Shameema Anvarsadath,
Fathiya Ibrahim Abo Diba, Surendra Nayak,
Iman Al Shamali ,Michael F.E. Diejomaoh
Maternity hospital Kuwait
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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
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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
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After 3 hours
Abdominal pain and distension!
O/E :
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No pallor,
 Pulse 118/mt. BP: 105/70,
 Temp: 37.90c
 SPO2:100% on room air,Respiratory rate:20-/mt.
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Abdomen was distended with generalized
diffuse tenderness.
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Investigations:
Hb: 11.6gm/dl, WBC: 17.4, P : 93%,L: 3%,
Platelet : 149
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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.
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CT abdomen was planned
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Abdominal pain increased in severity over
next 2 hours.
Diff.diagnosis
Ruptured uterus
other surgical emergencies
Decision for laparotomy
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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 .
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Normal appendix, liver, spleen, intestines
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Few enlarged mesenteric nodes
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Biopsy from the node and cheesy
material
Omental biopsy
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Fluid for culture
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Post op:
 IV ceftriaxone & metronidazole.
 Recovery was uneventful
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
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A very unusual complication
Due to inflammatory response to amniotic fluid
spilled into the maternal peritoneal cavity presenting
as acute abdomen
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Only 24 cases have been reported
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All are after uneventful caesarean section
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3 cases had onset from the antenatal period.
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Ours is the first case of VCP reported following
vaginal delivery.
Vernix caseosa:
 Cheesy white cutaneous material covering
the skin of the newborn
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Sebaceous glandular secretions+ lanugo
hairs +desquamated squamous
cells.
Numerous squamous cells are present in the
amniotic fluid
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Incomplete peritoneal lavage of spilled
amniotic fluid after Caesarean
Antenatal or intra partum leakage of
amniotic fluid
◦ ?? utero tubal reflux
◦ ?? unrecognized uterine perforation
Exact mechanism is unknown
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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.
Acute abdomen
◦ Generalized severe abdominal pain,
◦ Pyrexia,
◦ Peritonism
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Present in few days to weeks after an inciting
event.
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Elevated white cell count
Inconclusive or normal imaging.
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Other causes of peritonism should be excluded
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Essential feature:
 White and yellow cheesy plaques within the
peritoneal cavity and on serosal surfaces in
the absence of inflamed organs
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Histopathology confirms the diagnosis
Desquamated anucleate squamous cells
sorrounded by acute,chronic(granulomatous) or
mixed inflammatory infiltrate depending on the
duration of onset
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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 obstruction
also has been reported (stuart et al 2009)
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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)
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Subsequent finding of normal histology in
the excised organs.
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Role of preoperative CT and fine needle
aspiration cytology /guided biopsy?---( james etal2011)
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not practical
Diagnostic laparoscopy with intraoperative
pathological examination is suggested
(Bailey etal2012)
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Vernix Caseosa peritonitis is an infrequent cause
of puerperal peritonitis
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Can occur even after vaginal delivery as the
inciting event can be antenatal or intra partum
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Postpartum patients with acute abdomen—keep
in mind diff: diagnosis of VCP .
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Characteristic intra op findings and intra op
involvement of pathologist help to resort to a
more conservative approach and prevent
unnecessary invasive procedures.
References:1.
2.
Jonathan G Bailey,Dennis Klassen:Laparoscopic experience with vernix caseosa
peritonitis.surg endosc DOI 1007/s00464-012-2320-6
James Richard Myers, Charitha Fernando : Radiology of vernix caseosa
peritonitis : case report and discussion.
Journal of Medical Imaging and Radiation Oncology 2011, 55(3) : 301 – 303.
3.
Erika Wisanto, Mathieu D'Hondt : A cheesy diagnosis Lancet 2010 376
(9740) : 564
4. Olivia A Stuart, Alastair R Morris: Vernix Caseosa Peritonitis – no longer rare or
innocent : a case series.
Journal of Medical Case Reports 2009, 3:60
5. Selo- Ojeme D; Vernix caseosa peritonitis
J Obstet Gynaecol 2007, 27(7): 660-663
6. Cummings B, Scarth HM, Tran HT, Walley VM: Caseosa peritonitis presenting
post partum as acute cholecystitis.
Can J Surg 2001, 44(4): 298-300
7. Tawfik O, Prather J, Bhatia P, Woodroof J, Gunter J, Webb P: Caseosa peritonitis
as a rare complication of cesarean section . A case report.
J Reprod Med 1998, 43 (6): 547- 550
8. Davis JR, Miller HS, Feng JD: Caseosa peritonitis : Report of two cases with
antenatal onset.
Am J Clin Pathol 1998, 109(3): 320-323
9. Mahmoud A, Silapaswan S, Lin K, Penney D: Vernix caseosa : An unusual cause
of post cesarean section peritonitis.
Am Surg 1997, 63 (5): 382 – 385
10. George E, Leyser S, Zimmer HL, Simonowitz DA, Agress RL, Nordin DD: Vernix
caseosa peritonitis. An infrequent complication of cesarean section with
distinctive histopathologic features. Am J Clin Pathol 1995, 1.3 (6 ) : 681-684
11. Boothby R, Lammert N, Benrubi GI, Weiss B: Vernix caseosa granuloma : A rare
complication of cesarean section.