Vernix - obgynkw
Vernix - obgynkw
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
in active labour
◦ 1 st :LSCS for fetal distress
◦ 2nd Term vaginal delivery of 3.5 kg
baby 1 year back
Current pregnancy uneventful
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%.
After 1 hour :Fully dilated with vx at +1
Fetal heart decelerations
Vacuum extraction-male baby 4.410 Kg Apgar 7&8
After 3 hours
Abdominal pain and distension!
Pulse 118/mt. BP: 105/70,
SPO2:100% on room air,Respiratory rate:20-/mt.
Abdomen was distended with generalized
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
Abdominal pain increased in severity over
next 2 hours.
other surgical emergencies
Decision for laparotomy
LAPAROTOMY –MIDLINE INCISION
◦ 500 ml turbid fluid in the peritoneal
◦ Patches of cheesy material on the serosal
surface of all the viscera.
Uterus intact .
Normal appendix, liver, spleen, intestines
Few enlarged mesenteric nodes
Biopsy from the node and cheesy
Fluid for culture
IV ceftriaxone & metronidazole.
Recovery was uneventful
Squamous epithelium surrounded
by acute inflammatory response.
Lanugo hair surrounded by
acute inflammatory response.
◦ Peritoneal content and omentum :
VERNIX CASEOSA PERITONITIS
◦ Mesenteric lymph node
Nonspecific reactive changes
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
Cheesy white cutaneous material covering
the skin of the newborn
Sebaceous glandular secretions+ lanugo
hairs +desquamated squamous
Numerous squamous cells are present in the
Incomplete peritoneal lavage of spilled
amniotic fluid after Caesarean
Antenatal or intra partum leakage of
◦ ?? utero tubal reflux
◦ ?? unrecognized uterine perforation
Exact mechanism is unknown
Mechanical irritation by keratinised squamous
(as in meconium peritonitis/ruptured keratinous
? Hypersensitivity reaction
( in multipara or from an antenatal primary
Concentration of vernix caseosa in the amniotic
fluid may have pathogenetic significance.
◦ Generalized severe abdominal pain,
Present in few days to weeks after an inciting
Elevated white cell count
Inconclusive or normal imaging.
Other causes of peritonism should be excluded
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
Most are self limiting.
Resolves with conservative management
post op antibiotic therapy
adjuvant steroid therapy may be used
Significant morbidities following the initial
diagnosis of VCP including bowel obstruction
also has been reported (stuart et al 2009)
Many cases had significant additional
procedures including cholecystectomy ,
appendectomy ,partial colectomy , total
hysterectomy and bilateral salpingectomy.
(stuartetal 2009, boothby et al1985,cummingsetal 2001,
Subsequent finding of normal histology in
the excised organs.
Role of preoperative CT and fine needle
aspiration cytology /guided biopsy?---( james etal2011)
Diagnostic laparoscopy with intraoperative
pathological examination is suggested
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.
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