A 32-year-old woman, gravida 1 para 0, at 20 weeks gestation comes to the clinic for a routine prenatal anatomy ultrasound. Recent genetic testing was normal, and the patient has no concerns. She has no chronic medical conditions, and her only medication is a daily prenatal vitamin. Vital signs are normal. BMI is 24 kg/m². Transabdominal ultrasound reveals a female fetus in breech position. Cardiopulmonary and abdominal examinations are normal. Examination of both lower extremities during fetal movement shows that the plantar surface of each foot is maintained in the same plane as the tibia and fibula, findings consistent with a clubfoot deformity. The amniotic fluid is normal and there is a fundal placenta. The remainder of the ultrasound is normal. After delivery, the infant will require which of the following interventions?

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11ec25c8_d738_4a75_bc81_2d12a25d3d23_MD0003_00 This fetus has a fixed, bilateral clubfoot (talipes equinovarus) deformity, which is caused by abnormal development of the talus bone. Most cases are isolated without other congenital or structural abnormalities, and the etiology is usually genetic or due to extrinsic compression of the fetus (eg, breech positioning, oligohydramnios, uterine fibroids). During fetal development, the connective tissue and musculature of the foot and distal calf surrounding the talus bone do not fully develop, resulting in a fixed, plantar flexed foot with an adducted and internally rotated forefoot. Imaging typically reveals the foot in the same plane as the tibia and fibula, as seen in this patient. Initial management of clubfoot is gentle manipulation and stretching with serial molding casts, ideally beginning the neonatal period. Once an optimal position is achieved by casting, long-term bracing is typically required; surgical correction is reserved for refractory cases or recurrence of clubfoot after nonsurgical treatment (Choice B). If untreated, clubfoot will lead to an abnormal gait with weight bearing on the lateral aspects of the feet. (Choice A) Vitamin D supplementation can be used to treat congenital rickets, which is caused by severe maternal vitamin D deficiency. Poor bone mineralization causes pathologic bowing of the forearm and tibia, not clubfoot. (Choice C) Although patients with congenital myotonic dystrophy have an increased incidence of clubfoot, glucocorticoids are usually indicated only for those with muscle pain. Moreover, most cases of clubfoot are isolated, and management does not include pharmacotherapy. (Choice E) Reassurance and observation may be appropriate management of positional clubfoot, which can have an appearance similar to that of clubfoot. However, the foot moves flexibly with fetal movement, unlike this patient's fixed deformity. Educational objective: Clubfoot is a developmental deformity of the talus bone and presents as a fixed, plantar flexed foot that is adducted and internally rotated. Initial treatment is stretching with serial molding casts. References: Clubfoot. (http://www.ncbi.nlm.nih.gov/pubmed/31855401) Ponseti method in management of clubfoot under 2 years of age: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/28632733)

A 32-Year-Old Woman, Gravida 1 Para 0, at 20 Weeks