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    Very Large Yolk Sac and Bicornuate Uterus in A Live Birth: Case Report

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    Very Large Yolk Sac and Bicornuate Uterus in A Live Birth: Case Report

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    Very Large Yolk Sac and Bicornuate Uterus in A Live Birth: Case Report

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    CASE REPORT

    Very Large Yolk Sac and


    Bicornuate Uterus in a Live Birth
    Fu-Nan Cho*, Yuen-Yee Kan, San-Nung Chen, Tsung-Lung Yang1, Pei-Hua Hsu
    1
    Department of Obstetrics and Gynecology, and Department of Radiology,
    Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, R.O.C.

    Pregnancies with a very large yolk sac are generally always associated with poor outcomes. Herein, we present
    a case in which a very large yolk sac (mean diameter, 8.1 mm) and a bicornuate uterus were shown on transvaginal
    sonography in the first trimester, but which resulted in a live birth. To our knowledge, this is the largest yolk sac
    among all cases accompanying live births which have been published in the literature. The unusual enlargement
    of the yolk sac may be secondary to the compensation effect for the poor blood supply in the medial wall of the
    bicornuate uterus for the conceptus. To predict the outcome of pregnancy, based on this case report, the quality
    of the yolk sac might be more important than its size. [J Chin Med Assoc 2005;68(11):535–537]

    Key Words: bicornuate uterus, live birth, pregnancy outcome, yolk sac

    Introduction past history included 2 spontaneous abortions during


    the first trimester. There was no other history of
    Pregnant women who have congenital uterine disease. Transvaginal sonography (Acuson Aspen,
    abnormalities, such as a septate uterus or bicornuate Mountain View, CA, USA) showed a gestational sac in
    uterus, are inclined to suffer from abortion and preterm the left cavity of a bicornuate uterus (Figure 1),
    delivery. Transvaginal sonography can be used to accompanied by a living embryo with a crown–rump
    survey for a yolk sac of abnormal shape or size, length (CRL) of 2.4 mm. Five days later, sonography
    1–8
    which generally results in a poor outcome. The showed a relatively large yolk sac (mean diameter, 4.4
    sonographic findings of a relatively large yolk sac in a mm) and a living embryo (CRL, 7 mm) (Figure 2).
    pregnancy with a bicornuate uterus have not been Over the next 7 days, sonography revealed a normal
    clearly shown. Here, we present the case of a pregnant amniotic cavity, a relatively large yolk sac (mean
    woman with a bicornuate uterus in which a very large diameter, 4.8 mm), and a 7+1-week-old embryo (CRL,
    yolk sac was incidentally noted in the first trimester. 10.6 mm). Over the subsequent 2 weeks, sonography
    Eventually, this case proceeded to term delivery. To showed a very large yolk sac (mean diameter, 8.1 mm)
    our knowledge, the yolk sac in this patient is the largest with a living embryo (CRL, 28.7 mm) (Figure 3). The
    yolk sac among all cases with good pregnancy outcomes results of the remaining follow-up prenatal care
    1–4,6
    which have been published in the literature. examinations were unremarkable. Rest and limit-
    ation of exercise were advised. At 37+5 weeks of ges-
    tation, a grossly normal female baby, weighing
    Case Report 2,480 g, was delivered by cesarean section due to
    malpresentation. The placenta was located at the
    A 23-year-old, gravida 3, para 0, woman visited our medial wall of the left cavity. The bicornuate uterus
    +6
    hospital for prenatal care at 5 weeks of gestation. Her was confirmed during the operation (Figure 4).

    *Correspondence to: Dr. Fu-Nan Cho, Department of Obstetrics and Gynecology, Kaohsiung Veterans General
    st
    Hospital, 386 Ta-Chung 1 Road, Kaohsiung 813, Taiwan, R.O.C.
    E-mail: [email protected] •
    Received: January 14, 2005 •
    Accepted: June 16, 2005

    J Chin Med Assoc • November 2005 • Vol 68 • No 11 535


    ©2005 Elsevier. All rights reserved.
    F.N. Cho, et al

    Figure 1. A gestational sac (S) with a living embryo (+) was found Figure 3. A very large yolk sac (Y) (mean diameter, 8.1 mm) and
    in the left cavity of a bicornuate uterus. The decidual change of a living embryo (E) (crown–rump length, 28.7 mm; 167 heartbeats/
    the endometrium in the right cavity is shown (arrowheads). min) are shown on transvaginal sonography.

    Figure 2. Transvaginal sonography shows a relatively large yolk Figure 4. A bicornuate uterus is confirmed (arrow) after the
    sac (Y) (mean diameter, 4.4 mm) and a living embryo (arrow) newborn was delivered by cesarean section.
    (crown–rump length, 7 mm) in a gestational sac (mean diameter,
    10.9 mm).

    Discussion case report is that a very large yolk sac, but with a nor-
    mal shape and normal embryonic heartbeats, should
    In normal pregnancies, the yolk sac progressively not be hastily identified as an abnormal pregnancy.
    th
    increases in size until the 11 week of gestation and To predict the outcome in a pregnancy with normal
    1–3,6
    then shrinks. The shape of the yolk sac is usually embryonic heartbeats, the quality of the yolk sac might
    nearly spherical. The yolk sac always appears before be more important than its size, especially in deter-
    embryonic heartbeats under transvaginal ultrasound mining which embryos should be selected during
    examination. There have been no reports among live- embryo reduction for multiple pregnancies. For cases
    birth pregnancies that a yolk sac could reach 8 mm in without positive embryonic heartbeats, the appearance
    1–4,6
    mean diameter. Yolk sacs with a variety of deformed of a relatively large yolk sac is an ominous sign of poor
    shapes have been associated with poor pregnancy prognosis (anembryonic gestation).
    outcomes.1–3,6,8 One previous report tried to predict Both genetic and environmental factors may affect
    the possibilities of poor outcomes in cases with relatively the growth patterns of yolk sacs. One study has shown
    large yolk sacs, compared with normal cases.6 The that the anticardiolipin antibodies from patients with
    important concept derived from the findings in this systemic lupus erythematosus were able to inhibit the

    536 J Chin Med Assoc • November 2005 • Vol 68 • No 11


    Yolk sac in bicornuate uterus

    growth of yolk sacs in rat embryos.9 In our case, the Am J Roentgenol 1992;158:843–7.
    2. Lindsay DJ, Lovett IS, Lyons EA, Levi CS, Zheng XH, Holt
    genetic effect was excluded on the basis of the normal
    SC, Dashefsky SM. Yolk sac diameter and shape at endovaginal
    newborn. We presume that the unusual growth pattern US: predictors of pregnancy outcome in the first trimester.
    of the yolk sac in our case might be secondary to the Radiology 1992;183:115–8.
    compensation effect for the poor blood supply in the 3. Stampone C, Nicotra M, Muttinelli C, Cosmi EV. Transvaginal
    sonography of the yolk sac in normal and abnormal pregnancy.
    medial wall of the bicornuate uterus for the conceptus.
    J Clin Ultrasound 1996;24:3–9.
    Further prospective studies are warranted to determine 4. Rowling SE, Coleman BG, Langer JE, Arger PH, Nisenbaum
    the growth patterns of yolk sacs in relation to abnormal HL, Horii SC. First-trimester US parameters of failed pregnancy.
    uterine conditions. Early diagnosis of a bicornuate Radiology 1997;203:211–7.
    5. Mara E, Foster GS. Spontaneous regression of a yolk sac
    uterus and meticulous prenatal care will ensure the
    associated with embryonic death. J Ultrasound Med 2000;19:
    best results for the pregnancy. 655–6.
    In conclusion, if normal embryonic heartbeats 6. Kucuk T, Duru NK, Yenen MC, Dede M, Ergun A, Baser I.
    exist, a very large yolk sac should not be mistaken as Yolk sac size and shape as predictors of poor pregnancy
    outcome. J Perinat Med 1999;27:316–20.
    an ominous sign for poor prognosis, even when it is
    7. Schouwink MH, Fong BF, Mol BW, van der Veen F.
    associated with a bicornuate uterus. Ultrasonographic criteria for non-viability of first trimester
    intra-uterine pregnancy. Early Pregnancy [Electronic Resource]
    2000;4:203–13.
    8. Nyberg DA, Filly RA. Predicting pregnancy failure in ‘empty’
    References gestational sacs. Ultrasound Obstet Gynecol 2003;21:9–12.
    9. Matalon ST, Shoenfeld Y, Blank M, Yacobi S, Blumenfeld Z,
    1. Kurtz AB, Needleman L, Pennell RG, Baltarowich O, Vilaro Ornoy A. The effects of IgG purified from women with SLE
    M, Goldberg BB. Can detection of the yolk sac in the first and associated pregnancy loss on rat embryo in culture. Am J
    trimester be used to predict the outcome of pregnancy? AJR Reprod Immunol 2002;48:296–304.

    J Chin Med Assoc • November 2005 • Vol 68 • No 11 537

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