Sudden Collapse of a Newborn Infant Following Delivery Complicated by Shoulder Dystocia

To editor: Shoulder dystocia (SD) constitutes an obstetric emergency, bearing associations with maternal and neonatal morbidity due to its unique pathophysiology. In a comprehensive series involving 228,438 women, SD occurred in 2159 patients, accounting for 1.7% of the total.1 Various techniques have been described to facilitate successful delivery in SD patients;2 however, these maneuvers are not without associated complications.3 This correspondence highlights a case of a newborn experiencing a collapse following such a delivery. The guardian granted written and informed consent for the publication of the patient's clinical information and associated images. Case presentation The delivery involved a male infant weighing 3800 gram, born at 395/7 weeks of gestation through vacuum-assisted vaginal delivery, and was further complicated by meconium-stained amniotic fluid, fetal decelerations, and shoulder dystocia. The delivery physicians used the McRoberts maneuver and applied suprapubic pressure with Kiwi's vacuum device (utilizing the cup and hand pump suction). The Apgar scores at 1 and 5 minutes were 5 and 7, respectively. Analysis of cord venous gas revealed a pH of 7.27, pCO2 of 31, pO2 of 33, HCO3 of 15, and a base excess of 12.5, while cord arterial gas analysis indicated a pH of 7.14, pCO2 of 51, pO2 of 15, HCO3 of 24, and a base excess of 11. After delivery, the infant developed respiratory distress in the delivery room, necessitating placement on continuous positive airway pressure, and subsequent transfer to the neonatal intensive care unit (NICU). In the NICU, the infant, while under continuous observation, exhibited sudden lethargy accompanied by hypotonia. A moderate caput succedaneum/cephalohematoma was identified along with overriding sutures. The abdomen presented as soft, with no palpable mass at the initial assessment. The initial hematocrit, measured at 39.5%, declined to 22.2% at three hours of life and further to 17% at six hours of life. In the NICU, infant was transfused blood for a hematocrit of 22%. Abdominal magnetic resonance imaging (MRI) revealed a moderate-sized hepatic subcapsular hematoma. Elevated liver enzymes were observed, with aspartate aminotransferase 290 U/L, and alanine aminotransferase 100 U/L, while ammonia level remained normal, and lactate levels increased. A head computerized tomography scan showed no intracranial bleeding. Abdominal MRI revealed a moderate-sized hepatic subcapsular hematoma (Fig. 1A). Mother was actively involved in the NICU care. Parents had emotional moments as the hepatic subcapsular bleed had the potential of extension. They were provided with extensive counseling and support by the NICU multidisciplinary team.Figure 1: Hepatic subcapsular mass and follow-up imaging. A Abdominal MRI, axial plane, shows the right upper quadrant biconvex shape hepatic subcapsular mass. White lines represent the extent of the bleeding. B A follow-up liver ultrasound performed at 7 months of age shows the hepatic parenchyma with normal echogenicity and contour. There is no sonographic evidence of focal lesions or intrahepatic biliary dilatation. MRI: magnetic resonance imaging.Although a surgical consultation was obtained, the decision to clinically observe the bleeding with frequent follow-ups was made because of the high risk of intervention-related complications. By day eight, the infant's hematocrit stabilized after packed red cell transfusions. Serial ultrasonograms were employed to monitor the resolution of the hematoma. A follow-up liver ultrasound conducted at seven months of age indicated results within normal limits (Fig. 1B). The infant was discharged home with close follow-up. Infant was followed by the primary care provider in addition to high-risk neonatology developmental clinic. At the last clinic visit at 2.5 years of age, he exhibited no neurological deficits and was in overall good health, demonstrating age-appropriate developmental milestones. Discussion Hepatic subcapsular hematoma is a rare occurrence in newborns but can pose a life-threatening risk. Hepatic injury may be associated with a traumatic birth, particularly in cases involving obstetric maneuvers for managing shoulder dystocia, as evidenced by a high incidence of birth injuries in comparative studies.3 A study by Singer et al.4 analyzed 755 perinatal autopsies and found that 2.8% of infants exhibited hepatic subcapsular hematomas. The severity and presentation of hepatic subcapsular hematomas can vary widely, presenting a challenge in identification.5,6 The case presented here suggests a potential pathophysiology related to the compression of the infant's torso during delivery, resulting in liver injury. The subcapsular tear confined the blood to the liver, and no peritoneal bleeding was observed. The tear in the liver healed over time, and the infant's recovery was favorable. Conclusion In conclusion, shoulder dystocia remains unpredictable, and effective management in the labor room may have positive implications for the newborn beyond that immediate setting. Careful observation and thorough follow-up are essential in all cases of deliveries complicated by shoulder dystocia.