OBGY Radiology


Case 23

A 27 week HIV seropositive pregnant patient with PET presented with a cystic intracranial mass lesion on antenatal sonography. Obstetric MRI has been performed.  What is the diagnosis?

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Diagnosis

In utero Grade IV germinal matrix hemorrhage

Discussion

Prenatal finding of intracranial hemorrhage has been widely reported. Hemorrhage can occur anywhere in the fetal cranium, but prenatally is mostly identified as an intraventricular hemorrhage. Bleeding can take place within subarachnoid, subdural, or intraparenchymal locations too. The most of prenatally diagnosed intracranial hemorrhages are located in the supratentorial area and less frequently in infra-tentorial fossa. Germinal matrix-intraventricular hemorrhage in the fetus is very rare.

The cause of fetal intracranial hemorrhage is not always clear and in many cases the cause of bleeding cannot be identified. Intracranial hemorrhage has been reported in pregnancies with maternal or fetal complications like maternal abdominal trauma, pancreatitis, cholestasis, pre-eclampsia and epileptic seizures, drug abuse (cocaine), ingestion of platelets function altering medicaments, fetal coagulation disorders, asphyxia, intra-uterine infection, congenital vascular defects.
Fetal coagulations disorders include factor V or X deficiency, as well as impaired fetal coagulation from maternal warfarin therapy, alloimmune and isoimmune idiopathic thrombocytopenia, autoimmune thrombocytopenia have also been related to the fetal intracranial hemorrhage. Congenital tumors, twin-twin transfusion, demise of a co-twin or fetomaternal hemorrhage can be responsible for intracranial hemorrhage of the either fetus.

The review of the literature suggest that prenatally diagnosed intracranial hemorrhages have a poor outcome. About 40 % of fetuses die either in utero or within the first month of life. Among the survivors, less than half appear neuro-developmentally normal at short term follow-up.

The survival rate is similar from subdural hematomas and intraventricular hemorrhage, but at a follow up of one year, a slightly better outcome was observed with subdural hematomas than with intraventricular hemorrhage (normal development in 67 % versus 48 %). In accordance with postnatal studies the outcome of fetal intraventricular hemorrhage was strongly related to the grade of the lesion. Perinatal mortality with grades 1 and 2I was 7 %. Perinatal mortality with grades I3 and 4 was 44%



Dr Paresh Desai, Goa