Prenatal diagnosis of a chest wall mass with ultrasonography and Doppler velocimetry A case report Leon G. Smith,Jr., MD: RobertJ. Carpenter,Jr., MD:·b Whitney Gonsoulin, MD: Giancarlo Mari, MD: Alexander A. Reiter, MD: Frank Greenberg, MD,a. b and Carolyn Powell, RN, BSNa.b Houston, Texas An isolated mass protruding from the chest wall of the fetus was visualized by ultrasonography. Doppler velocimetry over the mass revealed low-resistance blood flow through cystic areas, implicating a highly vascular lesion. An operative delivery was performed to avoid possible rupture of the mass. (AM J CasrEr GYNECOL 1990;163:567-9.)
Key words: Hemangioma, Doppler velocimetry, prenatal diagnosis
From the Department of Obstetrics and Gynecologf and the Institute of Molecular Genetics/ Baylor College of Medicine. Received for publication December 12, 1989; accepted March 1, 1990. Reprint requests: Leon G. Smith,Jr. , MD, Baylor College ofMedicine, Department of Obstetrics and Gynecology, One Baylor Plaza, Houston, TX 77030. 611 /20573
Internal chest tumors have been diagnosed prenatally in numerous cases. However, an external chest wall mass has not been visualized in utero by ultrasonography to our knowledge. An understanding of external tumors located in other anatomic regions of the fetus and application of Doppler velocimetry were helpful in the management of this case.
Fig.!. Ultrasonography of chest circumference. Small arrows show outline of chest wall. Large arrow demonstrates mass.
567
568 Smith et al.
AuguSll990 Am J Obslet Gynecol
Fig. 2. Cavernous hemangioma on infant's chest wall.
Case report
A 17-year-old black primigravid patient was referred to our tertiary care center for an abnormal screening ultrasonogram. Her prenatal course had been unremarkable, including a normal maternal serum (lfetoprotein at 16 weeks' gestation. Her medical history was not significant for any diseases including dermatologic or vascular disorders. The patient denied any use of medications or exposure to drugs during the pregnancy. Her family history disclosed no neural tube defects, mental retardation, or birth defects. The father of the fetus had a history of a right chest wall mass seen at birth and removed at age 6. The pathologic diagnosis was mature teratoma. Sequential ultrasonography with General Electric model 3000 equipment showed a normal-appearing male fetus except for a discrete right-sided anterior chest wall mass, that did not involve the axilla or neck. Free movement of the upper extremities was noted. The contents within the chest appeared normal, including a four-chamber heart. The mass projected from the external chest and did not appear to penetrate the ribs. It measured 3.4 x 3.1 cm and was echodense with three small (0.3 cm) hypoechoic structures within
the tumor. We performed continuous Doppler velocimetry over the mass with a 3.5 MHz transducer. A flow wave pattern with a systolic/diastolic ratio of 1.5 was noted, consistent with blood flow through low resistance channels. I Serial ultrasonography with a General Electric model 3200 showed little growth of the mass over the next eight weeks. Fig. 1 shows the mass on real-time ultrasonography. At 35 weeks' gestation the patient came to the labor and delivery suite with a chief complaint of leakage of fluid per vagina for 6 hours and contractions every 3 minutes. Vaginal examination showed the cervix to be 4 cm dilated and completely effaced with a cephalic presentation. A male infant weighing 2680 gm with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively, was delivered by low transverse cesarean section. Apurple, spongy mass was noted on the right anterior chest wall that displaced the areola laterally (Fig. 2). The mass then measured 4.3 x 4.2 cm. No bruits were heard or pulsations felt within the mass. The infant's platelet count was 175,000/cm3 • On the fifth day of life, the infant had the mass resected without difficulty. The histologic diagnosis was cavernous hemangioma. The infant was discharged on the second postoperative day.
Prenatal diagnosis of hemangioma
Volume 163 Number 2
At 6 months of age the infant was healthy and doing well. Comment The appearance of a solid and cystic mass by ultrasonography elsewhere on the outer surface of the fetus led to a differential diagnosis including teratoma, hemangioma, and mesenchymal sarcoma. With the use of Doppler velocimetry, we demonstrated that the mass had a low-resistance blood flow. Similar results were obtained in a case of a craniofacial hemangioma. 1 We speculate that low vascular resistance as evaluated by Doppler ultrasonography could differentiate vascular lesions such as hemangiomas from neoplasias such as teratomas. However, further Doppler studies of fetal tumors are necessary to substantiate the potential of this diagnostic modality.
The size of the mass did not suggest that soft tissue dystocia was likely. However, a cesarean section was performed because the risk of trauma to a very vascular mass lesion existed. Hemangiomas in the newborn have been noted to have a microangiopathic anemia and thrombocytopenia caused by trauma of the blood elements as flow occurs through the vascular lesion. 2 Therefore abdominal delivery may be appropriate in the management of rare external masses of the fetus. REFERENCES 1. Lasser D, Preis 0, Dor N, Tancer ML. Antenatal diagnosis of giant cystic cavernous hemangioma by doppler velocimetry. Obstet GynecoI1988;72:476-7. 2. David Tj, Evans DIK. Stevens RF. Haemangioma with thrombocytopenia (Kasabach-Merritt syndrome). Arch Dis Child 1983;58: 1022-3.
Relationship of fetal biophysical profile and blood gas values at cordocentesis in severely growth-retarded fetuses Lucie S. M. Ribbert, MD,' Rosalinde J. M. Snijders, MSc,b K. H. Nicolaides, MD,b and G. H. A. Visser, MD' London, England, and Groningen, The Netherlands In 14 severely growth-retarded fetuses the biophysical prOfile score was analyzed in relation to blood P02, pH. oxygen saturation, and oxygen content in samples obtained by cordocentesis. The data suggest that the biophysical profile score can predict the degree of fetal acidemia. (AM J DesTET GVNECOL 1990;163:569-71.)
Key words: Biophysical profile, cordocentesis, fetal blood gases, intrauterine growth retardation The biophysical profile is widely used for the assessment of fetal well-being. All previous studies with the biophysical profile have related the results of the test with outcome of pregnancy or with cord blood gas levels at delivery. 1.2 This study examines the relationship beFrom the Harris Birthright Research Centre for Fetal Medicine, Department of Obstetrics and Gynaecology, King's College Hospital/ and the Department of Obstetrics and Gynaecology. University Hospital Groningen." Supported by the Netherland Organization for Scientific Research and Action Research for the Crippled Child. Receivedfor publication December 11.1989; revised February 12, 1990; accepted February 23.1990. Reprint requests: K. H. Nicolaides, MD, Harris Birthright Research Centre for Fetal Medicine. Department of Obstetrics and Gynaecology, King's College Hospital, London, England SE5 8RX. 611120358
tween the biophysical profile and fetal blood gas levels in samples obtained by cordocentesis. Patients and methods In 14 severely growth-retarded fetuses that were referred to our unit for further assessment at 25 to 39 weeks' gestation, the biophysical profile was studied immediately before umbilical venous blood sampling. The methods and definitions for fetal tone, fetal gross body movements, fetal breathing movements, amniotic fluid volume, and fetal heart rate reactivity were those described by Manning. l Cordocentesis was performed without maternal sedation or fetal paralysis. All fetuses were anatomically and chromosomally normal. The fetal blood gas and hemoglobin levels (grams per deciliter) were measured by Radiometer ABL 330 (Copen-
569
Key words: Hemangioma, Doppler velocimetry, prenatal diagnosis
From the Department of Obstetrics and Gynecologf and the Institute of Molecular Genetics/ Baylor College of Medicine. Received for publication December 12, 1989; accepted March 1, 1990. Reprint requests: Leon G. Smith,Jr. , MD, Baylor College ofMedicine, Department of Obstetrics and Gynecology, One Baylor Plaza, Houston, TX 77030. 611 /20573
Internal chest tumors have been diagnosed prenatally in numerous cases. However, an external chest wall mass has not been visualized in utero by ultrasonography to our knowledge. An understanding of external tumors located in other anatomic regions of the fetus and application of Doppler velocimetry were helpful in the management of this case.
Fig.!. Ultrasonography of chest circumference. Small arrows show outline of chest wall. Large arrow demonstrates mass.
567
568 Smith et al.
AuguSll990 Am J Obslet Gynecol
Fig. 2. Cavernous hemangioma on infant's chest wall.
Case report
A 17-year-old black primigravid patient was referred to our tertiary care center for an abnormal screening ultrasonogram. Her prenatal course had been unremarkable, including a normal maternal serum (lfetoprotein at 16 weeks' gestation. Her medical history was not significant for any diseases including dermatologic or vascular disorders. The patient denied any use of medications or exposure to drugs during the pregnancy. Her family history disclosed no neural tube defects, mental retardation, or birth defects. The father of the fetus had a history of a right chest wall mass seen at birth and removed at age 6. The pathologic diagnosis was mature teratoma. Sequential ultrasonography with General Electric model 3000 equipment showed a normal-appearing male fetus except for a discrete right-sided anterior chest wall mass, that did not involve the axilla or neck. Free movement of the upper extremities was noted. The contents within the chest appeared normal, including a four-chamber heart. The mass projected from the external chest and did not appear to penetrate the ribs. It measured 3.4 x 3.1 cm and was echodense with three small (0.3 cm) hypoechoic structures within
the tumor. We performed continuous Doppler velocimetry over the mass with a 3.5 MHz transducer. A flow wave pattern with a systolic/diastolic ratio of 1.5 was noted, consistent with blood flow through low resistance channels. I Serial ultrasonography with a General Electric model 3200 showed little growth of the mass over the next eight weeks. Fig. 1 shows the mass on real-time ultrasonography. At 35 weeks' gestation the patient came to the labor and delivery suite with a chief complaint of leakage of fluid per vagina for 6 hours and contractions every 3 minutes. Vaginal examination showed the cervix to be 4 cm dilated and completely effaced with a cephalic presentation. A male infant weighing 2680 gm with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively, was delivered by low transverse cesarean section. Apurple, spongy mass was noted on the right anterior chest wall that displaced the areola laterally (Fig. 2). The mass then measured 4.3 x 4.2 cm. No bruits were heard or pulsations felt within the mass. The infant's platelet count was 175,000/cm3 • On the fifth day of life, the infant had the mass resected without difficulty. The histologic diagnosis was cavernous hemangioma. The infant was discharged on the second postoperative day.
Prenatal diagnosis of hemangioma
Volume 163 Number 2
At 6 months of age the infant was healthy and doing well. Comment The appearance of a solid and cystic mass by ultrasonography elsewhere on the outer surface of the fetus led to a differential diagnosis including teratoma, hemangioma, and mesenchymal sarcoma. With the use of Doppler velocimetry, we demonstrated that the mass had a low-resistance blood flow. Similar results were obtained in a case of a craniofacial hemangioma. 1 We speculate that low vascular resistance as evaluated by Doppler ultrasonography could differentiate vascular lesions such as hemangiomas from neoplasias such as teratomas. However, further Doppler studies of fetal tumors are necessary to substantiate the potential of this diagnostic modality.
The size of the mass did not suggest that soft tissue dystocia was likely. However, a cesarean section was performed because the risk of trauma to a very vascular mass lesion existed. Hemangiomas in the newborn have been noted to have a microangiopathic anemia and thrombocytopenia caused by trauma of the blood elements as flow occurs through the vascular lesion. 2 Therefore abdominal delivery may be appropriate in the management of rare external masses of the fetus. REFERENCES 1. Lasser D, Preis 0, Dor N, Tancer ML. Antenatal diagnosis of giant cystic cavernous hemangioma by doppler velocimetry. Obstet GynecoI1988;72:476-7. 2. David Tj, Evans DIK. Stevens RF. Haemangioma with thrombocytopenia (Kasabach-Merritt syndrome). Arch Dis Child 1983;58: 1022-3.
Relationship of fetal biophysical profile and blood gas values at cordocentesis in severely growth-retarded fetuses Lucie S. M. Ribbert, MD,' Rosalinde J. M. Snijders, MSc,b K. H. Nicolaides, MD,b and G. H. A. Visser, MD' London, England, and Groningen, The Netherlands In 14 severely growth-retarded fetuses the biophysical prOfile score was analyzed in relation to blood P02, pH. oxygen saturation, and oxygen content in samples obtained by cordocentesis. The data suggest that the biophysical profile score can predict the degree of fetal acidemia. (AM J DesTET GVNECOL 1990;163:569-71.)
Key words: Biophysical profile, cordocentesis, fetal blood gases, intrauterine growth retardation The biophysical profile is widely used for the assessment of fetal well-being. All previous studies with the biophysical profile have related the results of the test with outcome of pregnancy or with cord blood gas levels at delivery. 1.2 This study examines the relationship beFrom the Harris Birthright Research Centre for Fetal Medicine, Department of Obstetrics and Gynaecology, King's College Hospital/ and the Department of Obstetrics and Gynaecology. University Hospital Groningen." Supported by the Netherland Organization for Scientific Research and Action Research for the Crippled Child. Receivedfor publication December 11.1989; revised February 12, 1990; accepted February 23.1990. Reprint requests: K. H. Nicolaides, MD, Harris Birthright Research Centre for Fetal Medicine. Department of Obstetrics and Gynaecology, King's College Hospital, London, England SE5 8RX. 611120358
tween the biophysical profile and fetal blood gas levels in samples obtained by cordocentesis. Patients and methods In 14 severely growth-retarded fetuses that were referred to our unit for further assessment at 25 to 39 weeks' gestation, the biophysical profile was studied immediately before umbilical venous blood sampling. The methods and definitions for fetal tone, fetal gross body movements, fetal breathing movements, amniotic fluid volume, and fetal heart rate reactivity were those described by Manning. l Cordocentesis was performed without maternal sedation or fetal paralysis. All fetuses were anatomically and chromosomally normal. The fetal blood gas and hemoglobin levels (grams per deciliter) were measured by Radiometer ABL 330 (Copen-
569
