Giant cystic hygroma complicating on one of the twin pregnancy: case report

Objective

Our aim is to report a twin pregnacy that determined a giant cystic hygroma on one of the twin after the birth.

Case(s)

38 years old woman had applied to a second step hospital with single pregnancy, on her pelvic examination complete openness had been determined and urgently she had spontaneus vaginal delivery, after her placenta couldn’t be pulled out, on ultrasound examination aproximetly 20 cm of septated cyst has been explained as overian cancer and she referred to our clinic. In our clınıc on the pelvic examination we found taht she had 8 cm of openness, the uterus was 36 weeks in growth and on the ultrasound examination we found 20x24 cm of multiseptated and multicystic lesion. When we detailed our examination we understood that this lesion is a giant cystic hygroma of the other fetus of the twin pregnancy. Under ultrasound we aspirated the cysts with spinal needle and second fetus had burned. (1200g, 36 cm , APGAR 00)

Conclusion

In the pregnancies that have no antenatal care, both multiple pregnancy and cystic hygroma could not be diagnosed and than the cystic hygroma could grow to advanced size and causes to delay in the diagnosis and the treatment. So we have to remember cystic hygroma when we see a giant and septated cystic mass.

Keywords

Twin pregnancy, cystic hygroma

Introduction

Cystic hygroma, also known as cystic lymphangioma, is a congenital lesion of the lymphatic system appearing most commonly in the neck region although it can arise anywhere as a result of failure of lymphatics to connect to the jugular veins and also rarely accompanies with genetic disorders (1). In case of cystic hgyroma Turner, Noonan, Achondroplasia, Lethal multiple pterygium, Roberts, Gumming, Cowchock syndromes are important syndromes for differential diagnosis due to increased risk of incidence. Additionally, the use of alchocol, amniopterine and timetadion have been reported as teratogenic agents in ethology(2). In this report, a case with giant cystic hygroma in one of the twin pair has been diagnosed at the time of detailed anatomy scan which was referred to our clinic for a suspected mass for ovarian cancer.

Case(s)

38 years old woman,gravidy 10 parity 8, had applied to a second step hospital with single pregnancy.On her pelvic examination complete dilatation had been determined and urgently she had spontaneous vaginal delivery, after her placenta could not be pulled out she had ultrasound examination and aproximetly 20 cm of septated cyst has been explained as overian cancer and she referred to our clinic. At our clınıc on the pelvic examination we found that she had 8 cm of dilatation, the uterus was 36 weeks in growth and on the ultrasound examination we found 20x24 cm of multiseptated and multicystic lesion. When we detailed our examination we understood that this lesion was a giant cystic hygroma of the other fetus of the twin pregnancy.There was not fetal cardiac activity. We decided that the delivery was inpossible because of the cysts ,we aspirated the cysts with spinal needle under ultrasound and second fetus had burned. (1200g, 36 cm , APGAR 0/0) .The fetus was hydrophic. When we evaluated the placenta,it was monocorionic and diamniotic.We discharged the case on day 2 of clinical follow up without any complication.

Discussion

The most common genetic abnormality that associates with cystic hygroma is Turner syndrome (1,2). In our case, genetic analyses couldn’t be performed due to lack of parental permission. The lymphatic system develops around the fifth week and communicates with jugular vein in the seventh week. Cystic hygroma arises when this communication fails to happen untill 11-12th weeks (4). They can be septated or nonseptated,can also reach to giant size as reported in our case. Shulam et al,reported that smaller hygromas,having better prognosis, can regress spontaneously and echocardiographical findings can detected as normal, as well as fetal karyotypes (3) . They affirmed that giant cystic and multiseptated cystic hygromas with hydrops fetalis have bad prognosis (5). The giant cystic hygroma presented in our case, having multiple septations, had bad prognosis. Surgical resection, depending on the anatomical location, is the mainstay of therapy in early detection. The nonsurgical treatment options are radiotherapy, aspiration, administration of sclerosing agents (bleomycin, OKT-432) and CO’ laser vaporisation (6). Besides, pregnancy termination could be offered in early prenatal diagnosis.as a result antenatal follow-up is critically important.in pregnancies without antenatal care, multiple pregnancies can be overlooked as well as any cystic hygroma in fetus/fetuses may reach huge sizes that can be misdiagnosed causing a delay in treatment. Therefore, cystic hygroma should be kept in mind in the differential diagnosis of septated cysts.

Conclusion

In pregnancies without antenatal care, multiple pregnancies can be overlooked as well as any cystic hygroma in fetus/fetuses may reach huge sizes that can be misdiagnosed causing a delay in treatment. Therefore, cystic hygroma should be kept in mind in the differential diagnosis of septated cysts.

References

1. Fleischer AC, Manning FA, Jeanty P, Romero R. Sonography in obstetrics and gynecology. London: Appleton – Lange; 1996; 393-4.
2. Rottem S, Chervenak FA. Ultrasound diagnosis of fetal anomalies. Obstet Gynecol Clin North Am 1990; 17: 17-40.
3. Shulman LP, Emerson DS, Fekler RE. High frequency of cytogenetic abnormalities in fetusus with cystic hygroma diagnosed in the first trimester. Obstet Gynecol 80: 80, 1992.
4. Charabi B, Bretlau P, Bille M, Holmelund M. Cystic hygroma of head and neck – a long term follow up of 44 cases. Acta Otolaryngol 2000; 543(Suppl): 248-50.
5. Brumfield CG, Wenstrom KD, Davis RO, Owen J, Cosper P. Second trimester cystic hygroma: prognosis of septated and nonseptated lesions. Obstet Gynecol 1996; 88: 979-82.
6. Kibar AE, Çakır BÇ, Tiryaki T. Göğüs duvarında kistik higroma: Nadir bir yerleşim yeri. Türk Pediatri Arşivi 2005; 40: 241-3.