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2008-05-24-03 Answer to the case of the week #221 © Cuillier

Answer to the case of the week #221

June 20-July 3, 2008

Fabrice Cuillier, MD*; J. Chouchani, MD**; A. Hamas, MD**.

*    Department of Gynecology, Felix Martin’Hospital, 97460 Saint-Paul, Ile de la Réunion, France;
**   Department of Gynecology, Félix Guyon’Hospital, 97400 Saint-Denis, Ile de la Réunion, France.


Case report

This was a nonconsanguineous dichorionic twin pregnancy of a woman (G1P0), who presented to our unit at 33 weeks of pregnancy. Her ultrasound examinations performed at 13 and 23 weeks were normal. Triple test was not done. The patient was referred to our unit due to intrauterine growth restriction of one of the fetuses at 33 weeks of pregnancy. Our ultrasonographic examination revealed marked intrauterine growth restriction (estimated weight 650 g) and the fetus presented with a voluminous cerebral hyperechogenic mass, which was considered to be a subdural hematoma. Lateral cerebral ventricles were normal. The fetus showed signs of cardiac insufficiency, with cardiomegaly, pericardial effusion and abnormal umbilical artery Doppler. The second twin was normal.
Serological tests (Toxoplasmosis, Rubeola, CMV, Herpes, Chikungunya) were negative. The parents were counseled and opted for the continuation of the pregnancy. The affected fetus died one day later and the pregnancy was terminated one week later due to maternal preeclampsia.

Etiology of the intracranial hemorrhage was not completely clear but we hypothesize that the fetal suffering, hypoxia and cardiac failure may have played a role in the pathophysiology of this finding. No history of maternal trauma was noted and the mother"s examinations (TORCH blood test, alloimmune antiplatelet antibodies, platelet count, prothrombin time) were normal.

No external morphological anomalies of the dead fetus were found. Postmortal findings confirmed the presence of hemosiderin within the cerebral mass.

Images 1, 2: Transverse scans of the fetal skull showing the subdural mass consistent with hematoma.


Images 3, 4: Transverse scans of the fetal skull showing the subdural mass consistent with hematoma.


Images 5, 6: Image 5 shows transverse scan of the fetal thorax at the level of the four-chamber view showing the cardiomegaly. Image 6 shows sagittal scan of the superior and inferior vena cava. The veins are dilated due to the fetal cardiac failure.


Image 7: Abnormal umbilical artery Doppler of the fetus presented with the subdural hematoma.


Video 1: The video shows fetal cardiomegaly and pericardial effusion.


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