Vernix - obgynkw

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Transcript Vernix - obgynkw

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
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!
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.
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.
Ruptured uterus
other surgical emergencies
Decision for laparotomy
◦ 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
Omental biopsy
Fluid for culture
Post op:
 IV ceftriaxone & metronidazole.
 Recovery was uneventful
Squamous epithelium surrounded
by acute inflammatory response.
Lanugo hair surrounded by
acute inflammatory response.
◦ Peritoneal content and omentum :
◦ 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
vaginal delivery.
Vernix caseosa:
 Cheesy white cutaneous material covering
the skin of the newborn
Sebaceous glandular secretions+ lanugo
hairs +desquamated squamous
Numerous squamous cells are present in the
amniotic fluid
Incomplete peritoneal lavage of spilled
amniotic fluid after Caesarean
Antenatal or intra partum leakage of
amniotic fluid
◦ ?? 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.
Acute abdomen
◦ Generalized severe abdominal pain,
◦ Pyrexia,
◦ Peritonism
Present in few days to weeks after an inciting
Elevated white cell count
Inconclusive or normal imaging.
Other causes of peritonism should be excluded
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
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 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,
Hertzetal1985,Mahmoudetal 1997)
Subsequent finding of normal histology in
the excised organs.
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)
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.
Jonathan G Bailey,Dennis Klassen:Laparoscopic experience with vernix caseosa
peritonitis.surg endosc DOI 1007/s00464-012-2320-6
James Richard Myers, Charitha Fernando : Radiology of vernix caseosa
peritonitis : case report and discussion.
Journal of Medical Imaging and Radiation Oncology 2011, 55(3) : 301 – 303.
Erika Wisanto, Mathieu D'Hondt : A cheesy diagnosis Lancet 2010 376
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4. Olivia A Stuart, Alastair R Morris: Vernix Caseosa Peritonitis – no longer rare or
innocent : a case series.
Journal of Medical Case Reports 2009, 3:60
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J Obstet Gynaecol 2007, 27(7): 660-663
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post partum as acute cholecystitis.
Can J Surg 2001, 44(4): 298-300
7. Tawfik O, Prather J, Bhatia P, Woodroof J, Gunter J, Webb P: Caseosa peritonitis
as a rare complication of cesarean section . A case report.
J Reprod Med 1998, 43 (6): 547- 550
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antenatal onset.
Am J Clin Pathol 1998, 109(3): 320-323
9. Mahmoud A, Silapaswan S, Lin K, Penney D: Vernix caseosa : An unusual cause
of post cesarean section peritonitis.
Am Surg 1997, 63 (5): 382 – 385
10. George E, Leyser S, Zimmer HL, Simonowitz DA, Agress RL, Nordin DD: Vernix
caseosa peritonitis. An infrequent complication of cesarean section with
distinctive histopathologic features. Am J Clin Pathol 1995, 1.3 (6 ) : 681-684
11. Boothby R, Lammert N, Benrubi GI, Weiss B: Vernix caseosa granuloma : A rare
complication of cesarean section.