EP17.71: Vasa previa: variety of presentation and unexpected tragedy

Vasa previa is seen more commonly with velamentous insertion of the umbilical cord and in vitro fertilisation pregnancies. Membrane rupture, painless vaginal bleeding and fetal bradycardia or death are classic triad of vasa previa. We present the case of vasa previa that was not detected during pregnancy and resulted in early neonatal death. A 36-year-old woman, G1 P0, was referred to the hospital at 38+5 weeks due to suspicious CTG trace with reduced variability and absence of accelerations. The pregnancy was achieved by ET of genetically tested embryo. Antenatal follow-up was uneventful. During the first trimester screening the membranous attachment of cord was noted, but not reported latter on anomaly and follow up ultrasound. On admission the patient did not complain of decreased fetal movements. The hospital CTG trace was classified as normal. Ultrasound revealed excellent BPP, but separated membranes with some Doppler signal in tubular structures in between were recognised. Placenta located fundal. A decision on labour induction was made. A Foley catheter was inserted and 25mg of peroral misoprostol was given twice. After 12 hours the fetal membranes had ruptured spontaneously and 100ml of fresh blood with clear amniotic fluid leaked out. Vaginally cervix was effaced and 5 cm dilated. Fetal heart rate demonstrated bradycardia. At the very ward, no fetal heart rate was detected, and the patient was assigned to the I-category Caesarean section. The decision to deliver time was 8 minutes. An anemic neonate with APGAR 1/6/6 was born. Despite all neonatal interventions, exitus lethalis in 11 hours was reported. Placenta after birth revealed thick vessels coursing in membrane, one of which was ruptured on gross and microscopic examination. Umbilical cord was attached membraneously. In conclusion, mandatory and rigorous screening for vasa previa and membranous umbilical cord during the 1st and 2nd trimesters, without exception, promotes newborn life and welfare.