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2014-01-10-10 Case of the week #364 © Grochal www.TheFetus.net 

 
Answer to the case of the week #364

March 06, 2014 - March 20, 2014

Frantisek Grochal, MD.

Femicare, Center of prenatal ultrasonographic diagnostics, Martin, Slovak Republic. Catholic University in Ruzomberok, Faculty of Health Care, Ruzomberok, Slovak Republic.
 

Case report

43-year-old woman (G1P0), with non-contributive history, presented to our office at 24 weeks of pregnancy due to abnormal fetal biometry. The patient had refused amniocentesis.

Our ultrasonographic examination revealed following findings:
- shortening of long bones (femur, humerus, ulna, radius, fibula, tibia) - in average the difference between the biometry of the bones and biometry of the fetal head was about 3-5 weeks;
- inadequate abdominal biometry;
- normal ossification of the skeleton;
- slightly depressed nasal bridge.

Another examination was done at 30 weeks and the differences between the biometry of fetal head (corresponding to 28-29 weeks) and long bones (corresponding to 22-23 weeks) were even more striking. Abdominal biometry was also behind expected gestational age (corresponding to 25 weeks).

Amount of the amniotic fluid was normal. Doppler measurements at the level of the middle cerebral artery were in normal limits. Doppler of the umbilical arteries was normal in most of our records and only one tracing showed absent diastolic flow during a few cardiac cycles.

The severe discrepancy between the biometry of the long bones and the rest of the body, normal amniotic fluid volume, normal appearance of the placenta, and mostly normal Doppler tracings led us to think about some skeletal dysplasias that could be behind the findings.

The baby was delivered prematurely at 32 weeks with signs of severe hypotrophy (820 g, 35 cm, Apgar 6, 8,10) - intrauterine growth restriction. No genetic anomalies or signs of skeletal dysplasias were found.

This case illustrates that amount of the amniotic fluid and Doppler measurements sometime do not reflect markedly the hemodynamic changes accompanying the fetal hypotrophy. Disproportionate fetal growth sparing the fetal head may be sometime so conspicuous that may become a source of confusion. Such fetuses are often suspected from skeletal dysplasias.

Images 1, 2: 23+3 weeks of gestation; the images show normal shape and ossification of the fetal skull. Biometry of the fetal head corresponds to 22 weeks.

 

Images 3, 4: 23+3 weeks of gestation; the images show fetal profile with normal nasal bone and slightly depressed nasal bridge.

 

Images 5, 6
: 23+3 weeks of gestation; the images show transverse scans of the fetal abdomen and thorax. Abdominal circumference was behind expected gestational age and corresponded to 19+1 weeks of pregnancy.

 

Images 7, 8: 23+3 weeks of gestation; the images show normal shape on ossification of the femur and humerus. Biometry of the long bones was behind the expected gestational age (femur corresponded to approximately 17 weeks, humerus corresponded to 19 weeks).

 

Images 9, 10
: 23+3 weeks of gestation; 3D images of the fetal face with slightly depressed nasal bridge.

 


Image 11: 23+3 weeks of gestation; table showing disproportionate fetal biometry.



Images 12, 13: 29+5 weeks of gestation; the images show biometry of the fetal head and abdomen. The biometry of the head corresponds to approximately 28 weeks; abdominal biometry corresponds to 25 weeks.

 

Images 14, 15: 29+5 weeks of gestation; the images show normal shape on ossification of the femur and humerus. Biometry of the long bones was behind the expected gestational age (femur corresponded to approximately 22 weeks, humerus corresponded to 23 weeks).

 

Image 16: 29+5 weeks of gestation; normal fetal spine.

 

Images 17, 18: 29+5 weeks of gestation; 3D images of the fetal face with slightly depressed nasal bridge.

 

Images 17, 18, 19, 20: 29+5 weeks of gestation; Doppler measurements at the level of the middle cerebral artery (image 17) was in normal limits. Doppler of the umbilical arteries (images 18, 19, 20) was normal in most of our records and only one tracing (image 20) showed absent diastolic flow during a few cardiac cycles. 

 


 


Image 11: 29+5 weeks of gestation; table showing disproportionate fetal biometry with marked head sparing effect.



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