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). C, Fragmented and reduced elastic fibers in the dermis (orcein staining, original magnification ×100).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Procedures and drugs in pediatric dermatology: Iatrogenic risks and situations of concern" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. Reddy" 1 => "S. Kogan" 2 => "S.A. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 18 | 16 | 34 |
| 2024 Octubre | 155 | 49 | 204 |
| 2024 Septiembre | 188 | 45 | 233 |
| 2024 Agosto | 189 | 90 | 279 |
| 2024 Julio | 191 | 44 | 235 |
| 2024 Junio | 166 | 44 | 210 |
| 2024 Mayo | 147 | 32 | 179 |
| 2024 Abril | 126 | 27 | 153 |
| 2024 Marzo | 173 | 36 | 209 |
| 2024 Febrero | 135 | 40 | 175 |
| 2024 Enero | 134 | 30 | 164 |
| 2023 Diciembre | 154 | 46 | 200 |
| 2023 Noviembre | 150 | 78 | 228 |
| 2023 Octubre | 157 | 53 | 210 |
| 2023 Septiembre | 159 | 59 | 218 |
| 2023 Agosto | 120 | 32 | 152 |
| 2023 Julio | 121 | 55 | 176 |
| 2023 Junio | 85 | 34 | 119 |
| 2023 Mayo | 101 | 32 | 133 |
| 2023 Abril | 96 | 37 | 133 |
| 2023 Marzo | 107 | 30 | 137 |
| 2023 Febrero | 44 | 33 | 77 |
| 2023 Enero | 41 | 31 | 72 |
| 2022 Diciembre | 52 | 45 | 97 |
| 2022 Noviembre | 39 | 43 | 82 |
| 2022 Octubre | 60 | 22 | 82 |
| 2022 Septiembre | 45 | 55 | 100 |
| 2022 Agosto | 35 | 28 | 63 |
| 2022 Julio | 58 | 44 | 102 |
| 2022 Junio | 30 | 25 | 55 |
| 2022 Mayo | 69 | 53 | 122 |
| 2022 Abril | 81 | 37 | 118 |
| 2022 Marzo | 90 | 54 | 144 |
| 2022 Febrero | 77 | 28 | 105 |
| 2022 Enero | 125 | 48 | 173 |
| 2021 Diciembre | 78 | 42 | 120 |
| 2021 Noviembre | 89 | 65 | 154 |
| 2021 Octubre | 74 | 59 | 133 |
| 2021 Septiembre | 78 | 53 | 131 |
| 2021 Agosto | 75 | 36 | 111 |
| 2021 Julio | 48 | 47 | 95 |
| 2021 Junio | 62 | 41 | 103 |
| 2021 Mayo | 79 | 51 | 130 |
| 2021 Abril | 218 | 86 | 304 |
| 2021 Marzo | 100 | 31 | 131 |
| 2021 Febrero | 71 | 36 | 107 |
| 2021 Enero | 52 | 23 | 75 |
| 2020 Diciembre | 39 | 25 | 64 |
| 2020 Noviembre | 27 | 15 | 42 |
| 2020 Octubre | 27 | 15 | 42 |
| 2020 Septiembre | 38 | 12 | 50 |
| 2020 Agosto | 16 | 19 | 35 |
| 2020 Julio | 22 | 12 | 34 |
| 2020 Junio | 47 | 25 | 72 |
| 2020 Mayo | 19 | 16 | 35 |
| 2020 Abril | 29 | 18 | 47 |
| 2020 Marzo | 35 | 19 | 54 |
| 2020 Febrero | 1 | 4 | 5 |
| 2020 Enero | 0 | 2 | 2 |
| 2019 Diciembre | 4 | 10 | 14 |
| 2019 Noviembre | 0 | 3 | 3 |
| 2019 Octubre | 0 | 6 | 6 |
| 2019 Septiembre | 4 | 3 | 7 |
| 2019 Agosto | 0 | 5 | 5 |
| 2019 Julio | 0 | 4 | 4 |
| 2019 Junio | 2 | 5 | 7 |
| 2019 Mayo | 0 | 51 | 51 |
| 2019 Abril | 3 | 1 | 4 |
| 2019 Marzo | 2 | 9 | 11 |
| 2019 Enero | 3 | 0 | 3 |
| 2018 Noviembre | 4 | 0 | 4 |
| 2018 Octubre | 1 | 0 | 1 |
| 2018 Septiembre | 2 | 0 | 2 |
| 2018 Junio | 0 | 3 | 3 |
| 2018 Mayo | 0 | 7 | 7 |
| 2018 Abril | 0 | 3 | 3 |
| 2018 Marzo | 2 | 3 | 5 |
| 2018 Febrero | 113 | 4 | 117 |
| 2018 Enero | 72 | 6 | 78 |
| 2017 Diciembre | 116 | 5 | 121 |
| 2017 Noviembre | 53 | 7 | 60 |
| 2017 Octubre | 47 | 10 | 57 |
| 2017 Septiembre | 63 | 10 | 73 |
| 2017 Agosto | 69 | 9 | 78 |
| 2017 Julio | 78 | 9 | 87 |
| 2017 Junio | 79 | 21 | 100 |
| 2017 Mayo | 56 | 19 | 75 |
| 2017 Abril | 39 | 6 | 45 |
| 2017 Marzo | 49 | 25 | 74 |
| 2017 Febrero | 40 | 11 | 51 |
| 2017 Enero | 43 | 5 | 48 |
| 2016 Diciembre | 55 | 5 | 60 |
| 2016 Noviembre | 80 | 18 | 98 |
| 2016 Octubre | 108 | 13 | 121 |
| 2016 Septiembre | 176 | 14 | 190 |
| 2016 Agosto | 153 | 7 | 160 |
| 2016 Julio | 69 | 6 | 75 |
| 2016 Junio | 7 | 13 | 20 |
| 2016 Mayo | 6 | 3 | 9 |
| 2016 Abril | 10 | 2 | 12 |
| 2016 Marzo | 2 | 4 | 6 |
| 2016 Febrero | 6 | 3 | 9 |
| 2016 Enero | 11 | 1 | 12 |
| 2015 Diciembre | 15 | 2 | 17 |
| 2015 Noviembre | 4 | 4 | 8 |
| 2015 Octubre | 4 | 5 | 9 |
| 2015 Septiembre | 2 | 1 | 3 |
| 2015 Agosto | 5 | 3 | 8 |
| 2015 Julio | 121 | 2 | 123 |
| 2015 Junio | 54 | 0 | 54 |
| 2015 Mayo | 73 | 4 | 77 |
| 2015 Abril | 71 | 3 | 74 |
| 2015 Marzo | 48 | 1 | 49 |
| 2015 Febrero | 68 | 5 | 73 |
| 2015 Enero | 43 | 2 | 45 |
| 2014 Diciembre | 50 | 7 | 57 |
| 2014 Noviembre | 50 | 6 | 56 |
| 2014 Octubre | 57 | 3 | 60 |
| 2014 Septiembre | 30 | 0 | 30 |
| 2014 Agosto | 30 | 7 | 37 |
| 2014 Julio | 27 | 6 | 33 |
| 2014 Junio | 55 | 5 | 60 |
| 2014 Mayo | 40 | 6 | 46 |
| 2014 Abril | 43 | 4 | 47 |
| 2014 Marzo | 46 | 8 | 54 |
| 2014 Febrero | 21 | 3 | 24 |
| 2014 Enero | 25 | 3 | 28 |
| 2013 Diciembre | 7 | 4 | 11 |
| 2013 Noviembre | 0 | 3 | 3 |
| 2013 Octubre | 3 | 1 | 4 |
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