Vernix Caseosa peritonitis after vaginal delivery – A case report
Shameema Anvarsadath, Fathiya Ibrahim Abo Diba, Surendra Nayak,
Iman Al Shamali ,Michael F.E. Diejomaoh Maternity hospital Kuwait
Mrs. A, 28 years, G3 P2+0+0+2 41 weeks in active labour Obs history
◦1 st :LSCS for fetal distress◦2nd Term vaginal delivery of 3.5 kg
baby 1 year back Current pregnancy uneventful
Case presentation
At admission to labour room Pulse rate 110 /mt, BP : 115/80 Temp : 37.20c Vaginal examination : Cervix 8 cm dilated . Vertex at -2 Artificial rupture of membranes - clear liquor.
Investigations at admission: Hb: 12.9gm/dl ,WBC:10.6, P75%,L16%.
Platelet:158 After 1 hour :Fully dilated with vx at +1 Fetal heart decelerations Vacuum extraction-male baby 4.410 Kg Apgar
7&8
Case presentation 2
After 3 hours Abdominal pain and distension!
O/E : No pallor, Pulse 118/mt. BP: 105/70, Temp: 37.90c SPO2:100% on room air,Respiratory rate:20-/mt.
Abdomen was distended with generalized
diffuse tenderness.
Case presentation
Investigations: Hb: 11.6gm/dl, WBC: 17.4, P : 93%,L: 3%, Platelet : 149
Ultrasound abdomen : Significant amount of free fluid in hepatorenal and lienorenal angles and in the pelvis .Normal puerperal uterus and ovaries Small hemangioma in the liver.
CT abdomen was planned
Case presentation
Abdominal pain increased in severity over next 2 hours.
Diff.diagnosis Ruptured uterus other surgical emergencies
Decision for laparotomy
Case presentation
LAPAROTOMY –MIDLINE INCISION◦ 500 ml turbid fluid in the peritoneal
cavity.◦ Patches of cheesy material on the
serosal surface of all the viscera. Uterus intact .
Normal appendix, liver, spleen, intestines
Few enlarged mesenteric nodes
Case presentation
Biopsy from the node and cheesy material
Omental biopsy
Fluid for culturePost op: IV ceftriaxone & metronidazole. Recovery was uneventful
Case presentation
Histopathology
Squamous epithelium surrounded by acute inflammatory response.
Lanugo hair surrounded by acute inflammatory response.
Histopathology:◦ Peritoneal content and omentum :VERNIX CASEOSA PERITONITIS
◦ Mesenteric lymph node Nonspecific reactive changes
Case presentation
A very unusual complication Due to inflammatory response to amniotic fluid spilled into
the maternal peritoneal cavity presenting as acute abdomen
Only 24 cases have been reported
All are after uneventful caesarean section 3 cases had onset from the antenatal period.
Ours is the first case of VCP reported following vaginal delivery.
Vernix caseosa peritonitis[VCP]
Vernix caseosa: Cheesy white cutaneous material covering
the skin of the newborn Sebaceous glandular secretions+ lanugo
hairs +desquamated squamous cells.
Numerous squamous cells are present in the amniotic fluid
VCP
Incomplete peritoneal lavage of spilled amniotic fluid after Caesarean
Antenatal or intra partum leakage of
amniotic fluid ◦ ?? utero tubal reflux ◦ ?? unrecognized uterine perforation
VCP- Aetiopathogenesis
Exact mechanism is unknown
Mechanical irritation by keratinised squamous cells (as in meconium peritonitis/ruptured keratinous cysts)
? Hypersensitivity reaction ( in multipara or from an antenatal primary event)
Concentration of vernix caseosa in the amniotic fluid may have pathogenetic significance.
Pathogenesis of VCP
Acute abdomen◦ Generalized severe abdominal pain, ◦ Pyrexia,◦ Peritonism
Present in few days to weeks after an inciting event.
Elevated white cell count Inconclusive or normal imaging.
Other causes of peritonism should be excluded
VCP-clinical presentation
Essential feature: White and yellow cheesy plaques within
the peritoneal cavity and on serosal surfaces in the absence of inflamed organs
Histopathology confirms the diagnosis Desquamated anucleate squamous cells sorrounded by acute,chronic(granulomatous) or mixed inflammatory infiltrate depending on the duration of onset
Diagnosis of VCP
Most are self limiting.
Resolves with conservative management post op antibiotic therapy adjuvant steroid therapy may be used
(mahmoudetal 1997)
Significant morbidities following the initial diagnosis of VCP including bowel obstructionalso has been reported (stuart et al 2009)
Management
Many cases had significant additional procedures including cholecystectomy , appendectomy ,partial colectomy , total hysterectomy and bilateral salpingectomy.
(stuartetal 2009, boothby et al1985,cummingsetal 2001,Hertzetal1985,Mahmoudetal 1997)
Subsequent finding of normal histology in the excised organs.
VCP-management
Role of preoperative CT and fine needle aspiration cytology /guided biopsy?----
( james etal2011)
not practical
Diagnostic laparoscopy with intraoperative pathological examination is suggested
(Bailey etal2012)
VCP-Management
Vernix Caseosa peritonitis is an infrequent cause of puerperal peritonitis
Can occur even after vaginal delivery as the inciting event can be antenatal or intra partum
Postpartum patients with acute abdomen—keep in
mind diff: diagnosis of VCP .
Characteristic intra op findings and intra op involvement of pathologist help to resort to a more conservative approach and prevent unnecessary invasive procedures.
conclusion
References:-
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