No abstract

No abstract

The management of monoamniotic twin pregnancies remains controversial. Umbilical cord entanglement with constriction of the vessels contributes to the increased perinatal mortality with this condition. 1 The prenatal diagnosis of cord entanglement is now possible with the advent of improved ultrasonographic resolution and color Doppler flow sonography; however, even if the diagnosis is suspected, there is no clear management pathway to follow. The use of umbilical artery Doppler velocimetry has been advocated as an adjunctive management tool; but, again, no agreement exists on the appropriate response to abnormal results. Some authors employ continuous fetal monitoring in the hospital 2 and others suggest less frequent testing, 3 but these are empiric recommendations. Abnormal Doppler sonographic findings range in severity from the presence of a diastolic notch or increased venous velocity to absent or reversed diastolic velocity. The latter findings, in singleton gestations, have been associated with intrauterine growth retardation, fetal distress, and fetal death. 4 We report a case of monoamniotic twins with cord entanglement diagnosed at 22 weeks and, in one twin, absent end diastolic Doppler velocimetry that persisted until delivery at 32 weeks. Good perinatal outcomes were obtained with twice-weekly fetal monitoring (nonstress test or biophysical profile with Doppler examination or both). This case raises questions about the interpretation of and response to Doppler sonographic data in cases of suspected cord entanglement. CASE REPORTA 33 year old gravida 5 para 4 woman was diagnosed as having a monoamniotic twin pregnancy at 14 weeks' estimated gestational age and was followed with serial ultrasonographic examinations. At 18 weeks, no structural anomalies were observed in either twin. At 22 weeks, the placental cord insertions were noted to be in close proximity to each other, and when followed distally, a tangled mass of cord was observed, from which the two cords exited and were traced separately to each fetus.A Doppler sonographic examination near the abdominal cord insertion for each twin revealed normal velocimetry in twin A and AEDV in twin B. Owing to an extremely short distance from the placental cord insertion site to the point of entanglement, Doppler sonographic readings proximal to the entanglement could not be obtained reliably. Mild polyhydramnios also was noted.At 25 weeks, concordant growth of each twin was noted, but persistent cord entanglement and discrepant Doppler sonographic results (systolic-diastolic ratio 5.25 for twin A; AEDV for twin B) were found. Because of persistent polyhydramnios, an amniocentesis was performed with the removal of 1000 ml of fluid. The following week, no signifi-

Neonatal intracranial tumors are rare and usually indicate a poor prognosis. The first case report of the identification of a fetal intracranial tumor by transabdominal ultrasonography was in 1980. Transvaginal ultrasonography and MR imaging have recently been employed to improve the imaging of fetal intracranial structures and abnormalities. Neonatal brain biopsy is still necessary, however, to assign a definitive diagnosis, since images of two histologically different tumors can appear the same. Teratomas are the most frequent intracranial tumors found in the neonate, with meningeal sarcoma, craniopharyngioma, lipoma of the corpus callosum, and oligodendroglioma being found less commonly. We report a patient diagnosed prenatally as having an enlarging intracranial mass that proved to be a gangliocytoma.

No abstract