Acta Obstet Gynecol Scand 58: 217-220,1979

CASE REPORT

ULTRASONOGRAPHIC DIAGNOSIS OF FETAL ASCITES IN A TWIN PREGNANCY Z. Weinraub, R. Langer, I. Bukovsky, D. Schneider and E. Caspi From the Department of Obstetrics and Gynecology, Ultrasonographic Sub-unit. Asaf Harofe Government Hospital, University of Tel Aviv Medical School, Zerifin, Israel

In the last two decades, ultrasonographic examinations have become a useful noninvasive diagnostic tool in various obstetric conditions. A case is described where fetal ascites due to Rh-isoimmunisation in a twin pregnancy was antenatally diagnosed by means of B-scan technique. To our knowledge, this is the first report of such a case.

CASEREPORT A 30-year-old Rh-negative patient was first seen in our department in her sixth pregnancy. Her first pregnancy in 1968 was terminated by artificial abortion. Her second pregnancy in 1971 ended in a premature delivery after 34 weeks of an infant weighing 2000 g; the newborn developed severe HDN and died after one week. Her third pregnancy in 1972 terminated in early spontaneous abor-

tion. Her fourth pregnancy in 1973 ended in a premature delivery at 28 weeks gestation of a fetus weighing 1 100 g, which died shortly after delivery. At 27 weeks of this gestation, the Coombs test was positive 1 : 128. Her fifth pregnancy in 1974 was terminated by artificial abortion. No anti-D was administered after any pregnancy. When seen in our department in 1976, the woman was 12 weeks into her sixth pregnancy. On ultrasonographic examination, a twin pregnancy was diagnosed and, because of an already known cervical incompetence, a ccrclage was performed. At 14 weeks gestation, the Coombs test was positive 1 :2; it rose gradually to 1 :32 at 20 weeks; then, unexpectedly, it dropped to 1 :4. Similar values were obtained by repeated measurements and different laboratories. Ultrasonographic examinations performed at 17 and 20 weeks of gestation demonstrated no pathological findings. At 28 weeks gestation, there was ultrasonographic evidence of polyhydramnios, large placenta and, most prominent, ascites in both fetuses (Fig. 14). The patient went into labour spontaneously in the

Fig. 1. At 28 weeks gestation, mild oblique cross-section shows both heads and polyhydramnios. U, umbilicus; H,heads; S,symphysis; PH,polyhydramnios. Acta Obstet Gynecol Scand 38 (1979)

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Fig. 2. Transverse cross-section showing anterior hydropic placenta, polyhydramniosand both fetuses. A W, abdominal wall; PL, placenta.

29th week of gestation and delivered hydropic twins weighing 950 and 1100 g. Neonatal death occurred immediately after delivery.

DISCUSSION Despite large scale anti-D administration, the Rhisoimmunisation still presents a problem in obstetrics. Diagnostic procedures in patients whose fetuses are jeopardized by Rh-isoimmunisationpro-

cesses, namely, repeated amniocenteses for amniotic fluid bilirubin assessments, are associated with some risks (4). Various reports suggest that careful ultrasonographic surveillance may indicate intrauterine fetal demise in pregnancies complicated by Rh-isoimmunisation. It has been demonstrated that placental hydrops (3, 5) is the first ultrasonographic sign of isoimmunisation, followed by hydrops foetalis, double

Fig. 3. Transverse crosssection-ascites in both fetuses. A W, abdominal wall, AF,amniotic fluid; a , ascites. Acto Obstet Gynecol Scnnd 58 (19791

Ultrasonographic diagnosis offetal ascites

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Fig. 4. Transverse scan of one of the fetuses showing fetal abdomen which has a perfectly circular shape filled with ascites. The intestines are concentrated in the center forming a homogeneous round mass. a , ascites; i, intestines;AF, amniotic fluid.

contour of the head and chest, fetal hepato- and cardiomegaly (1, 5 ) . In a few cases, fetal ascites could be diagnosed by ultrasonography (2, 5 ) . These findings on the dynamics of fetal involvement in the isoimmunisation process may facilitate handling of such pregnancies and indicate the proper timing for intervention. In our case, we must point out that the patient disappeared from ultrasonographic surveillance after the 20th week of gestation because of the recurrent low Coombs test titers. She was readmitted by her physician in the 28th week because of suspected polyhydramnios; ultrasonographic examination at this time revealed the severity of the condition of both fetuses and the hopelessness of the case. Amniotic fluid volume estimation still presents a diagnostic problem on ultrasonographic examination and, in fact, until now is based on the empirical experience of the examiner. Even if the exact amounts of amniotic fluid cannot be estimated, a well-trained ultrasonographer can easily diagnose polyhydramnios. Hydropic placenta, on the other hand, can be very well defined by ultrasound and precisely measured by calipers on the A-scan system. The typical snow-flake-like appearance of a hydropic placenta on B-scan display can be obtained easily by proper attenuation of the transmitter. The finding of this kind of placenta on a routine ul-

trasonographic examination marks the beginning of a search for the causative conditions, which can be diabetes or Rh-isoimmunisation. Fetal ascites is a rare finding on ultrasonographic examination and very few articles have appeared in the obstetric-ultrasonographicliterature. This condition presents such a specific picture on ultrasonography that it is nearly impossible to miss. The fetal abdomen has a perfectly circular shape filled with fluid and the intestines are concentrated in the center, forming a homogeneous round mass. In our case, there were no other pathological findings, as have been described by others (1,5). We present this case because of the antenatal diagnosis of fetal ascites in a twin pregnancy by B-scan technique, which, to the best of our knowledge, has not been previously reported.

REFERENCES 1. Campogrande, M., Brugnoli, C. A. & Mattone, P. G . : Impiego degli ultrasuoni nella diagnostica della isoimmunizzazione anti-Rh. Minerva Ginecol26: 571, 1974. 2. Cederqvist, L. L., Williams, L. R. & Symchych, P. S.: Prenatal diagnosis of fetal ascites by ultrasound. Am J Obstet GynecolZ28: 229, 1977. 3. Holliinder, H. J. & Mast, H.: Intrauterine Dickenmessung der Placenta mittels Ultraschalls bei normalen Schwangerschaften und bei Rhesus Inkompatibilitat. Geburtshilfe Frauenheilkd28: 626, 1968. Actu Obstet Gvnecol Scund 58 (19791

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4. Scrimgeour, J. B.: Amniocentesis: Technique and Complications, Antenatal Diagnosis of Genetic Diseases (ed. A. E. H. Emery), pp. 11-39. Williams & Wilkins, Baltimore, 1973. 5. Weib. P. A. M.: Typische Ultraschallbilder bei schwerer foetaler Rhesus Erkrankung. Geburtshilfe Frauenheilkd34:640, 1974.

Acto Obstet Gynecol Scand 58 (1979)

Submitted for publication March 28, 1978

Zwi Weinraub, M.D. Dept. of Obst. and Gyn. UltrasonographicSub-Unit Asaf Harofe Government Hospital Zerifin, Israel

Ultrasonographic diagnosis of fetal ascites in a twin pregnancy.

Acta Obstet Gynecol Scand 58: 217-220,1979 CASE REPORT ULTRASONOGRAPHIC DIAGNOSIS OF FETAL ASCITES IN A TWIN PREGNANCY Z. Weinraub, R. Langer, I. Bu...
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