Quiz: Baby boy with difficult forceps delivery

Exhibit 1.

A newborn baby boy had a tough forceps delivery. Exhibit 1 (above) is a gross photograph of his genitalia.

Exhibit 2.

Exhibit 3.

Sonogram of the right kidney and retroperitoneum

Exhibits 2 and 3 are two representative sonographic images of right kidney.

Continue to the next page for the answer.

Answer

D. Adrenal hemorrhage (with scrotal ecchymosis)

Discussion

Forceps delivery can be associated with trauma. In this baby, a scrotal sonogram is indicated secondary to the color changes on the physical exam to rule out testicular fracture/hematoma/torsion.

On critical evaluation of the genital photograph, (Exhibit 1) the scrotum looks symmetric except for color. Some swelling and changes in the size of the testis would be expected in the case of in utero torsion.

Forceps deliveries are also associated with adrenal trauma, the adrenal gland being relatively large in the fetus and neonate. Therefore, a sonogram of the kidneys is also indicated, which in this case shows the typical complex adrenal hemorrhage (Exhibits 2 and 3). This complex mass can be confused with tumors, the most common being neuroblastoma. However, common things happen more commonly, and adrenal hemorrhage in the setting of a traumatic delivery is the most likely diagnosis.

Exhibit 4.

MRI showing a suprarenal complex mass above the right kidney consistent with adrenal hemorrhage

Obtaining 24-hour urine for VMA and OVA and potentially an MRI (Exhibit 4) will rule out neuroblastoma. A better choice is follow-up with physical exam, sonogram, and acutely serial hematocrits, which will show resolution of the scrotal ecchymosis and adrenal hemorrhage, ruling out a duplex system with an ectopic ureter, tumor, and segmental renal dysplasia.

Dr. Baskin, professor of pediatric urology at the University of California, San Francisco, is section editor for Urology Times Pediatric Quiz.

Suggested reading

Hemiscrotal hematoma in the newborn-don't forget adrenal hemorrhage. J Pediatr 2015; 166:491-91.e1.

Adrenal haemorrhage in term neonates: a retrospective study from the period 2001-2013. J Matern Fetal Neonatal Med 2015; 28:2062-5.

Neonatal adrenal hematoma: various modes of presentation. Arch Pediatr 2014; 21:990-4.