1976, British Journal of Radiology, 49, 580-582
Fetal cervical hypertension in breech presentation By J. G. B. Russell and Margaret R. C. Aird St. Mary's Hospital, Manchester 13 (Received April, 1975)
The causes of a hyperextended neck in a breech presentation (a "stargazing fetus") were listed by Behrman (1962) who found 14 associated factors. He believed fetal hypertonicity was the usual cause. The finding of this posture is important because cervical cord injury may be caused, and become apparent after delivery (Hellstrom and Sallmander, 1968; Caterini et al, 1975). More recently Birnbaum (1971) described a further association, in six cases, of cervical hyperextension with Down's syndrome, and all the Down's syndrome fetuses
radiographed had cervical hyperextension. A fetus with cervical hyperextension and transverse lie was illustrated by Rosslin (1513). We have reviewed 71 Down's syndrome births occurring from 1963 to 1974 in this hospital. Of these 15 had been radiographed antenatally, and seven were shown to have an abnormal posture. Four, at bone ages 36, 39, 37 and 34 weeks, were "stargazers" (Fig. 1). The abnormal postures in the other three were: one, a face presentation (bone age 36 weeks); the second, a transverse lie (bone age 37 weeks) with a laterally flexed neck (Fig. 2); and the third, a laterally flexed body (bone age 36 weeks) with head presentation (Fig. 3). A search was made of the radiological examinations in the period 1972-74 to look for stargazing fetuses: eight were found in 4,130 (0-19 per cent)
FIG. 1. 'Stargazing" fetus, which on delivery was diagnosed as a Down's syndrome.
FIG. 2. Transverse lie, with a laterally flexed neck, associated with Down's svndrome.
ABSTRACT
A review has been made of Down's syndrome patients who were radiographed as fetuses and the majority were found to be in abnormal postures, often "star gazing". Further review of "star gazing" fetuses showed that two of eight were normal and the rest were abnormal. Hypotonia was a frequent association.
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JULY
1976
Fetal cervical hypertension in breech presentation
FIG. 3. Another fetus with Down's syndrome with lateral spinal flexion.
examinations. Three of these were mongols, included above. Two were normal fetuses. The sixth had cervical hyperextension which persisted for three months after delivery, but who is now considered neurologically normal. The remaining two were severely hypotonic. The seventh had strikingly poor muscle bulk and tone, and no tendon reflexes were elicited. The hips were subluxed and there was bilateral talipes equinovarus. The baby fed well and is now gaining weight, being treated for its deformities, and the muscle tone is improving. The eighth infant had deformities of the hands and feet and micrognathia. The limb bones fractured easily. He died at five days, and a diagnosis of arthrogryposis (amyoplasia congenita) was made (Fig. 4). No cord injury was seen at autopsy. DISCUSSION
In our experience nearly half the fetuses with Down's syndrome near term show an abnormal posture, and frequently they are "stargazers". Out of eight consecutive "stargazers" six were abnormal. Five showed degrees of hypotonia and one had hypertonia of the neck, persisting for three months. Injury to the cervical cords apparent after delivery of "stargazers" has been clearly demonstrated
FIG. 4. "Stargazing" fetus, with arthrogryposis (amyoplasia congenita). Note the thinness of the long bones.
(Behrman, 1962). It has not been definitely established whether this develops during pregnancy or during labour. Caesarian section has been advocated for "stargazers" to reduce the risk of injury (Bhagwanani et ah, 1973; Caterini et al., 1975) although Taylor (1948) records a case of cervical cord injury after caesarian section on a "stargazing" fetus. It seems probable that in the majority of cases hypotonia allows an abnormal posture of the fetus, rather than the posture causing cord injury giving a secondary hypotonia. Both the last two cases we describe had signs indicating hypotonia of some duration—poor muscle bulk, joint subluxation or osteoporosis, and could not have had a primary injury of the cord during delivery. It remains a possibility that a hypotonic Down's syndrome baby finds itself a "stargazer" and then sustains a cervical cord injury, accentuating the hypotonia—cord injuries in the new born are difficult to diagnose clinically. Rarely a large neck tumour will cause cervical hyperextension in a fetus. We have seen this twice, outside the period of this review. Near term the
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J. G. B. Russell and Margaret R. C. Aird hyoid is calcified and in a neck tumour is displaced from its usual position near the mandibular angle. In both our cases the tumour showed calcification (Russell, 1973) which again allows an antenatal diagnosis. Abnormal postures of fetuses are not unusual with plural pregnancies, and the finding is probably of less significance in these circumstances. One of our Down's syndrome patients had a face presentation. There were 177 face presentations during the period of the review who had not Down's syndrome, so Down's syndrome is not likely with this finding. Other causes of cervical hyperextension suggested by Behrman include uterine tumours and uterine malformations. Skeletal changes in Down's syndrome are common, e.g. in the pelvis and fingers, but their demonstration requires careful radiographic positioning, and it is not possible to see these antenatally.
REFERENCES BEHRMAN, S. J., 1962. Fetal cervical hyperextension. Clinical Obstetrics and Gynecology, 5, 1018-1030. BHAGWANANI, S. G., PRICE, H. V., LAWRENCE, K. M., and
GINZ, B., 1972. Risks and prevention of cervical cord injury in the management of breech presentation with hyperextension of the fetal head. American Journal of Obstetrics and Gynecology, 115, 1159-1161. BIRNBAUM, S. J., 1971. Prenatal diagnosis of mongolism by X-ray. Obstetrics and Gynecology, 37, 394—395. CATERINI, H., LANGER, A., SAMA, J. C , DEVANESAN, M.,
and PELOSI, M. A., 1975. Fetal risk in hyperextension of the fetal head in breach presentation. American Journal of Obstetrics and Gynecology, 123, 632—636. HELLSTROM, B., and SALLMANDER, U., 1968. Prevention of
spinal cord injury in hyperextension of the fetal head. Journal of the American Medical Association, 204,107-110. ROSSLIN, E., 1513. Der Szvangern frawen und hebammen roszgarten. (Hagenan H. Gran, 1513. Reprinted Miinchen, Kuhn, 1910). RUSSELL, J. G. B., 1973. Radiology in Obstetrics and Antenatal Paediatrics, p. 219 (Butterworths, London). TAYLOR, H. C , 1948. Breech presentation with hyperextension of the neck and intrauterine dislocation of cervical vertebrae. American Journal of Obstetrics and Gynecology, 56, 381-383.
Book review Basic Radiation Biology. By D. J. Pizzarello and R. L. Witcofski, pp. ix+143, 1975 (Philadelphia, Lea and Febiger, Distributed in U.K. by Henry Kimpton Publishers London), £5-90. There are now quite a number of text-books which are intended to convey the elements of radiobiology to students, radiology residents, radiologists and radiation physicists. But to insist that there is a "best" one which makes the rest redundant is to deny the differing demands set by requirements, taste or temperament. This volume will appeal to those potential readers who are intimidated by big books containing unrelieved stretches of print, especially if it is only a basic knowledge they can hope to get from such dreary involvement. Here, we have the subject adequately covered in 18 chapters and two appendices (one on dose measurement and one on techniques for irradiating cells or animals)—all within 150 pages. Very little previous knowledge is assumed, and explanations are more patient than we might expect to find in a relatively short book. Each chapter is divided into several sequentially numbered sections, few of which extend over more than one page, and ends with a concise summary. In this way, concepts or definitions are neatly parcelled. The matter is illustrated by 40 simple
figures designed more to convey the gist of a matter than to reproduce precise data. Such an appealing presentation earns forgiveness for some few errors of fact, an occasional misconception and the odd howler; such departures have been substantially reduced from the first edition. The first reported survival curve for cells irradiated in vivo, although a technique is described and the correct reference given, did not employ ascites tumours; changing the oxygen concentration in an in vitro cell system does not "change the fraction of resistant cells"— it alters the resistance of the cells uniformly; even sixth formers will resent being told that the atmospheric pressure is 760 mm Hg and that air contains 21 per cent oxygen; and an informed layman may question: " . . . a hysterical state resembling meningitis . . . ". We can set beside these minor irritations the exceptionally good accounts of the haematopoetic, gastrointestinal and cerebrovascular syndromes; few of the rival volumes mention that the response of the gastro-intestinal tract is affected by coincident damage to the marrow. There is a lot to be said for a study course attractively laid out in a relatively cheap book with a narrow spine
582
H. B. HEWITT.
Fetal cervical hypertension in breech presentation By J. G. B. Russell and Margaret R. C. Aird St. Mary's Hospital, Manchester 13 (Received April, 1975)
The causes of a hyperextended neck in a breech presentation (a "stargazing fetus") were listed by Behrman (1962) who found 14 associated factors. He believed fetal hypertonicity was the usual cause. The finding of this posture is important because cervical cord injury may be caused, and become apparent after delivery (Hellstrom and Sallmander, 1968; Caterini et al, 1975). More recently Birnbaum (1971) described a further association, in six cases, of cervical hyperextension with Down's syndrome, and all the Down's syndrome fetuses
radiographed had cervical hyperextension. A fetus with cervical hyperextension and transverse lie was illustrated by Rosslin (1513). We have reviewed 71 Down's syndrome births occurring from 1963 to 1974 in this hospital. Of these 15 had been radiographed antenatally, and seven were shown to have an abnormal posture. Four, at bone ages 36, 39, 37 and 34 weeks, were "stargazers" (Fig. 1). The abnormal postures in the other three were: one, a face presentation (bone age 36 weeks); the second, a transverse lie (bone age 37 weeks) with a laterally flexed neck (Fig. 2); and the third, a laterally flexed body (bone age 36 weeks) with head presentation (Fig. 3). A search was made of the radiological examinations in the period 1972-74 to look for stargazing fetuses: eight were found in 4,130 (0-19 per cent)
FIG. 1. 'Stargazing" fetus, which on delivery was diagnosed as a Down's syndrome.
FIG. 2. Transverse lie, with a laterally flexed neck, associated with Down's svndrome.
ABSTRACT
A review has been made of Down's syndrome patients who were radiographed as fetuses and the majority were found to be in abnormal postures, often "star gazing". Further review of "star gazing" fetuses showed that two of eight were normal and the rest were abnormal. Hypotonia was a frequent association.
580
JULY
1976
Fetal cervical hypertension in breech presentation
FIG. 3. Another fetus with Down's syndrome with lateral spinal flexion.
examinations. Three of these were mongols, included above. Two were normal fetuses. The sixth had cervical hyperextension which persisted for three months after delivery, but who is now considered neurologically normal. The remaining two were severely hypotonic. The seventh had strikingly poor muscle bulk and tone, and no tendon reflexes were elicited. The hips were subluxed and there was bilateral talipes equinovarus. The baby fed well and is now gaining weight, being treated for its deformities, and the muscle tone is improving. The eighth infant had deformities of the hands and feet and micrognathia. The limb bones fractured easily. He died at five days, and a diagnosis of arthrogryposis (amyoplasia congenita) was made (Fig. 4). No cord injury was seen at autopsy. DISCUSSION
In our experience nearly half the fetuses with Down's syndrome near term show an abnormal posture, and frequently they are "stargazers". Out of eight consecutive "stargazers" six were abnormal. Five showed degrees of hypotonia and one had hypertonia of the neck, persisting for three months. Injury to the cervical cords apparent after delivery of "stargazers" has been clearly demonstrated
FIG. 4. "Stargazing" fetus, with arthrogryposis (amyoplasia congenita). Note the thinness of the long bones.
(Behrman, 1962). It has not been definitely established whether this develops during pregnancy or during labour. Caesarian section has been advocated for "stargazers" to reduce the risk of injury (Bhagwanani et ah, 1973; Caterini et al., 1975) although Taylor (1948) records a case of cervical cord injury after caesarian section on a "stargazing" fetus. It seems probable that in the majority of cases hypotonia allows an abnormal posture of the fetus, rather than the posture causing cord injury giving a secondary hypotonia. Both the last two cases we describe had signs indicating hypotonia of some duration—poor muscle bulk, joint subluxation or osteoporosis, and could not have had a primary injury of the cord during delivery. It remains a possibility that a hypotonic Down's syndrome baby finds itself a "stargazer" and then sustains a cervical cord injury, accentuating the hypotonia—cord injuries in the new born are difficult to diagnose clinically. Rarely a large neck tumour will cause cervical hyperextension in a fetus. We have seen this twice, outside the period of this review. Near term the
581
VOL. 49, No. 583
J. G. B. Russell and Margaret R. C. Aird hyoid is calcified and in a neck tumour is displaced from its usual position near the mandibular angle. In both our cases the tumour showed calcification (Russell, 1973) which again allows an antenatal diagnosis. Abnormal postures of fetuses are not unusual with plural pregnancies, and the finding is probably of less significance in these circumstances. One of our Down's syndrome patients had a face presentation. There were 177 face presentations during the period of the review who had not Down's syndrome, so Down's syndrome is not likely with this finding. Other causes of cervical hyperextension suggested by Behrman include uterine tumours and uterine malformations. Skeletal changes in Down's syndrome are common, e.g. in the pelvis and fingers, but their demonstration requires careful radiographic positioning, and it is not possible to see these antenatally.
REFERENCES BEHRMAN, S. J., 1962. Fetal cervical hyperextension. Clinical Obstetrics and Gynecology, 5, 1018-1030. BHAGWANANI, S. G., PRICE, H. V., LAWRENCE, K. M., and
GINZ, B., 1972. Risks and prevention of cervical cord injury in the management of breech presentation with hyperextension of the fetal head. American Journal of Obstetrics and Gynecology, 115, 1159-1161. BIRNBAUM, S. J., 1971. Prenatal diagnosis of mongolism by X-ray. Obstetrics and Gynecology, 37, 394—395. CATERINI, H., LANGER, A., SAMA, J. C , DEVANESAN, M.,
and PELOSI, M. A., 1975. Fetal risk in hyperextension of the fetal head in breach presentation. American Journal of Obstetrics and Gynecology, 123, 632—636. HELLSTROM, B., and SALLMANDER, U., 1968. Prevention of
spinal cord injury in hyperextension of the fetal head. Journal of the American Medical Association, 204,107-110. ROSSLIN, E., 1513. Der Szvangern frawen und hebammen roszgarten. (Hagenan H. Gran, 1513. Reprinted Miinchen, Kuhn, 1910). RUSSELL, J. G. B., 1973. Radiology in Obstetrics and Antenatal Paediatrics, p. 219 (Butterworths, London). TAYLOR, H. C , 1948. Breech presentation with hyperextension of the neck and intrauterine dislocation of cervical vertebrae. American Journal of Obstetrics and Gynecology, 56, 381-383.
Book review Basic Radiation Biology. By D. J. Pizzarello and R. L. Witcofski, pp. ix+143, 1975 (Philadelphia, Lea and Febiger, Distributed in U.K. by Henry Kimpton Publishers London), £5-90. There are now quite a number of text-books which are intended to convey the elements of radiobiology to students, radiology residents, radiologists and radiation physicists. But to insist that there is a "best" one which makes the rest redundant is to deny the differing demands set by requirements, taste or temperament. This volume will appeal to those potential readers who are intimidated by big books containing unrelieved stretches of print, especially if it is only a basic knowledge they can hope to get from such dreary involvement. Here, we have the subject adequately covered in 18 chapters and two appendices (one on dose measurement and one on techniques for irradiating cells or animals)—all within 150 pages. Very little previous knowledge is assumed, and explanations are more patient than we might expect to find in a relatively short book. Each chapter is divided into several sequentially numbered sections, few of which extend over more than one page, and ends with a concise summary. In this way, concepts or definitions are neatly parcelled. The matter is illustrated by 40 simple
figures designed more to convey the gist of a matter than to reproduce precise data. Such an appealing presentation earns forgiveness for some few errors of fact, an occasional misconception and the odd howler; such departures have been substantially reduced from the first edition. The first reported survival curve for cells irradiated in vivo, although a technique is described and the correct reference given, did not employ ascites tumours; changing the oxygen concentration in an in vitro cell system does not "change the fraction of resistant cells"— it alters the resistance of the cells uniformly; even sixth formers will resent being told that the atmospheric pressure is 760 mm Hg and that air contains 21 per cent oxygen; and an informed layman may question: " . . . a hysterical state resembling meningitis . . . ". We can set beside these minor irritations the exceptionally good accounts of the haematopoetic, gastrointestinal and cerebrovascular syndromes; few of the rival volumes mention that the response of the gastro-intestinal tract is affected by coincident damage to the marrow. There is a lot to be said for a study course attractively laid out in a relatively cheap book with a narrow spine
582
H. B. HEWITT.
