Case Presentation Vaginal Bleeding

Department of Radiology
Henry Ford Health System
Detroit, Michigan
Case Presentation:
Vaginal Bleeding
Justin Dueweke, MSIII
Emi Masuda, PGY-II
Wayne State University School of Medicine
6/19/2009

History
• 22 year old presents to the ED with vaginal
bleeding and severe abdominal cramping
over the past few hours
• Serum HCG level = 9417
• LMP ~3 months ago
• Patient not aware that she had been
pregnant.

OB Ultrasound - Transabdominal

OB Ultrasound - Transabdominal
No Heart Tones

OB Ultrasound - Transabdominal

OB Ultrasound - Transabdominal

OB Ultrasound - Transabdominal

OB Ultrasound - Transabdominal
edematous
abdominal wall

Our Report
• FINDINGS:
An intrauterine gestational sac is identified with a crown-rump rump length of 54
mm corresponding to gestational age of 12 weeks and 1 day. No fetal heart
tones are identified despite multiple attempts. There is evidence of diffuse
fetal hydrops. . There is a hypoechoic cystic structure in the fetal head/neck
region bilaterally, the largest cystic structure measuring approximately 2.5 x
1.5 x 1.4 cm. There is discontinuation of the cranium.
[Ovaries unremarkable, small amt of free fluid in cul-de
de-sac]
• IMPRESSION:
Findings consistent with intrauterine fetal demise with no visualized
heart tones, fetal hydrops, and cystic abnormality of the head/neck eck which
may relate to cystic hygroma…

Differential Dx – Cystic Structure
• Cystic Hygroma
• Neural Tube Defect
• Posterior Encephalocele, Cervical Meningocele
• Cystic Teratoma
• Hemangioma

What is Cystic Hygroma?
• Congenital malformation of lymphatics
• Communication between lymph and venous pathways
leads to fluid accumulation in the jugular lymphatic sacs
• May be septated or simple
• Prevalence: 1 in 100 1 st trimester fetuses

Cystic Hygroma –
Chromosomal Abnormalities
• 1 st Trimester – Often trisomies
• 2 nd Trimester – Usually Monosomy X (Turner’s)
• Simple vs Septated Hygroma
• Septated more likely a chromosomal abnormality
• In one study of 1 st Trimester Simple Cystic Hygromas >2mm:
• 60% had abnormal karyotype
• ¼ of these were Trisomy 21
• However, studies have not been consistent in their findings about
correlation between size, septation, and chromosome abnormalities,
or even overall incidence.

Cystic Hygroma –
Other Abnormalities
• Up to 1/3 of euploid fetuses with cystic hygroma will have major
structural abnormalities
• Including: cardiac defects, diaphragmatic hernia, renal anomalies, and
abdominal wall defects
• In addition, there are also associations with other rare diseases s and
syndromes…
• …multiple pterygium syndrome, Cornelia de Lange syndrome, Noonan
syndrome, Roberts syndrome, and skeletal dysplasias

Non-Immune Hydrops Fetalis
CAUSES:
• Cardiovascular Abnormalities – up to 40%
• Anemia – up to 27%
• Lysosomal Storage Diseases – up to 15%
• Chromosomal – ~10%
• Monosomy X: 42-67% of this
• Trisomy 21: 23-30%
30%
• The development of hydrops in these cases generally secondary to
lymphatic dysplasia…
• Thoracic Abnormalities - ~10%
• Infection – ~8%

Wrapping Up
• Recall that 50-65% of 1 st trimester fetal loss is due to fetal
chromosomal abnormality
• Most common single abnormality is Monosomy X - ~14%
• Trisomies account for ~25%
• Most common is Trisomy 21
• Although we do not have a pathologic diagnosis, it is extremely
likely the fetus had a chromosomal abnormality.
• Probably either Monosomy X or Trisomy 21
Follow up: The patient was sent home from the ER after a dose of Cytotec
and instructed to return for a D&C in the AM however she passed tissue at
home. Follow up US was negative for IUP or retained products.

References
• Graesslin, O, Derniaux, E, Alanio, E, et al. Characteristics and
outcome of fetal cystic hygroma diagnosed in the first trimester. . Acta
Obstet Gynecol Scand 2007; 86:1442.
• Malone, FD, Ball, RH, Nyberg, DA, et al. First-trimester trimester septated
cystic hygroma. Prevalence, natural history, and pediatric outcomes
mes.
Obstet Gynecol 2005; 106:288.
• Puscheck, EE, et al. First trimester pregnancy loss. In: eMedicine.
Accessed 2009.
• Simpson, LL, et al. First trimester cystic hygroma and enlarged
nuchal translucency. . In: UpToDate, Basow, DS (Ed), UpToDate,
Waltham, MA, 2009.
• Lockwood, CJ, et al. Nonimmune hydrops fetalis. . In: UpToDate,
Basow, DS (Ed), UpToDate, Waltham, MA, 2009.