Prenatal diagnosis of imperforate hymen with hydrometrocolpos

Prenatal diagnosis of isolated fetal hydrometrocolpos: A case report

A rare congenital condition known as hydrometrocolpos (HMC) is characterized by the buildup of secretions in the vagina and uterus as a result of distal obstruction; this condition is frequently linked to imperforate hymen. This case report presents a prenatal diagnosis of isolated HMC in a 30-year-old primigravida, detected at 36 weeks gestation. Initial ultrasound revealed a large cystic mass, confirmed by fetal magnetic resonance imaging to be HMC. Postnatal examination of the new born confirmed imperforate hymen and HMC, which was effectively treated with hymenotomy, resulting in early resolution. This case underscores the importance of prenatal imaging in the early identification and management of HMC to prevent potential complications.

Hydrometrocolpos: antenatal diagnosis and postnatal management

Hydrometrocolpos is a rare finding in newborns. It can be an isolated finding or may be associated with syndromes. Antenatal diagnosis is possible. It is due to the accumulation of secretion in the uterus, distending it and resulting in abdominal swelling. In case of suspected syndromes, an attempt should be made to look for other organ involvement and genetic diagnosis. We here report a term neonate with hydrometrocolpos, which was antenatally diagnosed and was managed conservatively.

Prenatal sirenomelia diagnosis in the first trimester: A case report and literature review

Key Clinical Message

Sirenomelia is a lethal condition in the perinatal period. The sonographic examination in the first trimester can effectively detect sirenomelia with a high degree of accuracy. Furthermore, vascular examinations using color flow imaging and augmented imaging techniques such as 3D sonography can improve diagnostic accuracy. Parents should get advice from a multidisciplinary team concerning sirenomelia care and prognosis as soon as possible.

Abstract

Sirenomelia is a rare condition with an uncommon congenital malformation; its most remarkable feature is lower extremity fusion with multiple visceral anomalies. Accordingly, the appearance resembles a mermaid's tail, hence mermaid syndrome. Sirenomelia has an incidence rate of 1.5-4.2 per 100,000 births, a male-to-female 2.7:1 ratio, and shows no differences across races. The condition is generally associated with renal agenesis, exterior genitalia defects, a single umbilical artery, and an imperforate anus. Here, we describe the first sirenomelia case in our hospital; a 13-week-old fetus with conjoined lower limbs was identified by ultrasound in the first trimester. We discuss this rare case with reference to the literature and provide insights on diagnosing this condition by ultrasound.

Virginity-sparing management of hematocolpos with imperforate hymen: case report and literature review

Imperforate hymen results from failure of the endoderm of the urogenital sinus to completely canalize and has an incidence of 0.01% to 0.05%. This sometimes presents as a pelvic mass that compresses the bladder causing acute urinary retention. A 13-year-old girl was referred to our department with a history of primary amenorrhea, cyclic lower abdominal pain, abdominal–pelvic mass, constipation and acute urinary retention. She had an ultrasonography misdiagnosis of a huge ovarian mass before referral to our unit. On examination, the vagina was bulging and compressing the rectum. Repeat abdominal ultrasonography confirmed the diagnosis of hematometrocolpos. She underwent X-shaped hymenotomy with a favorable outcome. Diagnosis of imperforate hymen requires high suspicion index. Virginity-sparing surgery constitutes a good treatment option for cultural and religious reasons.

Fetal hydrometrocolpos and congenital imperforate hymen: Prenatal and postnatal imaging features

Congenital imperforate hymen is probably the most common obstructive anomaly of the female reproductive tract. The accumulation of fluid in the genital tract leads to a distended uterus and vagina, causing hydrometrocolpos. Prenatal diagnosis of fetal hydrometrocolpos is uncommon, with only 22 cases reported in the literature and only a few cases of prenatal imaging of this condition available to date. The main ultrasound finding is a fetal pelvic mass posterior to the bladder and anterior to the rectum. We present the case of a 37-week female fetus with a fetal pelvic mass detected in a routine obstetric ultrasound examination, and the correlation between the prenatal and postnatal findings.

Fetal MRI compared with ultrasound for the diagnosis of obstructive genital malformations

OBJECTIVE

To compare the accuracy of magnetic resonance imaging (MRI) and ultrasound (US) to diagnose and characterize congenital obstructive genital abnormalities.

METHOD

Retrospective cohort of 20 fetuses who underwent a fetal MRI following a US diagnosis of obstructive urogenital malformation. We compared MRI and US findings and their correlation with the definitive diagnosis.

RESULT

The correct diagnosis was obtained in 6/20 (30%) cases and 19/20 cases (95%) with US and MRI, respectively. MRI revealed additional information to US in 15/20 cases (75%) and modified the prenatal management in 14 fetuses (70%). The identification rates of the most important anatomical landmarks for the diagnosis, using US and MRI, were compared. Bladder: US 17/20 (85%) vs MRI 20/20 (100%) P = 0.23; vagina: US 6/19 (31.5%) vs MRI 19/19 (100%) P < 10^-4 ; uterus: US 11/19 (57.8%) vs MRI 19/19 (100%) P = 0.003, kidneys: US: 40/40 (100%) MRI: 40/40 (100%) P = 1, ureters: US 14/40 (35%) vs MRI 30/40 (75%) P=0.001, rectum: US 6/20 (30%) MRI 20/20 (100%) P < 10^-4 , and sacrum: US 20/20 (100%) vs MRI 17/20 (85%) P = 0.23.

CONCLUSION

In fetuses with obstructive urogenital malformations, MRI facilitates assessment of major pelvic organs and provides significant information that may alter the prenatal management.

Magnetic resonance imaging of fetal pelvic cysts

The detection of fetal anomalies has improved in the last years as a result of the generalization of ultrasound pregnancy screening exams. The presence of a cystic imaging in the fetal pelvis is a relatively common finding, which can correspond to a real congenital cystic lesion or result from the anomalous liquid accumulation in a whole pelvic organ, mainly the urinary bladder, the uterus, or the vagina. In selected cases with poor prognosis and/or inconclusive echographic findings, magnetic resonance may bring additional information in terms of the characterization, anatomical location, and real extension of the pathology. This pictorial essay describes the normal pelvic fetal anatomy, as well as the most common pelvic cysts. It also describes the causes of an anomalous distension of the whole pelvic organs detected in utero, with emphasis on prenatal magnetic resonance imaging exams. Moreover, it proposes practical teaching points to reduce the differential diagnosis of these lesions based on the sex of the fetus, the division of the pelvis in anatomical spaces, and the imaging findings of the pathology. Finally, it discusses the real utility of complementary MRI.

Experience with neonatal hydrometrocolpos in the Niger Delta area of Nigeria: Upsurge or increased recognition?

BACKGROUND

Hydrometrocolpos (HMC) is a clinical condition in which there is a cystic distension of the vagina (hydrocolpos), uterus and sometimes, fallopian tubes (hydrosalpinx) with fluid. This study described our experience with cases of HMC seen in our practice, and highlighted the flare in our practice.

PATIENTS AND METHODS

A retrospective study of cases of HMC managed at the University of Port Harcourt Teaching Hospital between September 2010 and August 2012.

RESULTS

There were seven cases; their ages ranged from 2 to 27 days (median 13 days). All the patients had abdominal distension but abdominal mass was obvious only in four. Other features varied depending on the presence of sepsis or other associated anomalies. The diagnosis of HMC was missed in all cases by the referring clinicians. One patient was referred with the diagnosis of tracheoesophageal fistula and esophageal atresia, 2 with bladder outlet obstruction, 1 with intestinal obstruction, 2 with anorectal malformation, and 1 with neonatal sepsis. Ultrasound identified bulky uterus in two cases and upper urinary tract dilatation in 3 patients. Six patients had laparotomy, 1 had hymenotomy only. Postoperative complications were basically wound sepsis and rectovaginal fistula resulted.

CONCLUSION

Diagnosis of HMC should be considered as a differential in newborn girls presenting with lower abdominal mass. Attention to clinical detail is necessary to avoid a misdiagnosis.

[Spontaneous rupture of the imperforate hymen in two newborns]

Imperforate hymen is the most frequent congenital malformation of the female genital tract and usually remains asymptomatic until puberty. The diagnosis of this malformation is rarely made at birth and surgical treatment is often by hymenotomy. However, spontaneous rupture of the imperforate hymen is possible but is very rare. We report two cases of imperforate hymen revealed by mucocolpos at birth. Ultrasound examination does not objectify hydrocolpos or hydrometrocolpos. Spontaneous rupture of the imperforate hymen was observed respectively in the 4th and 7th day of life with a satisfactory result at 1 month of age. Screening for the imperforate hymen must be systematic at birth to offer early hymenotomy if the spontaneous rupture is not adequate and prevent serious complications of the disease at puberty.

A case of hydrometrocolpos and polydactyly

Neonatal hydrometrocolpos (HMC) is a rare Mullerian duct anomaly with an incidence of 0.006%. It occurs due to blockage of the vagina with accumulation of mucus secretions proximal to the obstacle. These secretions are secondary to intrauterine and postnatal stimulation of uterine and cervical glands by maternal estrogens. A triad of congenital HMC, polydactyly, and cardiac anomalies are the cardinal features of McKusick–Kaufman syndrome, which is also known as hydrometrocolpos-polydactyly syndrome. Bardet–Biedl syndrome is a well-known combination of hypogonadism, obesity, postaxial polydactyly, renal dysplasia, retinal degeneration, and mental impairment. In this case report, we describe a neonate with HMC, polydactyly, and hydronephrosis.

Prenatal pelvic MRI: additional clues for assessment of urogenital obstructive anomalies

OBJECTIVE

Ultrasound prenatal evaluation of pelvic cystic mass can be challenging. After having ruled out a cloaca anterior to a large hydrocolpos, it is important to differentiate between combined urogenital anomalies such as urogenital sinus and isolated genital anomalies.

PATIENTS AND METHODS

We reviewed the charts of 13 women referred for a third trimester pelvic MRI for cystic pelvic mass discovered in second trimester ultrasound. We evaluated MRI compared with postnatal surgical findings in order to determine clues for improving prenatal diagnoses.

RESULTS

MRI excluded the diagnosis of cloacal malformation in nine cases with no false negative. Once a cloaca is ruled out, a different signal between the bladder and the hydrocolpos on T2 sequences is in favor of an isolated genital obstruction. In contrast, in case of urogenital sinus, the vagina is filled with a mixture of genital secretions and urine, which gives it an MRI signal similar to the bladder on T2 sequences.

CONCLUSION

Third trimester fetal MRI is an essential exam for characterization of pelvic cystic mass diagnosed by ultrasound. This exam appears valuable for invalidating the diagnosis of cloacal malformation and for differentiating between isolated genital obstruction and urogenital sinus.

Mucocolpos in a toddler: central precocious puberty with vaginal atresia

OBJECTIVE

To report the first case of imperforate hymen and vaginal atresia in a patient with mucocolpos during toddlerhood who was found to have central precocious puberty.

METHODS

We review the details of assessment of an 18-month-old girl who had the presence of pubic hair and breast enlargement. She underwent biochemical evaluation with serum follicle-stimulating hormone, luteinizing hormone, and estradiol and radiologic evaluation with ultrasonography of the abdomen and pelvis as well as magnetic resonance imaging of the pelvis and brain.

RESULTS

This young female patient had clinical and imaging findings suggestive of idiopathic central precocious puberty. Imaging also revealed imperforate hymen, vaginal atresia, and mucocolpos. She underwent surgical treatment to ensure an unobstructed vaginal opening before initiation of gonadotropin-releasing hormone agonist therapy, since the latter may precipitate uterine bleeding and might have converted mucocolpos to a combination of mucocolpos and hematocolpos.

CONCLUSION

This case highlights the need to suspect the presence of precocious puberty in all female patients in whom mucocolpos is detected beyond infancy but before adolescence.

Prenatal diagnosis of a paraurethral cyst

Paraurethral cysts arising from Skene's gland are a rare cause of urogenital masses in the neonate. We report the case of a pelvic mass noted at the vaginal introitus on prenatal ultrasound that following delivery was found to be a paraurethral cyst. On prenatal ultrasound, there was no evidence of involvement of the urinary, gastrointestinal, or upper genital tract. Serial ultrasounds demonstrated slight enlargement of the cyst without other changes. The patient delivered at 33 weeks and postnatal evaluation demonstrated a paraurethral cyst. The cyst was managed expectantly and drained spontaneously on the second day of life with complete resolution.

Anatomy of female puberty: The clinical relevance of developmental changes in the reproductive system

Puberty is the period of biologic transition from childhood to adulthood. The changes that occur at this time are related to the increasing concentrations of sex steroid hormones. In females, most pubertal changes are caused by estrogen stimulation that results from the onset of central puberty. Significant development occurs in the organs of the female reproductive system and results in anatomic changes that characterize reproductive maturity. Adrenal and ovarian androgens also increase during puberty, affecting change that includes the promotion of certain secondary sex characteristics. The ability to recognize normal pubertal anatomy and distinguish between estrogen and androgen effects is important in the ability to diagnose and treat disorders of sex development, precocious puberty, pubertal delay, and menstrual irregularities in children and adolescents. An understanding of this developmental process can also help clinicians identify and treat reproductive pathology in adults and across all female life stages.

Magnetic resonance as an aid in the diagnosis of a transverse vaginal septum

Transverse vaginal septum is a rare, often overlooked congenital abnormality that is typically not diagnosed until adolescence. We present the case of a transverse vaginal septum and partial bicornuate uterus in a 16-year-old adolescent girl with developmental delay and cerebral palsy. Magnetic resonance is an excellent diagnostic tool to delineate the specific anatomy before surgery. The effects of delayed diagnosis and the utility of magnetic resonance in diagnosis will be discussed.

Subependymal Pseudocysts in the Fetal Brain and Unrelated Hydrocolpos

Subependymal pseudocysts are found in approximately 5% of all neonates. When they are isolated, the outcome is usually favorable. However, when they are associated with other anomalies, the prognosis is often poor. The diagnosis of imperforate hymen is rarely diagnosed before puberty, but reports of diagnosis in utero have been documented. The authors present a case with two coexisting rare findings in one fetus. The postnatal outcome for the infant with these isolated unrelated findings proved to be reassuring.

Congenital imperforate hymen with hydrocolpos and hydronephrosis associated with severe hydramnios and increase of maternal ovarian steroidogenic enzymes

STUDY OBJECTIVE

To study clinical features of patient presented with severe hydramnios, associated with hydronephrosis, that was antenatally diagnosed and has been successfully treated immediately after birth. At a molecular level, we investigated the gene expression of key steroidogenic enzymes from the maternal ovary.

DESIGN

Ultrasound scan, MRI, semi-quantitative RT-PCR SETTING: The patient was admitted to the University Hospital, University of Crete, Medical School, Greece, where all clinical data has been obtained. Gene expression studies took place at Biosciences, Brunel University, UK.

RESULTS

Semi-quantitative RT-PCR analyses revealed that there is upregulation of key steroidogenic genes in the maternal ovary, including steroidogenic acute regulatory protein, and the cytochrome P450 heme-containing proteins CYP11A, CYP17 and CYP19. From a clinical perspective, the prenatal ultrasound scan and MRI findings showed a multicystic pelvic mass, bilateral hydronephrosis and prior to delivery severe polyhydramnios.

CONCLUSION

This clinical case is the only one that we have found in the current literature where congenital imperforate hymen accompanied with hematocolpos is associated with renal obstruction in combination with polyhydramnios and increase in maternal steroidogenic enzymes.