Female Genital Trauma Associated With Breech Presentation
A girl was delivered via cesarean delivery at 28 weeks of gestation to a 32-year-old primiparous woman. The pregnancy had been uneventful aside from the preterm labor, for which the mother had been admitted to the hospital 3 days before delivery.
Magnesium sulfate had been started for tocolysis but had failed to inhibit contractions. The infant was born by way of elective cesarean birth as a result of breech presentation and preterm labor. The membrane ruptured 1 hour before the delivery.
The neonate’s Apgar score was 6 and 8 at 1 and 5 minutes, respectively. She weighed 1,285 g (75th percentile), measured 40 cm (75th percentile) long, and had a head circumference of 29 cm (50th percentile).
Physical examination findings were unremarkable except for ecchymosis of the labia majora and bluish black discoloration of the labia minora, clitoris, and hymen (Figure 1).
Figure 1. In this photograph taken few hours after birth, note the ecchymosis of the labia majora and the bluish black labia minora and lower part of the clitoris.
By postnatal day 3, the ecchymosis of the labia majora had largely resolved, as had much (but not all) of the necrosis of the labia minora (Figure 2). By day 7, the ecchymosis of the labia majora and the necrotic darkening of the clitoris and labia minora had completely resolved (Figure 3).
Figure 2. On day 3, necrosis was still visible on the clitoris but was almost absent on the labia minora; the ecchymosis on the labia majora had resolved completely.
DISCUSSION
Breech presentation occurs in 3% to 4% of all deliveries. The frequency increases with maternal age and parity, with 87% of fetuses with breech presentation born to multigravidas in one case series.1 The incidence of fetal breech presentation decreases as gestational age increases: 33% at 21 to 24 weeks, 28% at 25 to 28 weeks, 14% at 29 to 32 weeks, 9% at 33 to 36 weeks, and 7% at 37 to 40 weeks.2
Perinatal mortality increases twofold to fourfold with breech presentation; perinatal mortality associated with vaginal breech delivery is 5 to 10 times higher than with a planned cesarean delivery.1 At autopsy, the organs that most frequently have been found injured (in descending order of frequency) are the brain, the spinal cord, the liver, the adrenal glands, and the spleen.3 Neonatal morbidity in infants with breech presentation result from asphyxia, prolapsed cord, skeletal injuries (eg, hip/knee dislocation, clavicular/long bone fractures, separation of epiphyses), neuromuscular injuries (eg, brachial plexus injuries, torticollis), and genital injuries (scrotal/testicular injury, labial injury).3
Figure 3. Photographs taken on day 7 (top) and day 10 (bottom) show that the ecchymosis and necrosis of the clitoris, labia minora, and labia majora had completely resolved.
Neonatal genital trauma is quite rare, especially in female newborns. The neonatal male genitalia are more prone to injury than are the female genitalia. Reported neonatal male genital injuries secondary to breech deliveries include scrotal hematoma, scrotal rupture, and anorchia.4,5 Genital trauma is more common in infants with a birth of 2,500 g or greater.
There appears to be only one report in the literature of a full-term neonatal female genital with injuries associated with breech presentation.6
Theoretically, this rare injury and resulting necrosis of the genitalia as a complication of breech presentation may be prevented by cesarean delivery without a trial of labor. Our case demonstrates that a serious injury of the female genitalia in a very-low-birth weight fetus with breech presentation still can occur without a trial of labor. To the best of our knowledge, our patient is the first report of a preterm female neonate with genital injury secondary to breech presentation.
REFERENCES:
1. Jadoon S, Jadoon SMK, Shah R. Maternal and neonatal complications in term breech delivered vaginally. J Coll Physicians Surg Pak. 2008;18(9):555-558.
2. Jenis AD. Breech delivery. Medscape. http://
reference.medscape.com/article/797690-overview#a0199. Updated April 4, 2012.
Accessed October 18, 2013.
3. Breech presentation and delivery. In: Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap LC III, Wenstrom KD. Williams Obstetrics. 22nd ed. New York, NY: McGraw Hill; 2010: 565-586.
4. Negrine R, Easter W, Fraser I, Ellis S. Neonatal testicular trauma: scrotal rupture. Arch Dis Child Fetal Neonatal Ed. 2010;95(3):F193.
5. Tiwary CM. Testicular injury in breech delivery: possible implications. Urology. 1989;34(4):210-212.
6. Carceller A, Dansereau C, Blanchard H. Neonatal genital trauma associated with breech presentation. CMAJ. 2002;166(10):1306-1307.
Dr Puvabanditsin, Dr Khan, Dr Torres, and Dr Mahadeo are in the Department of Pediatrics at Rutgers Robert Wood Johnson Medical School in New Brunswick, New Jersey. Dr Garrow is an associate professor in the Department of Surgery at SUNY Downstate Medical Center in Brooklyn, New York.