Case Of ………..

1. Case Of ………..

2. Case 1 • A.Y 19 year- old gravida 2 para 1 was referred to RazanCenter – Nablus on 24/03/2012 at GA 29 + as a case of hydropsfetalis . • US revealed moderate amount of feta ascites and mild skin edema. • There was no other structural abnormality identified. • Biometries consistent with 32 weeks .

3. Fetal M – mode echocardiography revealed Supraventricular tachycardia at a rate of 240 beats per minute with no evidence of atrio ventricular block . • Structurally heart appears normal apart from small ventricular VSD . • The diagnosis of fetalsupraventricular tachycardia with hydropic change was made. • The patient was otherwise healthy.

6. Treatment intiated with Digoxin ( Transplacentally ) 250 mcg 4 times a day for 3 days .

7. After 3 days , ( 28/03/2012 ) cardioversion noted with heart rate 139 bpm . • Ascites remains the same . • Dose of digoxin was reduced to 250 mcg twice daily .

8. 31/3 /2012; 3 days later , there was intermittent SVT again with moderate ascites . • MCA doppler was normal . • Maternal ECG was normal with normal K level. • So , dose increased again to 750 mcg daily .

9. On 2 /04/2012 , no response ( cardioversion was not happen) . • Start Flecainide 200 mg daily . • Maternal ECG was normal with no any side effects .

10. Over 96 hours , cardioversion noted with heart rate was 160 bpm , with no evidence of heart block . • On 10/04 /2012 , GA 32+ weeks . • Ascites improved dramatically with normal heart rate . • No maternal side effects . • Continue on Flecinide till delivery .

11. On 14 /04 /2012 • Ascites dissapeared completely . • Heart rate 145 bpm . • Normal growth scan , normal AF. • Doppler was normal .

12. Patient was delivered vaginally at 34 + weeks , male baby , 2200 g • After birth heart rate was 250 bpm , which return to sinus rhythm by single dose of adenosine . • Followed up after one month , heart rate showed sinus rhythm with normal heart by Echo . • There was no attack of SVT after 10 months of follow-up.

14. Case 2 • N.R 37 Year- old , P2 +1 was seen at Razan medical Center on 21/01/2012 for the first time .her LMP was 19/08/2011 , GA 22 + . • Her Antenatal care was in UAE , and she had a report said that her pregnancy complicated with a case of Placental mesenchymal dysplasia ?

15. Ultrasound findings revealed a viable fetus structurally normal, biometries consistent with 20 + weeks’ with normal thin placenta and an adjacent thickened, nonhomogeneous placenta with a diffuse multicysticappearance ocuppying the lower segment . • The adjacent placental mass was consistent with a coexisting molar gestation, and it was noted to be overlying the cervix.

17. the patient was counseled on the risks of continuing the pregnancy. Especially that coexisting molar pregnancy was confirmed to be covering the internal cervical os as a complete placenta previa. • The patient also met with the gynecologic oncology ( Dr SaadahSubhi ), who counseled her on the risk for persistent gestational trophoblastic diseaseas well as the possibility of invasive placentation . • and established a plan for follow up her in a weekly basis with repeat the basic invstigation and vital signs .

18. An amniocentesis was performed which returned as a normal 46, XY karyotype

19. the parents opted to continue the pregnancy. • Further evaluation included thyroid function tests, LFTs , KFTs and coagulation profile was done . • and in agreement with the patient, we proceeded with imaging studies, as the presence of any metastases may have resulted in her decision to terminate the pregnancy(CXR , abdominal US )

21. During the following 9 weeks , she developed several episodes of APH which settled spontaneously. • Molar placenta continued increase in size . • All fetalbiometries had been declined but doppler was normal . • Maternal investigations were normal all the time with normal BP and HR .

22. At 29 weeks, the patient presented to the hospital with a marked increase in vaginal bleeding and passage of large clots. Her labs remained stable with a hemoglobin of 11.0 g/dL. • US : viable fetus . Biometries consistent with 26 + weeks, EFW 900 g , doppler was normal .

23. The decision was made to hospitalize the patient for the remainder of her pregnancy due to the persistent vaginal bleeding in a complete previa molar pregnancy.

24. 2 days later , delivery was done by CS in the presence of excessive vaginal bleeding . • Viable male fetus 950 g with very thick meconium , apgar score was low 1 and 5 . • Molar placenta was delivered easliywith classic hydropic villi of the molar component appeared to be degenerating.

25. Uterus was well contracted after evacuation of the molar placenta with no bleeding by using aggressive medical management . • She was followed in weekly basis till B hcG was negative.

26. In summary, pregnancies complicated by CHMF may result in a viable liveborn infant approximately 25 % of the time. • Continuing such a pregnancy may be an option, granted the mother has been appropriately counseled on the numerous risks. • In cases where the molar component is presenting as a placenta previa, the degenerating molar tissue may further clinically manifest as a placenta accreta.

27. Thus, anticipation for increased surgical blood loss and possible cesarean hysterectomy may assist in decreasing maternal morbidity and mortality. • A complete multidisciplinary approach to assist in the management of these difficult surgical cases has become increasingly more common, and our case highlights the benefits of such a team approach.

28. Case 3 • W A 19 year- old , Primigravida was referred at 24 + weeks as a case of suspected cardiac abnormality . • Fetal Echo done at Razan Medical Center and showed mild to moderate cardiomegaly .

30. Umblical vein drains directley to right atrium . • Otherwise no abnormalities were seen . • Diagnosis is Agenesis of DuctusVenosus , type 6 .

32. Review of literature suggest that absence of the ductusvenosus is associated with a high incidence of fetal anomalies and adverse outcomes, including • associated malformations • chromosomal abnormalities • in utero heart failure • absence of the portal vein • hydrposfetalis and IUFD .

33. Amniocenteis was done . • Normal Karyotyping 46 XX .

34. Then she followed every 2 weeks to look for • Growth velocity • Any sign of heart failure and hydropic changes • Doppler scan

35. At 31 weeks , growth velocity start to be declined but with normal doppler and amniotic fluid . • No hydropic changes were seen but cardiomegaly became more than moderate . • So decision for planned delivery at 34 weeks at Makassed Hospital was made , if dopplers remain normal .

36. Delivered female baby , 1980 g at 34 weeks by CS at makassed hospital . • Baby was admitted to NIUC for 2 weeks , Echo showed cardiomegaly with good function . • Discharged home with no adverse outcome.

37. Case 4 • M.J 36 year- old , Gravida 7 para 6 , • Presented at 12 + weeks gestation , spontaneous triplet for NT scan.

38. US revealed triplet pregnancy , one of them was miscarried confirmed by colordoppler . • In term of chorionicity , I labeled the pregnancy as MonochorionicDiamniotic twins with ignoring the missed . • Twin 1 CRL 64mm , NT 1.2 mm . • Twin 2 CRL 68.4mm , NT 2.2 mm . • Dead fetus was 12 mm . • No obvious abnormalities were seen at that GA.

39. At 22 weeks , on 11/08/2012 , she was referred as acardiacfetus. • Scan revealed triplet pregnancy : • Dead fetus has a feeding vessel , it’s lenghth was17 cm . • Twin 2 : severe polyhydroaminious , normal growth and doppler , mild dilated cardiomegaly . • Twin 1: severe oligohydroaminious , growth on 20th centile , doppler was normal , bladder was small .

41. Diagnosis Triplet , MonochorionicTriamnioticcmplicated by TRAP sequense and TTTS ( moderate ) between twin 1 and 2 .

42. Management options were discussed . • Parents opted a LASER therapy . • LASER ablation was done at Hadassah Hospital after 2 days . • Ablation was done for the vessels between the twin 1 and 2 , and for the large vessel feeding the acardiac one

43. Followed up weekly for : • Growth velocity • doppler studies • amniotic fluid . • Growth for both was normal , discrepancy in size remained the same during the follow up 18 %. • Doppler and amniotic fluid were normal • Size of the acardiac decreased .

44. Elective CS at 35 weeks was done • First twin female , B.WT 2170 g , A/S 7/9 , PH 7.38 . • Seconed twin female , B.WT 2610 g , A/S 9/10 , PH 7.36. • Acardiac : 10 cm .

45. Any question ?