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2019-06-22  Case of the week # 500  © Rami Mohamed Bakr Barakat

Answer to the case of the week # 500
July 18, 2019 - August 1, 2019

Case report

A 28-years-old woman referred to Fetal Care Clinic of Assiut due to accumulation of an ascitic fluid inside the fetal abdomen.

Detailed ultrasound examination revealed a 30 weeks gestation female fetus with an abdominal enlargement. 

The underlying cause of the abdominal enlargement was a right upper abdominal cyst measured 100 x 80 x 90 mm.

The large abdominal cyst was distended with a clear fluid . A heterogeneous mass could be identified suspended inside the cyst . Incomplete limbs , hypomineralized fluid filled skull and disfigured trunk were seen as the main components of the
irregular mass.

A vascular stalk could be seen connecting the parasitic twin to the wall of the sac and the color Doppler showed a single feeding vessel traversed this pedicle with a pattern of spectral Doppler very similar to the pattern of the umbilical artery.

The patient continued her pregnancy without complications and the fetus was delivered via C.S with gentle extraction to avoid the rupture of the abdominal cyst. 

The baby was admitted to the neonatology unit of the children university hospital of Assiut because it had a mild respiratory distress.

The baby was fully investigated . The serum level of the alpha fetoprotein was markedly high. The conventional X-ray revealed a soft tissue mass with vertebral column and long bones of incomplete limbs.

Computed tomography and CT-angio scan demonstrated an extraperitoneal sac in which a fetus resembling mass could be seen. The vertebral column and long bones of lower limbs could be identified easily but there was no vascular pedicle which denoted cessation of the blood flow to the parasitic twin.

Preoperative platelet transfusion was required several times to correct the neonatal thrombocytopenia.

Once the baby was fit for operation, the decision was taken by the pediatric surgeons to excise the mass.

The cystic mass was in the right upper retroperitoneal space and it was large enough to displace the right kidney superiorly and to displace the liver to the left side.

The final diagnosis was ¨Fetus in fetu¨.

Images 1 and 2:
2D transverse images of the fetal abdomen showing a large cyst with a heterogeneous mass inside of it.

Images 3 and 4: Tomographic ultrasound imaging (TUI) of the lesion revealed cystic, soft tissue and bone components inside the mass.

Video 1: 2D images showing the fetus in fetu.

Images 5 and 6: color and spectral Doppler study of the lesion shows a vascular stalk connecting the parasitic twin to the wall of the sac and a single feeding vessel traversed to this pedicle with a pattern very similar to the pattern of the umbilical artery.

Images 7, 8 and 9: CT scan showing bone structures located in the right hemiabdomen, as a part of the parasitic fetus.

Image 10: post-surgery specimen shows  the aspect of the parasitic twin.
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