Maria Okumura

Conjoined twins pregnancies: experience with 36 cases from a single center.

To review a single center´s experience in the management of twin pregnancies with conjoined fetuses.

Afinidades biológicas de grupos pré-históricos do vale do rio Ribeira de Iguape (SP): uma análise preliminar

Apesar da existencia de contatos entre planalto e litoral brasileiros ser atualmente quase um consenso entre os arqueologos nacionais, nao ha muita certeza de como teria se dado tal contato e qual seria o fluxo entre interior e costa. O vale do Ribeira de Iguape (SP) e uma das raras regioes do Sul-Sudeste do pais onde tal comunicacao seria bastante facilitada devido a peculiaridades de sua geomorfologia. Neste trabalho, apresentamos os resultados de uma analise craniometrica comparativa entre 12 esqueletos provenientes de sambaquis fluviais do vale do Ribeira datados entre 6.000 e 1.200 anos AP e 225 esqueletos oriundos de diversas series pre-historicas brasileiras do interior e do litoral. Ao contrario do que se observa no inicio do Holoceno nesse vale, nao ha qualquer afinidade biologica entre os ribeirinhos mais tardios e os paleoindios de Lagoa Santa ou qualquer outra serie interiorana. Os grupos fluviais (ambos os sexos) associam-se aos sambaquis da costa de Sao Paulo e do Parana, mostrando que houve realmente um contato consideravel entre a planicie costeira e o planalto, ao menos no estado de Sao Paulo a partir da segunda metade do Holoceno.

Prenatal detection and postnatal management of an intranasal glioma

Nasal gliomas are rare benign congenital midline tumors composed of heterotopic neuroglial tissue. They have potential for intracranial extension through a bony defect in the skull base. Neuroimaging is essential for identifying nasal lesions and for determining their exact location and any possible intracranial extension. Computed tomography is often the initial imaging study obtained because it provides good visualization of the bony landmarks of the skull base; it is not, however, well suited for soft tissue imaging. Magnetic resonance imaging has better soft tissue resolution and may be the best initial study in patients seen early in life because the anterior skull base consists of an unossified cartilage and may falsely appear as if there is a bony dehiscence on computed tomography. A frontal craniotomy approach is recommended if intracranial extension is identified, followed by a transnasal endoscopic approach for intranasal glioma. A case is presented of a huge fetal facial mass that was shown by ultrasound that protruded through the left nostril at 33 weeks of gestation. Computed tomography of the neonate suggested a transethmoidal encephalocele. Magnetic resonance imaging showed a huge mass occupying the nasopharynx and the nasal cavity and protruding externally to the face but ruled out bony discontinuity in the skull base and, therefore, any intracranial connection. The infant underwent an endoscopic resection of the mass via oral and nasal routes and pathologic examination revealed intranasal glioma.

Sonographic appearance of gestational trophoblastic disease evolving into epithelioid trophoblastic tumor

Epithelioid trophoblastic tumor is a distinctive but rare trophoblastic tumor. It derives from intermediate trophoblastic cells of the chorion laeve and is usually associated with a previous gestational event. We report the case of a patient who had undergone dilatation and curettage for a missed miscarriage. Three months later gestational trophoblastic disease was suspected because of persistent vaginal bleeding and high levels of β‐human chorionic gonadotropin (β‐hCG). Transvaginal ultrasound revealed irregular echolucent lacunae within the myometrium, some of them filled with low‐resistance, turbulent blood flow on Doppler examination, emphasizing the diagnosis of gestational trophoblastic disease. The patient was treated with 12 courses of multiagent chemotherapy. After a 2‐year remission, a low rise in serum β‐hCG was observed. Transvaginal ultrasound revealed a well‐circumscribed echogenic lesion with a diameter of 1.8 cm in the uterine fundus, with no detectable blood flow on Doppler imaging. A diagnosis of tumor of intermediate trophoblastic cells was suspected and total hysterectomy was performed. On pathological examination, the histological and immunohistochemical features were characteristic of epithelioid trophoblastic tumor. Most reported cases of epithelioid trophoblastic tumor have solitary nodules with sharp margins, which is consistent with our ultrasound findings. Ultrasound may be helpful in differentiating epithelioid trophoblastic tumor from placental‐site trophoblastic tumor, another tumor of intermediate trophoblastic cells, which shows infiltrative growth insinuating between muscle fibers. Copyright

Origem e dispersão dos Tupiguarani: o que diz a morfologia craniana?

Resumo: A origem e a dispersao dos povos Tupiguarani tem sido intensamente debatidas entre arqueologos e linguistas nas ultimas cinco decadas. Em resumo, pode-se dizer que a ideia de que esses povos, que ocuparam grande parte do territorio brasileiro e parte da Bolivia, do Paraguai, do Uruguai e da Argentina, tiveram sua etnogenese na Amazonia e dali partiram para o leste e para o sul, por volta de 2.500 anos antes do presente, e bastante aceita entre os especialistas, embora uma dispersao no sentido oposto, isto e, do sul para o norte, com origem na bacia do Tiete-Parana, nao seja completamente descartada. Entre os arqueologos que consideram a Amazonia como berco desses povos, alguns acreditam que esse surgimento se deu na Amazonia central. Outros acreditam que a etnogenese Tupiguarani ocorreu no sudoeste da Amazonia, onde hoje se concentra a maior diversidade linguistica do tronco Tupi. Neste trabalho, a morfologia de 19 crânios associados a cerâmica Tupiguarani ou etnograficamente classificados como tais foram comparados a varias series cranianas pre-historicas e etnograficas brasileiras por meio de estatisticas multivariadas. Duas tecnicas multivariadas foram empregadas: Analise de Componentes Principais, aplicada sobre os centroides de cada serie, e Distâncias de Mahalanobis, aplicadas aos dados individuais. Os resultados obtidos sugerem uma origem amazonica para os povos Tupiguarani, sobretudo pela forte associacao encontrada entre crânios Tupi e Guarani do sudeste e do sul brasileiro e dos Tupi do norte do Brasil, com os especimes provenientes da ilha de Marajo incluidos no estudo. Palavras-chave: Analise multivariada. Craniometria. Nativos americanos.

Massive Necrosis of a Complete Hydatidiform Mole in a Twin Pregnancy With a Surviving Coexistent Fetus

We describe a case of a twin pregnancy with a complete hydatidiform mole and a coexistent fetus diagnosed at 15 weeks’ gestation that resulted in a surviving fetus and massively necrotic molar tissue at 32 weeks 2 days’ gestation. Sonographic examination of a 27-year-old woman, gravida 2, para 1, showed a 15-week-old live fetus with a normal placenta and a mass with multiple cysts in the right lateral portion of the uterus (Figure 1A). Both ovaries were enlarged and multicystic. The serum β-human chorionic gonadotropin (β-hCG) value was greater than 200,000 mIU/mL. Amniocentesis revealed a normal 46,XY karyotype at 16 weeks, and a diagnosis of a complete hydatidiform mole with a coexistent fetus was made. On subsequent sonographic examinations the molar tissue was seen to have changed in appearance; at 26 weeks, it showed a heterogeneous texture with irregular cystic areas (Figure 1B), and at 32 weeks it was indistinguishable from a normallooking placenta with few anechoic images (Figure 1C). Fetal growth restriction was detected. At 32 weeks, a rise in blood pressure to 150/90 mm Hg and proteinuria of 1.8 g/24 h were observed after a decrease in the platelet count to 57,000 cells/mm3 had occurred 2 days earlier. Other laboratory test results for HELLP syndrome (hemolysis, elevated liver enzyme lev-

Onfalocele: Prognóstico Fetal em 51 Casos com Diagnóstico Pré-Natal

Purpose: to evaluate the prognosis of fetal omphalocele after prenatal diagnosis. Methods: fifty-one cases with prenatal diagnosis of fetal omphalocele were divided into three groups: group 1, isolated omphalocele; group 2, omphalocele associated with structural abnormalities and normal karyotype; group 3, omphalocele with abnormal karyotype. The data were analyzed for overall survival rate and postsurgery survival, considering associated malformations, gestational age at delivery, birth weight and size of omphalocele. Results: group 1 corresponded to 21% (n = 11), group 2, 55% (n = 28) and group 3,24% (n = 12). All of Group 3 died, and trisomy 18 was the most frequent chromosomal abnormality. The survival rate was 80% for group 1 and 25% for group 2. Sixteen cases underwent surgery (10 isolated and 6 associated), 81% survived (8 isolated and 5 associated). The median birth weight was 3,140 g and 2,000 g for survivals and non-survivals after surgery, respectively (p = 0.148), and the corresponding gestational age at delivery was 37 and 36 weeks (p = 0.836). The ratio of omphalocele/abdominal circumference decreased with gestation, 0.88 between 25-29 weeks and 0.65 between 30-35 weeks (p = 0.043). The size of omphalocele was not significantly different between the 3 groups (p = 0.988), and it was not associated to postsurgery prognosis (p = 0.553). Conclusion: the overall and postsurgery survival rates were 25 and 81%, respectively. Associated malformations were the main prognostic factor in prenatally diagnosed omphaloceles, since they are associated with prematurity and low birth weight.

Triploid twin gestation with single fetal demise associated with partial mole and pre-eclampsia

Both partial mole and twin gestation are conditions associated with the risk of the early onset of pre‐eclampsia. In cases of twin gestation, the death or selective termination of a severely growth‐restricted fetus may lead to the reversal of maternal pre‐eclampsia because of the involution or death of the pathological placenta, as has been reported by some authors. This case demonstrates that in a twin triploid gestation, in spite of the demise of one of the fetuses, the respective partial molar placenta can continue to grow and may contribute to the development or to the worsening of the pre‐eclampsia.

Complex Fetal Ovarian Cyst

A 16-year-old primigravida was referred for investigation of a fetal intra-abdominal mass at 33 weeks’ gestation. A sonographic fetal survey showed appropriate growth and a unilateral intra-abdominal mass located to the left of the midline measuring 5.3 × 5 × 3 cm. It was predominantly solid with some small peripheral cysts. The solid component showed scattered echogenic dots suggesting calcifications (Figure 1A). Color Doppler interrogation did not depict any flow signal within or around the mass. The normal appearance of the urinary and gastrointestinal tracts of the female fetus suggested that the mass was of ovarian origin. Ovarian intra-cystic hemorrhage or benign cystic teratoma was hypothesized. Because another scan at 36 weeks showed no change in the size and appearance of the mass, benign cystic teratoma was considered the most likely diagnosis. The patient went into spontaneous labor at 37 weeks, and a 2940-g female neonate was delivered. The neonate presented no symptoms. Postnatal sonography confirmed the prenatal findings. On the ninth day of life, the child underwent surgical exploration. A dark hemorrhagic cystic left ovary was found. Because there was no recognizable normal ovarian tissue to be preserved, oophorectomy was performed. The pathologic diagnosis was massive hemorrhagic necrosis of the ovarian parenchyma with stroma and some follicular cysts showing dystrophic calcifications (Figure 1B). The postoperative course was uneventful, and the neonate was discharged 2 days later. The criteria of Nussbaum et al1 are used for discriminating between complex and simple cysts. “Simple cysts” are completely anechoic, thin walled, and frequently unilocular, whereas “complex cysts,” which denote intracystic hemorrhage, may be thick walled, partially anechoic with a fluid-debris level (formed by cyst fluid and liquid hematoma), or partially anechoic with a retracting clot and septations (septa formed by strands of organized hematoma). Occasionally, a hemorrhagic ovarian cyst may be of similar appearance as a benign cystic teratoma. The latter can be differentiated by the fact that it does not change its echo pattern over days or weeks.2 Intracystic hemorrhage raises the suspicion of torsion, but it may occur spontaneously, as in this case.3,4 Hemorrhagic cysts are associated with torsion in 25% to 89% of cases.4–7 There is a consensus as to the conservative approach, with sonographic monitoring to be adopted during the management of fetal or neonatal simple ovarian cysts, because most them regress spontaneously prenatally or within some period after birth.4,6 Prenatal and postnatal management of complex ovarian cysts is still controversial. Some investigators have recommended conservative management for all types of cysts (whether simple or complex) because spontaneous involution has also been documented for complex cysts, and most patients are healthy and asymptomatic at birth.3,6,8,9 Surgery would be justified only when sonographic signs are suggestive of teratoma,6 as in this case, for very large lesions, or for those causing symptoms attributable to the mass.8 Complex cysts that have spontaneously disappeared on sonography may have undergone involution or may be cysts that underwent initial torsion and subsequent spontaneous detorsion.6 The mechanism that accounts for the

Sonographic appearance of an advanced invasive mole and associated metastatic thrombus in the inferior vena cava

We present a case of an advanced invasive mole with a metastatic thrombus in the inferior vena cava in which sonography clearly showed vesicles in the myometrium, ovaries, and metastatic thrombus leading to a diagnosis of invasive mole rather than choriocarcinoma.