From the Department of Dermatology, Sourasky Medical Center (Drs Metzker and Brenner), the Department of Neonatology, Rabin Medical Center, Beilinson Campus (Dr Merlob), Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv (Drs Metzker, Brenner, and Merlob), Israel.
Iatrogenic cutaneous injuries of the neonate have decreased in number in the last 30 years because of changes in the medical procedures during the prenatal, perinatal, and postnatal periods.
The emergence of such cutaneous injuries derived from the use of instruments, blunt and sharp, from manual manipulations, from medications, and from hesitation or abstaining from intervention.
The dermatologist, unfamiliar with handling of neonates in the nursery, should be capable of recognizing and dealing with these phenomena when encountered in the acute stage or with their residue.
THE PROGRESS in medical knowledge and technology in the last 30 years has decreased the incidence of birth injuries, from 5.6 per 1000 live births from 1931 to 1941 to 0.22 from 1973 to 1974,1 and even more since then. However, iatrogenic injury has not yet been completely eliminated, although its nature and causes have changed.
With the changing modes of diagnosis and treatment during pregnancy and delivery, iatrogenic cutaneous lesions are rare in the newborn. Dermatologists must be able to recognize them in the acute stage for proper management, and to recognize the appearance of residual lesions as well.
There are no current comprehensive studies of iatrogenic injury, though a number of reviews list those that have become obsolete.1- 3 The purpose of this work is to describe the cutaneous injuries that may occur in the newborn as a consequence of prenatal, perinatal and postnatal medical procedures. However, many of these cutaneous lesions have multiple causes, and iatrogenic injury is only one of them (Table 1).
Amniocentesis is widely used today to determine the presence of certain suspected genetic diseases in the fetus. If the aspirating needle meets fetal skin, it may leave a dimpled scar on the neonatal trunk, extremities, or ears (Figure 1). The diagnosis is supported by careful examination and history.4 This type of scar may also be caused by fetal skin biopsy, but one has to keep in mind other scarring causes that mimic this finding, such as amniotic band or partial ainhum. Thanks to the sterile in utero environment, the wound heals promptly.
A deep dimplelike scar (0.4×0.2 cm) on the abdomen of a newborn, caused by amniocentesis.
Amniography, performed incorrectly, can lead to severe complications. Errors include injection of the contrast material into fetal tissue instead of the amnion fluid (Figure 2 and Figure 3). The injection may introduce infection, leading to staphylococcal scalded skin syndrome, or to toxic epidermal necrolysis in reaction to the iodine in the contrast material. This will result in premature delivery and severe shedding of the skin (Figure 4). Similar harmful effects have been noted after failed emergency intrauterine fetal transfusions and blood exchange.
A gaping wound on the lower part of the neck caused by injection of contrast material during an amniography trial.
Chest x-ray film showing the contrast material injected into the neck of the fetus in Figure 2.
One-day-old newborn with toxic epidermal necrolysis syndrome whose mother had had amniography 10 days earlier.
A survey reported a 3-fold increased incidence of hemangiomas in infants born after chorionic villus sampling,5 a phenomenon that has no plausible explanation.
Monitoring of the fetal heart is common during uterine contractions; a spiral electrode is applied to the presenting vertex of the fetus in the early stage of labor. In a recent work, neonatal scalp changes were found in 41.3% of monitored infants. These were mainly attributed to 2 factors: duration of monitoring and primiparity.6 Though the procedure is usually nontraumatic, if the electrode is abruptly removed, the fetus may suffer a mild laceration or tear or, rarely, a small ulcer or abscess (Figure 5). Multiple tiny ulcers may also result from the accidental separation of the electrode from the scalp (because of the mother's vigorous movements during contractions) and its subsequent reapplication. This yields a small scarred alopecia (Figure 6), often mistaken for congenital cutis aplasia or for organoid nevus, focal dermal hypoplasia, or obscuring meningomyelocele. Very rarely the electrode can damage the fetus' ears, eyes, or face or penetrate through the fontanels.
Ulcer with granulation on a newborn's scalp, 3 days after monitoring during labor.
Scars on the scalp after numerous applications of monitoring electrodes during labor.
Amniotomy or episiotomy may be performed to ease or hasten delivery once the cervix is sufficiently opened. Too-deep penetration of the scissors may cause a laceration injury to the presenting part of the newborn (Figure 7).
Lacerations on a newborn's scalp caused by misplaced scissors during amniotomy.
On the other hand, prolonged or precipitous delivery, unattended delivery, or postponement of any procedure to hasten the birth of the infant may result in caput succedaneum (Figure 8), a diffuse edema and extravasation mostly over the presenting vertex, with no sharp borders. It appears at birth or within hours after delivery because of pressure on the scalp and subsides after up to 3 days, usually without any complications.7 However, alopecia may rarely be present in the form of a halo ring.8 One patient with sonographic demonstration of an in utero caput succedaneum was also reported.9 By contrast, cephalhematoma is a subperiosteal hemorrhage, located mainly over the parietal bones and restricted to one of the cranial bones, not extending across the sutures.10- 11 It appears as a round or oval, nonreducible mass, fluctuant at the beginning, firmer later on, without pulsation. It develops gradually 1 to 3 days after delivery and takes 3 to 8 weeks to shrink and be entirely resorbed, rarely leaving some calcification. There is no need for intervention. Secondary anemia and infection are rare, but hyperbilirubinemia is very frequent.12 Cephalhematoma often masquerades as a linear skull fracture.
An elongated, edematous scalp with an extensive caput succedaneum a few hours after delivery.
Subaponeurotic hemorrhage usually occurs in association with vacuum or forceps delivery. This hemorrhage appears at birth and is diffused along the insertion of the aponeurosa and thus extends across the lines of the sutures. It usually disappears spontaneously after 7 to 10 days. Very rarely is it complicated by anemia and hemorrhagic shock.
The availability today of easier and safer agents for spinal anesthesia have increased the use of cesarean section to circumvent difficulties in the passage of the newborn through the birth canal. In cases that require rapid extraction of the neonate from the uterus (neonatal distress or avoiding superfluous anesthesia), a misplaced cut by the scalpel may cause a laceration on the trunk, extremities, or face of the newborn (Figure 9).
Deep laceration on the shoulder that occurred during cesarean section.
Delay in delivery is overcome with vacuum extraction (Figure 10), wherein controlled suction pressure is applied so that the bell of the extractor will adhere to the presenting vertex. Mild ecchymoses are hardly avoidable in these cases, but at times there is severe purpura, edema, or even hematomas of different degrees.13- 14 These will subside spontaneously; the superficial lesions need only topical care to prevent secondary infection. Very rarely is slight subcutaneous emphysema observed after vacuum extraction applied in the region of the scalp electrode.15
Annular arrangement of suction blisters after application of vacuum extraction; mild ecchymoses are seen in the surrounding skin.
Difficult delivery of the shoulders in vertex presentation and extended arms in breech deliveries are the major causes of clavicular fracture (prevalence, 2.7%-29%). Edema with a full supraclavicular fossa and hematoma, together with the difficulty in feeling the margins of the affected clavicle, and sometimes crepitation on palpation, should raise the suspicion of clavicular fracture. It has also been described to cause difficulty during breast-feeding on one side. A callus appears at 7 to 10 days of life; at this stage no further therapy is needed. Later, the clavicle returns to its normal configuration.16- 17
Sudden onset of increased intrathoracic pressure (Valsalva maneuver) during extraction of the neonate from the birth canal will manifest as purpura on the upper part of the chest and the face. The purpura, caused by rupture of capillaries, is not associated with any platelet dysfunction, thrombocytopenia, coagulation defect, or infection and will resolve spontaneously within days.18
Manually aided vaginal delivery in breech presentation can cause severe edema of the arm (Figure 11) and Erb or Klumpke paralysis. Brachial plexus palsy is much more frequent in breech delivery (up to 2.45%) than in vertex presentation (0.14%).19 The prognosis depends on the severity and extent of the lesion; usually 88% will resolve by 8 months and 92% by 1 year of age. In persistent cases, trophic ulcers can develop later. Not all brachial plexus palsies are the result of trauma; in some of them, intrauterine maladaptation may play a role.20- 21
Edema and ecchymosis of the left arm after breech presentation delivery.
Edema of the upper part of the arm with redness, tenderness, and sometimes crepitation should raise the possibility of epiphyseal separation (epiphysiolysis). The clinical appearance is almost identical to that of brachial plexus palsy, but the mechanism and treatment are completely different. Traumas to the genital organs during breech delivery, particularly the penis shaft, scrotum, or labia majora, result in edema, ecchymoses, hematoma, or even deep tears (Figure 12 and
Figure 13), which can progress to extensive necrosis.
Hematoma of the scrotum that occurred after traumatic breech delivery.
Deep tear of labia majora of an infant's vulva during breech delivery.
Forceps-aided deliveries can be very traumatic in inexperienced hands. Forceps application is easily recognized by the typical configuration of hematomas on the temples and cheeks of the newborn (Figure 14). The injury varies from ecchymoses to deep erosions. Too much applied force can cause subconjunctival hemorrhages, retinal hemorrhage, and even skull fractures or skull bone depression (Figure 15 and Figure 16). Such a fracture on the base of the skull will manifest as orbital hematomas (Figure 17). The most frequent complication of forceps is facial palsy, with a prevalence of 1.8 per 1000 live births. Complete recovery is observed in 89% of these patients.
A bowlike fresh ecchymosis on a newborn's temple after forceps delivery.
Depression of the frontal bone, right side (arrow), at the moment of delivery caused by a forceful forceps application.
X-ray film of the skull demonstrating depression of the right frontal bone (arrow) in the newborn in Figure 15.
Bilateral subsiding orbital ecchymoses in a newborn a few days old resulting from hemorrhage in the base of the skull after forceful forceps delivery.
Most injuries to the neonate are iatrogenic and thus avoidable. The neonate cannot move at will, correct his or her position, or indicate the source of discomfort to the caregiver; thus, caregivers need to be on constant lookout for any disturbances.
During clamping of the umbilical cord, the midwife or obstetrician may miss and place the clamp too near neighboring organs, such as the umbilicus, the penis shaft, or the labia majora, thus causing compression wounds.
The identification tag attached to the wrist or leg at the moment of delivery can be placed too tightly, causing erosion or even laceration (Figure 18). The tag may also be a source of local irritation because of contact dermatitis.
Erythema and scaling on the ankle caused by friction because of a tightly applied identification tag.
Edema of eyelids and conjunctival irritation may be caused by contact dermatitis from the silver nitrate drops used to prevent gonorrhea (Crédè method). The recent use of antibiotic ointment is considered safe. Nevertheless, gentamicin ointment applied to the eye proved to cause primary neonatal orbital irritation from contact dermatitis.22
A newborn's skin is exposed to various chemical irritants. Potassium permanganate used in a bath can cause tiny, deep localized areas of necrosis on the skin surface, because of the presence of a few undissolved crystals (Figure 19). Prolonged contact with alcohol solution resulting from failure to properly wash it off after preoperative cleansing is widely known to cause chemical burn, and ensuing deep erythema (actually a second-degree burn) may have serious aftereffects (Figure 20). Such may be the case with iodine and povidone-iodine; topical iodine application may even cause transient hypothyroidism.23 The paste used for electroencephalography and electrocardiography too can act as a local irritant.
Two tiny lesions of necrosis after local contact with potassium permanganate crystals.
Second-degree chemical burn after prolonged contact with alcohol on a newborn's back.
Premature neonates, particularly the tiny ones, are more prone to injuries because of their very delicate constitution, their prolonged stay in the nursery, and the exposure to manipulation with sophisticated instrumentation.
Frank combustion can arise when the neonate is placed for too long on a heating pad. It leads to second- and third-degree burns with permanent scarring (Figure 21). A circumscribed burn wound and ensuing small scar has been reported mainly in premature neonates because of the heat from PO2 monitoring electrodes left for more than 30 minutes on the same spot (Figure 22). Likewise, a heating burn to the nostrils can result from supply of heated humidified air via nasal prongs.
Third-degree burn on the upper part of the back of a newborn after too close exposure to a heating radiator.
Superficial scar on a newborn's chest after localized combustion from warm PO2 monitoring electrode.
Prone positioning of the neonate will cause edema and erosions on the tip of the nose or the toes and symmetrical erosions on the knees from friction; this can lead to mild erythema or deep erosion with oozing (Figure 23).
Circumscribed erosion on the tip of the nose after continuous friction in a prone-positioned neonate.
Blood sampling by heel prick is performed with a sharp blade and results in a sharp-edged cut of 0.3 to 0.4 cm (Figure 24) that heals well within a few days, but sometimes calcifications in the form of small plaques or nodules develop on the spot. A rare complication is osteomyelitis localized to the calcaneous bone or thick scars that may become pressure-sensitive masses. Scars are also caused in various areas of the body from infusions, other types of blood sampling, central lines, percutaneous aspiration, and thoracic drains. During urgent insertion of a thorax drain, the nipple may be destroyed, with severe consequences for females later in life.
Localized inflammation of the heel around a small deep laceration after blood sampling.
The insertion of an intravenous flow catheter is only rarely associated with complications, such as local necrosis after multiple punctures of the same spot (Figure 25). After intravenous puncture, persistent white papules resembling milia may appear as a regrowth of inverted epidermis. Injection of certain medications, such as calcium gluconate, can result in local dermal calcifications (Figure 26). An immediate ill effect is secondary infection at the site of puncture; an extreme example is subcutaneous abscess on the spine after lumbar puncture (Figure 27).
An ulcer and surrounding necrosis after "cutdown" procedure on the ankle of a newborn.
Calcified remnants of intravenous calcium gluconate injection through a scalp vein.
A red swelling with an underlying sacral abscess (arrow) that developed days after a lumbar puncture.
Phototherapy applied usually to treat hyperbilirubinemia requires precaution, such as shielding the neonate's eyes; because of the heat, one may encounter generalized miliaria crystallina, which subsides promptly. Purpuric patches appeared in neonates who underwent blood transfusion and were exposed to phototherapy. The purpuric patches developed at the sites of maximal exposure, with sparing at shielded sites. The patches appeared within 24 hours after initiation of phototherapy and cleared within a week after discontinuation of phototherapy. It is suggested that the procedures provoked transient porphyrinemia in these neonates.24
Exposure of naked skin to cold produces cold panniculitis, common in underdeveloped cold-weather countries. Applications of cold compresses or ice bags on the face, as in supraventricular tachycardia, can cause localized erythema, followed by hardening of the subcutaneous tissue (Figure 28). With gradual rewarming, this kind of iatrogenic cold panniculitis has a good prognosis.25
Cold panniculitis showing a shiny swelling, hardening, and inflammation of the cheek after an ice-bag technique applied for supraventricular tachycardia.
Less favorable is the outcome of subcutaneous fat necrosis secondary to hypoxia, hypothermia, or obstetric trauma. The cutaneous lesions appear as small nodules or plaques in areas where a fat pad is present: cheeks, chest, back, buttocks, arms, and thighs. They develop gradually within 2 weeks (usually 5-10 days), first as erythema, then as circumscribed or extensive hardening of the subcutaneous tissue. After a few weeks the erythema fades, but a bluish hue persists; very rarely, some subcutaneous atrophy remains (Figure 29). Complications include transient thrombocytopenia, hypercalcemia, and calcification of the involved tissue.26
Hardening, erythematous, and warm plaque representing subcutaneous fat necrosis in a 2-week-old newborn who suffered respiratory distress at birth.
Neonatal care is becoming more and more meticulous. Correct medicolegal policies are keeping the medical team alert. Iatrogenic cutaneous injuries have not disappeared, but they are mostly fleeting and mild; incidence of the more severe ones is decreasing as the more difficult procedures are being replaced by improved techniques. Modern neonatal care aims to prevent as much as possible all unnecessary risks and exposures.
Accepted for publication December 1, 1998.
Reprints: Paul Merlob, MD, Department of Neonatology, Rabin Medical Center, Beilinson Campus, Petah Tiqva 49100, Israel (e-mail: firstname.lastname@example.org).
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