Case Study Posted By : Dr. TLN Praveen
- 22-year-old primigravida was referred to our institute for an anomaly scan.
- There was history of consanguinity.
- She was normotensive with normal GTT.
- Her blood parameters were normal with normal hemoglobin of 12gms/dl.
- Fundal height was corresponding to period of gestation.
- She was perceiving good fetal movements.
- Ultrasound examination revealed a single live intrauterine gestation in cephalic presentation.
- Fetal biometry and growth factors were corresponding to period of gestation
- Fetal biometry and the ultrasound assigned gestational age was corresponding to 22 weeks
- First trimester screening done elsewhere showed low risk for aneuploidies (1 in 3879 for T21).
- Fetal anomaly scan showed normal anatomy.
- The AFI (Amniotic fluid index) was 28 - suggesting mild hydramnios.( SVP 9 cms)
- Placenta was fundal and posterior with normal retroplacental complex.
- There was a well defined, sharply marginated hypoechoic area which was identified in the sub-chorionic region of the placenta, presenting as a bulge on the fetal surface measuring 5.4 x 5.7 cms.
- The mass had uniformly homogenous echotexture.
- It was located near the insertion of the umbilical cord.
- Large chorioangiomas may result in fetal anemia and thrombocytopenia due to sequestration of red blood cells and platelets by the tumor.
- Hyperdynamic circulation due to arteriovenous shunts in the tumor can lead to fetal heart failure (pericardial effusion), hydrops and placentomegaly..
- There will be associated polyhydramnios due to direct transudation into amniotic fluid and due to fetal polyuria secondary to hyperdynamic circulation.
- These tumors can also result in maternal fluid overload and preeclampsia
Minimal pericardial effusion / polyhydramnios
Middle Cerebral Artery Doppler
Management depends upon the gestational age and fetal symptoms.
Interventions are mainly aimed at blocking the vascular supply of the tumor.
Various management options - either fetoscopic or ultrasound guided procedures are available
Fetoscopic ligation Interstitial laser coagulation.
Radio frequency ablation Micro coil embolization
Intra-tumoral absolute alcohol injection Tissue glue tumor embolization
Management plan of the present case
- Management options were - expected management with regular follow up at two weekly interval.
- Planning to intervene depends on increase in size of the tumor, further increase in hydramnios or development of features of hydrops such as pericardial effusion, cardiomegaly and development of pleural/ peritoneal fluid.
- Middle cerebral artery Doppler showing increased peak systolic velocity indicating development of fetal anemia.
- In our case - The tumor was of large size, there was increased amniotic fluid and minimal pericardial effusion.
- The literature reveals ideal time to intervene is at 22 to 24 weeks with early features of fetal complications
- Vascular mapping of the tumor done by 3D power Doppler angio.
- Intra-tumoral vessels identified
Ultrasound guided intra tumoral tissue glue injection
- Tissue glue- n-Butyl-2- Cyanoacrylate
- It is a liquid adhesive that polymerizes immediately upon contact with blood or body fluid.
- It has been used as an effective embolising agent in surgical conditions (e.g., cerebral arteriovenous malformations) .
- It is extensively used in interventional Radiological procedures
Placenta after delivery
Pale infarcted, necrosed Chorioangioma
Early detection of Chorioangioma
Key learning factors
- The incidence of placental chorioangioma is 1 in 5000 pregnancies
- Size of the tumor varies.
- Small tumors are usually not detected and are asymptomatic.
- Tumors less than 5 cms can be managed expectantly resulting in spontaneous regression.
- Tumors which are large and causing fetal complications such as fetal anemia, polyhydramnios, cardiac overload and hydrops should be prenatally managed.
- Various management options are available
- Tissue glue embolization is a less invasive procedure and can be performed under local anesthesia with insignificant complications.
- Percutaneous cyanoacrylate embolization should be considered as the primary in utero therapy for placental chorioangioma.