Case and Research Letter
Skin Dimpling as a Complication of Amniocentesis: Histopathologic Findings
Hoyuelos cutáneos como consecuencia de amniocentesis: hallazgos histopatológicos
a Servicio de Dermatología, Hospital Arquitecto Marcide, Área Sanitaria de Ferrol, SERGAS, Ferrol, A Coruña, Spain
b Servicio de Dermatología, Complejo Hospitalario Universitario A Coruña, SERGAS, A Coruña, Spain
c Pediatría, Centro de Salud de Mugardos, Área Sanitaria de Ferrol, SERGAS, Mugardos, A Coruña, Spain
d Servicio de Anatomía Patológica, Complejo Hospitalario Universitario A Coruña, SERGAS, A Coruña, Spain
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Monteagudo, J. del Pozo, B. Suárez-Traba, F. Sacristán" "autores" => array:4 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "Monteagudo" "email" => array:1 [ 0 => "benigno.monteagudo.sanchez@sergas.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "del Pozo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "B." "apellidos" => "Suárez-Traba" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "F." "apellidos" => "Sacristán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Arquitecto Marcide, Área Sanitaria de Ferrol, SERGAS, Ferrol, A Coruña, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Complejo Hospitalario Universitario A Coruña, SERGAS, A Coruña, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Pediatría, Centro de Salud de Mugardos, Área Sanitaria de Ferrol, SERGAS, Mugardos, A Coruña, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Complejo Hospitalario Universitario A Coruña, SERGAS, A Coruña, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hoyuelos cutáneos como consecuencia de amniocentesis: hallazgos histopatológicos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 555 "Ancho" => 1500 "Tamanyo" => 104783 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Two dimples on the left side of the abdomen (←). B, Linear depression on the front of the left thigh (¿).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">During pregnancy, delivery, and postpartum, a series of diagnostic and therapeutic procedures are currently performed which have led to reduced neonatal morbidity and mortality but which have also increased the risk of certain iatrogenic cutaneous and traumatic injuries.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The incidence of fetal puncture due to amniocentesis has declined since the introduction of ultrasound guidance<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a>; however, increasing maternal age has led to more frequent use of amniocentesis,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> thus making awareness of fetal puncture a matter of importance for dermatologists, obstetricians, and pediatricians.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This letter describes the case of a 3-month-old infant who presented several skin dimples as a result of amniocentesis-related puncture. A search of the literature found no other cases of this entity in which a histopathologic study had been performed.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A male infant aged 3 months with no relevant medical history presented for assessment of a number of skin lesions on the abdomen and left thigh which were first noticed during the first month of life. The infant had no congenital abnormalities and had been born following a full-term pregnancy by unassisted vaginal delivery in cephalic presentation. One of the techniques performed on the mother during gestation and delivery was an amniocentesis in the 18th week which required several punctures.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A physical examination revealed 2 dimples measuring 2 mm in diameter on the left side of the abdomen and a linear depression 1.2 cm long on the anterior aspect of the proximal third of the left thigh (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). The patient did not present any other skin lesions, involvement of the oral or genital mucosae, or abnormalities of the hair or nails. The infant's weight and height were normal.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">A diagnosis of skin dimpling as a complication of amniocentesis was established. The parents were informed of the benign nature of the skin condition, although they decided to request a biopsy of the thigh lesion so as to rule out other pathologies. The histopathologic study revealed a dermis with collagen bundles having an abnormal morphology and distribution (fine bundles arranged in multiple directions). A reduction and fragmentation of elastic fibers was observed using orcein staining. No abnormalities were seen in the epidermis or the subcutaneous tissue (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The skin lesions remained unchanged over the subsequent 8 months.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Amniocentesis is the most frequently used technique for prenatal diagnosis of genetic alterations. It is usually performed during the second trimester of pregnancy. One of the possible complications of the procedure is fetal puncture, the most frequent manifestation of which is skin dimpling.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Amniocentesis may also cause injury to underlying structures, such as peripheral nerves, tendons, or the eyeball, and result in ileocutaneous or arteriovenous fistulas.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Skin dimpling as a complication of amniocentesis presents as punctate depressions or linear scars measuring 1 to 5 mm in diameter. These manifestations may be isolated or multiple; when multiple, they are sometimes grouped and sometimes follow a linear path due to fetal puncture along a single plane. Clearer observation may be achieved by pinching the surrounding skin.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Skin dimples caused by amniocentesis are present at birth, although some are not clearly visible until weeks or months later; they do not resolve spontaneously.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The most common site is the thigh, followed by the abdomen, buttocks, and upper limbs. These dimples tend to be found by chance during examination and are not usually the reason for consultation.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> It has been speculated that dimpling results from localized lipoatrophy or a loss of subcutaneous tissue. The histopathologic findings in this case, namely, fine collagen bundles and a reduction in elastic fibers, are consistent with localized depressed scarring secondary to skin retraction caused by a puncture wound.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The advent of ultrasound guidance during amniocentesis reduced the incidence of skin dimpling from nearly 9% to under 1%.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However, the unpredictability of fetal movement—especially of the limbs—makes some instances of puncture inevitable.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,8</span></a> Several factors increase the risk of this complication, such as performing the technique in the third trimester, when the fetus is of a larger size in proportion to the amniotic cavity; repeated puncture attempts; and lack of obstetrician experience.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The diagnosis, although never absolutely certain, is established by ruling out other associated findings, the location of the dimples, and a history of amniocentesis.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,7</span></a> These indicators allow clinicians to rule out other iatrogenic and traumatic injuries resulting from fetal monitoring, amniotomy, episiotomy, venous and arterial puncture, assisted delivery (i.e., vacuum-assisted, forceps, or spatula-assisted), or cesarean section (long but very superficial scalpel related lacerations).<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3,6</span></a> Additionally, diagnosis must take into consideration other congenital causes of skin dimpling. These congenital causes can be either dermal sinuses with cutaneous openings or deep cutaneous depressions. Congenital skin dimples are almost always variations of normality and are situated over bony prominences, especially those of the face. They may be familial forms or related to infection, metabolic disorders, or the use of certain drugs during pregnancy; occasionally they are signs of an underlying abnormality, a polymalformative syndrome, or a neurological or bone and muscle disorder.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Other processes that should be taken into consideration include cutaneous aplasia, focal dermal hypoplasia, amniotic band syndrome, and supernumerary nipples.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In summary, dermatologists should be aware of the presence of skin dimpling as a complication of amniocentesis both to avoid incorrect diagnostic presumption and to limit the number of additional and potentially aggressive tests performed.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Monteagudo B, et al. Hoyuelos cutáneos como consecuencia de amniocentesis: hallazgos histopatológicos. Actas Dermosifiliogr. 2013;104:729–31.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 713 "Ancho" => 950 "Tamanyo" => 108572 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cutaneous scars on the abdomen (←) and right thigh (¿).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 555 "Ancho" => 1500 "Tamanyo" => 104783 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Two dimples on the left side of the abdomen (←). B, Linear depression on the front of the left thigh (¿).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1289 "Ancho" => 1497 "Tamanyo" => 517452 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A, Low-magnification view, epidermis with 2 scalloped areas and compact, wide dermis with few adnexa (hematoxylin-eosin, original magnification ×20). B, In greater detail, thin collagen bundles in the dermis (hematoxylin-eosin, original magnification ×100). 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 18 | 16 | 34 |
| 2024 October | 155 | 49 | 204 |
| 2024 September | 188 | 45 | 233 |
| 2024 August | 189 | 90 | 279 |
| 2024 July | 191 | 44 | 235 |
| 2024 June | 166 | 44 | 210 |
| 2024 May | 147 | 32 | 179 |
| 2024 April | 126 | 27 | 153 |
| 2024 March | 173 | 36 | 209 |
| 2024 February | 135 | 40 | 175 |
| 2024 January | 134 | 30 | 164 |
| 2023 December | 154 | 46 | 200 |
| 2023 November | 150 | 78 | 228 |
| 2023 October | 157 | 53 | 210 |
| 2023 September | 159 | 59 | 218 |
| 2023 August | 120 | 32 | 152 |
| 2023 July | 121 | 55 | 176 |
| 2023 June | 85 | 34 | 119 |
| 2023 May | 101 | 32 | 133 |
| 2023 April | 96 | 37 | 133 |
| 2023 March | 107 | 30 | 137 |
| 2023 February | 44 | 33 | 77 |
| 2023 January | 41 | 31 | 72 |
| 2022 December | 52 | 45 | 97 |
| 2022 November | 39 | 43 | 82 |
| 2022 October | 60 | 22 | 82 |
| 2022 September | 45 | 55 | 100 |
| 2022 August | 35 | 28 | 63 |
| 2022 July | 58 | 44 | 102 |
| 2022 June | 30 | 25 | 55 |
| 2022 May | 69 | 53 | 122 |
| 2022 April | 81 | 37 | 118 |
| 2022 March | 90 | 54 | 144 |
| 2022 February | 77 | 28 | 105 |
| 2022 January | 125 | 48 | 173 |
| 2021 December | 78 | 42 | 120 |
| 2021 November | 89 | 65 | 154 |
| 2021 October | 74 | 59 | 133 |
| 2021 September | 78 | 53 | 131 |
| 2021 August | 75 | 36 | 111 |
| 2021 July | 48 | 47 | 95 |
| 2021 June | 62 | 41 | 103 |
| 2021 May | 79 | 51 | 130 |
| 2021 April | 218 | 86 | 304 |
| 2021 March | 100 | 31 | 131 |
| 2021 February | 71 | 36 | 107 |
| 2021 January | 52 | 23 | 75 |
| 2020 December | 39 | 25 | 64 |
| 2020 November | 27 | 15 | 42 |
| 2020 October | 27 | 15 | 42 |
| 2020 September | 38 | 12 | 50 |
| 2020 August | 16 | 19 | 35 |
| 2020 July | 22 | 12 | 34 |
| 2020 June | 47 | 25 | 72 |
| 2020 May | 19 | 16 | 35 |
| 2020 April | 29 | 18 | 47 |
| 2020 March | 35 | 19 | 54 |
| 2020 February | 1 | 4 | 5 |
| 2020 January | 0 | 2 | 2 |
| 2019 December | 4 | 10 | 14 |
| 2019 November | 0 | 3 | 3 |
| 2019 October | 0 | 6 | 6 |
| 2019 September | 4 | 3 | 7 |
| 2019 August | 0 | 5 | 5 |
| 2019 July | 0 | 4 | 4 |
| 2019 June | 2 | 5 | 7 |
| 2019 May | 0 | 51 | 51 |
| 2019 April | 3 | 1 | 4 |
| 2019 March | 2 | 9 | 11 |
| 2019 January | 3 | 0 | 3 |
| 2018 November | 4 | 0 | 4 |
| 2018 October | 1 | 0 | 1 |
| 2018 September | 2 | 0 | 2 |
| 2018 June | 0 | 3 | 3 |
| 2018 May | 0 | 7 | 7 |
| 2018 April | 0 | 3 | 3 |
| 2018 March | 2 | 3 | 5 |
| 2018 February | 113 | 4 | 117 |
| 2018 January | 72 | 6 | 78 |
| 2017 December | 116 | 5 | 121 |
| 2017 November | 53 | 7 | 60 |
| 2017 October | 47 | 10 | 57 |
| 2017 September | 63 | 10 | 73 |
| 2017 August | 69 | 9 | 78 |
| 2017 July | 78 | 9 | 87 |
| 2017 June | 79 | 21 | 100 |
| 2017 May | 56 | 19 | 75 |
| 2017 April | 39 | 6 | 45 |
| 2017 March | 49 | 25 | 74 |
| 2017 February | 40 | 11 | 51 |
| 2017 January | 43 | 5 | 48 |
| 2016 December | 55 | 5 | 60 |
| 2016 November | 80 | 18 | 98 |
| 2016 October | 108 | 13 | 121 |
| 2016 September | 176 | 14 | 190 |
| 2016 August | 153 | 7 | 160 |
| 2016 July | 69 | 6 | 75 |
| 2016 June | 7 | 13 | 20 |
| 2016 May | 6 | 3 | 9 |
| 2016 April | 10 | 2 | 12 |
| 2016 March | 2 | 4 | 6 |
| 2016 February | 6 | 3 | 9 |
| 2016 January | 11 | 1 | 12 |
| 2015 December | 15 | 2 | 17 |
| 2015 November | 4 | 4 | 8 |
| 2015 October | 4 | 5 | 9 |
| 2015 September | 2 | 1 | 3 |
| 2015 August | 5 | 3 | 8 |
| 2015 July | 121 | 2 | 123 |
| 2015 June | 54 | 0 | 54 |
| 2015 May | 73 | 4 | 77 |
| 2015 April | 71 | 3 | 74 |
| 2015 March | 48 | 1 | 49 |
| 2015 February | 68 | 5 | 73 |
| 2015 January | 43 | 2 | 45 |
| 2014 December | 50 | 7 | 57 |
| 2014 November | 50 | 6 | 56 |
| 2014 October | 57 | 3 | 60 |
| 2014 September | 30 | 0 | 30 |
| 2014 August | 30 | 7 | 37 |
| 2014 July | 27 | 6 | 33 |
| 2014 June | 55 | 5 | 60 |
| 2014 May | 40 | 6 | 46 |
| 2014 April | 43 | 4 | 47 |
| 2014 March | 46 | 8 | 54 |
| 2014 February | 21 | 3 | 24 |
| 2014 January | 25 | 3 | 28 |
| 2013 December | 7 | 4 | 11 |
| 2013 November | 0 | 3 | 3 |
| 2013 October | 3 | 1 | 4 |
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