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

Cheesy exudates 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

THANK YOU

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