Extremity Necrosis Due to Intrauterine Arterial Ischemia

A preterm male infant weighing 1230 g was delivered by cesarean section at 321/7 gestational weeks. His twin weighed 1300 g and neither required resuscitation. On physical examination, the left lower extremity was rudimentary, pale, shorter than the right, and had a club-foot deformity. Computerized tomographic angiography demonstrated a bluntly filled femoral artery with no distal passage. During follow-up, the demarcation line became clear on the 5th day and amputation was performed under the left hip joint (Figure 1).

Figure 1

(a-d) Left lower extremity was rudimentary, pale, shorter than the right, and had a club-foot deformity. The demarcation line became clear on the 5th day and amputation was performed under the left hip joint.

Laboratory tests including homocysteine, folate, prothrombin time, activated partial thromboplastin time, protein C and S activity, fibrinogen, and antithrombin III activity were within normal limits according to gestational age, except for high D-dimer (4.13 mg/dL). Antiphospholipid and anticardiolipin antibodies were also negative. The patient was found to be homozygous for methylenetetrahydrofolate reductase C677T; thrombosis was not observed in histopathological examination. The patient was successfully discharged from the hospital on the 40th day of life.

Arterial ischemia of the limb can be seen after thromboembolic events or vascular interventions [1,2]. Ischemic changes present at birth suggested intrauterine onset causes that might be attributable to occlusive vascular disruption [3]. Diminished blood flow altered normal soft tissue and osseous growth and resulted in ischemia in fetal life, ending with limb loss.