Case study: Prenatal diagnosis of Fetal gingival tumour (Epulis) Roslani AL1, Ahmad S2, Ismail H3, Yusof MA4 1.Department of Obstetrics & Gynaecology, Hospital Tengku Ampuan Afzan, Kuantan, Pahang 2.Department of Obstetrics & Gynaecology, Hospital Raja Perempuan Zainab II, Kota Bharu 3.Department of ENT, Hospital Raja Perempuan Zainab II, Kota Bharu 4.Department of Obstetrics & Gynaecology, Hospital Pekan, Pahang CASE DESCRIPTION: A 20 year old primigravidae was referred at 35 weeks for a fetal oral tumour detected during a growth scan. She had had 1 previous ultrasound examination which was normal. The tumour measured 30 X 24 X 20mm and was homogenously solid in nature. It was arising from the lower anterior oral cavity, behind the lower lip. The roof of the oral cavity and the tongue was visualized to be separate from the tumour. It was not in continuation with the brain. Reassessment after 2 weeks showed no significant change in size. In view of possible airways obstruction at birth, an EXIT procedure was planned. An elective lower segment caesarean section was performed at 38 weeks gestation under spinal anaesthesia. An obstetrician, anaesthetist, paediatrician and paediatric ENT specialist were present in theatre. On delivery of the baby’s head and upper body, the ENT specialist assessed the baby’s airway and decided she could be intubated and did not need a tracheostomy. The delivery was then completed. The baby was a healthy girl weighing 2600g. Resection of the tumour was performed on day 4 of life. She made an uneventful recovery. Histopathological examination confirmed a granular cell myoblastoma. DISCUSSION: Fetal oral tumours are rare. Although most prenatal diagnoses are made via 2D ultrasonography, 3D ultrasound multislice view and fetal MRI provides more accuracy.1 When diagnosed prenatally, the following needs to be assessed/determined: 1. Rule out macroglossia. 2. The size of the tumour and whether it is rapidly growing in size. 3. Location/extension of tumour. If located at the roof of the oral cavity, it may be extension of the central nervous system (encephalocoele) and carries a grave prognosis. If located in the posterior oral cavity or larynx, it is likely to cause airway obstruction. 4. Pedunculated or broad attachment. Pedunculated tumours are less likely to obstruct the airways, and more amenable to surgical resection. 5. Colour Doppler to look for vascularity. Vascular tumours grow more rapidly. 6. Amniotic fluid index. Polyhydramnios would indicate pharyngeal obstruction as the fetus is unable to swallow. Look for swallowing movements. Polyhydramnios is associated with a poor prognosis2. 7. Cystic, solid or mixed. Mixed tumours are commonly teratomas. Solid tumours are more likely to be myoblastomas. Cystic tumours are almost always benign. Fetal gingival tumours (epulis) are even more rare. The incidence is 1:7000 of all prenatally diagnosed fetal anomalies3. There is a marked female preponderance of 8:14. The majority of cases are diagnosed in the newborn and missed during routine anomaly scans before 24 weeks, suggesting rapid growth in the third trimester when oestrogen levels are highest. It may be a consequence of excessive oestrogen production by fetal ovaries under human chorionic gonadotrophin stimulation. Limited cases have been diagnosed prenatally in the 3rd trimester. Epulis is most frequently located on the anterior maxillary alveolar ridge and usually occurs as a single mass although 10% cases occur as multiple. Recurrences of the tumor and damage to future dentition have not been reported.4 CONCLUSION: When a fetal oral tumour is detected prenatally, it is essential to assess for risk of airways obstruction. The highest risk for airway obstruction are tumours arising posteriorly in the oro-pharynx, arising from the palate or nasal cavity, are broad-based (non-pedunculated), and have associated polyhydramnios. If in doubt, an EXIT procedure should be planned to avoid asphyxia at birth. REFERENCES 1. Kim SK, Won HS, Lee SW, Kim JK, Shim JY, Lee PR, Kim A. Prenatal diagnosis of congenital epulis by three-dimensional ultrasound and magnetic resonance imaging. Prenatal Diagn. 2006 Feb;26(2):171-4 2. Pilu G, Segata M and Perolo A. Ultrasound evaluation of the fetal face and neck. Peter W Callen: Ultrasonography in obstetrics and gynaecology 5th edition. 3. Forys S, Krajewski J, Krasomski G, Makowski A, Zielinski A, Kulig A, Respondek-Liberska M. Prenatal ultrasonographic diagnosis of congenital epulis: two case reports and literature review. Ginekol Pol. 2010 Jun;81(6):461-6 4. Eghbalian F, Monsef A. Congenital epulis in the newborn, review of the literature and a case report. J Pediatr Hematol Oncol. 2009 Mar;31(3):198-9. Fig 1. Fig 2. Fig 3. Fig 4. Figure 1. 2D image: Sagittal view of the face showing a homogenously solid tumour protruding from the fetal mouth. Figure 2. 3D image of the face showing the tumour protruding from the mouth Figure 3. Assessment of the baby’s airways on delivery of the head during caesarean section Figure 4. The baby, after being intubated. Figure 5. 3 days after surgical resection, the gums had healed well.