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2012-05-29-17 Dysplastic tricuspid valve and subdural hematoma ©Fabrice Cuillier 

Dysplastic tricuspid valve and subdural hematoma.

Fabrice Cuillier, MD*; H. M‘Lamali, MD**, L. Vinatier, MD*. 
*    Department of Gynecology, Felix Martin’Hospital, 97460 Saint-Paul, Ile de la Réunion, France; 
**   Department of Gynecology, Gabriel Martin’Hospital, 97450 Saint-Paul, Ile de la Réunion, France.

Case report:   

This was a nonconsanguineous dichorionic twin pregnancy of a patient (G3P2) who was referred to our unit at 24 weeks of pregnancy due to cardiac anomalies of the second fetus. 
Her ultrasound at 13 weeks was normal (Normal nuchal translucency). Triple test was 1:1450. 
Our ultrasound examination showed normal intrauterine growth. The second fetus presented abnormal tricuspid valve: theses valves did not move, and were dysplastic (Figure 1, 2). There was low flow between the valve. The right ventricle seemed hypoplastic with hypertrophy of its walls. The first twin was normal.  

At  27 weeks, anasarca appeared (Figure 3,4). We observed cardiomegaly with an absence of flow inside the tricuspid, hydrothorax, ascite and edema.(Figure 5-7). 

At 31 weeks, a voluminous cerebral hyperechogenic mass suggested a subdural hematoma (Figure 8). Lateral cerebral ventricles were normal. The fetus presented important signs of cardiac insufficiency with cardiomegaly, pericardial effusion and abnormal umbilical artery Doppler (Figure 9). The first twin was always normal. 

At 32 weeks, the affected fetus died. Serological tests (Toxoplasmosis, Rubella, CMV, Herpes, Chikungunya) were negative. After counseling, the parents decided to continue  the pregnancy to term. 
Etiology of the intracranial hemorrhage was not completely clear, but we supposed that the fetal suffering, hypoxia and cardiac failure might play a role in pathophysiology of this finding. No history of maternal trauma was noted and the mothers examinations (TORCH blood test, autoimmune antiplatelet antibodies, platelet count, prothrombin time) were normal. The delivery happened at 37 weeks. The first fetus was normal. Autopsy of the second fetus was refused.  
Figure 1, 2: 
2D views of the heart showing hypoplastic right ventricle with absence of flow through the tricuspid valve.

Figure 3: 
2D views of the heart showing calcification of the tricuspid valve.  

2D views showing fetal sign of cardiac decompensation.  

Figure 8:
Transverse scans of the fetal skull showed the subdural mass suggesting hematoma

Firgure 9: Abnormal umbilical artery Doppler.

Video 1:
Video shows transverse scan of the fetal thorax at the level of the four-chamber view showing the cardiomegaly and pericardial effusion.

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