T r a u m a t i c A r t e r i o v e n o u s Fistula: A C o m p l i c a t i o n of A m n i o c e n t e s i s By Daniel J. Ledbetter and Dale G. Hall
Seattle, Washington 9 Fetal injury is a potential complication of amniocentesis. We report the case of an infant w h o had an isolated arteriovenous fistula between the popliteal artery and vein that resulted from amniocentesis. Unlike the usual congenital arteriovenous communications that are multiple and difficult to treat, this case was completely cured by division of the fistula and vascular repair. This case emphasizes that newborns and infants who have had invasive prenatal interventions such as amniocentesis should be identified and the possibility of fetal injury be considered when evaluating their clinical signs and symptoms. Copyright 9 1992 by W.B. Saunders Company INDEX WORDS: Amniocentesis; arteriovenous fistula.
A
MNIOCENTESIS is a standard technique in obstetric practice. It can cause fetal injuries that may be recognized immediately or that may only become apparent after birth.' CASE REPORT A 2-month-old girl came to medical attention because of a thrill in her right leg that had been noted for the previous month. Amniocentesis had been done during the second trimester because of advanced maternal age. The amniocentesis, the remainder of the pregnancy, labor, delivery, and first month of life were reportedly normal. Physical examination showed a grade [ to II over V] systolic heart murmur. Her legs were asymmetric with the right midthigh being 3 cm in diameter larger than the left. The right leg was also slightly longer than the left leg. The pulses in the right leg were bounding compared to the left. There was a thrill and a continuous bruit over the right lower thigh. The bruit and thrill could be obliterated by compression of the proximal right femoral artery. The skin had a small, punctate scar over the region of the thrill and bruit. There were no other skin changes. The remainder of her physical examination was normal. Chest x-ray showed slight cardiomegaly. Electrocardiogram was normal. Because of the heart murmur cardiac catheterization was performed and showed a structurally normal heart with a patent foramen ovale. There was marked elevation of oxygen saturations measured in the inferior vena cava and right atrium (93% and 89%) compared with the superior vena cava (54%), suggesting a significant left-to-right shunt in the lower half of the body. Angiography showed a markedly dilated right femoral artery and vein with early venous filling. At 41/2 months of age exploration of the right adductor canal and
From the Department of Surgery, Children ~ Hospital and Medical Center, Seattle, WA. Presented at the 24th Annual Meeting of the Pacific Association of Pediatric Surgeons, Hong Kong, May 20-24, 199l. Address reprint requests to Dale G. Hall, MD, Department of Surgery, Children's Hospital and Medical Center, 4800 Sand Point Way NE, PO Box C5371, Seattle, WA 98105. Copyright 9 1992 by W.B. Saunders Company 0022-3468/92 / 2706-0010503. O0/ 0 720
popliteal space showed a single, 0.5-cm-diameter artefiovenous fistula between the proximal popliteal artery and vein (Fig 1). The fistula was divided and the artery and vein were repaired by lateral suture. She did well postoperatively. She has been followed for 5 years and noted to have normal growth and development. She enjoys full physical activities. Her legs are of equal length and diameter, her extremity pulses are equal and symmetric, and her lower extremity blood pressures are equal. DISCUSSION
Amniocentesis is usually either done early in the second trimester to obtain cells for chromosome analysis and to determine the ~-fetoprotein level or done during the third trimester to assess fetal pulmonary maturity. In experienced hands the overall complication rate is 1OW2,3; however, a wide variety of complications have been previously reported in both the mother and the fetus, a Adverse maternal consequences are very rare but include amniotic fluid leakage, bleeding, infection, and premature labor. 2,3 Significant fetal morbidity and even mortality may result if the fetal-maternal circulation is compromised by umbilical vessel or placental trauma. 4 In addition to the fetal morbidity and mortality due to the interruption of the fetalmaternal circulation and the problems that occur because of amniocentesis-induced premature birth, there may be direct fetal injury by the amniocentesis needle. Many different fetal injuries have been reported. Some fetal injuries cause fetal distress that leads to early delivery or fetal death. Laceration of the heart has caused cardiac tamponade and fetal death. 5 Lacerations of the fetal spleen (' and kidney7 have caused fetal bleeding, which led to fetal distress and early delivery, and although the baby with renal laceration required transfusion both were managed without operation and survived. In addition to amniocentesis-induced fetal bleeding there have been several cases of neonatal pneumothorax after apparent amniocentesis needle penetration of the chest. 1,8 Other fetal injuries have not resulted in fetal distress but have been noted postnatally. Probably the most common fetal injury resulting from amniocentesis is skin penetration leading to cutaneous scars, depressions, or dimples. 1 They can be an isolated injury or, as in this case, a marker of underlying internal injury. 6,8-~~Others have observed a remarkable lack of scarring after fetal skin incision and excision in a variety of experimental models and a few Journal of Pediatric Surgery, Vol 27, No 6 (June), 1992: pp 720-721
TRAUMATIC ARTERIOVENOUS FISTULA
J ,
~ ~.~,
b l i t A a l
721
A wOAru
Fig 1. Traumatic arteriovenous fistula between popliteal artery and vein caused by amniocentesis.
clinical situations 11 so the often observed skin marks resulting from amniocentesis penetration may be explained by the specific nature of the amniocentesis injury of the skin and underlying tissue or perhaps by the timing of the injury and later delivery. Traumatic arteriovenous fistula was first described by William Hunter in 1757 and the clinical spectrum of congenital and acquired arteriovenous communica-
tions has been extensively reviewed. 12 Another case of an arteriovenous fistula suspected of being caused by amniocentesis was reported by Gottdiener et al. 9 They described a 489 girl with a chest murmur who was found by angiography to have an abnormal arteriovenous connection between the aorta and a right lower lobe pulmonary vein. Her history was notable for a diagnostic amniocentesis done 2 weeks before birth that was complicated by bloody fluid aspiration. Physical examination at birth was remarkable for a puncture mark on the right chest. Others thought that the angiographic findings in that case represented a congenital anomalous systemic arterialization of the lung. 13 In the present case the presenting signs and symptoms, the angiographic and operative findings, and the response to treatment are all characteristic of an acquired, traumatic arteriovenous fistula rather than a congenital arteriovenous malformation.a4,t5 This case and other reported fetal injuries caused by amniocentesis suggest that newborns and infants who have had invasive prenatal interventions such as amniocentesis should be identified and the possibility of fetal injury be considered when evaluating their clinical signs and symptoms.
REFERENCES
1. Galle PC, Meis PJ: Complications of amniocentesis--A review. J Reprod Med 27:149-155, 1982 2. Tabor A, Madsen M, Obel EB, et al: Randomized controlled trial of genetic amniocentesis in 4606 low-risk women. Lancet 1:1287-1293, 1986 3. NICHD National Registry for Amniocentesis Study Group: Midtrimester amniocentesis for prenatal diagnosis--Safety and efficacy. JAMA 236:1471-1476, 1976 4. Haberstroh WD, Hochman M, Slate WG: Fetal bleeding and bradycardia following diagnostic amniocentesis. Del Med J 55:211213, 1983 5. Berner HW, Seisler EP, Barlow J: Fetal cardiac tamponade-A complication of amniocentesis. Obstet Gynecol 40:599-604, 1972 6. Egley CC: Laceration of fetal spleen during amniocentesis. J Obstet Gynecol 116:582-583, 1973 7. Cromie W J, Bates RB, Duckett JW: Penetrating renal trauma in the neonate. J Urol 119:259-260, 1978 8. Cook LN, Shott RJ, Andrews BF: Fetal complications of diagnostic amniocentesis: A review and report of a case with pneumothorax. Pediatrics 53:421-424, 1974
9. Gottdiener JS, Ellison RC, Lorenzo RL: Arteriovenous fistula after fetal penetration at amniocentesis. N Engl J Med 293:1302-1303, 1975 10. Creasman WT, Lawrence RA, Thiede HA: Fetal complications of amniocentesis. JAMA 204:949-952, 1968 11. Longaker MT, Adzick NS: The biology of fetal wound healing: A review. Plast Reconstr Surg 87:788-798, 1991 12. Young AE: Arteriovenous malformations, in Mnlliken JB, Young AE (eds): Vascular Birthmarks--Hemangiomas and Malformations. Philadelphia, PA, Saunders, 1988, pp 228-245 13. Fellows KE, Griscom NT: Traumatic fistula or anomalous systemic arterialization? N Engl J Med 294:784-785, 1976 14. Young AE: Vascular malformations of the lower limb, in Mulliken JB, Young AE (eds): Vascular Birthmarks--Hemangiomas and Malformations. Philadelphia, PA, Saunders, 1988, pp 400-423 15. Woolley MM, Stanley P, Wesley JR: Peripherally located congenital arteriovenous fistulae in infancy and childhood. J Pediatr Surg 12:165-176, 1977
Seattle, Washington 9 Fetal injury is a potential complication of amniocentesis. We report the case of an infant w h o had an isolated arteriovenous fistula between the popliteal artery and vein that resulted from amniocentesis. Unlike the usual congenital arteriovenous communications that are multiple and difficult to treat, this case was completely cured by division of the fistula and vascular repair. This case emphasizes that newborns and infants who have had invasive prenatal interventions such as amniocentesis should be identified and the possibility of fetal injury be considered when evaluating their clinical signs and symptoms. Copyright 9 1992 by W.B. Saunders Company INDEX WORDS: Amniocentesis; arteriovenous fistula.
A
MNIOCENTESIS is a standard technique in obstetric practice. It can cause fetal injuries that may be recognized immediately or that may only become apparent after birth.' CASE REPORT A 2-month-old girl came to medical attention because of a thrill in her right leg that had been noted for the previous month. Amniocentesis had been done during the second trimester because of advanced maternal age. The amniocentesis, the remainder of the pregnancy, labor, delivery, and first month of life were reportedly normal. Physical examination showed a grade [ to II over V] systolic heart murmur. Her legs were asymmetric with the right midthigh being 3 cm in diameter larger than the left. The right leg was also slightly longer than the left leg. The pulses in the right leg were bounding compared to the left. There was a thrill and a continuous bruit over the right lower thigh. The bruit and thrill could be obliterated by compression of the proximal right femoral artery. The skin had a small, punctate scar over the region of the thrill and bruit. There were no other skin changes. The remainder of her physical examination was normal. Chest x-ray showed slight cardiomegaly. Electrocardiogram was normal. Because of the heart murmur cardiac catheterization was performed and showed a structurally normal heart with a patent foramen ovale. There was marked elevation of oxygen saturations measured in the inferior vena cava and right atrium (93% and 89%) compared with the superior vena cava (54%), suggesting a significant left-to-right shunt in the lower half of the body. Angiography showed a markedly dilated right femoral artery and vein with early venous filling. At 41/2 months of age exploration of the right adductor canal and
From the Department of Surgery, Children ~ Hospital and Medical Center, Seattle, WA. Presented at the 24th Annual Meeting of the Pacific Association of Pediatric Surgeons, Hong Kong, May 20-24, 199l. Address reprint requests to Dale G. Hall, MD, Department of Surgery, Children's Hospital and Medical Center, 4800 Sand Point Way NE, PO Box C5371, Seattle, WA 98105. Copyright 9 1992 by W.B. Saunders Company 0022-3468/92 / 2706-0010503. O0/ 0 720
popliteal space showed a single, 0.5-cm-diameter artefiovenous fistula between the proximal popliteal artery and vein (Fig 1). The fistula was divided and the artery and vein were repaired by lateral suture. She did well postoperatively. She has been followed for 5 years and noted to have normal growth and development. She enjoys full physical activities. Her legs are of equal length and diameter, her extremity pulses are equal and symmetric, and her lower extremity blood pressures are equal. DISCUSSION
Amniocentesis is usually either done early in the second trimester to obtain cells for chromosome analysis and to determine the ~-fetoprotein level or done during the third trimester to assess fetal pulmonary maturity. In experienced hands the overall complication rate is 1OW2,3; however, a wide variety of complications have been previously reported in both the mother and the fetus, a Adverse maternal consequences are very rare but include amniotic fluid leakage, bleeding, infection, and premature labor. 2,3 Significant fetal morbidity and even mortality may result if the fetal-maternal circulation is compromised by umbilical vessel or placental trauma. 4 In addition to the fetal morbidity and mortality due to the interruption of the fetalmaternal circulation and the problems that occur because of amniocentesis-induced premature birth, there may be direct fetal injury by the amniocentesis needle. Many different fetal injuries have been reported. Some fetal injuries cause fetal distress that leads to early delivery or fetal death. Laceration of the heart has caused cardiac tamponade and fetal death. 5 Lacerations of the fetal spleen (' and kidney7 have caused fetal bleeding, which led to fetal distress and early delivery, and although the baby with renal laceration required transfusion both were managed without operation and survived. In addition to amniocentesis-induced fetal bleeding there have been several cases of neonatal pneumothorax after apparent amniocentesis needle penetration of the chest. 1,8 Other fetal injuries have not resulted in fetal distress but have been noted postnatally. Probably the most common fetal injury resulting from amniocentesis is skin penetration leading to cutaneous scars, depressions, or dimples. 1 They can be an isolated injury or, as in this case, a marker of underlying internal injury. 6,8-~~Others have observed a remarkable lack of scarring after fetal skin incision and excision in a variety of experimental models and a few Journal of Pediatric Surgery, Vol 27, No 6 (June), 1992: pp 720-721
TRAUMATIC ARTERIOVENOUS FISTULA
J ,
~ ~.~,
b l i t A a l
721
A wOAru
Fig 1. Traumatic arteriovenous fistula between popliteal artery and vein caused by amniocentesis.
clinical situations 11 so the often observed skin marks resulting from amniocentesis penetration may be explained by the specific nature of the amniocentesis injury of the skin and underlying tissue or perhaps by the timing of the injury and later delivery. Traumatic arteriovenous fistula was first described by William Hunter in 1757 and the clinical spectrum of congenital and acquired arteriovenous communica-
tions has been extensively reviewed. 12 Another case of an arteriovenous fistula suspected of being caused by amniocentesis was reported by Gottdiener et al. 9 They described a 489 girl with a chest murmur who was found by angiography to have an abnormal arteriovenous connection between the aorta and a right lower lobe pulmonary vein. Her history was notable for a diagnostic amniocentesis done 2 weeks before birth that was complicated by bloody fluid aspiration. Physical examination at birth was remarkable for a puncture mark on the right chest. Others thought that the angiographic findings in that case represented a congenital anomalous systemic arterialization of the lung. 13 In the present case the presenting signs and symptoms, the angiographic and operative findings, and the response to treatment are all characteristic of an acquired, traumatic arteriovenous fistula rather than a congenital arteriovenous malformation.a4,t5 This case and other reported fetal injuries caused by amniocentesis suggest that newborns and infants who have had invasive prenatal interventions such as amniocentesis should be identified and the possibility of fetal injury be considered when evaluating their clinical signs and symptoms.
REFERENCES
1. Galle PC, Meis PJ: Complications of amniocentesis--A review. J Reprod Med 27:149-155, 1982 2. Tabor A, Madsen M, Obel EB, et al: Randomized controlled trial of genetic amniocentesis in 4606 low-risk women. Lancet 1:1287-1293, 1986 3. NICHD National Registry for Amniocentesis Study Group: Midtrimester amniocentesis for prenatal diagnosis--Safety and efficacy. JAMA 236:1471-1476, 1976 4. Haberstroh WD, Hochman M, Slate WG: Fetal bleeding and bradycardia following diagnostic amniocentesis. Del Med J 55:211213, 1983 5. Berner HW, Seisler EP, Barlow J: Fetal cardiac tamponade-A complication of amniocentesis. Obstet Gynecol 40:599-604, 1972 6. Egley CC: Laceration of fetal spleen during amniocentesis. J Obstet Gynecol 116:582-583, 1973 7. Cromie W J, Bates RB, Duckett JW: Penetrating renal trauma in the neonate. J Urol 119:259-260, 1978 8. Cook LN, Shott RJ, Andrews BF: Fetal complications of diagnostic amniocentesis: A review and report of a case with pneumothorax. Pediatrics 53:421-424, 1974
9. Gottdiener JS, Ellison RC, Lorenzo RL: Arteriovenous fistula after fetal penetration at amniocentesis. N Engl J Med 293:1302-1303, 1975 10. Creasman WT, Lawrence RA, Thiede HA: Fetal complications of amniocentesis. JAMA 204:949-952, 1968 11. Longaker MT, Adzick NS: The biology of fetal wound healing: A review. Plast Reconstr Surg 87:788-798, 1991 12. Young AE: Arteriovenous malformations, in Mnlliken JB, Young AE (eds): Vascular Birthmarks--Hemangiomas and Malformations. Philadelphia, PA, Saunders, 1988, pp 228-245 13. Fellows KE, Griscom NT: Traumatic fistula or anomalous systemic arterialization? N Engl J Med 294:784-785, 1976 14. Young AE: Vascular malformations of the lower limb, in Mulliken JB, Young AE (eds): Vascular Birthmarks--Hemangiomas and Malformations. Philadelphia, PA, Saunders, 1988, pp 400-423 15. Woolley MM, Stanley P, Wesley JR: Peripherally located congenital arteriovenous fistulae in infancy and childhood. J Pediatr Surg 12:165-176, 1977
