Experimental Biology 2010: Pathology Of Some Obstetric-Pediatric Interventions

Purpose of Study: Many perinatal-pediatric interventions are thought to be safe but the pathology and effects on lab data are poorly known. Labor manipulation by forceps or vacuum assist devices (VAD) has risks. Moribund infants are often revived by intraosseous tibial injection (ITI) to force fluids into the circulation.

Methods Used: Five cases: 2 VAD, 2 ITI, and 1-both. One, by section after 4 failed VAD, survived; the placenta revealed trauma. The others were autopsied.

Summary of Results: Male, 3370 g, born vaginally post 4 failed VAD, died at 136 hrs with marked angulation of medulla and upper spinal cord, cerebellar tonsil herniation, and precystic necrosis. #2: 16 day male, 3200 g, vaginal birth after 3 VAD; infant collapsed at home; no evidence of overlay, suffocation, or external trauma. Posterior skull had subclinical incomplete fracture lines subtended by small old subdural hemorrhages, thickened dura, and hemosiderosis. Attempted ITI resulted in fat emboli to lung, a brief but not sustained heart response. #3: section delivery after 4 failed VAD and lacerated lower uterine segment, 3+ bleeding after 4th VAD; 3500 g male had skull fracture but survived with massive hemispheric infarction, left middle cerebral artery field. Laceration of surface placental vessels and numerous intraplacental air emboli were identified. #4: 7.5 month female with incomplete immunizations died in a pertussis epidemic with bronchiolitis, pneumonia, and severe acute meningitis. Forceful left ITI dislocated the superior epiphyseal plate, releasing multiple fat emboli to lung. #5: 28 month female with multiple traumatic injuries resuscitated by 3 ITI before admission; 10 minutes later many myelocytes and bands were in the WBC; serum lipase was 1100 U/dl; at 16 hrs no myelocytes were seen; lipase was normal. Autopsy after 44 hr survival found many fat emboli in lung and more recent fat emboli in brain, adrenal capsule, kidney.

Conclusions: VAD may cause significant fetal and placental trauma. The number of tries and results should be included in the clinical summary and those placentas examined thoroughly. Emergent ITI causes marrow and fat emboli with potential to worsen the clinical status of the child. Recipient tibias should be studied pathologically for disruption, hemorrhage, and trauma to the epiphyseal plate, and brain and lung tissue frozen for fat stain.