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with oral contraceptives. J Adolesc Health Care 1984;5: 1-6. 9. Scher PW, Emans SJ, Grace EM. Factors associated with compliance to oral contraceptive use in an adolescent population. J Adolesc Health Care 1982;3: 120-3. 10. Neel EU, Jay S, Litt IF. The relationship of self-concept and autonomy to oral contraceptive compliance among adolescent females. J Adolesc Health Care 1985;6:445-7. 11. Kastner LS. Ecological factors predicting adolescent con-

traceptive use: implications for intervention. J Adolesc Health CAre 1984;5:79-86. 12. SAS user's guide: statistics. Cary, North Carolina: SAS Institute, 1982. 13. Satterthwarth FW. An approximate distribution of variance components. Biomet Bull 1946;2:110-4. 14. Spivak H, Weitsman M. Social barriers faced by adolescent parents and their children. JAMA 1987;258:1500-4.

Prenatal ultrasonographic diagnosis of fetal scrotal inguinal hernia Israel Meizner, MD, Arie Levy, MD, Miriam Katz, MD, Tzippi Simhon, and Marek Glezerman, MD Beer-Sheva, Israel Fetal scrotal inguinal hernia was diagnosed at 33 weeks of pregnancy by ultrasonographic examination. Moving, echo-free, cystlike structures representing peristalsis within trapped loops of bowel in an abnormally enlarged scrotum were the main ultrasonographic finding. The diagnosis was confirmed post partum, and surgery was successfully carried out 4 days after delivery. (AM J OSSTET GVNECOL

1992;166:907-9.)

Key words: Prenatal diagnosis, ultrasonography, inguinal hernia The most common defect in the abdominal wall in infants and children is indirect inguinal hernia. I The early detection of this pathologic condition is extremely important because segments of bowel may become trapped in the hernia pouch, subsequently leading to partial or complete obstruction of the lumen. We report a case of scrotal inguinal hernia diagnosed at 33 weeks of gestation. To the best of our knowledge this is the first report in the English literature of in utero diagnosis of fetal inguinal hernia.

Case report A 21-year-old-woman, gravida 0 para 0, was referred for ultrasonography at 33 weeks' gestation because the

From the Ultrasound Unit, Department of Obstetrics and Gynecology, Soroka Medical Center, and the Faculty of Health Sciences, BenGurion University of the Negev. Received for publication June 25, 1991; revised September 23, 1991; accepted November 15,1991. Reprint requests: Israel Meizner, MD, Ultrasound Unit, Department of Obstetrics and Gynecology, Soroka Medical Center, Beer-Sheva, 84101, Israel. 611 135043

fundal height did not correspond to the dates. On ultrasonographic examination, a single vertex-presenting fetus was observed. Measurements of biparietal diameter, head circumference, abdominal circumference, and femur length (86 mm, 30.6 em, 27.5 em, and 65 mm, respectively) corresponded perfectly to the dates. No other fetal abnormalities were detected. The fetus was male, and a huge scrotum measuring 65 x 56 x 64 mm was observed (Fig. I). The penis was pushed aside by the enlarged scrotum. The testicles were very close to each other. Small, fluid-filled, cystlike formations occupied a considerable part of the scrotum. These structures demonstrated obvious peristalsis and represented loops of small bowel trapped in the scrotum (Fig. 2). On the basis of this observation scrotal inguinal hernia was diagnosed. No intraabdominal pathologic condition that would cause elevated pressure within the abdominal cavity was observed on repeated ultrasonographic examinations performed at 2-week intervals. No evidence of bowel obstruction was found in the repeated scans, and the patient was allowed to continue the pregnancy. Normal spontaneous delivery occurred at term, and a male infant weighing 3.4 kg was delivered vaginally.

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Fig. 1. Ultrasonographic scan at 36 weeks' gestation. Note huge scrotum (arrow) as compared with both thighs (arrowheads). Loops of bowel are evident inside scrotum (curoed arrow).

Fig. 2. Ultrasonogram illustrating trapped loop of bowel undergoing wave of peristalsis inside scrotum. Arrow, Loop of bowel.

The infant appeared normal except for a huge scrotum that was opaque to transmitted light (Fig. 3). Marked swelling was noted at the left external inguinal ring extending downward into the scrotum. On examination both testicles were palpated. A scrotal mass representing condensed bowel loops was also encountered. Reduction of the herniated bowel was carried out in the labor ward by the attending neonatologist; however, the herniated bowel reappeared when the infant started crying. At the end of the first week, surgical repair was successfully completed.

Comment As the testes descend retroperitoneally from the genital ridge during the latter stages of embryonic life, the processus vaginalis, an outpouching of peritoneum, precedes the testes into the scrotum. The processus vaginalis originates at the internal ring, and as it leaves the canal at the external ring it turns inferiorly into the scrotum. The lower portion of this sac envelopes the testis to form the tunica vaginalis. The remainder of the sac normally atrophies before birth. The indirect

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Fig. 3. Infant immediately after delivery. Huge scrotum is evident. Note bulging inguinal mass containing herniated small bowel (arrow).

inguinal hernia results from a persistence of the processus vaginalis and manifests itself as a mass in the inguinal region when an abdominal viscus or peritoneal fluid is forced into it. Although the hernial sac is present at birth, it usually remains empty for a variable period of time. By 2 or 3 months of age, when the infant is capable of increasing intraabdominal pressure, the sac may open and either fluid or abdominal content is forced into it. The hernial sac then appears as a swelling in the inguinal region, but it may extend in the male for a variable distance downward into the scrotum. In complicated cases a loop of bowel may become incarcerated in the sac. The ultrasonographic markers for correct prenatal ultrasonographic diagnosis of inguinal scrotal hernia include the following: (1) huge scrotum, (2) cystic, fluidcontaining structures inside the scrotum representing bowel loops, (3) evidence of peristalsis in the bowel, and (4) close relationship of both testicles. Because scrotal hernias in fetuses are rare, intraabdominal pathologic cause of elevation in abdominal pressure should be excluded first. Fetuses with multiple congenital anomalies, particularly those involving the lower abdomen, may

display inguinal hernias as part of the anomaly complex. An inguinal hernia extending into the scrotum should be carefully differentiated from a congenital hydrocele! This differentiation is simpler in fetuses than in infants. In hydrocele the testicles are easily recognized because they are in clear peritoneal fluid, which gives a characteristically echo-free picture. This is not the case with scrotal hernia, in which the scrotum is filled with a partially echogenic mass with evident peristalsis. Addendum

After submission of this article for publication, Ober et al. 3 reported a similar case. REFERENCES

l. Nelson WE, Vaughan VC, McKay RJ. Textbook of pedi-

atrics. 12th ed., Philadelphia: WB Saunders, 1979:1107. 2. Meizner I, Katz M, Zmora E, et al. In utero diagnosis of congenital hydrocele. J Clin Ultrasound 1983;11 :449. 3. Ober KJ, Smith CV. Prenatal ultrasound diagnosis of a fetal inguinal hernia containing small bowel. Obstet Gynecol 1991;78:905.

Prenatal ultrasonographic diagnosis of fetal scrotal inguinal hernia.

Fetal scrotal inguinal hernia was diagnosed at 33 weeks of pregnancy by ultrasonographic examination. Moving, echo-free, cystlike structures represent...
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