Laurence Baskin, MD, presents the case of a baby boy who had a tough forceps delivery, with accompanying sonographic images.
A newborn baby boy had a tough forceps delivery. Exhibit 1 (above) is a gross photograph of his genitalia.
Sonogram of the right kidney and retroperitoneum
Exhibits 2 and 3 are two representative sonographic images of right kidney.
D. Adrenal hemorrhage (with scrotal ecchymosis)
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.
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.
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Neonatal adrenal hematoma: various modes of presentation. Arch Pediatr 2014; 21:990-4.