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Clinical Case
Case of a posterior
Urethral valve in a Viable
Twin Intrauterine
Gestation Of About
23W2D, affecting the
leading Twin in a 23-year-
old woman.
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Patient Clinical History
History :
A 23-year-old pregnant woman presented
asymptomatic.
With no clinical signs of oligohydramnios
No complains of lower abdominal pains
First pregnancy and with no history of
abortion.
Normal heart rate of fetus on midwifes
examination.
Abdomen was normal for GA
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Family his. Of twin GA
REFERRING PHYSICIAN
(MIDWIFE) REQUEST
Obstetric scan
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Department Protocol
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The Examination
Patient in supine position.
Machine Exam preset: Gen. OB
Transducer: curvilinear (2- 5MHZ) Fetal
Trans-abdominal approach
biometry taken (i.e. HC, BPD, AC, FL, EGA and
EFW)
For sex determination patients are asked to
vary their position (in terms of difficulty)
There is variation of protocol and examination
in terms of twin gestation.
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Ultrasound findings
Noted is an intrauterine twin gestation
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Ultrasound findings
The fetal biometry of both twin
TA TB
BPD-(23W3D) -(21W6D)
HC-(22W3D) -(21W5D)
AC-(24W1D) -(22W3D)
FL-(23W1D) -(22W2D)
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On gray scale 2D BPD/HC
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AC
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AC
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FL
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Ultrasound findings
Twin B
Ultrasound report MANHYIA DISTRICT
HOSPITAL PM.pdf
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Ultrasound findings TWIN A
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Ultrasound findings
Also noted was dilated echogenic
thickened walled urinary
bladder, with a dilated
proximal urethra (keyhole sign)
and bilateral hydronephrosis .
Adequate amniotic fluid was also
note
Differences in GA
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Dilated urinary bladder showing
the key hole sign
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Thickened bladder wall
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Thickened bladder wall
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Bilateral hydronephrosis
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Ultrasound findings
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Thorax and kidney showing
pelvicalyceal dilatation
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Anterior and posterior placenta
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Relation of encountered pathology in relation
to patient presentation and our findings.
The presence of intrauterine twin gestation with twin A
not affected with any obstructive uropathy, in this case
is an indication of adequate amniotic fluid noted
around both twins, which ruled out oligohydramnios
associated with PUV. Thus the affected twin only
swallows the amniotic fluid without urinating into it
but the unaffected one swallows and at the same time
urinates into the amnion which keeps the fluid
balanced.
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Conclusions drawn:
After discussing case with my
supervisor we came to a
conclusion that the findings were
consistent with posterior urethral
valve in a twin gestation of about
23w2d affecting twin B.
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Ultrasound Exams Final Report
Differentials
Urethral atresia/agenesis
Neurogenic bladder
Prune-belly syndrome
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Follow-up
Follow up was done and patients was asked to
come for antenatal care consistently and
routine ultrasound examinations will be done
to monitor the progress of the condition.
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Discussion:
Megacystis
In the first trimester, an enlarged bladder >7 mm (megacystis)
should raise the suspicion of either chromosomal abnormalities
or obstructive uropathy. Approximately 20% of fetuses with
megacystis measuring 715 mm have an underlying
chromosomal abnormality such as trisomy 13 or 18. If the
bladder measures >15 mm, the risk of an underlying bladder
outlet obstruction (urethral atresia, posterior urethral valves, or
cloacal abnormalities) is very high and is associated with a very
poor prognosis. With megacystis >15 mm, it is sometimes
possible to find echogenic or dysplastic kidneys and reduced
liquor volume in the first trimester.
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From: www. medscape.com
Discussion: associate conditions
Kidney failure
Pulmonary hypoplasia
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Discussion:
Role of Ultrasonography in Diagnosis and
assessment
Ultrasound can accurately detect fetal lower urinary tract Obstruction with a
sensitivity of 95% and a specificity of 80%. The sensitivity of ultrasound screening
for these abnormalities is improved because anomalies of the renal tractand kidneys
are also associated with secondary findings,such as oligohydramnios.
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References
Diagnostic Ultrasound, 4th Ed vol 1;
Rumack, Wilson, Charboneau, Levine
Posterior%20Urethral%20Valves%20Symp
toms%20and%20Treatment.htm
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THANK YOU!!!
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