© 2023, Hemmati
Received Day: 12 Month: 02 Year: 2023
Accepted Day: 30 Month: 04 Year: 2023
J Neonatal Surg. 2023; 12: 16.
DOI: 10.47338/jns.v12.1186
Intrauterine toes gangrene in a neonate
Fariba Hemmati Neonatal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
Hamide Barzegar Neonatal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
[corresp] Hamide Barzegar, Neonatal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. E-mail: hamide.barzegar@gmail.com

We present a case of a 3-day-old girl with intrauterine gangrene of the left foot toes. The patient was the third live child of a 27-year-old woman with a history of two previous abortions without a definitive cause. Her pregnancy was uneventful except for hypertension and thrombocytopenia detected at the delivery time. There was no history of proteinuria, gestational diabetes mellitus, infections, or drug consumption during pregnancy. Prenatal sonography showed a normal uterus shape with adequate amounts of amniotic fluid and a single normal fetus. The baby was born at the 37th week of gestation with good Apgar scores (9 and 10 at 1st and 5th minutes) by normal vaginal delivery with vertex position. Her growth indices were: weight 2600 grams (10th percentile), length 45 centimeters (3rd percentile), and head circumference 33 centimeters (50th percentile).

Physical examination revealed gangrene of the second and third toes (Fig. 1A) with no other apparent abnormalities. The patient appeared well and had no signs of lethargy or poor feeding. Her vital signs were stable. Blood culture and CRP were negative. Laboratory data showed PT 13, PTT 35.6, INR 1.15, and platelets 30000/mm3. Antithrombin 3, protein C, and S were within normal ranges for neonates. Doppler ultrasonography of the leg and foot was normal. Enoxaparin and fresh frozen plasma were started for her, and amputation of two toes (Fig. 1B) was done. She was discharged in good condition five days after the operation.

Numerous risk factors may contribute to intrauterine gangrene that includes prematurity, gestational diabetes, gestational hypertension, oligohydramnios, placental abruption, polycythemia, dehydration, congenital heart disease, twin-twin transfusion syndrome, abnormal fetal presentation, coagulation abnormalities, trauma, amniotic band, and thromboembolic events. [1], [2], [3] Cissouma et al. reported a preterm neonate with hand cyanosis, gangrene, anemia, and sepsis at birth. She was a product of a twin pregnancy and the other sibling was stillbirth. She was treated with antibiotics, and amputation was performed. [4] Seker et al. reported a premature infant with tetralogy of Fallot who had lower extremity gangrene at birth. [1] In our case, the only possible risk factor was maternal gestational hypertension. Management of intrauterine gangrene includes maintenance of hemostasis, thrombolytic agents and anticoagulants, prevention of infection, and amputation when necessary. [1], [5] Timely intervention can significantly improve the patient's outcomes.


Figure 1 

A) Gangrenous toes. B) After amputation.


n1Conflicts of interest. None

n2Source of Support: Nil

n3Author contributions: Author(s) declared to fulfill authorship criteria as devised by ICMJE and approved the final version. Authorship declaration form, submitted by the author(s), is available with the editorial office.

n4Consent to Publication: Author(s) declared taking informed written consent for the publication of clinical photographs/material (if any used), from the legal guardian of the patient with an understanding that every effort will be made to conceal the identity of the patient, however it cannot be guaranteed.


The authors would like to thank Shiraz University of Medical Sciences, Shiraz, Iran and also Center for Development of Clinical Research of Nemazee Hospital and Dr. Nasrin Shokrpour for editorial assistance.

1. Seker A, Kayaalp ME, Malkoc M, Kara A. Intrauterine lower extremity gangrene in a newborn with Tetralogy of Fallot. BMJ Case Rep. 2016; 2016.
2. Quddusi AI, Nizami N, Razzaq A, Husain S. Bilateral gangrene of lower limbs in a neonate. J Coll Physicians Surg Pak. 2014; 24:s1190.
3. Vaidya SV, Pinto DA, Mehta R, Agashe MV, Aroojis A. Lower-limb ischemia at birth because of spontaneous arterial thrombosis: A case report. JBJS Case Connector. 2021; 11:e20.
4. Cissouma A, Coulibaly MB, Kassogué D, Poma HA, Diassana M, Traoré B, et al. Congenital gangrene in a premature newborn: a case report. Open J Pediatr. 2021; 11:393-7.
5. Arshad A, McCarthy M. Management of limb ischaemia in the neonate and infant. Eur J Vasc Endovasc Surg. 2009; 38:61-5.