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MRCOG PART 2 SBAs and EMQs

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Choroid plexus cysts

Choroid plexus cysts Posted by narmin B.
Justify your management of a primigravida whose fetus has been found to have a choroid plexus cyst during the anomaly scan at 20 weeks gestation.

Choroid plexus cysts (CPC) are cystic structures in the choroids plexus of the lateral ventricles. They are soft markers for chromosomal abnormalities especially trisomy 18. CPCs may be unilateral, bilateral or septated and present in different sizes, however these characteristics do not have any impact on decision with regard to diagnostic tests.

This finding will cause considerable anxiety in the parents, there fore a thorough counselling is required to explain the finding and its importance. A supportive approach is necessary in order to reduce the level of anxiety. It should be explained that CPC is not an abnormality and in the majority of cases they disappear after a few weeks. However as in small number of cases, CPC is associated with chromosomal abnormalities such as trisomy 18, a high resolution scan can be arranged (preferably in a tertiary centre) to look for the presence of other soft markers. In addition her age ( age above 35 is associated with more risk), history of chromosomal abnormalities in the family, the result of first or second trimester serum screening tests and nuchal translucency scan should be reviewed. If there is another indicator for chromosomal abnormalities, an amniocentesis should be offered for determining fetal karyotype. It should be explained that this diagnostic test has 1% risk of fetal loss and infection and if chromosomal abnormality was confirmed, termination of pregnancy is advisable as chromosomal abnormalities can cause intrauterine death, still birth and early neonatal death (especially in the case of trisomy 18 which is always lethal). Parent?s attitude should be assessed towards an affected fetus. A careful documentation is also mandatory as further referral with regard to medical or legal issues may be required.

If there was no other indicator for chromosomal abnormality, a repeat scan should be arranged at 24 weeks. In most of the patients, the second scan is normal and she can be reassured and there is no need for further tests.

However in the case of chromosomal abnormality, parents should be seen again to discuss the result and termination or continuation of pregnancy. The method of termination at this gestational age is medical as it is less traumatic and has fewer complications compared to surgical termination. Mifepristone is used first followed by the administration of misopristol.As this is a difficult time for the couple care should be undertaken in a dedicated room on the labour ward. Support from medical staff and family is required . Post mortem examination also should be discussed and arranged for complete assessment. Ethical issues such as funeral and cremation should also need to be considered.

Another appointment must be arranged to see the couple 6 weeks after termination. This is to discuss any post-mortem results and referral to genetic department for prognosis with regard to future pregnancies.

In the case of continuation of pregnancy full psychological support and respect to religious beliefs of the parents is required throughout the rest of the pregnancy.