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Transient recurrent laryngeal nerve paresis after shoulder dystocia
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87
Labor was induced at 38 weeks and the woman delivered vaginally. The neonate was healthy (1815 g, 44 cm, 10-minute Apgar score of 10). The infant had no neurological impairment at 2 years of follow-up. Written informed consent from the patient and ethics committee approval were obtained for publication. The causes of new-onset pancytopenia vary [3]; simple etiologies such as malnutrition should not be omitted. B vitamins have a crucial role in intrauterine development and function of many systems [4]. However, in the case presented here, the severe deficiency diagnosed in late pregnancy had no adverse longterm outcomes, even if the fetal status was severely altered at diagnosis. References
Fig. 1. Bone marrow biopsy sample showing megaloblasts, erythroblasts, and the absence of megakaryoblasts.
10 days. Fetal growth persisted at less than the fifth percentile, but the amount of amniotic fluid and umbilical blood flow pattern were normal. Magnetic resonance imaging of the fetal brain detected no significant anomalies.
[1] Stibbe KJ, Wildschut HI, Lugtenburg PJ. Management of aplastic anemia in a woman during pregnancy: a case report. J Med Case Rep 2011;5:66. [2] Varma R, Wallace R, Barton C. Successful outcome following preterm abruption complicated by pancytopenia secondary to folate deficiency: important learning points. J Matern Fetal Neonatal Med 2004;15(2):138–40. [3] Weinzierl EP, Arber DA. The differential diagnosis and bone marrow evaluation of new-onset pancytopenia. Am J Clin Pathol 2013;139(1):9–29. [4] Van de Velde A, Van Droogenbroeck J, Tjalma W, Jorens PG, Schroyens W, Berneman Z. Folate and Vitamin B(12) deficiency presenting as pancytopenia in pregnancy: a case report and review of the literature. Eur J Obstet Gynecol Reprod Biol 2002; 100(2):251–4.
http://dx.doi.org/10.1016/j.ijgo.2015.02.020 0020-7292/© 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Transient recurrent laryngeal nerve paresis after shoulder dystocia Dubravko Habek ⁎ Department of Obstetrics and Gynecology, University Hospital “Sveti Duh” Zagreb, Croatian Catholic University, Zagreb, Croatia
a r t i c l e
i n f o
Article history: Received 24 October 2014 Received in revised form 5 December 2014 Accepted 19 February 2015 Keywords: Injury Larynx Nerve paresis Shoulder dystocia
Shoulder dystocia is an unpredictable and unexpected obstetric emergency associated with major fetal and maternal complications. Dajani and Magann [1] reported that brachial plexus palsy is noted in 4.4% of cases, humerus and clavicle fractures in 10.6%, hypoxic ischemic encephalopathy in 0.5%–23%, and fetal death in 0.4%. Soft tissue lesions of the neck are rarely described. In February, 2013, a woman aged 29 years with a parity of two delivered a live male macrosomic newborn (4860 g, 54 cm) in the maternity ward of the University Hospital “Sveti Duh”, Zagreb, Croatia. The ⁎ Department of Obstetrics and Gynecology, University Hospital “Sveti Duh” Zagreb, Croatian Catholic University Zagreb, Sveti Duh 64, 10000 Zagreb, Croatia. Tel.: +385 1 3712317; fax: +385 1 3745534. E-mail address: [email protected].
pregnancy had progressed normally, although the mother had controlled gestational diabetes. After passing through the normal stages, the labor became complicated by shoulder dystocia, which was relieved by McRoberts’ and Resnik’s maneuvers. The newborn's 1-minute Apgar score was 8 and the 5-minute score was 9, but he cried with a rasping, low, and broken voice. Oxygen saturation and breathing were normal, and clinical examination and laryngobronchoscopy revealed no injury, except for a mildly paretic and swollen vocal cord. Therefore, recurrent nerve lesion was suspected. The neonate was observed closely, and, 3 hours after birth, his crying was loud and penetrating. At 6 hours, the clinical and laryngoscopy findings were normal. The newborn was discharged on the third day with his mother. It was concluded that the initial vocal problems were probably due to compression as a result of local edema caused by the use of head traction to relieve shoulder dystocia. Neonatal cervical injuries can be associated with traumatic labor, shoulder dystocia, and endotracheal intubation, as described in several reports [2–4]. Obstetric maneuvers to relieve shoulder dystocia should be performed carefully and cautiously, with minimal neck and head manipulation. However, most nerve lesions occurring during resolution of shoulder dystocia cannot be prevented, as demonstrated by the present report.
Conflict of interest The author has no conflicts of interest.
88
BRIEF COMMUNICATIONS
References [1] Dajani NK, Magann EF. Complications of shoulder dystocia. Semin Perinatol 2014; 38(4):201–4. [2] Wittekindt C, Kribs A, Roth B, Streppel M. Rupture of the larynx in a newborn. Obstet Gynecol 2002;99(5 Pt 2):904–6.
[3] Mahieu HF, de Bree R, Ekkelkamp S, Sibarani-Ponsen RD, Haasnoot K. Tracheal and laryngeal rupture in neonates: complication of delivery or of intubation? Ann Otol Rhinol Laryngol 2004;113(10):786–92. [4] de Bree R, Van Nieuwkerk EB, Vos A, Ekkelkamp S, Sibarani-Ponsen RD, Haasnoot K, et al. Rupture of larynx or trachea resulting from injuries sustained at birth. Ned Tijdschr Geneeskd 1999;143(30):1564–8.
http://dx.doi.org/10.1016/j.ijgo.2014.12.010 0020-7292/© 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
87
Labor was induced at 38 weeks and the woman delivered vaginally. The neonate was healthy (1815 g, 44 cm, 10-minute Apgar score of 10). The infant had no neurological impairment at 2 years of follow-up. Written informed consent from the patient and ethics committee approval were obtained for publication. The causes of new-onset pancytopenia vary [3]; simple etiologies such as malnutrition should not be omitted. B vitamins have a crucial role in intrauterine development and function of many systems [4]. However, in the case presented here, the severe deficiency diagnosed in late pregnancy had no adverse longterm outcomes, even if the fetal status was severely altered at diagnosis. References
Fig. 1. Bone marrow biopsy sample showing megaloblasts, erythroblasts, and the absence of megakaryoblasts.
10 days. Fetal growth persisted at less than the fifth percentile, but the amount of amniotic fluid and umbilical blood flow pattern were normal. Magnetic resonance imaging of the fetal brain detected no significant anomalies.
[1] Stibbe KJ, Wildschut HI, Lugtenburg PJ. Management of aplastic anemia in a woman during pregnancy: a case report. J Med Case Rep 2011;5:66. [2] Varma R, Wallace R, Barton C. Successful outcome following preterm abruption complicated by pancytopenia secondary to folate deficiency: important learning points. J Matern Fetal Neonatal Med 2004;15(2):138–40. [3] Weinzierl EP, Arber DA. The differential diagnosis and bone marrow evaluation of new-onset pancytopenia. Am J Clin Pathol 2013;139(1):9–29. [4] Van de Velde A, Van Droogenbroeck J, Tjalma W, Jorens PG, Schroyens W, Berneman Z. Folate and Vitamin B(12) deficiency presenting as pancytopenia in pregnancy: a case report and review of the literature. Eur J Obstet Gynecol Reprod Biol 2002; 100(2):251–4.
http://dx.doi.org/10.1016/j.ijgo.2015.02.020 0020-7292/© 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Transient recurrent laryngeal nerve paresis after shoulder dystocia Dubravko Habek ⁎ Department of Obstetrics and Gynecology, University Hospital “Sveti Duh” Zagreb, Croatian Catholic University, Zagreb, Croatia
a r t i c l e
i n f o
Article history: Received 24 October 2014 Received in revised form 5 December 2014 Accepted 19 February 2015 Keywords: Injury Larynx Nerve paresis Shoulder dystocia
Shoulder dystocia is an unpredictable and unexpected obstetric emergency associated with major fetal and maternal complications. Dajani and Magann [1] reported that brachial plexus palsy is noted in 4.4% of cases, humerus and clavicle fractures in 10.6%, hypoxic ischemic encephalopathy in 0.5%–23%, and fetal death in 0.4%. Soft tissue lesions of the neck are rarely described. In February, 2013, a woman aged 29 years with a parity of two delivered a live male macrosomic newborn (4860 g, 54 cm) in the maternity ward of the University Hospital “Sveti Duh”, Zagreb, Croatia. The ⁎ Department of Obstetrics and Gynecology, University Hospital “Sveti Duh” Zagreb, Croatian Catholic University Zagreb, Sveti Duh 64, 10000 Zagreb, Croatia. Tel.: +385 1 3712317; fax: +385 1 3745534. E-mail address: [email protected].
pregnancy had progressed normally, although the mother had controlled gestational diabetes. After passing through the normal stages, the labor became complicated by shoulder dystocia, which was relieved by McRoberts’ and Resnik’s maneuvers. The newborn's 1-minute Apgar score was 8 and the 5-minute score was 9, but he cried with a rasping, low, and broken voice. Oxygen saturation and breathing were normal, and clinical examination and laryngobronchoscopy revealed no injury, except for a mildly paretic and swollen vocal cord. Therefore, recurrent nerve lesion was suspected. The neonate was observed closely, and, 3 hours after birth, his crying was loud and penetrating. At 6 hours, the clinical and laryngoscopy findings were normal. The newborn was discharged on the third day with his mother. It was concluded that the initial vocal problems were probably due to compression as a result of local edema caused by the use of head traction to relieve shoulder dystocia. Neonatal cervical injuries can be associated with traumatic labor, shoulder dystocia, and endotracheal intubation, as described in several reports [2–4]. Obstetric maneuvers to relieve shoulder dystocia should be performed carefully and cautiously, with minimal neck and head manipulation. However, most nerve lesions occurring during resolution of shoulder dystocia cannot be prevented, as demonstrated by the present report.
Conflict of interest The author has no conflicts of interest.
88
BRIEF COMMUNICATIONS
References [1] Dajani NK, Magann EF. Complications of shoulder dystocia. Semin Perinatol 2014; 38(4):201–4. [2] Wittekindt C, Kribs A, Roth B, Streppel M. Rupture of the larynx in a newborn. Obstet Gynecol 2002;99(5 Pt 2):904–6.
[3] Mahieu HF, de Bree R, Ekkelkamp S, Sibarani-Ponsen RD, Haasnoot K. Tracheal and laryngeal rupture in neonates: complication of delivery or of intubation? Ann Otol Rhinol Laryngol 2004;113(10):786–92. [4] de Bree R, Van Nieuwkerk EB, Vos A, Ekkelkamp S, Sibarani-Ponsen RD, Haasnoot K, et al. Rupture of larynx or trachea resulting from injuries sustained at birth. Ned Tijdschr Geneeskd 1999;143(30):1564–8.
http://dx.doi.org/10.1016/j.ijgo.2014.12.010 0020-7292/© 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.