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Fetal abdominoscrotal hydrocele
Amniotic fluid bedside test
Volume 165 Number 5, Part 1
search laboratory introduced one of those alternatives, the spun OD 65o , which has been shown to compare favorably with the LIS ratio and phosphatidylglycerol analysis in predicting the likelihood of respiratory distress syndrome in newborns.'-6 However, even spun optical density determinations require centrifugation. To improve clinical access for evaluating amniotic fluid to determine fetal pulmonary maturity, we have developed a rapid, easily performed test that needs no laboratory support. Our method requires only two turbidity tubes and a needle for amniocentesis. We have not yet validated amniotic fluid specimens obtained from vaginal pools. Although we do not suggest that our rapid test should displace accepted laboratory standards for determining fetal lung maturity, we do believe that our simple method can be a useful preliminary assessment in many hospitals. Furthermore, in remote locales that do not enjoy the advantages of more sophisticated methods, our test (which has a 91 % sensitivity and thus a 9% false-positive rate that must be considered in any clin-
ical decision-making) can provide information about pulmonary maturity when no other test is available. REFERENCES 1. McCulloch JC, Medelson D. An emergency test for fetal lung maturity: OD 65o or Amniostat-FLM? Clin Chern 1987;33:2123-5. 2. Chaudhury AK, Sbarra AJ, Wang HH, et al. Determination of fetal pulmonary maturity status by visual observation of amniotic fluid. In: Proceedings of the Ninth Annual Meeting of the Society of Perinatal Obstetricians, New Orleans, Louisiana, February 2-4, 1989. New Orleans: Society of Perinatal Obstetricians, 1989:346. 3. Sbarra AJ, Michlewitz H, Selvaraj RJ, et al. Relation between optical density at 650 nm and LIS ratios. Obstet Cynecol 1977 ;50: 723-4. 4. Sbarra AJ, Selvaraj RJ, Cetrulo CL, et al. Positive correlation of optical density at 650 nm with lecithin/sphingomyelin ratios in amniotic fluid. AM J OBSTET CYNECOL 1978; 130:788-90. 5. Cetrulo CL, Sbarra AJ, Selvaraj RJ, et al. Positive correlation between mature amniotic fluid optical density readings and the absence of neonatal hyaline membrane disease. J Reprod Med 1985;27:34-8. 6. Turner RJ, Read JA. Practical use and efficiency of amniotic fluid OD 65o as a predictor of fetal pulmonary maturity. Obstet Cynecol 1983;61:551-5.
Fetal abdominoscrotal hydrocele P. Sasidharan, MD,. Stanley Crankson, MB,' and Saeed Ahmed, MB b Riyadh, Saudi Arabia A case of abdominoscrotal hydrocele detected initially as an intraabdominal cyst on antenatal ultrasonography is described. Abdominoscrotal hydrocele should be included in the differential diagnosis of antenatally recognized intraabdominal cysts and abdominal masses in the newborn. (AM J OBSTET GVNECOL 1991 ;165:1353-5.)
Key words: Abdominoscrotal hydrocele, fetus, ultrasonography Antenatal maternal ultrasonography is an ideal way of evaluating pregnancy from both the obstetric and fetal points of view. Even though the precise nature of the abnormality may not be clear antenatally, antenatal recognition leads to appropriate postnatal assessment and treatment. Abdominoscrotal hydrocele is a rare condition, and there are no reports of antenatal detecFrom the Departments of Pediatrics' and Surgery,! King Faisal Specialist Hospital Research Center. Received for publication January 16, 1991; revised April 3, 1991; accepted May 8, 1991. Reprint requests: P. Sasidharan, MD, Division of Neonatology, Medical College of Wisconsin, Milwaukee County Medical Center, 8700 W. Wisconsin Ave., Milwaukee, W153226 6/1 130949
tion of this disorder. I. 2 We report a case of abdominoscrotal hydrocele recognized as an intraabdominal cyst before 30 weeks of gestation that was managed surgically at 5 days of age. Case report Routine abdominal ultrasonography in a 28-year-old, gravida 11, para 10 woman at 22 weeks' gestation revealed a prominent cystic mass in the fetal abdomen that was thought to be a distended urinary bladder. Subsequent ultrasonography at 30 and 34 weeks' gestation revealed a fetal abdominal cyst of 5.7 X 4.5 em (Fig. 1). The cyst was distinct from the urinary bladder, and the kidneys were normal. There was no evidence of any alimentary tract abnormality, and the exact na-
1353
1354 Sasidharan, Crankson, and Ahmed
November 1991 Am J Obstet Gynecol
Fig. I. Ultrasonography at 30 weeks' gestation.
Fig. 2. Postnata l ultrasonography showing cystic mass of a bdominoscrotal hydrocele.
ture of the fetal cyst was not clear, although mesenteric cyst was considered a possibility. The baby was born at 37 weeks' gestation by cesarean section; the birth weight was 3150 gm. Abdominal examination revealed an undistended abdomen with a soft suprapubic mass with ill-defined margins. There was also a large left inguinal swelling that could be reduced into the peritoneal cavity and was thought to be a hernia. The testes were normal. Postnatal ultrasonography and abdominal x-ray film confirmed the presence of the suprapubic cystic mass (Fig. 2). A precise diagnosis was not made, but as a result of the "hernia" early surgery was undertaken at 5 days of age. On exploration of the left inguinal canal a large cystic swelling was . noted that extended into the abdominal cavity. Laparotomy was performed through a separate iliac
fossa incision when it was obvious that the "cyst" was an abdominoscrotal hydrocele that was retroperitoneal in position. The hydrocele sac extended posteriorly just lateral to the bladder, to which it was adherent. It was se parated from the testicular vessels and vas and was then removed; the procedure was completed with an orchiopexy. The postoperative course was uneventful, and the baby was discharged on the fourth postoperative d ay. He was well and thriving at 6 months of age and had no sign of residual abdominoscrotal swelling. The testes were normal. Comment
Abdominoscrotal hydrocele is essentially a hydrocele of the tunica vaginalis that has an inguinoscrotal and an abdominal component. Even though various etio-
Fetal abdominoscrotal hydrocele
Volume 165 Number 5, Part 1
logic theories about this condition have been proposed, the likely mechanism is that increased pressure from overdistention of an inguinoscrotallesion produces the proximal (abdominal) herniation. I, 2 It is also possible that the hydrocele may originate within the abdominal cavity and may extend or prolapse into the inguinoscrotal region. Our case was unique in that the abdominal component was recognized ante natally, possibly at 22 weeks' gestation but certainly by 30 weeks. Although testicular descent normally takes place at 28 to 30 weeks' gestation, it is logical to assume that the hydrocele developed primarily within the abdominal cavity. Because the testes were in the normal scrotal position at birth, it is also likely that an abdominal hydrocele became an abdomino scrotal hydrocele by virtue of increased pressure within the abdominal component and downward displacement. It would also appear that with the increasing use of ultrasonography, both ante natally and postnatally, an "abdominal" hydrocele without an inguinoscrotal component may be seen.
1355
Although abdominoscrotal hydrocele is extremely rare, it must be considered in the differential diagnosis of a lower abdominal cystic mass in a fetus. Hydronephrosis and hydroureter also may be seen with an abdomino scrotal hydrocele. During postnatal assessment, ultrasonography is the most appropriate investigation. In a newborn with an inguinoscrotal swelling, the abdomen should be carefully palpated. If a lower abdominal cystic swelling is palpable, pressure on the mass may produce a scrotal swelling or make it more obvious and thus lead to a clinical diagnosis of abdominoscrotal hydrocele. Treatment of this condition is total excision, and recurrence is rare unless it is not totally excised.
REFERENCES 1. Squire R, Gough DeS. Abdominoscrotal hydrocele in infancy, Br J UroI1988;61:347-9. 2, Khan AH, Yazbeck S. Abdominoscrotal hydrocele: a cause of abdominal mass in children. A case report and review of literature. J Pediatr Surg 1987;22:809-10,
Editors' note The AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY introduces a new format for abstracts accompanying regular articles, society articles, and Current Investigation articles. Authors submitting these manuscripts to the JOURNAL should provide an abstract of no more than 150 words structured according to the following headings: Objective(s), Study Design, Results, and Conclusion(s). Exceptions to this requirement include Clinical Opinion, Current Development, case report, and brief communication articles. Abstracts for these articles will continue to follow the standard abstract format. Please consult the Information for Authors for details.
Volume 165 Number 5, Part 1
search laboratory introduced one of those alternatives, the spun OD 65o , which has been shown to compare favorably with the LIS ratio and phosphatidylglycerol analysis in predicting the likelihood of respiratory distress syndrome in newborns.'-6 However, even spun optical density determinations require centrifugation. To improve clinical access for evaluating amniotic fluid to determine fetal pulmonary maturity, we have developed a rapid, easily performed test that needs no laboratory support. Our method requires only two turbidity tubes and a needle for amniocentesis. We have not yet validated amniotic fluid specimens obtained from vaginal pools. Although we do not suggest that our rapid test should displace accepted laboratory standards for determining fetal lung maturity, we do believe that our simple method can be a useful preliminary assessment in many hospitals. Furthermore, in remote locales that do not enjoy the advantages of more sophisticated methods, our test (which has a 91 % sensitivity and thus a 9% false-positive rate that must be considered in any clin-
ical decision-making) can provide information about pulmonary maturity when no other test is available. REFERENCES 1. McCulloch JC, Medelson D. An emergency test for fetal lung maturity: OD 65o or Amniostat-FLM? Clin Chern 1987;33:2123-5. 2. Chaudhury AK, Sbarra AJ, Wang HH, et al. Determination of fetal pulmonary maturity status by visual observation of amniotic fluid. In: Proceedings of the Ninth Annual Meeting of the Society of Perinatal Obstetricians, New Orleans, Louisiana, February 2-4, 1989. New Orleans: Society of Perinatal Obstetricians, 1989:346. 3. Sbarra AJ, Michlewitz H, Selvaraj RJ, et al. Relation between optical density at 650 nm and LIS ratios. Obstet Cynecol 1977 ;50: 723-4. 4. Sbarra AJ, Selvaraj RJ, Cetrulo CL, et al. Positive correlation of optical density at 650 nm with lecithin/sphingomyelin ratios in amniotic fluid. AM J OBSTET CYNECOL 1978; 130:788-90. 5. Cetrulo CL, Sbarra AJ, Selvaraj RJ, et al. Positive correlation between mature amniotic fluid optical density readings and the absence of neonatal hyaline membrane disease. J Reprod Med 1985;27:34-8. 6. Turner RJ, Read JA. Practical use and efficiency of amniotic fluid OD 65o as a predictor of fetal pulmonary maturity. Obstet Cynecol 1983;61:551-5.
Fetal abdominoscrotal hydrocele P. Sasidharan, MD,. Stanley Crankson, MB,' and Saeed Ahmed, MB b Riyadh, Saudi Arabia A case of abdominoscrotal hydrocele detected initially as an intraabdominal cyst on antenatal ultrasonography is described. Abdominoscrotal hydrocele should be included in the differential diagnosis of antenatally recognized intraabdominal cysts and abdominal masses in the newborn. (AM J OBSTET GVNECOL 1991 ;165:1353-5.)
Key words: Abdominoscrotal hydrocele, fetus, ultrasonography Antenatal maternal ultrasonography is an ideal way of evaluating pregnancy from both the obstetric and fetal points of view. Even though the precise nature of the abnormality may not be clear antenatally, antenatal recognition leads to appropriate postnatal assessment and treatment. Abdominoscrotal hydrocele is a rare condition, and there are no reports of antenatal detecFrom the Departments of Pediatrics' and Surgery,! King Faisal Specialist Hospital Research Center. Received for publication January 16, 1991; revised April 3, 1991; accepted May 8, 1991. Reprint requests: P. Sasidharan, MD, Division of Neonatology, Medical College of Wisconsin, Milwaukee County Medical Center, 8700 W. Wisconsin Ave., Milwaukee, W153226 6/1 130949
tion of this disorder. I. 2 We report a case of abdominoscrotal hydrocele recognized as an intraabdominal cyst before 30 weeks of gestation that was managed surgically at 5 days of age. Case report Routine abdominal ultrasonography in a 28-year-old, gravida 11, para 10 woman at 22 weeks' gestation revealed a prominent cystic mass in the fetal abdomen that was thought to be a distended urinary bladder. Subsequent ultrasonography at 30 and 34 weeks' gestation revealed a fetal abdominal cyst of 5.7 X 4.5 em (Fig. 1). The cyst was distinct from the urinary bladder, and the kidneys were normal. There was no evidence of any alimentary tract abnormality, and the exact na-
1353
1354 Sasidharan, Crankson, and Ahmed
November 1991 Am J Obstet Gynecol
Fig. I. Ultrasonography at 30 weeks' gestation.
Fig. 2. Postnata l ultrasonography showing cystic mass of a bdominoscrotal hydrocele.
ture of the fetal cyst was not clear, although mesenteric cyst was considered a possibility. The baby was born at 37 weeks' gestation by cesarean section; the birth weight was 3150 gm. Abdominal examination revealed an undistended abdomen with a soft suprapubic mass with ill-defined margins. There was also a large left inguinal swelling that could be reduced into the peritoneal cavity and was thought to be a hernia. The testes were normal. Postnatal ultrasonography and abdominal x-ray film confirmed the presence of the suprapubic cystic mass (Fig. 2). A precise diagnosis was not made, but as a result of the "hernia" early surgery was undertaken at 5 days of age. On exploration of the left inguinal canal a large cystic swelling was . noted that extended into the abdominal cavity. Laparotomy was performed through a separate iliac
fossa incision when it was obvious that the "cyst" was an abdominoscrotal hydrocele that was retroperitoneal in position. The hydrocele sac extended posteriorly just lateral to the bladder, to which it was adherent. It was se parated from the testicular vessels and vas and was then removed; the procedure was completed with an orchiopexy. The postoperative course was uneventful, and the baby was discharged on the fourth postoperative d ay. He was well and thriving at 6 months of age and had no sign of residual abdominoscrotal swelling. The testes were normal. Comment
Abdominoscrotal hydrocele is essentially a hydrocele of the tunica vaginalis that has an inguinoscrotal and an abdominal component. Even though various etio-
Fetal abdominoscrotal hydrocele
Volume 165 Number 5, Part 1
logic theories about this condition have been proposed, the likely mechanism is that increased pressure from overdistention of an inguinoscrotallesion produces the proximal (abdominal) herniation. I, 2 It is also possible that the hydrocele may originate within the abdominal cavity and may extend or prolapse into the inguinoscrotal region. Our case was unique in that the abdominal component was recognized ante natally, possibly at 22 weeks' gestation but certainly by 30 weeks. Although testicular descent normally takes place at 28 to 30 weeks' gestation, it is logical to assume that the hydrocele developed primarily within the abdominal cavity. Because the testes were in the normal scrotal position at birth, it is also likely that an abdominal hydrocele became an abdomino scrotal hydrocele by virtue of increased pressure within the abdominal component and downward displacement. It would also appear that with the increasing use of ultrasonography, both ante natally and postnatally, an "abdominal" hydrocele without an inguinoscrotal component may be seen.
1355
Although abdominoscrotal hydrocele is extremely rare, it must be considered in the differential diagnosis of a lower abdominal cystic mass in a fetus. Hydronephrosis and hydroureter also may be seen with an abdomino scrotal hydrocele. During postnatal assessment, ultrasonography is the most appropriate investigation. In a newborn with an inguinoscrotal swelling, the abdomen should be carefully palpated. If a lower abdominal cystic swelling is palpable, pressure on the mass may produce a scrotal swelling or make it more obvious and thus lead to a clinical diagnosis of abdominoscrotal hydrocele. Treatment of this condition is total excision, and recurrence is rare unless it is not totally excised.
REFERENCES 1. Squire R, Gough DeS. Abdominoscrotal hydrocele in infancy, Br J UroI1988;61:347-9. 2, Khan AH, Yazbeck S. Abdominoscrotal hydrocele: a cause of abdominal mass in children. A case report and review of literature. J Pediatr Surg 1987;22:809-10,
Editors' note The AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY introduces a new format for abstracts accompanying regular articles, society articles, and Current Investigation articles. Authors submitting these manuscripts to the JOURNAL should provide an abstract of no more than 150 words structured according to the following headings: Objective(s), Study Design, Results, and Conclusion(s). Exceptions to this requirement include Clinical Opinion, Current Development, case report, and brief communication articles. Abstracts for these articles will continue to follow the standard abstract format. Please consult the Information for Authors for details.