Perinatal/Neonatal Case Presentation &&&&&&&&&&&&&& Fetal Hydrocolpos Leading to Pierre Robin Sequence: An Unreported Effect of Oligohydramnios Sequence

Sandeep Aggarwal, MD hypertension. Antenatal ultrasonographic evaluation on admission Ajay Kumar, MD revealed oligohydramnios and fetal growth retardation. The fetal abdomen contained a cystic mass 4.07Â6.09 cm in size in the pelvis with bilateral hydrouretero-nephrosis. A separate urinary bladder could not be visualized. Ultrasonologist did not suspect any findings The presence of distal atretic vagina causing accumulation of fluid and suggestive of PRS on antenatal USG. Labor was induced for mucus secretions in the proximal vaginal cavity resulted in fetal uncontrolled hypertension. A female baby at 36 weeks’ gestation was hydrocolpos. Obstructive uropathy developed gradually because of direct born by breech vaginal delivery with normal APGAR scores and birth compression of hydrocolpos on bilateral lower ureters, resulting in weight of 1185 g (asymmetric IUGR). On examination, the baby had oligohydramnios from decreased urine formation. Oligohydramnios micrognathia, glossoptosis, and bilateral complete cleft palate inhibited normal mandibular development with resulting cleft palate and (PRS). Abdominal examination revealed a firm, smooth, nontender, glossoptosis (Pierre Robin Sequence). The development of sequence of suprapubic mass reaching just below umbilicus; right renal mass was events in this case indicates Pierre Robin Sequence as another effect of also palpable. The distal vaginal opening was absent, with the Oligohydramnios Sequence arising out of deformational forces acting on remaining external genitalia being normal. No limb deformities were cranio-facial structures. present. The baby did not require respiratory support during early Journal of Perinatology (2003) 23, 76 – 78 doi:10.1038/sj.jp.7210846 neonatal period. An ultrasonogram performed a few hours after birth demonstrated the rounded well-demarcated cystic lesion with echogenic contents seen in dependent portion (Figure 1) located posterior to compressed INTRODUCTION empty urinary bladder. Both the kidneys had hydronephrosis with Hydrocolpos is congenital cystic dilatation of the vagina caused by minimal cortical thickness but normal size and echotexture. Both the obstruction of the distal genital tract, with accumulation of fluid and ureters were dilated in the upper part, whereas lower ureters were mucus secretions.1 Hydrocolpos may manifest at birth as a palpable directly compressed by the mass. The blood urea was 81 mg% and mass in the hypogastric area, but usually it presents at puberty as serum creatinine was 1.8 mg% on day 1 of life. progressive accumulation of menstrual blood, causing hematome- Laparotomy was done on day 4 of life under spinal anesthesia trocolpos. The clinical and ultrasound features of neonatal because of anticipated intubation and postoperative airway presentation have been well described, but diagnosis of fetal management difficulties in a very low-birth-weight baby with oral hydrocolpos on prenatal ultrasound is still rare.2 We are reporting an malformations. The proximal dilated vaginal cavity contained association of Pierre Robin Sequence (PRS) with fetal hydrocolpos approximately 40 ml of fluid, whereas the distal vagina was atretic. in a neonate. No fistulous track could be visualized between vagina and urinary bladder. Both ovaries and uterus were normal. Abdominal vaginostomy was done to drain the contents of vagina. CASE REPORT Postoperative period was uneventful. Gavage feeding was initiated A 27-year-old, gravida 3 mother — having two children 8 and on the sixth day of life and gradually maximized. The infant was 6 years old, alive and healthy, born out of nonconsanguineous initiated on spoon feeds on the fifth week of life, when she was pregnancy as full-term normal vaginal delivery, with apparently discharged at a weight of 1330 g with normal kidney function (blood normal antenatal period — presented at 36 weeks’ gestation with urea 27 mg%, serum creatinine 1.2 mg%) and bilateral normal-sized kidneys with minimal pelvicalyceal separation on ultrasonogram.

DISCUSSION Department of Neonatology, Maulana Azad Medical College, New Delhi, India. This case represents previously unreported effect of Oligohydramnios Address correspondence and reprint requests to Ajay Kumar, MD, Department of Neonatology, Maulana Azad Medical College, New Delhi 1100 02, India. Sequence. In this case, the distal atretic vagina caused fetal

Journal of Perinatology 2003; 23:76 – 78 # 2003 Nature Publishing Group All rights reserved. 0743-8346/03 $25 76 www.nature.com / jp Oligohydramnios Sequence Resulting in Pierre Robin Sequence Aggarwal and Kumar

demonstrate a fistulous track between the vagina and urinary bladder, its presence seems likely because of the presence of the fluid debris level on ultrasonographic evaluation.8 Hydrocolpos has been associated with urinary obstruction causing bilateral hydroureter and hydronephrosis.9 When this is severe, there may be in utero oligo/anuria resulting in oligohydramnios. Our case had obstructive uropathy as a result of hydrocolpos resulting in oligohydramnios. The PRS describes a clinical triad of cleft palate, micrognathia, and glossoptosis affecting approximately 1/8500 births with 25% mortality.3 Sequences are comprised of a constellation of anomalies that may vary in the degree of expression, resulting from prior nonspecific developmental anomalies or mechanical processes. PRS may result from a variety of prenatal diseases or processes that lead to abnormal palatal and mandibular architecture. As PRS is not a unique disease, the Figure 1. Transverse sonogram (TS) of lower abdomen showing hydro- clinician may be able to determine the process or disease that colpos (HC) with hypoechoic fluid in upper part and hyperechoic debris in leads to the PRS in a specific patient. One of the initial lower part. characterizations is a distinction between deformational PRS and malformational PRS. Deformations are structural defects that represent abnormal morphogenesis caused by mechanical forces.10 hydrocolpos, leading to oligohydramnios resulting from obstructive The deformational causes (40% contribution) of PRS are isolated uropathy. Oligohydramnios in turn led to PRS as a conditions that are not associated with a syndromic diagnosis. consequence to deformational forces acting on development of the Deformational processes are encountered in the setting of jaw.3 oligohydramnios or abnormal uterine anatomy in which pressure Hydrocolpos was first described secondary to imperforate hymen mechanically inhibits normal mandibular development. Lack of by Godefrey4 in 1856. Hydrocolpos and hydrometrocolpos are the adequate amniotic fluid leads to compression of the chin on third most common causes of an abdominal mass in the newborn, sternum and subsequent micrognathia. Because the tongue accounting for 15% of all abdominal masses in female newborns remains between the developing palatal shelves, the palate fails to with an estimated occurrence rate of 1/16,000 female deliveries.5 close properly. Structural uterine anomalies, such as submucous Hydrocolpos and hydrometrocolpos arise from the entrapment of the fibroids, can compress the developing mandible. Amniotic bands infant’s cervical mucus gland secretions stimulated by maternal may also restrain mandibular growth and lead to the PRS.3 estrogen. The fluid may be acidic and serous or mucoid, containing In our case, oligohydramnios presumably inhibited normal large numbers of desquamated epithelial cells, leukocytes, and mandibular development with resulting cleft palate and erythrocytes.5 The cases that manifest in the newborn period may be glossoptosis (PRS). more sensitive to or exposed to higher levels of maternal estrogen or Early diagnosis and treatment of hydrocolpos or are discovered in the course of evaluation of associated congenital hydrometrocolpos is important to minimize various complications anomalies.6 of mechanical pressure exerted on surrounding structures. In its The causes of hydrocolpos or hydrometrocolpos include simplest form, hydrocolpos due to an isolated vaginal obstruction transvaginal septum, vaginal atresia, imperforate hymen, obstructed caused by distal atresia is treated by vaginostomy followed by urogenital sinus, and cloacal malformations.5 In our case, distal immediate vaginoplasty or vaginoplasty at a later date. As antenatal atretic vagina resulted in hydrocolpos. Associated anomalies are ultrasonography becomes more and more easily accessible, these relatively rare with an imperforate hymen7 but are common with anomalies will be recognized more frequently and long-term vaginal atresia, urogenital sinus, or cloacal malformations. Urinary sequelae (urinary for the most part) can be avoided. A reasonable anomalies include unilateral renal agenesis, renal hypoplasia or management approach to newly detected PRS is anticipation and dysplasia, polycystic kidneys, ureteral duplications, recto-vaginal treatment of respiratory compromise and attention to nutritional fistula, and genital duplications. Associated musculo-skeletal and needs. Prone positioning and laryngeal mask airways help transiently gastro-intestinal anomalies include sacral hypoplasia, congenital in respiratory failure. Feeding tubes use is common in severely hip dysplasia, esophageal and duodenal atresia, colon duplication, affected babies for ensuring adequate nutrition in preparation for and imperforate anus with recto-vaginal fistula. None of these future palatal surgery. anomalies was present in this case, thus making the possibility of Though Oligohydramnios Sequence is defined as tetrad of growth genetic or malformation syndromes unlikely. Though we could not retardation, pulmonary hypoplasia, facial and ear changes, and limb

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positioning defects,11 the development of sequence of events in this hydrocolpos with transverse vaginal septum in a newborn: a case report and case indicates PRS as another effect of Oligohydramnios Sequence review of the literature. J Perinatol 1999;19(6):454–9. arising out of deformational forces acting on cranio-facial 6. Reed MH, Griscom NT. Hydrometrocolpos in infancy. Am J Roentgenol structures. 1973;118:1–13. 7. Ogunyemi D. Prenatal sonographic diagnosis of bladder outlet obstruction caused by a ureterocele associated with hydrocolpos and imperforate hymen. References Am J Perinatol 2001;18:15–21. 1. Mahoney PJ, Chamberlain JW. Hydrometrocolpos in infancy: congenital 8. Black ARN, Sanders RC, Gearhart JP. Obstructed uterovaginal anomalies: atresia of the vagina with abnormally abundant cervical secretions. J Pediatr demonstration with sonography. Radiology 1991;179:79–83. 1940;17:772. 9. Cook GT, Marshall VF. Hydrocolpos causing urinary obstruction. J Urol 2. Mirk P, Pintus C, Speca S. Ultrasound diagnosis of hydrocolpos: prenatal 1964;92:127–32. findings and postnatal follow-up. J Clin Ultrasound 1994;22:55–8. 10. Rodriguez JI, Palacios J. Pathogenetic mechanisms of fetal akinesia defor- 3. Taylor MR. The Pierre Robin Sequence: a concise review for the practicing mation sequence and Oligohydramnios Sequence. Am J Med Genet 1991;40: pediatrician. Pediatr Rev 2001;22(4):125–30. 284–9. 4. Godefrey M. Imperforation de la membrane hymens. Lancette Francaise. 11. Thomas IT, Smith DW. Oligohydramnios, cause of the nonrenal features of Gasette Das Hop Civ Mil 1856;29:567. Potter’s syndrome, including pulmonary hypoplasia. J Pediatr 1974;84(6): 5. Liu WF, Borrego O, Weiss M, Sweet CR. Lethal pulmonary hypoplasia and 811–4.

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