Successful external cephalic version after preterm premature rupture of membranes utilizing amnioinfusion complicated by fetal femoral fracture

Introduction

Successful external cephalic version (ECV) is associated with a decreased rate of cesarean delivery [1]. Many babies with preterm malpresentation will spontaneously convert to cephalic presentation prior to term, so preterm ECV is typically no longer performed. With preterm premature rupture of membranes (PPROM) at or after 34 weeks of gestation, induction of labor has become the standard of care [2]. Patients with PPROM and malpresentation desiring attempted vaginal delivery may then represent a subgroup of candidates for ECV prior to 36 weeks of gestation, although limited data is available to routinely support this management approach. We report a case of successful ECV in a patient who presented with PPROM that was facilitated by transcervical amnioinfusion, but complicated by a neonatal right femoral fracture.

Case

A 32-year-old gravida 2 para 1 was noted in antenatal clinic to be in breech presentation in her third trimester of pregnancy. The patient was counseled about the possible management options and risks, benefits, and alternatives of ECV and she desired the procedure should the baby remain breech at term gestation. At 35 6/7 weeks, she presented with PPROM. Breech presentation and minimal amniotic fluid were noted on ultrasound and speculum examination confirmed positive amniotic fluid pooling which was fern positive on microscopy. She previously had an uncomplicated vaginal delivery, and was motivated to achieve the same with this pregnancy. A cesarean section was recommended, but after extensive counseling, the patient desired an attempt at ECV with a plan to proceed with cesarean delivery if unsuccessful.

After a reactive nonstress test, a spinal anesthetic was administered in the operative room in a dose sufficient for emergency cesarean section if the ECV trial failed and subcutaneous terbutaline 250 μg was given. An amnioinfusion was initiated at a continuous rate of 500 mL/h and the rate adjusted to maintain a 2 cm by 2 cm pocket of amniotic fluid. Successful ECV was achieved after two attempts utilizing the forward-roll technique. No fetal heart rate issues were noted by ultrasound during the procedure or external fetal heart rate monitoring subsequently. The patient was induced with intravenous oxytocin, and vaginal delivery (not assisted) was achieved within 5 h. APGARs were 7 and 8 at 1 and 5 min, respectively. The neonate was noted to have bilateral lower extremity bruising at the time of delivery and a Salter Harris type II fracture was diagnosed in the distal right femur. After 15 months of follow-up, the child does not have gait abnormalities or other problems related to this fracture.

Discussion

We present a case of successful external cephalic version after PPROM in which transcervical amnioinfusion was utilized due to anhydramnios. Written consent was obtained from the patient prior to publication. A search of PubMed and MEDLINE revealed six other reported cases of successful ECV after rupture of membranes [3–7] (Table 1). When our case is included with those previously reported, four of seven patients (57.1%) delivered vaginally after successful ECV in the setting of PPROM. Cesarean delivery occurred for three cases: one for failure to progress and two for umbilical cord prolapse. The success rate of ECV in PPROM is unknown as no case reports of failed ECV have been published in the peer-reviewed literature.

Use of transcervical amnioinfusion is common during labor and generally the reported rates of complications have been low [8]. Our case represents the second report of transcervical amnioinfusion to facilitate ECV in the setting of PPROM for decreased amniotic fluid. Buek et al. [7] reported using a single bolus of 600 mL with a preprocedure fluid pocket of 3 cm. We chose to use a continuous infusion rate of 500 mL/h adjusted to maintain at least of 2×2 cm pocket of fluid as ruptured membranes allows extravasation of the infusate from the uterine cavity. No complications were reported for either case associated with the amnioinfusion or ECV.

The postdelivery course in both these babies was complicated. This first baby experienced PPROM at 29 weeks of gestation and chorioamnionitis was suspected intrapartum (latency period of 5 weeks). The neonate required intubation and neonatal intensive care unit admission. These outcomes can occur as the consequence of preterm delivery and/or prolonged rupture of membranes, although amnioinfusion may have increased the risk of infection. The neonatal hospital course of our patient was complicated by a right distal femur fracture. Reports note these fractures occurring spontaneously or from birth trauma. Bruising of the lower extremities and a Salter-Harris type II fracture on X-ray suggests angular forces as the mechanism of injury. This injury is a rare event in ECV procedures as only one other case of neonatal femoral fracture has been reported [9].

Given that several case reports have raised concern for increased of maternal and neonatal morbidity associated with ECV after rupture of membranes, the clinician should proceed cautiously, with this procedure performed under a protocol setting until further study establishes the safety and efficacy.