Gangrene of the Newborn - Causes, Diagnosis, and Treatment

Introduction:

Gangrene is a condition that leads to organ or tissue death due to a lack of blood supply or a bacterial infection. Gangrene can be classified as wet, dry, or gas gangrene. Dry gangrene is due to a sudden loss of arterial supply to a tissue or organ, causing dry and shriveled skin with a black or blue appearance. Wet gangrene is a result of bacterial infection. As a result, the gangrene gives a wet appearance with swelling and blisters. Gas gangrene is caused by the bacteria Clostridium, which releases gas from necrosed tissues. Gangrene causes death or amputation of the affected organ. Therefore, early detection aids in effective management.

What Is Gangrene in Newborns?

Gangrene in newborns, also known as peripheral gangrene, is a rare condition affecting the extremities. The involvement of extremities may be unilateral or bilateral, symmetrical or asymmetrical. Among newborns, gangrene over the umbilicus, buttock, nose, and lip is uncommon. Although gangrene occurs after birth, it may also occur in an intrauterine environment. In newborns, the condition may lead to death or amputation. However, early diagnosis and adequate management may halt the progression of the disease. The occurrence of gangrene in newborns is rare in the United States. Less than 100 cases have been reported worldwide.

What Is The Etiology?

The exact etiology is unknown. Many studies have concluded that sepsis, dehydration, maternal diabetes, asphyxia (difficulty breathing), congenital anticoagulant deficiency; in pregnancies with spontaneous rupture of the amniotic sac, delayed delivery, dry labor, polycythemia (increased red blood room volume), syphilis, cold exposure, hyperglycemia, intravenous hyperosmolar infusion, hereditary thrombotic disorders, antiphospholipid antibody syndrome, congenital heart defect, and neonatal diabetes as possible etiology. If the ischemic changes are present at the time of birth, it has an intrauterine etiology.

What Are the Signs and Symptoms?

Upper limb gangrene is more common than lower limb gangrene in neonates.

• Black discoloration and coldness of the affected area.

• Poor feeding tendencies.

• Low-grade fever.

• Fast breathing.

• Grunting.

• Excessive crying.

• Depressed frontal, sunken eyeballs, dry lips.

• Lethargic.

• Dehydration.

• Jaundice.

• Blisters (fluid-filled bubbles).

• Absent or reduced neonatal reflexes.

• Hyperviscosity (thickening) of blood is seen in certain infants, which increases their risk of thrombosis.

• Coagulation disorder in neonates due to deficiencies in antithrombin III and protein C leads to thrombosis.

The extent of gangrene involvement varies based on the extent of thrombi formation. Gangrene acts as a source of infection, which leads to sepsis. If the condition remains untreated, it leads to mortality.

What Are the Diagnostic Tests?

Physicians conduct physical examinations and take medical histories to assess symptoms. History of complications during pregnancy, delivery, or later stage aid in arriving at a suitable treatment plan. Other tests done are

• Prothrombin time.

• Activated partial thrombin time.

• Maternal anticardiolipin antibodies in the pregnant mother's body increase the risk of a blood clot in the fetus.

• Computerized tomography (CT).

• Magnetic resonance imaging (MRI).

• Doppler and duplex ultrasound to detect renal vein and inferior vena cava thrombosis, including the level of obstruction in the vascular limb.

• Pathological examination of placenta to review thrombi.

• Assaying of plasminogen, antithrombin III, Protein C, and protein S activities as these factors are deficient in infants.

The diagnosis of gangrene in neonates is made purely on clinical assessment as the laboratory and radiographic diagnosis may yield normal results.

What Are the Treatment Options?

Early surgical intervention is avoided as gangrene is evolving and not properly restricted.

Physicians should assess the exact cause and treat the condition to halt the progression. Unfortunately, there is a lack of guidelines on treatment protocols.

Conservative approaches like hydration and prevention of infection are followed. The treatment for gangrene is of two types:

• Medical Treatment - This involves:

  • Intravenous antibiotics and local antibiotic dressing to control infection.

  • Fresh frozen plasma or thrombolytic agents - Thrombolytic treatment is safe and effective in neonates. Agents such as urokinase and recombinant tissue plasminogen activator (rtPA) are used to convert plasminogen to enzyme plasmin capable of dissolving fibrin clots. These drugs are administered systemically and are effective in arterial and venous blood clots.

• Heparin-Based Anticoagulation: Neonates require large amounts of heparin compared to adults to achieve similar therapeutic effects. The therapeutic effect is achieved by continuous intravenous infusion. This technique can also resolve thrombosis of femoral arteries.

• Surgical Management of Gangrene: The surgical treatment is deferred until a defined boundary of gangrene is achieved. In the case of well-defined gangrene, surgical management is the treatment of choice. Amputation in neonates is done with the preservation of growth plates which aid in prosthetic replacement.

1. Thrombectomy among young patients increases the risk of re-thrombosis, but it enables circulation in the affected organ. Since all catheters cannot pass through small vessels of neonates, aspiration of clot using a very small catheter such as two to three French Fogarty is used.

2. Vacuum-assisted closure (VAC) or negative pressure therapy is used to achieve wound healing after gangrene debridement. A device is used to decrease air pressure on the wound to fasten the healing process and remove bacteria and excess exudate. Patients must change the dressing every 24 to 72 hours.

3. Physicians can consider hyperbaric oxygen therapy (HBOT) in intrauterine limb ischemia to halt the progression to necrosis and save the limbs.

What Is Neonatal Fourniers Gangrene?

Infective gangrene affects the perineum and external genitalia in neonates called neonatal Fournier’s gangrene. The occurrence of gangrene in neonates is a rare phenomenon and can be life-threatening. Poor hygiene is known to cause this condition among neonates. The necrosis originates from a bacterial infection in the anorectal, the urogenital tract, or the skin of the genitalia. The bacteria produce enzymes like collagenase and hyaluronidase that damage the fascial plane causing vascular thrombosis that progresses to gangrene. The other causes of gangrene development among neonates are diaper rash, varicella infection, and premature birth. In addition, Streptococci, Staphylococci, and anaerobes are responsible for this disease.

The diagnosis is made through a plain X-ray, which reveals gas in subcutaneous tissues. Ultrasound may also be useful in diagnosis. The treatment option is aggressive management with multiple antibiotics. Hyperbaric oxygen therapy is also helpful for faster recovery in infants.

What Is the Prognosis?

Early detection and treatment can help lessen tissue damage and enable faster recovery of newborns. The progression of the disease to sepsis can be life-threatening. Early diagnosis is the key to effective management.

Conclusion

Gangrene in newborns is rare due to factors. However, it can be debilitating if not given treatment since there is limited knowledge of the disease's etiology, mechanism, and treatment due to a low number of reported cases. Therefore, studies need to be done to improve the quality of life of those affected.