TheFetus.net

Case of the Week # 500

Rami Mohamed Bakr Barakat, MD

Posting Dates: July 18 - August 1, 2019

Case report: A 28-year-old woman was referred to Fetal Care Clinic of Assiut due to accumulation of an ascitic fluid inside the fetal abdomen. Detailed ultrasound examination at 30 weeks of pregnancy was performed. We obtained the following images:

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Answer

We present a case of Fetus in Feto.

Detailed ultrasound examination revealed a 30 weeks gestation female fetus with an abdominal enlargement.  The underlying cause of the abdominal enlargement was a right upper abdominal cyst measured 100 x 80 x 90 mm and containing fluid (Image 1, 2, Video 1). A heterogeneous mass could be identified suspended inside the cyst containing soft tissue and bone components, Incomplete limbs, hypomineralized fluid filled skull and disfigured trunk were seen as the main components of the irregular mass. This is demonstrated using tomographic ultrasound imaging (TUI)  (Image 3,4). A vascular stalk could be seen connecting the parasitic twin to the wall of the sac and the color Doppler showed a single feeding vessel traversed this pedicle with a pattern of spectral Doppler very similar to the pattern of the umbilical artery (Image 5,6).

The patient continued her pregnancy without complications and the fetus was delivered via Caesarean section with gentle extraction to avoid the rupture of the abdominal cyst. The baby was admitted to the neonatology unit of the children university hospital of Assiut due to mild respiratory distress.  The baby was fully investigated. The serum level of the alpha fetoprotein was markedly high. The conventional X-ray revealed a soft tissue mass with vertebral column and long bones of incomplete limbs.  Computed tomography and CT-angio scan demonstrated an extraperitoneal sac in which a fetus resembling mass could be seen (Image 7-9). The vertebral column and long bones of lower limbs could be identified easily but there was no vascular pedicle which denoted cessation of the blood flow to the parasitic twin.

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Image 7: CT scan showing bone structures located in the right hemiabdomen, as a part of the parasitic fetus.
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Image 8: Computed tomography (CT) and volume-rendered CT images of the newborn show multiple vertebrae, rib-like structure, long bones and deformed skull.
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Image 9: CT scan showing bone structures located in the right hemiabdomen, as a part of the parasitic fetus.

Preoperative platelet transfusion was required several times to correct the neonatal thrombocytopenia.  Once the baby was fit for operation, the decision was taken by the pediatric surgeons to excise the mass.  Intraoperative findings revealed a cystic mass was in the right upper retroperitoneal space large enough to displace the right kidney superiorly and to displace the liver to the left side (Image 10)

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Image 10: post-surgery specimen shows the aspect of the parasitic twin.

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