Large placental chorioangiomas as a cause of cardiac failure in two fetuses

Fetal Heart Size: A Comparison Between the Point-to-Point Trace and Automated Ellipse Methods Between 20 and 40 Weeks' Gestation

OBJECTIVES

To evaluate whether the global area and circumference of the heart varies between two measurement techniques: the point-to-point trace and the electronic ellipse methods.

METHODS

The epicardial border of the 4-chamber view was measured in 200 fetuses between 20 and 40 weeks' gestation, from which the area and circumference using the point-to-point trace and electronic ellipse were measured. Analysis of variance, correlation, and regression analysis using fractional polynomials and 7 independent variables (head circumference, biparietal diameter, abdominal circumference, femur length, estimated fetal weight, mean ultrasound gestational age, and last menstrual period gestational age) were performed.

RESULTS

The correlation between the mean ultrasound gestational age and last menstrual period gestational age was 0.9880 (5% confidence limit, 0.9716; 95% confidence limit, 0.9880), with an R² of 0.9762. The R² value for the 7 independent variables regressed against the area and circumference using the point-to-point trace and electronic ellipse methods ranged between 0.885 and 0.965. Comparison of Z scores between this study and previous publications demonstrated that there were differences and similarities, depending on whether the area or circumference was measured.

CONCLUSIONS

This study shows high R² values when comparing measurements of the area and circumference against 7 independent variables, irrespective of whether the point-to-point trace or the electronic ellipse method was used to obtain the measurements. A calculator to evaluate the area and circumference is provided, using 7 independent variables from which Z scores and percentiles for individual measurements can be computed.

Intrauterine blood transfusion: current indications and associated risks

Fetal anemia is a serious complication in pregnancy and associated with perinatal mortality and morbidity. During 25 years of worldwide experience with intravascular intrauterine blood transfusion, a variety of indications have been described. Intrauterine transfusion (IUT) treatment is considered most successful for fetal anemia due to red cell alloimmunization. Moreover, the use of this procedure has also been reported in pregnancies with parvovirus B19 infection, fetomaternal hemorrhage and placental chorioangiomas, for example. This review focuses on the current indications of intrauterine blood transfusions. In addition, we describe the potential complications of IUT treatment.

Fetal cardiac output in monochorionic twins

OBJECTIVES

To compare fetal cardiac output (CO) in donor and recipient twins of twin-twin transfusion syndrome (TTTS) pregnancies after laser therapy with that of monochorionic twins without TTTS and normal singletons.

METHODS

In a longitudinal, prospective study, we sonographically assessed fetal CO in donors (n = 10) and recipients (n = 10) with TTTS after fetoscopic laser therapy, in monochorionic twins without TTTS (n = 20) and in normal singleton pregnancies (n = 20). The fetal CO of TTTS twins was determined 1 day and 1 week after laser treatment, and from then on every 2-4 weeks until birth. Twins without TTTS were examined biweekly until birth. Singletons were examined twice, with an 8-week interval, at different gestational ages between 17 and 35 weeks.

RESULTS

Absolute CO increased exponentially with advancing gestational age (P < 0.0001), and was significantly related to fetal weight in all groups (P < 0.0001). The median CO/kg in donors after laser therapy, recipients after laser therapy and non-TTTS monochorionic twins was significantly higher than that in singletons (all P < 0.001). Median CO/kg in donors after laser therapy, recipients after laser therapy, and non-TTTS monochorionic twins was not significantly different between groups.

CONCLUSIONS

Monochorionic twins with TTTS have higher CO after laser therapy than normal singletons.

Ultrasound of the placenta: a systematic approach. Part I: Imaging

Diagnostic ultrasound has been in use in clinical obstetrics for close to half-a-century. However, in the literature, examination of the placenta appears to be treated with less attention than the fetus or the pregnant uterus. This is somewhat unexpected, given the obvious major functions this organ performs during the entire pregnancy. Examination of the placenta plays a foremost role in the assessment of normal and abnormal pregnancies. A methodical sonographic evaluation of the placenta should include: location, visual estimation of the size (and, if appearing abnormal, measurement of thickness and/or volume), implantation, morphology, anatomy, as well as a search for anomalies, such as additional lobes and tumors. Additional assessment for multiple gestations consists of examining the intervening membranes (if present). The current review considers the various placental characteristics, as they can be evaluated by ultrasound, and the clinical significance of abnormalities of these features. Numerous and varied pathologies of the placenta can be detected by routine ultrasound. It is incumbent on the clinician performing obstetrical ultrasound to examine the placenta in details and in a methodical fashion because of the far reaching clinical significance and potentially avoidable severe consequences of many of these abnormalities.

A review of findings in fetal cardiac section drawings, part 1: The 4-chamber view

OBJECTIVES

The goal of this presentation is to review some of the common and rare fetal heart abnormalities and to provide an easy approach to these findings with schematic drawings.

METHODS

Over the past 10 years, we collected cases in which the common views of the heart were abnormal and the differential diagnoses that existed for each. The presentation shows the normal sonographic sections and then variations of these sections and the associated anomalies. We used illustrative drawings to present these findings, enabling us to point out the main sonographic features of abnormalities of the heart.

RESULTS

The work reviews 17 fetal heart abnormalities in schematic drawings.

CONCLUSIONS

This short review highlights several of the anomalies that can be recognized on the common sonographic views. The drawings tend to simplify the findings but serve as a basis for those doing fetal echocardiography when they encounter an unusual finding.

Severe transient cardiac failure caused by placental chorangiosis

BACKGROUND

Chorangiomas are villous capillary tumors of the placenta with high impact on neonatal morbidity and mortality. Cardiac complications have occasionally been reported.

OBJECTIVE

To elucidate clinical features, diagnosis and treatment of cardiac failure caused by chorangiomas.

METHOD

We report a case of a newborn, in whom massive chorangiomas were associated with severe cardiac failure, anemia, and thrombocytopenia.

RESULTS

Chorangiosis was not diagnosed prenatally. The pre-existing cardiac failure of the infant deteriorated soon after birth. Despite the severe stage, cardiac failure was reversible with intensive medical treatment including phosphodiesterase inhibitor. Complete recovery with no signs of cardiomyopathy was confirmed at the age of 5 months.

CONCLUSIONS

Severe cardiac failure in the neonate can be caused by chorangiosis. The time of diagnosis and treatment seems to be critical for the outcome of the infant. Prenatal treatment interventions should be considered.

Prenatal management of placental chorioangioma: value of the middle cerebral artery peak systolic velocity

Placental chorioangiomas are benign tumors of the placenta. Large chorioangiomas may cause severe complications such as fetal anemia, hydrops and fetal death. We report the use of sonographic findings and peak systolic velocity in the middle cerebral artery in the diagnosis and management of fetal anemia without the occurrence of hydrops fetalis in a pregnant woman with a large placental chorioangioma. Successful intrauterine blood transfusion was performed at 26 weeks. Spontaneous thrombosis of the main supplying blood vessel of the chorioangioma was detected at 33 weeks. The child was delivered at 39 weeks of pregnancy in normal clinical condition.

Fetal cardiovascular response to large placental chorioangiomas

A large placental chorioangioma is a relatively rare condition, which in 50% of all cases will lead to maternal and fetal complications. Since chorioangiomas are often associated with significant arterio-venous shunting within the placenta, several fetal hemodynamic compensatory mechanisms are initiated. Ultrasound and color Doppler flow mapping are important for the prenatal diagnosis of chorioangiomas, as an early prenatal diagnosis is crucial to minimize the risks for fetal well-being. Close surveillance of pregnancy and pregnancy termination by cesarean section at the earliest signs of fetal cardiac decompensation are indicated to reduce fetal and neonatal complications. Novel intrauterine treatment options include intravascular transfusion, fetoscopic devascularization, microcoil embolization, and intravascular injection of absolute alcohol.

Récurrence de chorio-angiomes multiples : à propos d’un cas

Diffuse chorioangiomatosis is a rare placental pathology characterized by multiple chorioangiomas, inducing a high risk of fetal complications, especially cardiovascular, with a risk of fetal death. The physiopathology is not clearly established but seems to be related with an over-expression of vascular growth factors related to hypobaric-hypoxia. Here, we describe a case of recurrent chorioangiomatosis with fetal demise. No risk factors were identified (high altitude, genetic disease like Beckwith-Wiedemann, diabetes). Intra-amniotic, plasmatic values of alphafetoprotein and plasmatic beta gonadotrophin chorionic hormone remained low. Ultrasonographic assessment of placental thickness was in the normal range, at 22 and 32 weeks of gestation. In case of previous chorioangiomatosis, we recommend a weekly sonographic monitoring to diagnose fetal complications associated with an early inpatient hospitalization for daily surveillance at the age of previous accidents. Labor will be induced in case of fetal intolerance or systematically after 37-38 weeks of gestation.

Role of color Doppler imaging in diagnosing and managing pregnancies complicated by placental chorioangioma

PURPOSE

The purpose of this study was to evaluate the role of color Doppler imaging in the diagnosis and management of placental chorioangioma.

METHODS

The medical records, sonographic reports, and sonograms of all pregnant women who had placental masses diagnosed in our sonography unit during the years 1992 through 2000 and had been evaluated using both gray-scale and color Doppler sonography were included in this study. Subjective evaluation of the amount and distribution of intralesional vascularity by color Doppler imaging was made in all cases. Cases of chorioangioma of the placenta were compared with cases of placental hemorrhage or subchorionic hematoma. The outcomes of the pregnancies were also recorded.

RESULTS

Fifteen cases of placental masses were evaluated; 8 of them were identified as placental hemorrhage or subchorionic hematoma on the basis of the sonographic findings. The other 7 cases were identified prenatally as placental chorioangioma, at a mean menstrual age of 23 weeks and a mean maternal age of 29 years. The mean size of the tumor was 6.5 cm (range, 4-13 cm). All cases of chorioangioma showed either substantial internal vascularity or a large feeding vessel within the tumor. Three infants were delivered at term with favorable outcome; 2 of them demonstrated reduction of the intratumoral blood flow during follow-up. The other 4 cases were delivered at or before 32 weeks' menstrual age (1 intrauterine fetal death, 2 terminated pregnancies, and 1 normal infant). No case of placental hematoma demonstrated blood flow within the lesion or was associated with complications of the pregnancy.

CONCLUSIONS

Color Doppler imaging helps differentiate placental chorioangioma from other placental lesions and may be useful in the prenatal follow-up of chorioangioma.

Prenatal diagnosis and management of fetuses with liver hemangiomata

OBJECTIVES

To study the relationship between prenatal appearance and perinatal outcome of fetuses with hepatic hemangiomata with special emphasis on criteria that may help to improve perinatal management.

METHODS

In a tertiary referral center six fetuses with hepatic hemangiomata were evaluated by gray-scale, color, and pulsed wave Doppler ultrasound between 1994 and 2000. Fetal blood sampling was performed in four cases. All data (computerized files and video tapes) were analyzed retrospectively.

RESULTS

Two fetuses showed very similar sonographic findings. They had an isolated large ('giant') round hepatic hemangioma (diameter 43 and 68 mm, respectively) supplied by one hepatic artery and drained by one hepatic vein, both of them showing high velocity and low pulsatility blood flow. Fetal blood count and coagulation parameters were normal in one case, whereas the other fetus showed a Kasabach-Merritt sequence with severe thrombocytopenia (10 platelets/nL) and mild disseminated intravascular coagulation. Intrauterine platelet transfusion was performed immediately prior to planned Cesarean delivery. Rapid platelet consumption continued postnatally, requiring several thrombocyte transfusions. Platelet counts stabilized only after tumor resection on the second day of life. One fetus with diffuse neonatal hemangiomatosis developed high-output cardiac failure with hydrops in addition to Kasabach-Merritt sequence (15 platelets/nL), and died following premature delivery. Three fetuses, however, showing an isolated small hyperechogenic hepatic hemangioma (5, 5, and 6 mm in diameter, respectively) did not develop any perinatal complications.

CONCLUSION

Large fetal liver hemangiomata and diffuse hemangiomatosis may cause severe perinatal complications, particularly high-output cardiac failure and/or Kasabach-Merritt sequence with severe consumption of platelets and clotting factors and hemolytic anemia. Fetal blood sampling enables the prenatal detection of these potential complications, allowing critical modification of perinatal management such as intrauterine platelet transfusion, especially directly before delivery. In contrast, isolated small hyperreflexic hepatic hemangiomata do not appear to be associated with any of these fetal and postnatal sequelae.

Prenatal MRI in a fetus with a giant neck hemangioma: a case report

We report a fetus with a giant neck hemangioma which was examined by MRI in utero. The initial diagnosis was made by ultrasonography. The sonolucent aspect of the mass, together with the presence of pulsating Doppler flow signals, was highly suggestive of a fetal hemangioma. In late pregnancy, fetal MRI revealed the location, size and characteristics of the neck tumor. Following prenatal corticosteroid treatment and premature delivery of the pregnancy due to fetal cardiac failure, the newborn received angiography and coil embolization of the tumor vessels. Despite vigorous treatments, the newborn died 12 h after birth. Evaluation of a fetal neck hemangioma by MRI is recommended late in pregnancy for precise information on the tumor and adjacent organs since the image is valuable for planning optimal perinatal treatment.

Prenatal diagnosis of solid placental masses: the value of color flow imaging

OBJECTIVES

To determine the value of color flow imaging in the prenatal differentiation of solid placental masses protruding from the fetal surface of the placenta.

METHODS

Seven pregnancies in which a large solid mass was seen on the fetal surface of the placenta were prospectively studied. Color flow imaging was used to identify vessels within the mass and the prenatal ultrasound finding correlated with placental pathology.

RESULTS

Postpartum examination of the placenta revealed four cases of chorioangioma, two cases of subchorionic thrombohematoma and one case of subamniotic hematoma. Prenatal ultrasound using color flow imaging correctly identified all cases of placental chorioangioma by the demonstration of blood flow within the mass. Conversely, absence of blood flow signals was invariably documented in both cases of subchorionic thrombohematoma and in the single case of subamniotic hematoma. Among the four cases of chorioangioma, two developed complications requiring delivery. No complications were noted in cases of avascular placental masses in this series.

CONCLUSIONS

Color Doppler ultrasound plays an important role in the prenatal evaluation of solid placental masses. This technique allows the identification of those cases at increased risk of pregnancy complications which need close monitoring throughout gestation.