Fetal trauma without significant maternal injury, although rare, has been reported on a number of occasions. We describe a case of fetal skull fracture that was diagnosed antenatally by ultrasound. CASE REPORTA 21-year-old multipara a t 26 weeks' gestation was admitted to Waikato Hospital, Hamilton, after being involved in a motorcycle accident.She had last noted fetal movements 8 hours before admission, before she and her husband started drinking a t the local bar. She had no recollection of the accident in which she was the passenger on a motorcycle which collided with a car. The driver, her husband, sustained lower limb and pelvic fractures.The general practitioner attending the accident recorded that the patient was unconscious and that the fetal heart beat was present.On arrival a t casualty, at 2100 hours, approximately 2% hours later, the patient was found to be conscious with stable vital signs. She was irritable and uncooperative and smelt of alcohol. There was a bruise on the right forehead, a right clavicular fracture and a small suprapubic bruise on the abdomen. The uterus was soft and nontender; the fundal height was compatible with a gestation of 26 weeks; the presentation was cephalic. There were no fetal heart sounds audible with the Sonicaid.Realtime ultrasound was performed the following morning and fetal death was confirmed by the absence of heart activity. Marked overlapping of the skull bones too extensive for postmortem changes was noted (figure I), and the presence of a depressed skull fracture was suggested. The midline brain echo appeared to be central (figure 2). There was no evidence of abruption o r other injury.Labour was induced with vaginal prostaglandins.1. House Officer. 2. Senior Registrar.
The antenatal diagnosis of conjoined twins remains a diagnostic challenge, but is very important if the mode of delivery is to be successfully planned and undertaken, and if surgical separation of the twins is to be performed. A number of findings on antenatal ultrasound examination have been described as characteristic of the condition and make ultrasonography the most important method for arriving at the diagnosis. A case of conjoined twins is described in which a number of these so-called diagnostic characteristics were absent. This case points out the need to carefully exclude conjunction in all cases in which twins are diagnosed. CASE REPORTA 21-year-old, gravida 1 para 0 woman was referred for ultrasound as a late presenter with uncertain dates, but clinically at about her 36th menstrual week. A twin pregnancy had not been diagnosed on clinical examination.Sonography demonstrated twins, at 32-33 weeks' menstrual age, by biparietal diameter and femoral diaphysis length measurements. One twin presented vertex and the other breech. There was a single placenta. The skin contour of the fetuses could not be identified separately in the lower thoracic and abdominal regions (Figure 1). Two separate fetal hearts were demonstrated. Each twin was shown to possess a liver, but these were joined ventrally by a bridge of liver tissue. One umbilical cord containing five vessels was seen and the umbilical vein was shared. No other fetal anomalies were demon- Due to the unusual features, in particular the absence of corresponding fetal parts at the same level, the absence of an en-face position and a vertex presentation of one twin but a breech presentation of the other, the referring clinician requested a further ultrasound examination. The patient was rescanned one week later. This scan confirmed the previous findings and also showed that the relative positions of the two fetuses had not changed. A diagnosis of conjoined twins was therefore confirmed.At her 34-35th menstrual week by ultrasound the patient went into premature labor and underwent immediate elective cesarian section. The two babies delivered were both female and were joined at the lower thorax and abdomen. They shared a single placenta and single umbilical cord with five vessels. They lay at an angle of almost 180" to each other, having apparently undergone spontaneous torsion around their thoraco-abdominal connection early in the pregnancy. The relative positions of the twins are shown in an X-ray taken shortly after delivery (Figure 2) and in a clinical photograph (Figure 3), which also shows the single cord.The next day surgical separation of the twins was successfully undertaken. The ultrasound finding of union by a bridge of liver tissue was confirmed. The separated twins weighed 2.3 kg and 2.2 kg. Subsequently they progressed well and no other congenital lesions were detected in either twin. DISCUSSIONThe prenatal diagnosis of conjoined twins is important for several reasons. In particular, it allows planning of the best mode of delivery and 0 1988 by...
SUMMARY 88 patients with non‐opacification of the gallbladder were examined by Ultrasound of the right upper quadrant of the abdomen. Criteria for the diagnosis of gallstones are described. Employing such criteria we have had no false positive results in the diagnosis of calculi. Our overall accuracy rate has been 90% and we feel that this has been improved in examinations after this analysis was completed by expanding our criteria to include stones and their acoustic “shadow”, even when the gallbladder itself cannot be demonstrated. Thirty‐three patients with jaundice were examined by Ultrasonography as an initial procedure, not only because of its accuracy, as shown by our figures, but also because it is a safe, noninvasive technique. Criteria for the diagnosis of obstructive jaundice are described. In those patients with obstructive jaundice caused by pancreatic disease, enlargement of the pancreas was successfully shown. In patients with hepatocellular jaundice, causes such as liver metastases, cirrhosis and Congestive Heart Failure were accurately diagnosed.
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