Laurence Baskin, MD, presents the case of a baby boy who had a tough forceps delivery, with accompanying sonographic images.
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.
Investigators prepare for first-in-human bladder transplant study
September 13th 2023"Our study is the first report of bladder auto-transplantation in heart-beating, brain-dead human research donors as a necessary preparatory step toward clinical bladder transplantation in living patients," says Inderbir S. Gill, MD.
Dr. Benjamin N. Breyer appointed chair of the UCSF Department of Urology
August 24th 2023Benjamin N. Breyer, MD, is a urologic surgeon who is internationally known for performing complex urethral and penile reconstruction for urethra stricture and cosmetic disfigurement, male incontinence, male fistula, and surgery for erectile dysfunction.
Study set to explore the impact of peer-support for patients undergoing gender-affirming surgery
July 21st 2023"Extra support from trusted peers can help make navigating complex health care systems easier for transgender patients, who often have to wait years before receiving gender-affirming genital surgery—while also managing the stress and trauma associated with being part of a society that often doesn’t accept non-conforming gender expression,” says Geolani Dy, MD, FACS