Home   Case of Week Home   Jobs  Conferences   Fellowships   Books

25 January 2013 - Case of the Week #264

All cases are archived on our website. To view them sorted by number, diagnosis or category, visit our Home Page and click on the Case of the Week button on the left hand side. To subscribe or unsubscribe to the Case of the Week or our other email lists, click here.

Thanks to Dr. Jitendra Khedkar, Krishna Institute of Health Sciences University, India, for contributing this case and the discussion. To contribute a Case of the Week, follow the guidelines on our Case of the Week page.


February 4-8, 2013
The Canyons Resort
Park City, Utah (USA)

26th Annual Park City
Combined AP/CP Pathology Update



Website
Schedule
Hotel
Registration

For more information, contact:
Leita Rogers
Telephone: (801) 581-2034
Email: Leita.Rogers@aruplab.com

Advertisement

Website news:

(1) To all reviewers / Case of Week contributors: we are now requiring you to provide us basic information (name, mailing address, US tax ID number (if any) and nonUS tax ID number (if any) to enable us to comply with US tax laws. We will send a 1099 form to US residents who earn $600 or more in any calendar year. For non US residents, unfortunately we must withhold 30% of all payments, and forward this amount to the US government (see IRS document). You may be able to get this money refunded - you should check with your tax advisor. Unfortunately, we are unable to give you tax advice. We will apply this rule to all new work started after today. If you change your mind about wanting to contribute cases or review topics, just let us know. We apologize for the change, but we have no choice.

(2) We posted a new article on our Management Page: A Managed Care Contracting Plan for Independent / Outreach Labs, Or How to stay profitable even if Medicare cuts your rates - Part One, by Mick Raich, President, Vachette Pathology.

(3) We have updated the Lung tumor chapter based on reviews by Drs. Deepali Jain and Fulvio Lonardo.

(4) New updates to our CME / Apps page include an advertisement for BoardVitals Pathology Question Bank and a free Apple app - Boardvitals Review for Clinical Pathology

Case of the Week #264

Clinical History:

A 22 year old primigravida woman with 25 weeks of amenorrhea presented with a rapidly enlarging abdomen and discomfort. Ultrasound at 25 weeks revealed twins. One twin had severe oligohydramnios, intrauterine growth restriction and was considered a "stuck" twin (donor) with gestational age of 20 weeks. The other twin (considered recipient) had polyhydramnios and gestational age of 25 weeks.

At 30 weeks, amniocentesis was performed to correct the polyhydramnios. At 35 weeks, caesarian section was performed to save the twin with polyhydramnios (the other twin suffered intrauterine death). The placentas were received for histopathological examination.

Gross images:


Figures 1 and 2: placental discs


Figures 3 and 4: cut section of recipient and donor territory

Micro images:


Figures 5 and 6: microscopy through "T" section of placenta


Figures 7 and 11: microscopy of donor placenta


Figure 8 and 12: microscopy of recipient placenta



What is your diagnosis?































Diagnosis:

Twin Transfusion Syndrome

Discussion:

Figures 1 and 2 show a single placental disc with two amniotic sacs of dissimilar size separated by a thin, wispy dividing membrane. The external surface shows tortuous anastomotic vessels, with the donor placenta showing velamentous insertion of the cord.

Figures 3 and 4: the cut section of the recipient territory shows extreme congestion and tortuous vessels. The cut section of the donor territory shows extreme pallor and collapsed vessels.

Figures 5 and 6: microscopy through the "T" section of the placenta shows a monochorionic diamniotic placenta

Figure 7 and 11: microscopy of the donor placenta shows collapsed vessels and features of intrauterine death.

Figure 8 and 12: microscopy of the recipient placenta shows tortuous anastomotic vessels.

Twin transfusion syndrome (TTS) is a serious condition that affects 10% to 15% of twin pregnancies with monochorionic diamniotic placentation, as well as other multiple births with a monochorionic placenta (Semin Perinatol 2012;36:182, Wikipedia). It occurs due to intrauterine blood transfusion from one twin (donor) to another twin (recipient) through placental vascular anastomoses from shared placental cotyledons. This results in increased fetal and neonatal mortality, premature delivery and neurologic complications in the surviving twin(s) (PathologyOutlines.com).

Nat Pernick, M.D., President
and Palak Thakore, Associate Medical Editor
PathologyOutlines.com, Inc.
30100 Telegraph Road, Suite 408
Bingham Farms, Michigan (USA) 48025
Telephone: 248/646-0325
Email: NatPernick@Hotmail.com
Alternate email: NatPernick@gmail.com