitude. The scars in the children described here were minor and, indeed, were overlooked in the first examination of one of the children. However, the possibility exists that a vital fetal part, such as the eye or a major blood vessel, might be punctured with interference of full development of a part of the body. It is of the utmost importance that all abortions and stilllbirths occurring after amniocentesis, as well as infants born after the procedure. be carefullv examined for evidence of fetal injury. We wish to acknowledge the contributions of Drs. Kenneth Dumars, Allen Iseri, and Nan<-y Shinno.
4. Nadler, H. L., and Gerbie, A. B.: Role of amniocentesis in the intrauterine detection of genetic disorders, N. Engl. J. Med. 282: 596, 1970. 5. Creasman, W. T., Lawrence, R. A., and I‘hiede, H. A.: Fetal complications of amniocentesis, ,J. A. M. A. 204: 91, 196%. 6. Hirschhorn. K.: The role and the hazards ~)f amniocentesis. Ann. N. Y. Acad. Sci. 240: 117, 197.5
7. Robinson, trauterine
A., Bowes, W., Droegemueller, W., et al.: Indiagnosis: Potential complications, AM. J. OBSTET. GYNECOL. 116: 937. 1973. 8. Lamb, M. P.: Gangrene of a fetal limb due to amniocentesis, J. Obstet. Gynaecol. Br. Commonw. 82: 829, 1975. 9. Cook, L. N., Shott, R. J.. and Andrews, B. F.: Fetal complications of diagnostic amniocentesis: A review and report of a case with pneumothorax, Pediatrics 53: 421. 1974.
10. Cross, H. E., and Maumenee, A. E.: Ocular traulna during amniocentesis, Ophthalmologica 90: 303. 1973. 11. Gottdiener, J. S., Ellison, R. C.. and Lorenlo, R. I... Arteriovenous fistula after fetal penetration at amniocentesis. N. Engl. J. Med. 293: 1302, 1975. 12. Broome, D. L., Kellogg, B., Weiss, B. A.. and Wilson, 31. G.: Needle puncture of the fetus during amniocentesis, Lancer 2: 604. 1975.