Differential diagnosis: The differential diagnosis can be divided in two main groups:
Peritoneal calcifications: The peritoneal hepatic calcifications might be differentiated from the meconium peritonitis and hydrometrocolpos rupture. Meconium peritonitis is a chemical peritonitis resulting from intrauterine bowel perforation. It can be identified as a group of calcifications with a peritoneal distribution. This occurs at shortly after the rupture. Later the fibrotic reaction will embed all the calcifications into a meconial cyst. Other sonographic findings can also be seen in fetuses with meconium peritonitis. These include polyhydramnios, dilatated loops of bowel, fetal ascites, echogenic ascites with mass effect on organs, inguinal hernia and meconium pseudocyst. The prognosis is variable and depends on associated abnormalities (5).
Parenchymal calcifications: The differential diagnosis includes primary and metastatic tumors. The primary tumors include the hemangioma, hemangioendothelioma, hamartoma, and teratoma. The most common metastatic tumor is the neuroblastoma most commonly originated in the adrenal gland
Associated anomalies: The association between hepatic calcifications and chromosomal anomalies are unlikely when the hepatic calcifications are an isolated finding. Koopman and Wladimiroff reported seven cases of intrahepatic echogenic foci; two with chromosomal anomalies and both of them showed major ultrasound abnormalities (6). Bronshtein and Blazer reported 14 cases of hepatic calcifications, three (21%) had associated severe malformations; two with trisomy 18 and one with skeletal dysplasia and hydronephrosis (7). In another similar study, Simchen et al. evaluated 61 fetuses with hepatic calcifications; ten patients (1.5%) had abnormal karyotype and all of these showed additional anomalies. All 22 cases of isolated hepatic calcification had a normal outcome (8).
Management: The management depends of the size, location and distribution of the calcifications. Screening test for fetal infections should be performed, including toxoplasmosis, rubella, syphilis and herpes simplex. The recommendations for serial ultrasound examinations are controversial. Follow-up scans may be required to evaluate the stability or the regression of the lesions. A careful search for associated anomalies should be performed. In selected patients, in cases in which additional findings are present, an amniocentesis should be performed for fetal karyotype or to obtain samples for specific infection tests (1,2).
Prognosis: The prognosis is generally good when one or two hepatic hyperechogenicities are diagnosed (3,5). However, when multiple calcifications are identified, the association with chromosomal anomalies may be present (5). In this case, the outcome is poor, accordingly to the extension of the abnormalities. Ascites is a sign of a poor outcome. The long-term outcome depends on the underlying causes.
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