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Antenatal diagnosis of bilateral fetal inguinal hernias
EUROPEAN JOURNAL OF
ELSEVIER
European Journal of Ultrasound 2 (1995) 211-213
Clinical report
Antenatal diagnosis of bilateral fetal inguinal hernias Sarwat Hussain*, Keri-Leigh Doiron Department of Radiology, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA Received 29 July 1994; revision received 17 February 1995; accepted 27 February 1995
Abstract
We report a case of prenatal ultrasound diagnosis of bilateral inguinal hernias. The two earlier ultrasound examinations at 17 and 22 weeks of gestations showed normal scrotal sac. An ultrasound examination at 41 weeks demonstrated non-cystic scrotal swelling that proved to be bilateral inguinal hernias containing loops of small intestines. Keywords: Antenatal diagnosis; Ultrasound diagnosis; Fetal inguinal hernia
1. Introduction
2. Case report
High resolution ultrasonography is routinely used for establishing normality of fetal structures and prenatally diagnosing fetal congenital abnormalities. Scrotal swelling is a common finding, most often presenting as varying degrees of hydrocele. In neonates, an indirect inguinal hernia is one of the most common abdominal wall defects. We report a case of large bilateral inguinal hernias presenting as an antenatal non-cystic scrotal mass.
A 32-year-old woman (gravida 2, par 1) was referred for a biophysical profile (BPP) ultrasound at 41.1 weeks of gestation. Two earlier examinations at 17.1 and 22.1 weeks showed normal fetal anatomical survey including a normal scrotum. An ultrasound study at 41.1 weeks was carried out for BPP. The BPP score was 8/8 with fetal breathing, major movements, tone and amniotic fluid for the gestational age. On anatomical survey there was a large (11 x 9 x 8 era) mass in the region of the scrotum that was seen in between the upper thighs (Fig. 1). This non-cystic mass seemed to contain small cystic tubular spaces that slowly shifted giving the impression of paristaltic waves. There was no evidence of significant flow on color Doppler
* Corresponding author, Department of Radiology, Boston University Medical Center Hospital, 88 East Newton Street, Boston MA 02118, USA Tel.: +1 617 6386556; Fax: +1 617 6386616.
0929-8266/95/$09.50 © 1995 Elsevier Science Ireland Ltd. All rights reserved SSD1 0929-8266(95)00102-W
212
S. Hussain, K-L. Doiron / European Journal of Ultrasound 2 (1995) 211-213
Fig. 1. Bilateral inguinal hernias: Ultrasound of scrotum seen between the two upper thighs. Small arrows point to the outline of the scrotal sac. 1, right testis; 2, left testis.
evaluation. The fetal cord insertion, the intraabdominal structures and the sacral spine were normal. On the basis of this examination the differential diagnosis of inguinal hernia or sacraococcygeal teratoma (SCT) was suggested. Two days later a 4096 g baby was delivered by caesarean section. At birth, the APGAR score was 8 at 1 min and 9 at 5 min. The infant appeared normal except for bilateral inguinal hernias containing loops of intestine. The hernias were easily reduced but reappeared readily with neonatal coughing and straining. The hernias were surgically repaired 2 days after birth without complications. 3. Discussion
During intra-uterine life the fetal testes descend into the scrotum from the site of their developmental origin in the genital ridge located high up in the retroperitonium. During testicular descent there is an out-pouching of the peritoneal sac into the scrotum. The part of the peritonium in the inguinal canal that connects the abdominal cavity with the scrotal peritoneal sac obliterates to form the processus vaginalis testis. An indirect inguinal hernia results from failure of complete obliteration of the processus vaginalis. Prenatal ultrasound diagnosis of inguinal hernia has been reported in the relevent literature (Ober & Smith 1991, Meinzer et al. 1992). An inguinal hernia can be diagnosed as early as 2-3 months of neonatal life
when the baby is able to raise intra-abdominal pressure and force abdominal contents, fluid or gut, into the scrotum. Fetal hydrocele is a common prenatal ultrasound finding. Depending on the presence or absence of communication with the general peritoneal cavity, respectively, a hydrocele may be of a communicating or non-communicating variety. In communicating hydrocele, the amount of scrotal fluid in the fetal scrotum may increase over time and a hernia may subsequently appear (Romero et al. 1988). If accompanied with meconium ascites, a communicating hydrocele may give an appearance of a solid scrotal mass due to the echogenic nature of the ascitic fluid (Kenney et al. 1985). In our patient, earlier ultrasounds at 17.1 and 22.1 weeks gestation demonstrated a normal scrotum without dydrocele. But, scanning at 41.1 weeks demonstrated a large scrotal mass. Differential diagnoses considered were SCT and a testicular mass, but probable presence of paristalsis pointed to the diagnosis of inguinal hernia. An SCT arises from totipotential cells of the presacral region (Holzgreve et al. 1977). As an SCT grows, it fills the pelvis and then begins to protrude through the perineum to a varying degree and may have a cystic, solid or mixed consistency. In our patient, careful scanning of the fetal sacrum demonstrated that the mass did not have any presacral component. Therefore, a diagnosis of SCT was excluded from serious consideration. Presence of a testicular mass was another consideration. Absence of a definite color Doppler flow did not help us to confirm or exclude a rarely occuring conginital testicular tumor (Johnson 1976). When the final diagnosis became known it was confirmed that small cystic spaces within the scrotum were actually loops of small intestines with paristalsis. In conclusion, we suggest that a diagnosis of inguinal hernia should be considered whenever a scrotal swelling is detected on prenatal ultrasound of the fetus. Contents of the scrotum may not be discernible on sonographic image and presence or absence of color flow may not be contributory. However, presence of paristalsis in scrotum should be actively sought by careful scanning of scrotum over a period of time. Inguinal hernia, a common
S. Hussain, K-L. Doiron/ European Journal of Ultrasound 2 (1995) 211-213
scrotal space occupying lesion should therefore always be considered in the differential diagnosis of prenatal non-cystic scrotal swelling. References Halzgreve W, Mahony BS, Glick PL et al. Radiology of hereditary presacral teratoma. Radiology 1977; 122: 187. Johnson DE. Epidimiology. In: Testicular Tumors. Medical Examination Publishing Co. Inc., 1976; 39.
213
Kenney PJ, Spirt BA, Ellis DA, Patil U. Scrotal masses caused by meconium peritonitis: prenatal sonographic diagnosis. Radiology 1985; 154: 362. Meizner I, Levy A, Katz M, Simhon T, Glazerman M. Prenatal ultrasonographic diagnosis of fetal scrotal hernia. Am J Obstet Gynecol 1992; 166: 907-909. Ober KJ, Smith CV. Prenatal ultrsound diagnosis of a fetal inguinal hernia containing small bowel. Obstet Gynecol 1991; 78: 905-906. Romero R, Pilu G, Jeanty P e t al. In: Prenatal Diagnosis of Congenital Anomalies. Norwalk, Connecticut: Appleton & Lange, 1988; 304.
ELSEVIER
European Journal of Ultrasound 2 (1995) 211-213
Clinical report
Antenatal diagnosis of bilateral fetal inguinal hernias Sarwat Hussain*, Keri-Leigh Doiron Department of Radiology, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA Received 29 July 1994; revision received 17 February 1995; accepted 27 February 1995
Abstract
We report a case of prenatal ultrasound diagnosis of bilateral inguinal hernias. The two earlier ultrasound examinations at 17 and 22 weeks of gestations showed normal scrotal sac. An ultrasound examination at 41 weeks demonstrated non-cystic scrotal swelling that proved to be bilateral inguinal hernias containing loops of small intestines. Keywords: Antenatal diagnosis; Ultrasound diagnosis; Fetal inguinal hernia
1. Introduction
2. Case report
High resolution ultrasonography is routinely used for establishing normality of fetal structures and prenatally diagnosing fetal congenital abnormalities. Scrotal swelling is a common finding, most often presenting as varying degrees of hydrocele. In neonates, an indirect inguinal hernia is one of the most common abdominal wall defects. We report a case of large bilateral inguinal hernias presenting as an antenatal non-cystic scrotal mass.
A 32-year-old woman (gravida 2, par 1) was referred for a biophysical profile (BPP) ultrasound at 41.1 weeks of gestation. Two earlier examinations at 17.1 and 22.1 weeks showed normal fetal anatomical survey including a normal scrotum. An ultrasound study at 41.1 weeks was carried out for BPP. The BPP score was 8/8 with fetal breathing, major movements, tone and amniotic fluid for the gestational age. On anatomical survey there was a large (11 x 9 x 8 era) mass in the region of the scrotum that was seen in between the upper thighs (Fig. 1). This non-cystic mass seemed to contain small cystic tubular spaces that slowly shifted giving the impression of paristaltic waves. There was no evidence of significant flow on color Doppler
* Corresponding author, Department of Radiology, Boston University Medical Center Hospital, 88 East Newton Street, Boston MA 02118, USA Tel.: +1 617 6386556; Fax: +1 617 6386616.
0929-8266/95/$09.50 © 1995 Elsevier Science Ireland Ltd. All rights reserved SSD1 0929-8266(95)00102-W
212
S. Hussain, K-L. Doiron / European Journal of Ultrasound 2 (1995) 211-213
Fig. 1. Bilateral inguinal hernias: Ultrasound of scrotum seen between the two upper thighs. Small arrows point to the outline of the scrotal sac. 1, right testis; 2, left testis.
evaluation. The fetal cord insertion, the intraabdominal structures and the sacral spine were normal. On the basis of this examination the differential diagnosis of inguinal hernia or sacraococcygeal teratoma (SCT) was suggested. Two days later a 4096 g baby was delivered by caesarean section. At birth, the APGAR score was 8 at 1 min and 9 at 5 min. The infant appeared normal except for bilateral inguinal hernias containing loops of intestine. The hernias were easily reduced but reappeared readily with neonatal coughing and straining. The hernias were surgically repaired 2 days after birth without complications. 3. Discussion
During intra-uterine life the fetal testes descend into the scrotum from the site of their developmental origin in the genital ridge located high up in the retroperitonium. During testicular descent there is an out-pouching of the peritoneal sac into the scrotum. The part of the peritonium in the inguinal canal that connects the abdominal cavity with the scrotal peritoneal sac obliterates to form the processus vaginalis testis. An indirect inguinal hernia results from failure of complete obliteration of the processus vaginalis. Prenatal ultrasound diagnosis of inguinal hernia has been reported in the relevent literature (Ober & Smith 1991, Meinzer et al. 1992). An inguinal hernia can be diagnosed as early as 2-3 months of neonatal life
when the baby is able to raise intra-abdominal pressure and force abdominal contents, fluid or gut, into the scrotum. Fetal hydrocele is a common prenatal ultrasound finding. Depending on the presence or absence of communication with the general peritoneal cavity, respectively, a hydrocele may be of a communicating or non-communicating variety. In communicating hydrocele, the amount of scrotal fluid in the fetal scrotum may increase over time and a hernia may subsequently appear (Romero et al. 1988). If accompanied with meconium ascites, a communicating hydrocele may give an appearance of a solid scrotal mass due to the echogenic nature of the ascitic fluid (Kenney et al. 1985). In our patient, earlier ultrasounds at 17.1 and 22.1 weeks gestation demonstrated a normal scrotum without dydrocele. But, scanning at 41.1 weeks demonstrated a large scrotal mass. Differential diagnoses considered were SCT and a testicular mass, but probable presence of paristalsis pointed to the diagnosis of inguinal hernia. An SCT arises from totipotential cells of the presacral region (Holzgreve et al. 1977). As an SCT grows, it fills the pelvis and then begins to protrude through the perineum to a varying degree and may have a cystic, solid or mixed consistency. In our patient, careful scanning of the fetal sacrum demonstrated that the mass did not have any presacral component. Therefore, a diagnosis of SCT was excluded from serious consideration. Presence of a testicular mass was another consideration. Absence of a definite color Doppler flow did not help us to confirm or exclude a rarely occuring conginital testicular tumor (Johnson 1976). When the final diagnosis became known it was confirmed that small cystic spaces within the scrotum were actually loops of small intestines with paristalsis. In conclusion, we suggest that a diagnosis of inguinal hernia should be considered whenever a scrotal swelling is detected on prenatal ultrasound of the fetus. Contents of the scrotum may not be discernible on sonographic image and presence or absence of color flow may not be contributory. However, presence of paristalsis in scrotum should be actively sought by careful scanning of scrotum over a period of time. Inguinal hernia, a common
S. Hussain, K-L. Doiron/ European Journal of Ultrasound 2 (1995) 211-213
scrotal space occupying lesion should therefore always be considered in the differential diagnosis of prenatal non-cystic scrotal swelling. References Halzgreve W, Mahony BS, Glick PL et al. Radiology of hereditary presacral teratoma. Radiology 1977; 122: 187. Johnson DE. Epidimiology. In: Testicular Tumors. Medical Examination Publishing Co. Inc., 1976; 39.
213
Kenney PJ, Spirt BA, Ellis DA, Patil U. Scrotal masses caused by meconium peritonitis: prenatal sonographic diagnosis. Radiology 1985; 154: 362. Meizner I, Levy A, Katz M, Simhon T, Glazerman M. Prenatal ultrasonographic diagnosis of fetal scrotal hernia. Am J Obstet Gynecol 1992; 166: 907-909. Ober KJ, Smith CV. Prenatal ultrsound diagnosis of a fetal inguinal hernia containing small bowel. Obstet Gynecol 1991; 78: 905-906. Romero R, Pilu G, Jeanty P e t al. In: Prenatal Diagnosis of Congenital Anomalies. Norwalk, Connecticut: Appleton & Lange, 1988; 304.