A case of massive fetal cardiac rhabdomyoma: ultrasound features and management

We report the case of a massive fetal cardiac rhabdomyoma recently occurred at our clinic. A woman at 23 weeks of gestational age was referred to our center for a fetal cardiac echogenic mass of 26 mm detected at the second-trimester screening ultrasound. During pregnancy, though, the mass progressively increased its dimensions until reaching 48 mm in diameter at 37 weeks of gestation. Fetal echoencephalography and brain magnetic resonance did not show any further fetal anomalies, but molecular genetic testing at amniocentesis revealed a heterozygotic missense variant of gene TSC2 associated with Tuberous Sclerosis. The mass was therefore most likely preferable to a single large rhabdomyoma of gradually increasing dimensions. The baby was delivered at term with a cesarean section. Because of the rhabdomyoma remarkable size and newborn ECG electrical alterations, postnatal therapies with Flecainide and Everolimus were started. Everolimus treatment led to a significant and progressive reduction in the cardiac mass volume. This case, therefore, shows the efficacy of what seems to be a promising treatment in pediatric patients with large rhabdomyomas.Learning points:Rhabdomyomas may present with different features: most often they appear as multiple masses along the interventricular sept, but they may also appear as a single large thoracic mass.When a rhabdomyoma is suspected, genetic counseling is recommended.Both before and after birth, a multidisciplinary approach is useful to choose the appropriate therapy for the newborn.mTOR inhibitors therapies look like promising therapeutic approaches to stimulate the involution of rhabdomyomas.

The ex-utero intrapartum treatment (EXIT) strategy for fetal giant sacrococcygeal teratoma with cardiac insufficiency: A case report and review of the literature

BACKGROUND

Antenatally diagnosed sacrococcygeal teratoma has been associated with risks of perinatal complications and death, especially when the foetus has symptoms of cardiac insufficiency, hydrops or anemia in utero; however, the method of intervention remains controversial.

CASE

A 25-year-old pregnant woman was found to have a cystic and solid tumor in the fetal sacrococcygeal region at 16 weeks of gestation. As the tumour grew, the mother developed polyhydramnios accompanied with gestational diabetes. Fetal and tumorous hemodynamics were closely monitored by ultrasound. Abnormal cardiac function was detected at 31 weeks' gestation, and we creatively performed pre-emptive delivery through the ex-utero intrapartum treatment with debulking. The teratoma was removed with utero-placental circulation support. The operation proceeded smoothly with favourable prognosis for both mother and newborn.

CONCLUSION

The ex-utero intrapartum treatment may improve the prognosis for fetuses with heart failure when they reach viable gestation.

A Multidisciplinary Approach in Prenatal Diagnosis of TSC With Cardiac Rhabdomyoma as the Initial Symptom

The long-term prognosis of a fetus with cardiac rhabdomyoma (CR) depends on the correlation with tuberous sclerosis complex (TSC). In recent years, the numerous variations of uncertain significance (VUS) of TSC genes produced by high-throughput sequencing have made counseling challenging, studies until now have tended to side-step the tricky topics. Here, we integrated detailed parental phenotype, echocardiography, neuro MRI, and genetic information to conduct a comprehensive evaluation of 61 CR fetuses. As a result, multiple CRs and cerebral lesions appeared in 90 and 80%, respectively of fetuses with pathogenic (P)/likely pathogenic (LP) TSC1/TSC2 variations. Overall, 85.7% of the live-born infants with P/LP presented with TSC-associated signs. While, 85.7% of VUS without nervous findings had good prognoses. Genetic evidence and cerebral MRI findings are the most sensitive index to assess long-term prognosis, which complement and confirm each other for a TSC diagnosis. In total, 68.9% of fetuses with CR could benefit from this multidisciplinary approach, which turned out to be potentially clinically actionable with precise clinical/genetic diagnosis or had a foreseeable outcome. Our practice provides a practical and feasible solution for perinatal management and prognostic guidance for fetuses with CR.

Huge fetal ovarian cyst

Most fetal ovarian cysts increase in size during the late stages of pregnancy. Early treatment of a huge neonatal cyst may reduce the risk of gastrointestinal obstruction.

Giant hepatic hemangioma in the fetus: case reports and updated review of the literature

OBJECTIVES

To describe three cases of giant fetal hepatic hemangioma detected by prenatal ultrasound in the third trimester of pregnancy and further confirmed by fetal magnetic resonance imaging (MRI). An updated review of the literature was also carried out.

RESULTS

In one case, there was an unexpected intrauterine demise at 35 weeks. The other two women delivered liveborn infants at term. The first of these two neonates had a stormy neonatal course and underwent endovascular embolization with limited clinical success. The infant presented multiple medical complications and was discharged home at five months of age. The second infant had an uneventful postnatal course. Subsequent follow-up scans showed progressive shrinkage of the lesion with no associated complications. A review of the English literature revealed a total of 42 cases prenatally diagnosed by ultrasound. The most relevant clinical and ultrasound findings are presented and the diverse perinatal outcomes related to this condition are discussed.

CONCLUSIONS

Fetal hepatic hemangiomas are exceedingly rare vascular tumors; however, they can be associated with several life-threatening conditions. They are usually detected by ultrasound, either incidentally or in the context of nonimmune hydrops secondary to high-output cardiac failure. Our review documents the increasing role of fetal MRI in the prenatal diagnosis and management of these cases. However, the improvement in prenatal diagnostic imaging techniques has not been associated with a better perinatal prognosis in the reported cases.

Fetal Head and Neck Masses: MRI Prediction of Significant Morbidity

OBJECTIVE

The purpose of this study is to determine which MRI parameters of fetal head and neck masses predict high-morbidity neonatal outcomes, including ex utero intrapartum treatment (EXIT) procedure.

MATERIALS AND METHODS

This retrospective study (2004-2016) included parameters of polyhydramnios (based on largest vertical pocket), mass effect on the trachea, mass midline extension, and morphologic grade and size of masses. The morbid cohort included those requiring an EXIT procedure, difficult intubation at delivery, or lethal outcome. Predictive modeling with a multivariable logistic regression and ROC analysis was then performed.

RESULTS

Of 36 fetuses, five were delivered by EXIT procedures, there was one neonatal death within 12 hours after delivery, and another neonate required multiple intubation attempts. The remaining 29 fetuses were delivered at outside institutions with no interventions or neonatal morbidity. The largest vertical pocket and mass effect on the trachea were selected as independent predictors by the logistic regression. The cross-validated ROC AUC was 0.951 (95% CI, 0.8795-1).

CONCLUSION

The largest vertical pocket measurement and mass effect on the trachea were the most contributory MRI parameters that predicted significant morbidity in fetuses with masses of the face and neck, along with other significant parameters. These parameters predict significant morbid neonatal outcomes, including the need for EXIT procedures.

The natural history of an umbilical cord hemangioma

Umbilical cord hemangiomas are rare, and the natural history is poorly understood. We present a case where the clinical course was complicated by distal umbilical cord edema, episodes of proximal obstruction of umbilical artery blood flow, transient fetal pleural and pericardial effusions, and position-dependent abnormal fetal heart rate monitoring with periods of sustained fetal tachycardia. Delivery was performed for fetal growth restriction with abnormal fetal surveillance. This case highlights possible mechanisms for fetal decompensation as well as the importance of a multifaceted approach to the management of an umbilical cord mass using multiple tools for fetal assessment. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:455-458, 2016.

Fetal intracranial immature teratoma: presentation of a case and a systematic review of the literature

OBJECTIVES

To describe a case diagnosed with intracranial teratoma in week 32 of gestation, as well as review of the literature in order to discern the appropriate treatment method and general prognosis of this anomaly.

METHODS

A literature search was performed on the prenatal diagnosis of congenital intracranial teratomas in MEDLINE, EMBASE, Cochrane library data bases. Evaluated in this review are parameters such as time of prenatal diagnosis, associated pathology, size of tumors, method of terminating pregnancy, perinatal outcome and histological study of the tumor.

RESULTS

A total of 49 cases were found, of which 12 were finished gestation, 28 cesarean section was performed and only nine had vaginal delivery. All died in the neonatal period except in three cases with intrauterine death after diagnosis.

CONCLUSION

As the incidence of intracranial immature teratomas is very low and the prognosis is poor, their prenatal diagnosis and obstetric management present a great challenge for the planning of a follow-up and treatment of the disease in accordance with the preferences of the parents.