Management of first trimester fetal megacystis: a case report Melike Nur Akın, B.Kasap, A.Camuzcuoğlu, S.Köseoğlu

Case 36 y, G3P1A1 12 week routine ultrasound; CRL : 50.85 mm 11weeks and 6 days NT : 0,96 mm Nazal bone + Fetal bladder size : 9 mm

1 week later bladder size :19 mm 13 week 4 days of gestation bladder size : 37 mm

Bilateral kidneys hyperechogenic and dysplastic Coryon villus sampling(CVS) and vesicocentesis performed CVS : normal karyotype

Fetal urine sapmling results:

Fetal urine results serves poor prognos Vesicoamniotic shunt didn’t offered Termination of pregnancy (TOP) offered Family didn’t accept termination Bladder size enlarged day after day

Gestationel week of 16 : oligohidramnios Gestationel week of 18 : bladder size 80 mm and anhidramnios That time family be conviced to the termination

Oral and vaginal misoprostol and oksitosin used 16 hoors later; 3-4 cm dilatation and full effasman Fetal kranium and toraks getout of the serviks but abdomen couldn’t Pain is became intolerable

Under general anesthesia vaginally inserted to the fetal bladder with a spinal nedlee . After fetal urine extraction fetus aborted totaly. Family didn’t accept autopsy.

Discussion Fetal megacystis has an estimated first-trimester prevalence of between 1:330 and 1:1670, During the first trimester, between 10 and 14 gestationel weeks, sagittal diameter of bladder is normally always 10% of the craniocaudal length. In different studies this threshold varies, between 6 and 8 mm. (Sebire NJ, Von Kaisenberg C, Rubio C, et al. Fetal megacystis at 10-14 weeks of gestation. Ultrasound Obstet Gynecol. 1996;8: 387-390. 3. ) (Favre R, Kohler M, Gasser B, et al. Early fetal megacystis between 11 and 15 weeks of gestation. Ultrasound Obstet Gynecol. 1999;14: 402-406)

Without intervention the condition may resolve spontaneously or may progress to severe obstructive uropathy which later in pregnancy may or may not be suitable for, or even improved by, bladder drainage.

The evolution of megacystis depends on ultrasound-associated anomalies and renal parenchymal features, karyotype anomalies, and the evolution of bladder size on control ultrasound scans. Major karyotype anomalies are found in 15% of affected fetuses.

Megacystis often carries a poor prognosis particularly when associated with oligohydramnios. Compared with the second and third trimesters, the outcome of prenatal megacystis in the first trimester is poor.

Bornes et al. reported that the earlier diagnosis of megacystis is made, the poorer the outcome. And in cases diagnosed in the first trimester of pregnancy they observed no live born children. (Bornes M, Spaggiari E, Schmitz T, Dreux S, Czerkiewicz I, Delezoide AL, El-Ghoneimi A, Oury JF, Muller F. Prenat Diagn. 2013 Dec;33(12):1162-6. doi: 10.1002/pd.4215. Epub 2013 Sep 3.)

It may result either from an obstruction of the proximal urethra. Fetal megacystis is more common in males than in females (male to female ratio of 8:1.) It may result either from an obstruction of the proximal urethra. Early vesicocentesis may be considered as an alternative management option to regular sonographic surveillance without intervention, second trimester vesicoamniotic shunting or termination of pregnancy. (Ultrasound Obstet Gynecol 2001; 18: 366–370 Blackwell Science Ltd Vesicocentesis at 10–14 weeks of gestation for treatment of fetal megacystis S. G. M. CARROLL, P. W. SOOTHILL, J. TIZARD* and P. M. KYLE)

Conclusion Megacystis can be an important sign of potential fetal pathology, and prognosis can be even more severe than initially thought. After birth, the patient should be referred to a multidisciplinary team (surgery, radiology, and nephrology) for adequate management and follow-up.