SHORT COMMUNICATION Myomectomy during the first trimester associated with fetal limb anomalies and hydrocephalus in a twin pregnancy E. Danzer, W. Holzgreve, C. Batukan, P. Miny, S. Tercanli and I. Hoesli* Department of Obstetrics and Gynaecology, University Hospital of Basel, Basel, Switzerland Objectives To present the complications of a twin pregnancy after first trimester myomectomy and to discuss the possible etiologic relationship. Case report A 44-year-old primigravida with a dichorionic-diamniotic twin pregnancy underwent myo- mectomy in another hospital at 12 weeks’ gestational age. At 28 weeks the patient was referred to our unit because of ventriculomegaly and limb anomalies in the second twin. The patient underwent a Caesarean section at 37 weeks of gestation delivering twin A, a healthy female weighing 3235 g and twin B, a female weighing 2810 g with hydrocephalus and limb anomalies (clubfeet and hypoplasia of the nails and terminal phalanges). The placenta from twin A was normal, but in the placenta of twin B haemorrhage, thrombosis and infarction were noted. Conclusions Despite several reports of myomectomy in pregnancy without any problems for mother and fetus, the authors believe that myomectomy – especially in the first trimester – may be associated with the type of problems observed in the present case. The pathophysiological relationship between placental trauma and haemodynamic alterations as a possible cause of the malformations in twin B is discussed. Copyright # 2001 John Wiley & Sons, Ltd. KEY WORDS: twin pregnancy; myomectomy; fetal limb anomalies; hydrocephalus INTRODUCTION Uterine myomata are common in pregnancies depend- ing on maternal age (2–15%) (Katz et al., 1989; Rice et al., 1989; Michalas et al., 1995). The vast majority are small and remain asymptomatic. How- ever, 10–40% of affected pregnancies will have myoma-related complications (Katz et al., 1989; Rice et al., 1989; Michalas et al., 1995). The major problems include an increased risk for spontaneous abortion, increase in size during the first trimester, premature rupture of membranes, abruptio placentae, intra- uterine fetal growth retardation, fetal malpresentation, preterm labour, Caesarean section following myo- mectomy, postpartum haemorrhage, puerperal sepsis and post-Caesarean hysterectomy (Rice et al., 1989; Michalas et al., 1995). In rare cases the finding of myomata leads to surgical intervention such as myomectomy during pregnancy because of persisting symptoms that cannot be counteracted by conservative means (Glavind et al., 1990). We report on a woman who had a myomectomy during the 12th week of gestation due to a large posterior subserous myoma (10 cm in diameter). Ultrasound examination at 28 weeks revealed a normal first twin, whereas the second twin showed hydrocephalus and limb defects. To our knowledge and review of the literature, a possible role of early myomectomy during pregnancy and the development of hydrocephalus and limb defects in a twin pregnancy has not been reported before. The features in the present case have interesting similar- ities to specific malformations occurring after early chorionic villus sampling (CVS) or misoprostol exposure in utero. CASE REPORT A 44-year-old woman (gravida 1, para 0) with a spontaneous sonographically defined dichorionic- diamniotic twin pregnancy was admitted to another hospital because of increasing diffuse abdominal pain and vaginal bleeding. Her medical history revealed no previous illness. Blood pressure and urine analysis were normal and prenatal laboratory test results were unremarkable. There was no exposure to teratogenic agents, ethanol, cigarettes or other drugs. Ultrasound examination revealed a large (10 cm in diameter) posterior retroplacental subserous uterine myoma. A myomectomy was subsequently performed in the referring hospital at 12 weeks’ gestation. There were *Correspondence to: I. Hoesli, Department of Obstetrics and Gynaecology, University Hospital of Basel, Schanzenstrasse 46, CH-4031 Basel, Switzerland. E-mail: ihoesli@uhbs.ch PRENATAL DIAGNOSIS Prenat Diagn 2001; 21: 848–851. DOI: 10.1002/pd.155 Copyright # 2001 John Wiley & Sons, Ltd. Received: 15 February 2001 Revised: 26 April 2001 Accepted: 30 April 2001