O&G Forum

OBSTETRICS & GYNAECOLOGY FORUM 2021 | ISSUE 2 | 18 O&G Forum 2021; 31: 17 - 18 CASE REPORT A C B D Figure 2. Female baby delivered with multiple cystic masses obliterating the airway. Note a corneal tissue highlighted by the green arrow and the bowels by the black arrow in A, Note how deep the mass is attached to the oral cavity of the host twin (blue arrow) in B. Figure 3. A nonhomogenous mass protruding out of the mouth, identified in the foetus oropharyngeal section. A sagittal view, B Coronal View. monozygotic diamniotic parasitic twin is incorporated into its sibling early in embryonic development and grows inside it. 3 Various locations have been reported in the literature, 80% in the abdomen, 8% in the skull, 8% in the sacral region, and only few cases of oral or oropharyngeal cases, and complications vary according to locations, with abdomen distention, emesis and peritoneal in ammation for an abdominal location, obstructive hydrocephalus and mental retardation for a cranial location, and dysphagia and airway obstruction for an oropharyngeal location, which requires an emergency surgery. 4 It has been reported that 97% of fetus in fetu had a good prognosis a er complete surgical resection of the parasitic twin. 4 erefore, the de nitive management of foetus in fetu is complete surgical excision of the parasitic twin. However, there have been isolated cases of malignancy following resection of a fetus in fetu, prompting some surgeons to recommend complete resectiononanurgent basis followedbypost-operative surveillance of tumour markers such as alfa-fetoprotein (AFP) and human chorionic gonadotrophin (HCG). 5 In cases of oropharyngeal location, the prognosis depends on how deep the mass in ltrates the oral cavity of the host twin and how fast the fetus’s airway is secured. Ling Wang et al reported a case of a 28 years old primi-gravida patient, with oropharyngeal fetus in fetu, discovered at 16 weeks during a routine sonographic examination. A nonhomogeneous mass of 32mm x 27mm x 28mm protruding out of the mouth was identi ed in foetus ( gure 3), with the lowest part of the mass located in the foetal chest and upper part in the foetal oral cavity. Parents opted for termination of pregnancy. 4 Prenatal diagnosis is a useful tool to identify well de ned organs in the fetus in fetu, help to guide the ex-utero intrapartummanagement procedure for the new-born fetus in fetu or o er the reasonable option of termination of pregnancy for severe cases. Tools for prenatal diagnosis include ultrasound andMRI. 6,7 Had the exit procedure been performed, the neonate would have possibly survived. e prerequisites for the procedure are appropriate uterine relaxation, fetal anaesthesia, and fetal immobility during the manipulation. e procedure entails delivery of the fetal head, body and upper extremities while the uterine volume and placental circulation are maintained. e fetus is intubated by direct laryngoscopy. Once the right position is assured, the umbilical cord is clamped and the fetus delivered. e Exit procedure allows for conversionof apotential catastrophic delivery into a controlled life-saving neonatal transition. Interventions performed during the Exit procedure can include the following: endotracheal intubation, tracheostomy, mass excision, removal of a temporary tracheal occlusive device, and treatment of congenital high airway obstruction syndrome. Preoperative counselling in anticipation of Post-partum haemorrhage (PPH) is mandatory. 8,9,10,11 For this case report, the ideal treatment modalities would have been endotracheal intubation and mass excision, had the patient been diagnosed with oropharyngeal fetus in fetu antenatally. Ex utero intrapartum (EXIT) procedure would have been the ideal option for the neonate. Requirement of an accurate antenatal diagnosis of the condition and a multidisciplinary team for the management of the case are mandatory. Multidisciplinary team should be composed of the Obstetricians, Paediatrics, Paediatrics surgeons, Anaesthesiologists, and Ear and Nasopharyngeal- roat (ENT) specialists. Conclusion Fetus in fetu remains a challenging and rare condition. Prenatal diagnosis with ultrasound and MRI forms the cornerstone of the diagnosis. Multidisciplinary approach will lead to successful outcome. References 1. Luzzatto C, Talenti E, Tregnaghi A, Fabris S, Scapinello A, Guglielmi M. Double fetus in fetu: diagnostic imaging. Paediatr Radiol. 1994;24:602-03. 2. Mohamed G.M.E Issa. Case Report Fetus in tetu: A rare case of intraabdominal mass. Radiology Case Reports. Science Direct, July 2019. 3. Yigan, Jun-Hui Wu, Jun Zhou, Ping-An Hu, Tie-Qiang Lai, Yun Tian, Chang-Qing Gao. Case Report: Abdominal fetus in fetu in a two-year-old boy. Journal of the Royal Society of Medicine Short Repors, 2012. Doi 10.1258/ shorts.2012.011174. 4. Lindsey M. Prescher, William J. Butter, Tyler A. Vachon, Marion C. Henry, omas Latendresse, Romeo C. Ignacio Jr. Fetus in fetu: Review of literature over the past 15 years. Journal of Paediatric Surgery Case Reports, December 2015, volume 3. 5. Ling Wang, Baiguo Long, Qichang Zhou and Shizeng. Prenatal diagnosis of a “living oropharyngeal fetus in fetu: a case report. BMC Pregnancy and Childbirth. Doi 10.1186/s12884-019-2612-0. 6. Hui P.W, Lam T.P, Chan K.L and Lee C.P. Fetus in fetu: from prenatal Ultrasound and MRI, diagnosis to postnatal Con rmation. Prenatal diagnosis. 2007, 27: 657-661. 7. Cooler J, Bradshaw B, Bhargava R, Less G, Demianczuk N. Fetus-in-fetu: Con rmation of Prenatal diagnosis with MRI. 2007, 27: 73-76. 8. Manjiri K. Dighe, Suzanne E. Peterson, eodore J. Dubinsky, Jonathan Perkins, Edith Cheng. Exit Procedure Technique and Indications with Prenatal imaging Parameters for Assessment of Airway Patency. RadioGraphics, Women’s imaging. 2011. Doi 10.1148/rg.312105108. 9. Batey N, McEwan A. e Management of Congenital Upper Airway anomalies and the ex-utero intrapartum treatment (EXIT) procedure. Obstetrics, Gynaecology and Reproductive Medicine. 2020, 262-265. 10. Bence C.M, Wagner A.J. Ex utero intrapartum treatment (EXIT procedure). Seminars in Paediatric surgery 2019 (28) 150820. Children’s Hospital of Wisconsin, Medical college of Wisconsin. www.elsevier.com/locate/sempedsurg. 11. Helfer D.C, Clivatti J, Yamashita A.M, Moron A.F. Anaesthesia for Ex utero intrapartum treatment (EXIT procedure) in Fetus with Prenatal Diagnosis of oral and cervical malformations: case report. Revista Brasileira de Anestesiologia. 2012 (62) 411-416.