Prenatal embolisation of a large chorioangioma using enbucrilate

Abstract

a Case reportThe patient was a 31-year-old nulliparous woman. She had a normal routine morphology scan at 19 weeks. The placenta was posterior, not low lying and without any local lesions. She presented at 24 weeks of gestation with an antepartum haemorrhage. According to the patient's dates, the uterus was large with a fundal height of 30 cm. Ultrasound examination revealed a hydropic fetus with marked generalized skin oedema, bilateral pleural effusion, pericardial effusion, placentomegaly and cardiomegaly. The amniotic fluid index was 21 cm and the umbilical venous blood flow was pulsatile. There was an 8 Â 9 cm well-circumscribed highly vascular solid tumour with low echogenicity arising from the lower part of the placenta protruding into the amniotic cavity (Fig. 1a). The umbilical cord inserted approximately 5 cm from the tumour, sending an artery to supply the tumour. The diagnosis was compatible with severe fetal hydrops secondary to high-output cardiac failure due to a large placental chorioangioma. Cordocentesis showed a fetal haemoglobin concentration of 12.3 g/dL and a normal fetal karyotype of 46XX.Due to extreme prematurity and grave prognosis, embolisation of the chorioangioma was discussed and accepted. The procedure was performed at 24 weeks and 2 days of gestation under local anaesthesia. Under ultrasound guidance, a 20-gauge spinal needle was inserted into the lumen of the distal end of the feeding vessel within the tumour. The needle was flushed with 7 mL of 5% dextrose solution, followed by 1.5 mL of enbucrilate (Histoacryl, Braun, Melsungen, Germany), diluted with lipiodol (Lipiodol Ultra-Fluid, Guerbet, Aulnay-sous-Bois, France) at a ratio of 1:5. There was immediate and complete blockage of the vascular tree starting from the distal end and cessation of blood flow (Fig. 1b), observable by grey-scale ultrasonography and confirmed by colour and gated Doppler. The whole procedure took 10 minutes.One week after the procedure, a repeat ultrasound scan confirmed the complete absence of blood flow within the tumour, resolving hydrops with mild scalp oedema and mild left pleural effusion, although cardiomegaly persisted. The tumour appeared more echolucent then before and the thrombosed vascular tree within the tumour was easily identified (Fig. 1b).Since admission, the patient had persistent vaginal spotting of blood, and presented with spontaneous rupture of the membranes followed by onset of labour at 26 weeks (12 days after embolisation) with the fetus in breech presentation. The baby was delivered by an emergency lower segment caesarean section. The baby girl weighed 845 g without observable hydropic features. The baby was immediately resuscitated and intubated. However, 27 h after the birth the baby succumbed because of severe cardiac failure.The placenta weighed 692 g. The 10 Â 8 Â 6 cm ovalshaped tumour which was attached to the edge of the placenta weighed 350 g. Cross section of the tumour revealed reddish to greyish necrotic tissues. Thrombosed vessels were grossly noted. The feeding v...

Giant Chorioangiomas: Perinatal Outcomes and Techniques in Fetoscopic Devascularization

“…Embolization by microcoils has been reported but seems to be limited by the size of coils, technical difficulty, and incomplete devascularization of the chorioangioma [16]. Enbucrilate embolization was reported by the same authors with improved devascularization [17]. However, in both cases, preterm labor and neonatal death followed, although a definite association to the procedure is difficult to make.…”

Prenatal management and perinatal outcome in giant placental chorioangioma complicated with hydrops fetalis, fetal anemia and maternal mirror syndrome

“…For that reason, other approaches have been used to stop vascular supply to the tumor and consequent heart failure. In addition to amniodrainage or fetal transfusion, different techniques have been used as injection of absolute alcohol [13-15], endoscopic laser coagulation [16,17], and interstitial laser therapy [4,7], endoscopic suture with bipolar electrosurgery [18], and microcoil and embucrilate embolization, the last two procedures without survivors [9,13,18]. Table 1 summarize a literature review of therapy (excluding amniodrainage alone) and the presence/absence of hydrops as well as other complications in chorioangioma cases.…”

Randomized clinical trial of gut-specific nutrients in critically ill surgical patients (Br J Surg 2010; 97: 1629–1636)

“…The most commonly used techniques have been injection of absolute alcohol (six cases with four survivors)7, 9, 11, 12 and endoscopic laser coagulation (five cases with two survivors)16–18. Alternative techniques such as endoscopic suture with bipolar electrosurgery, microcoil and enbucrilate embolization have been presented in case reports, with no survivors13–15.…”