A baby boy with vertex presentation was born with vaginal delivery associated to the Kristeller maneuver at 39 weeks of gestation. Obstetric history was significant for maternal trauma due to an accidental fall down the stairs at 37 weeks of gestation. An accurate prenatal ultrasound did not show trauma-related lesions or abnormalities.
Newborn birth weight was 3470 g. Apgar score was 8/9 and 9/9 at 1 and 5 min, respectively. At birth, the newborn presented an initial right hydrocele. Right scrotal swelling with bluish discoloration (Fig. 1) was noted 5 h after birth. All of the differential diagnostic procedure were performed in order to exclude strangulated hernia, NAH, and testicular torsion. Abdominal and testicular ultrasound with a Doppler study showed a right enlarged testicle (14 mm diameter) enveloped in dense hyperechoic tissue, presence of a blood hypoechoic layer, mild ascites, and no NAH. The color Doppler showed clear vascular spots (Fig. 2) that confirmed blood flow. The initial diagnosis was idiopathic SH.
Seven hours after birth, the general condition of the child suddenly worsened with the onset of paleness, blood pressure decrease, and development of tachycardia. For these reasons, he was admitted to the neonatal intensive care unit (NICU).
Physical examination revealed poor general appearance, hypoactive pupils, icteric sclera, a globular and not very treatable abdomen, and bluish discoloration of the right hemi scrotum. Vital signs indicate a pulse of 155/min, respiration 38/min, body temperature 36.7 °C, and blood pressure 60/40 mmHg. The X-ray was performed during orthostasis before the child underwent surgery and showed moderate abdominal distension without clear hydro-air levels and the absence of a subdiaphragmatic sickle and non-empty rectal ampulla. Laboratory tests showed pH 7.1, hemoglobin 8.2 g/dL, hematocrit 25.4%, white blood cell count of 28,280/mm3, and platelet count of 282,000/mm3.
Total and direct bilirubin levels were 10.71 and 0.43 mg/dL, respectively. Other signs were normal. Prothrombin time and activated partial thromboplastin time were normal. A blood transfusion of 50 mL of concentrated red blood cells was sufficient to stabilize the patient. Although the neonate was stabilized and diagnostic workup completed, the cause of bleeding was still unknown; a scrotal origin was suspected, indicating the need for surgical exploration. The laparoscopic approach in neonates is routinely used at our institution but not for scrotal disease (scrotal disease was our pre-operative diagnosis). A written consent for surgery was obtained from parents. Under general anesthesia, an inguinal incision was made to explore spermatic vessels and testis. We found severe adhesion between spermatic and surrounding tissues; however, this adhesion could not be explained by the recent bleeding episode. Also, the peritoneal vaginal duct was filed with red clotted blood while the testis appeared structure and perfused normally. After the cause of scrotal bleeding could not be found, we decided to extend the inguinal incision and reached the right iliac fossa through a subcutaneous dissection. At this point, the fascia was opened, and an hemoperitoneum was drained. At the same time, all intestinal segments, epigastric vessels, liver margins, and surrounding structures were explored; however, no cause of bleeding could be found. After drainage, the bleeding appeared completely stopped, and it was then decided not to proceed with a xifo-pubic laparotomy to further investigate the origin of bleeding. In fact, the modern approach to abdominal blunt trauma recommends not proceeding with the extended laparotomy if bleeding has stopped and hemodynamic parameters are stable.
The following day, in consideration of the unknown origin of bleeding and lack of useful information offered by abdominal ultrasound (clearly operator-dependent), we performed an abdominal computed tomography (CT) scan with contrast that showed some bloody collection in the subphrenic space and between splenic and renal vein (Fig. 3). An abdominal CT was preferred by parents because this procedure did not require additional anesthesia. The scrotal area, on the other hand, was normal. The postoperative course was uneventful. The neonate was discharged to home on the seventh post-operative day following a normal testicular and abdominal ultrasound and blood test value with the diagnosis of IH. On the 2-week follow-up ultrasound, minimal persistence of a hematoma between renal and splenic vessels was detected. The complete coagulative profile of the neonate and his parents were normal.
The newborn was evaluated 2 months after discharge at which time the abdominal and testicular ultrasounds were normal with no sign of residual liquid. Growth parameters of the baby were normal.
