Volume 4, Issue 2

Type II caesarean scar pregnancy (CSP) not only poses important maternal hazards, such as severe bleeding, uterine rupture, disseminated intravascular coagulation and maternal death due to its abnormal location and invasive characteristics, but its surgical management may lead to operative complications and even loss of fertility. The sonographic and Doppler findings of a “canal defect CSP” that has previously been hypothesised, but not illustrated, are presented here. A minimally invasive approach was performed in the presence of a 38.3 mm gestational sac (GS) with a crown rump length of 11.3 mm embryo (8+2 weeks of gestation) and cardiac activity with high (118,839.2 mIU/mL) human chorionic gonadotropin (hCG) levels. A transabdominal intragestational sac injection of potassium chloride to stop cardiac activity, and consecutively, methotrexate (MTX) was given before systemic MTX therapy. Embryonic cardiac activity stopped. Systemic methotrexate was repeated 8 days after the procedure. While vaginal bleeding ceased in 3 weeks with gradual shrinkage of the GS, hCG fell to non-pregnant levels within 112 days (16 weeks); complete resolution of the ectopic mass required 8 months. This is the first report presenting the success of a minimally invasive procedure at a hCG level of 118,839.2 mIU/mL with embryonic cardiac activity in type II CSP.

Acute abdomen in pregnancy poses special challenge to the pregnant woman, her unborn infant, and the attending physician. The problems are multifactorial, as the physiological changes in pregnancy mask some of the clinical signs that can be elicited in making accurate diagnosis. Some diagnostic modalities are not feasible in pregnancy because of their effects on the fetus. Another dilemma is that two lives are at stake. It becomes even more challenging when one is faced with rare causes. For these reasons, the choice of diagnostic modality becomes critical. The chosen diagnostic modality should not only be readily available, non-invasive, least hazardous to the mother and fetus, but should also provide adequate information to enable accurate diagnosis. Ultrasonography provides such an opportunity and should be utilized whenever the need arises. We present two cases of acute abdomen in pregnancy managed at Abubakar Tafawa Balewa University Teaching Hospital: one was seen in the third trimester and the other in the first trimester, each with its peculiar presentation. The review is meant to alert obstetricians on the critical role of ultrasound in enhancing accurate diagnosis in the face of a complex clinical condition like acute abdomen in pregnancy.

Hemangiomas are the most common benign tumor of the liver and are commonly seen as incidental findings on abdominal imaging. Little is known regarding the natural course and pathogenesis of hepatic hemangiomas during pregnancy. It is believed estrogen may play a role in their growth; however, the precise mechanism remains undefined. Here we describe a patient with hepatic hemangioma enlargement in consecutive pregnancies suggesting a hormonal role in their growth.

Background: While elevated serum amylase in the presence of abdominal pain can be indicative of pancreatitis, differential diagnosis of macroamylasemia depends on additional assessment of serum lipase and urinary amylase. The present report concerns misdiagnosis of pancreatitis in a pregnant woman with elevated serum amylase but normal lipase. Highlights: The patient was a nulligravid woman on her first pregnancy diagnosed with pancreatitis in her 32 nd week plus 3 days of gestation, on the basis of elevated serum amylase and abdominal pain, after treatment for premature contractions and antepartum vaginal bleeding with ritodrine HCl and nifedipine. She was started on painful and invasive intravenous hydration; oral intake was stopped. Repeat elevated serum amylase suggested that the patient might in fact have macroamylasemia, not pancreatitis. Conclusions: Normal serum lipase levels should be considered as a likely indication of an alternative cause of elevated serum amylase to pancreatitis, and urinary amylase should be routinely checked to assist in differential diagnosis to avoid unnecessary and invasive treatment and stress to pregnant women.

The aim of this paper is sharing our experience in an advanced cervical ectopic pregnancy (CEP), which is managed by conservative surgery. We herein report a case of a 24-week pregnant woman with CEP. She was first referred to a tertiary center due to early starting intrauterine growth retardation and oligohydramniosis. Surgery was planned as soon as the diagnosis of CEP was made. By taking measures to reduce bleeding, conservative surgery was succesfully performed, and a hysterectomy was avoided. The fertility of the patient was preserved. The possibilty of CEP must be always be kept in mind, and the exact localization of the gestational sac must be determined in all patients. In advanced pregnancies, ultrasonographic examination must not only focus on examination of the fetus but also focus on the examination of contours of the uterus. These will give us the chance to diagnose CEP as soon as possible and reduce morbidity and mortality.

Malformation affecting the genital tract is a rare condition. Enlargement of the mass and specific complications may occur following hemodynamic changes associated with pregnancy. A 25-year-old pregnant primigravida affected by an extended vulvar and thigh venous malformation with localised intravascular consumptive coagulopathy was referred to our hospital. Her antenatal care was uneventful until term. She underwent an elective caesarean section because the venous malformation location precluded vaginal birth. At 3 days postpartum, she suffered life-threatening bleeding in the abdominal cavity with disseminated intravascular coagulation requiring multiple blood and platelets transfusions as well as transarterial embolisation. The patient recovered and was discharged after 20 days. Specific counselling and management of pregnant patients with large vascular malformations is essential as it is associated with increased complications rate such as peripartal thrombosis and haemorrhages. These patients should be referred to tertiary centres and should be managed by a multidisciplinary team including an obstetrician, anaesthesiologist, haematologist, interventional radiologist and plastic surgeon.

Uterine rupture is an obstetric complication with potential catastrophic fetal and maternal consequences, if not detected early and managed promptly. We report a case of a 32-year-old primigravida in spontaneous labour at term who had unprovoked acute uterine rupture. Operative findings at emergency caesarean section were a live female infant weighing 3150 g requiring resuscitation, massive haemoperitoneum, and large right vertical posterolateral uterine rupture at the upper segment, extending to the ovarian pedicle and down to the vagina vault.

Preeclampsia is a systemic endothelial disorder triggered by many factors originated by the human placenta. The presence of massive ascites (more than 2 L of serous liquid in peritoneal cavity) signifies rare and severe complication of preeclampsia. We present a case of 25-year-old primigravida admitted to hospital due to preeclampsia who immediately after delivery developed a clinical condition similar to hemorrhagic shock, but the explorative laparotomy revealed only massive ascites of 4.5 L serous liquid. We suggest that appearance of massive ascites in women with preeclampsia is the underestimated fact that surprises us frequently. Sometimes, its sudden onset can mimic life-threatening conditions, as happened with our patient. Cautious evaluation of peritoneal fluid quantity in women with preeclampsia could warn the obstetrician about the potential risks that demand more intensive and more frequent maternal and fetal surveillance.

Loeys-Dietz syndrome results from mutations in genes encoding the transforming growth factor-β receptor. Women with similar syndromes are at risk of obstetrical complications, including vessel and uterine rupture during labor. There are few reports regarding the safety of pregnancy in women with Loeys-Dietz syndrome, and the available literature recommends early cesarean delivery. We report a case of a successful vaginal delivery at 36 weeks of gestation in a primigravid woman. Prenatal imaging revealed no vascular abnormalities and echocardiogram demonstrated normal cardiac anatomy. Her pregnancy and delivery were uneventful, and the baby was also found to have the mutation on postnatal molecular testing. In a low-risk individual, vaginal delivery at term may be considered a reasonable approach in this group of women.

A 36-year-old primigravida woman with a normal pregnancy course presented with fetal unilateral focal ventriculomegaly on routine ultrasonography performed at 28 weeks of gestation. Periventricular venous infarction (PVI) in utero was diagnosed with fetal magnetic resonance imaging (MRI). The neonate was born at term uneventfully and in utero PVI was confirmed by MRI after birth. The neonate was diagnosed with hereditary protein C deficiency after coagulation laboratory studies. At 10 months of age, the infant presented with mild retardation of motor development. This is the first report about prenatally diagnosed PVI in utero by fetal MRI. When focal, unilateral enlargement of the ventricles is detected in utero by prenatal ultrasonography, it is important to consider PVI and perform confirmatory fetal MRI.

Large placental chorioangioma is a rare but serious complication of pregnancy. To our knowledge, this case is the first reported diagnosis of consumption coagulopathy in a fetus using fetal blood sampling (FBS) during pregnancy complicated by placental chorioangioma. A 25-year-old woman, primigravida, was referred to our hospital at 29 weeks of gestation for placental chorioangioma. At 34+1 gestation, polyhydramnios and hyperdynamic circulation were observed in the fetus. FBS demonstrated microangiopathic hemolytic anemia and the presence of consumption coagulopathy. Cesarean section was performed at 34+4 gestation because fetal maturation was expected. A female infant weighing 2158 g was born, with Apgar scores of 6 and 8 at 1 and 5 min, respectively. Neonatal blood sampling results were similar to those of FBS. The infant was treated for hyperdynamic cardiac function, hemolytic anemia, and consumption coagulopathy on mechanical ventilation in the neonatal intensive care unit and recovered fully. When fetal anemia is suspected in a case of large placental chorioangioma, the possibility of developing consumption coagulopathy during the fetal period should be considered.

Objective: To study the clinical outcome of fetal ovarian cysts managed with in utero aspiration. Methods: All cases of fetal ovarian cysts diagnosed from 2002 to 2013 were reviewed. In utero aspiration was performed for patients with simple cysts larger than 4 cm before term gestation. Results: There were 21 cases of fetal ovarian cysts. Four patients (19%) were diagnosed with complex cysts at the time of referral. Among the 17 cases of simple cysts, in utero aspiration was performed in seven patients. There were no complications after the therapy and none of them developed complex cysts. An ovarian cyst was confirmed by cyst fluid that contained high levels of estradiol, progesterone and testosterone. For two patients with simple cysts who met the indications for in utero aspiration but did not receive therapy, one developed a complex cyst. Among the eight patients with simple cysts who did not fulfill the indications for aspiration, seven of them had cysts that regressed spontaneously, and one developed complex cysts during pregnancy. Conclusion: Torsion of fetal ovarian cysts was common with expectant management. Management of fetal ovarian cysts larger than 4 cm using in utero aspiration may avoid torsion, which could otherwise lead to ovarian loss.

Background: Fetal cardiac rupture is very rare and has been scarcely reported. Prenatal image diagnosis of fetal cardiac rupture is not well characterized. Case: An 18-week fetus with a pericardial mass and effusion revealed by ultrasound was suspected to have a pericardial tumor. Fetal demise occurred at 19 weeks’ gestation. Postmortem magnetic resonance image (MRI) found a pericardial mass diagnosed as a hematoma caused by cardiac rupture. Findings were confirmed by autopsy. Conclusion: MRI may be applicable for prenatal diagnosis of cardiac rupture.

Fetus in fetu (FIF) is a rare form of twinning in which an immature twin develops parasitically inside the other twin. The most frequent location of a parasitic fetus is the retroperitoneal region. A FIF located on the abdominal wall is an unusual condition, and it should be kept in mind as one of the differential diagnoses of abdominal wall masses.

Intrauterine fetal thrombosis is an extremely rare event with a devastating outcome. The etiology of the condition often remains unclear. A 29-year-old 2 nd gravida 1 st para presented with mild preeclampsia at 34 weeks of gestation with pathological cardiotocography (CTG), but normal resistance indices in the umbilical and the uterine arteries. The fetal middle cerebral artery (MCA) displayed a significantly reduced pulsatility index (PI). An immediate cesarean section was performed and a male neonate with a birth weight of 2300 g was delivered. Immediately after birth, a progressive necrosis of the neonate’s 4 th right final finger link and a palsy of the right brachial plexus were observed. MRI and ultrasound imaging did not display mechanical injuries. The Doppler ultrasound showed a thrombus in the right common carotid and subclavian artery with poststenotic decreased blood flow of the right middle cerebral artery. Further analysis did not reveal inherited or acquired thrombophilias of the neonate. The puzzling prenatal finding of a markedly decreased PI in the MCA as well as the initially suspected postnatal diagnosis of traumatic plexus injury were clarified by the diagnosis of the thrombosis.

We report a case of uncomplicated giant fetal hepatic hemangioma with a good outcome. A 57×38 mm heterogeneous hepatic mass, mostly hypoechogenic was observed post prenatal ultrasound, at 33 weeks’ gestation (WG) and 5 days. Color Doppler confirmed the vascular pattern of the mass. The image size stayed stable, with no associated complications, and a cesarean birth at 37 WG was performed for fetal protection. Subsequent postnatal follow-up showed spontaneous regression of the tumor. Antenatal diagnosis and management of fetal liver masses are discussed in this paper. This case supports the hypothesis that complications of giant fetal hepatic hemangioma are not related only to its size. Prognostic factors and guidelines for follow-up need to be determined.

In this case series, we aimed to determine the outcome of prenatally diagnosed fetal cardiac rhabdomyoma. This case series is a retrospective evaluation of seven cases of fetal cardiac rhabdomyoma determined during pregnancy. Only one of these cases has been associated with tuberous sclerosis (TS). Two of the cases had just a single tumor, whereas the others were found to have multiple tumors. Termination was performed to one fetus due to hydrops fetalis. The presence of risk factors of TS in a family and multifocal or large tumors, appears to be the most important factors affecting neonatal outcomes.

Polythelia, the presence of supernumerary nipples, is a common anomaly usually limited to cosmetic concerns. However, the existence of accessory mammary tissue may indicate associated anomalies of the kidneys and the urinary tract or other systemic diseases. The association of these anomalies and systemic disease is often controversial, although some authors report their significance in neonates and infants. We report the association of accessory nipple and right-sided hydronephrosis in a female term newborn. Prenatal ultrasound monitoring did not indicate hydronephrosis and it was diagnosed after birth with an ultrasound examination of the newborn, which was due to a fever and suspected urinary infection. We consider that in symptomatic infants with accessory breast tissue, a thorough physical examination, urine analysis, and renal ultrasound should be done in order to exclude associated urinary tract abnormalities.

Background: Necrotizing enterocolitis is rare in full-term infants, and is currently not considered a known complication of phototherapy. Highlights: Three cases of necrotizing enterocolitis in full-term babies possibly associated to intensive phototherapy for treatment of early neonatal hyperbilirubinemia due to isoimmune hemolytic disease of the newborn. Conclusions: Although rare, the association between occurrences of necrotizing enterocolitis in full-term newborn infants and intensive phototherapy merits caution and clinical awareness to such possible complication. Presumptive explanation is that intensive phototherapy causes marked vasodilataion in the skin that may result in decreased perfusion of the intestine leading to ischemia and necrotizing enterocolitis. This calls for further studies to investigate the effects of phototherapy on the vascular bed in the gut and other vital organs that could have clinical implications.

Background: Neonatal toxic shock syndrome-like exanthematous disease (NTED) and toxic shock syndrome (TSS) are both caused by the bacterial superantigen, toxic shock syndrome toxin-1 (TSST-1), which is mainly produced by methicillin-resistant Staphylococcus aureus (MRSA). However, the coincidence of NTED and maternal TSS has yet to be reported. Cases: A 4-day-old full-term infant showed a typical clinical profile and laboratory findings that matched the criteria for the diagnosis of NTED, resulting in complete remission after 7 days. Fever and a skin rash were observed in the mother of the infant 3 days postpartum. In both cases, marked expansion and activation of Vβ2+ T cells in the peripheral blood was confirmed by flow cytometry. Anti-TSST-1 antibody was not detected in the mother nor in the infant. Conclusion: Obstetricians should consider TSS for the differential diagnosis of puerperal fever and systemic erythema if the infant develops NTED.