Selective termination (ST) is an established management option in multifetal gestation complicated by discordant fetal abnormalities. Spontaneous expulsion of the terminated twin followed by delayed-interval delivery (DID) of the surviving twin is rare, and evidence guiding subsequent management is limited. This case report describes a dichorionic twin pregnancy complicated by trisomy 21 in the presenting twin. ST was performed at 16 + 4 weeks of gestation, followed by spontaneous expulsion of the terminated fetus at 22 + 6 weeks. As the cervix closed after expulsion of the terminated fetus, and there were no clinical signs of uterine contractions or intrauterine infection, expectant management was chosen, with the aim of achieving DID, prolonging gestation, and improving outcome for the remaining twin. Maternal and fetal management included prophylactic antibiotics, serial ultrasound examinations, monitoring for signs of infection, and home cardiotocography. At 28 + 0 weeks of gestation, an emergency cesarean section was performed because of suspected fetal anemia. The infant required immediate neonatal resuscitation including blood transfusions, followed by neonatal care for prematurity and respiratory distress syndrome. She was discharged in good clinical condition at a postmenstrual age of 38 + 6 weeks, 76 days postpartum. This case demonstrates that carefully selected patients may benefit from expectant management after spontaneous expulsion of a selectively terminated twin. Even without cervical cerclage or tocolytic therapy the pregnancy was successfully prolonged by 36 days, allowing administration of antenatal corticosteroids and magnesium sulfate, as well as transfer to a tertiary center, all of which likely improved the neonatal outcome.
Fetal goiter may compromise the airway and complicate delivery. Prenatal management requires assessment of fetal thyroid function and the mass effect of the enlarged gland.A fetal neck mass was detected at 18 + 5 weeks of gestation in a 32-year-old woman with a history of Hashimoto thyroiditis. Ultrasonography confirmed a bilobed goiter with neck hyperextension and apparent tracheal compression, and fetal hypothyroidism was confirmed by cordocentesis. Eleven intra-amniotic levothyroxine injections were administered between 24 + 4 and 35 + 6 weeks of gestation, initially at a dose of 400 μg and subsequently increased to 600 μg. Serial ultrasonography and hormonal monitoring showed progressive reduction in thyroid volume, resolution of the apparent tracheal compression, and restoration of normal fetal neck flexion. Following premature rupture of membranes, a girl was delivered by cesarean section at 36 + 3 weeks without a clinically apparent goiter. She received neonatal levothyroxine and, at 14 months, showed adequate growth and normal neurological and psychomotor development.Prenatal imaging and assessment of fetal thyroid function can identify thyroid disorders that may be amenable to treatment in utero. In the absence of a standardized intra-amniotic levothyroxine regimen, treatment should be individualized and coordinated by a multidisciplinary team.
Spontaneous intracranial hypotension, typically resulting from spontaneous leakage of spinal cerebrospinal fluid (CSF), is an uncommon and underrecognized condition, particularly during pregnancy. Diagnosis can be challenging when cranial imaging is normal, and presentations in very early pregnancy are sparsely reported.This report describes the case of a 33-year-old woman (gravida 2, para 1) who presented at 4 weeks and 4 days of gestation following frozen embryo transfer with a severe orthostatic bi-occipital headache associated with nausea, vomiting and neck pain. There was no preceding trauma or recent spinal instrumentation. Magnetic resonance imaging (MRI) of the brain was unremarkable; however, whole-spine MRI revealed an extensive longitudinal CSF-signal collection extending from the cervical to the lumbar spine, compatible with spinal CSF leakage. Three epidural blood patches produced partial but progressive symptomatic improvement. Residual symptoms were managed conservatively with hydration, caffeine, analgesia, and relative activity restriction, with eventual complete clinical resolution. The remainder of the pregnancy progressed to term without recurrence, and the patient underwent a repeat cesarean delivery under general anesthesia in accordance with maternal preference.Spontaneous intracranial hypotension should be considered in pregnant patients presenting with new-onset orthostatic headache. Normal brain MRI does not exclude the diagnosis, and spinal MRI may demonstrate evidence of CSF leakage when clinical suspicion remains high. This case highlights that spontaneous spinal CSF leakage may present in very early pregnancy, following a medicated frozen embryo transfer, an infrequently reported clinical scenario. Management should be individualized and multidisciplinary, given the limited pregnancy-specific evidence and variable response to epidural blood patching.
Clear cell carcinoma arising from ovarian endometrioma is well documented; however, its origin from uterine adenomyosis is exceptionally rare. A 60-year-old postmenopausal woman with long-standing adenomyosis and no gynecologic follow-up for approximately 10 years presented with a 7 cm pelvic mass detected on routine health screening. Magnetic resonance imaging revealed an intramural mass with mixed cystic and solid components, restricted diffusion, and contrast enhancement. Despite the absence of uterine bleeding and negative cervical and endometrial cytology, malignancy was suspected. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Histopathology confirmed clear cell carcinoma arising in adenomyosis, with transition foci from benign adenomyosis to carcinoma. This case highlights that clear cell carcinoma arising in adenomyosis should be considered when a long-standing cystic uterine lesion enlarges and develops suspicious imaging features, even in the absence of uterine bleeding or cytological abnormalities.
