Peripartum Ultrasound-Guided Drainage of Cystic Fetal Sacrococcygeal Teratoma for the Prevention of the Labor Dystocia: A Report of Two Cases

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Abstract

Fetal sacrococcygeal teratoma (SCT) is the most common tumor in the neonatal period and is easily detected by modern ultrasound techniques, mostly during the second-trimester screening. It can cause significant fetal/neonatal morbidity and mortality due to its size, vascular loading, possible rupture, and labor dystocia. Mostly cystic teratomas have favorable prognosis, but if untreated in utero, they may rupture or cause labor obstruction. Cesarean delivery, especially with the vertical incision, increases significantly maternal morbidity due to the hemorrhage and the risk of the uterine rupture in the subsequent pregnancies. The authors report in details two SCT cases with uncomplicated vaginal delivery after peripartum ultrasound-guided drainage of the cystic teratoma. We conclude that the percutaneous emptying of the cystic SCT is an easy, encouraging, safe, and efficient procedure and enables normal vaginal delivery, thus avoiding labor dystocia and possible complications of the cesarean delivery and the risk of tumor rupture.

Most cited references 10

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Sacrococcygeal teratoma: prenatal assessment, fetal intervention, and outcome.

Timothy M. Crombleholme, Alan W. Flake, N Scott Adzick … (2004)

To understand the natural history and define indications for fetal intervention in sacrococcygeal teratoma (SCT), the authors reviewed all cases of fetal SCT presenting for evaluation. Prenatal diagnostic studies including ultrasound scan, magnetic resonance imaging (MRI), echocardiography and pre- and postnatal outcomes were reviewed in 30 cases of SCT that presented between September 1995 and January 2003. The mean gestational age (GA) at presentation was 23.9 weeks (range, 19 to 38.5) with 3 sets of twins (10%). Overall outcomes included 4 terminations, 5 fetal demises, 7 neonatal deaths, and 14 survivors. Significant obstetric complications occurred in 81% of the 26 continuing pregnancies: polyhydramnios (n = 7), oligohydramnios (n = 4), preterm labor (n = 13), preeclampsia (n = 4), gestational diabetes (n = 1), HELLP syndrome (n = 1), and hyperemesis (n = 1). Fetal intervention included cyst aspiration (n = 6), amnioreduction (n = 3), amnioinfusion (n = 1), and open fetal surgical resection (n = 4). Indications for cyst aspiration and amnioreduction were maternal discomfort, preterm labor, and prevention of tumor rupture at delivery. Although 15 SCTs were solid causing risk for cardiac failure, only 4 fetuses met criteria for fetal debulking based on ultrasonographic and echocardiographic evidence of impending high output failure and favorable anatomy at 21, 23.6, 25, and 26 weeks' gestation. Intraoperative events included maternal blood transfusion (n = 1), fetal blood transfusion (n = 2), chorioamniotic membrane separation (n = 2), and fetal arrest requiring successful cardiopulmonary resuscitation (CPR) (n = 1). In the fetal resection group, 3 of 4 survived with mean GA at delivery of 29 weeks (range, 27.6 to 31.7 weeks), mean birth weight of 1.3 kg, hospital stay ranging from 16 to 34 weeks, and follow-up ranging from 20 months to 6 years. Postnatal complications in the fetal surgery group included neonatal death (n = 1, secondary to premature closure of ductus arteriosus with cardiac failure), embolic event (n = 1, resulting in unilateral renal agenesis, jejunal atresia), chronic lung disease (n = 1), and tumor recurrence (n = 1). For fetal SCT, the rapidity at which cardiac compromise can develop and the high incidence of obstetric complications warrant close prenatal surveillance. Amnioreduction, cyst aspiration, and surgical debulking are potentially life-saving interventions.

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Outcome of antenatally diagnosed sacrococcygeal teratomas: single-center experience (1993-2004).

Mark Davenport, C A Makin, Kypros Nicolaides … (2006)

Sacrococcygeal teratomas (SCTs) are the commonest neonatal tumors with an incidence of approximately 1:30,000. There are few large single-center series and even fewer describing both their antenatal and postnatal course. We report the outcome of all fetuses investigated at a tertiary fetal medicine center with this diagnosis. Demographic details were obtained from a prospectively maintained database. Patient records were examined for additional data including antenatal and postnatal interventions. Data were described as median (range). Forty-one SCTs were diagnosed antenatally during the period 1993 to 2004. Twelve were excluded from subsequent analysis (single antenatal visit or attending for second opinion [n = 6] and termination of pregnancy [n = 6]). Twelve underwent fetal intervention (laser vessel ablation [n = 4], alcohol sclerosis [n = 3], cyst drainage [n = 2], amniodrainage [n = 2], vesicoamniotic shunt [n = 1]) for fetal hydrops and polyhydramnios to aid in delivery and to prevent obstructive uropathy developing in the fetus. Of these, 3 died in utero and 9 survived to be born (median gestational age, 33 weeks [27-37 weeks]). A further 3 died in the neonatal period. There are 6 long-term survivors (50%) from this group. Seventeen infants, without intervention, were born at median gestational age 38 weeks (26-40 weeks). One infant with severe cardiac anomalies died on the day of birth. All surviving infants had definitive excisional surgery at a median of 2 days (1-16 days). Current median follow-up of survivors is 39 months (8-86 months). There have been no recurrences. One child has mild constipation, and 3 are awaiting cosmetic revision of their scars. The overall survival of antenatally diagnosed SCT is approximately 77%, with the development of hydrops and others requiring in utero intervention carrying a poor prognosis. Otherwise, the outcome after surgical excision is excellent.

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Prenatal diagnosis and the pediatric surgeon: the impact of prenatal consultation on perinatal management.

Paul W. Harris, M Cendron, G Klauber … (1995)

Pediatric surgeons are increasingly called on by obstetrical colleagues to counsel parents about the implications of a prenatal ultrasound finding. Our understanding of the natural history of many prenatally diagnosed surgical conditions has grown significantly in recent years. Whether prenatal surgical consultation can influence perinatal course had not been investigated. During an 21-month period, 12,865 prenatal ultrasound studies were performed on a total of 4,551 patients, and 221 prenatal surgical consultations were obtained through a newly established fetal treatment program at a tertiary care prenatal diagnostic center. To evaluate the impact of prenatal pediatric surgical consultation on perinatal course, the authors reviewed changes in management including termination of pregnancy, in utero intervention, and altered site, mode, or timing of delivery. Two hundred twenty-one fetuses were referred for consultation; their 234 congenital anomalies included genitourinary (36%), thoracic (16%), intraabdominal (14.5%), abdominal wall (10.6%), neurological (9%), skeletal (6%), and head and neck (2.5%) defects; 2.5% had tumors and 2.5% were twin pregnancies. Pregnancy was terminated in 9.5% of cases, because of patient request, chromosomal abnormality, or dismal prognosis. In 3.6%, the decision to terminate was changed as a result of consultation. Site of delivery was changed as a result of consultation in 37% to facilitate postnatal evaluation and initiate immediate treatment. Mode of delivery was changed in 6.8% to prevent dystocia, hemorrhage into a tumor, as in sacrococcygeal teratoma, or to provide an emergency airway, as in cervical teratoma. The timing of delivery was changed in 4.5% to avoid further damage to fetal organs in cases of obstructive uropathy, gastroschisis, sacrococcygeal teratoma with high-output failure, and hydrocephalus. Five percent (11) underwent treatment in utero for fetal hydrothorax, obstructive uropathy, twin-twin transfusion syndrome, or lymphangioma. The overall perinatal mortality rate was 2.5%. Prenatal pediatric surgical consultation may have a significant impact on the perinatal management of the fetus with a surgically correctable congenital anomaly. Providing obstetric colleagues and families with valuable insight into the surgical management of anomalies allows fetal intervention when appropriate, and delivery in an appropriate setting, by the safest mode of delivery, and at the gestational age appropriate to minimize effects of the anomaly.

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Author and article information

Journal

Journal ID (nlm-ta): AJP Rep

Journal ID (iso-abbrev): AJP Rep

Title: AJP Reports

Publisher: Thieme Medical Publishers (333 Seventh Avenue, New York, NY 10001, USA. )

ISSN (Print): 2157-6998

ISSN (Electronic): 2157-7005

Publication date (Electronic): 22 July 2011

Publication date (Print): December 2011

Volume: 1

Issue: 2

Pages: 87-90

Affiliations

[1 ]Department of Obstetrics and Gynaecology, Helsinki University Central Hospital, Helsinki, Finland

Author notes

Address for correspondence and reprint requests Vedran Stefanovic, M.D., Ph.D. Department of Obstetrics and Gynaecology, Helsinki University Central Hospital Haartmaninkatu 2, 00290 HelsinkiFinland vedran.stefanovic@ 123456yahoo.com vedran.stefanovic@ 123456hus.fi

Article

Publisher ID: 01087

DOI: 10.1055/s-0031-1284220

PMC ID: 3653534

PubMed ID: 23705093

SO-VID: 419a3b66-3757-40cb-b491-b61f4d6fd890

History

Date received : 05 March 2011

Date accepted : 23 May 2011

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Peripartum Ultrasound-Guided Drainage of Cystic Fetal Sacrococcygeal Teratoma for the Prevention of the Labor Dystocia: A Report of Two Cases

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Abstract

Most cited references 10

Sacrococcygeal teratoma: prenatal assessment, fetal intervention, and outcome.

Outcome of antenatally diagnosed sacrococcygeal teratomas: single-center experience (1993-2004).

Prenatal diagnosis and the pediatric surgeon: the impact of prenatal consultation on perinatal management.

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