Fabrice Cuillier, MD*; S. Bellec, MD**; J. L. Alessandri, MD***. 

*    Department of Gynecology, Félix Guyon"Hospital, 97400 Saint-Denis, Ile de la Réunion, France;
**   Department of Gynecology, Mamoudzou"s Hospital, 98000 Mamoudzou, Mayotte Island;
***  Department of Neonatology, Félix Guyon"Hospital, 97400 Saint-Denis, Ile de la Réunion.

Case report

A 30-year-old woman (G3P2) was referred to our antenatal unit at 24 weeks of her pregnancy due to a unilateral fetal hand anomaly. Her family history of skeletal congenital diseases was negative. She intended to interrupt her pregnancy at 7 weeks and misoprostol (Cytotec) and mifepristone (RU486) had been administered to her, but the medications failed to interrupt her pregnancy. At 13 weeks the fetus was scanned by ultrasound, but at that time no anomaly was found. Another scan was done at 24 weeks and the acheiria of the left hand was detected. Karyotype of the fetus was normal (46, XX). The patient opted for the termination of the pregnancy and the diagnosis was confirmed.

Discussion 

Misoprostol is a synthetic prostaglandin used in gastroenterology for treatment of gastroduodenal ulcers. Misoprostol is also used in gynecology as an abortive drug because of its effects on uterine muscles. The abortive effect has been largely used during the last years in countries where the voluntary abortion is illegal (frequently in Brazil).

In our case the administration of the misoprostol during the early pregnancy led to the teratogenic effect presenting as the acheiria.  The teratogenic effects of misoprostol are better known nowadays. Its side effects mainly consist of anomalies observed in vascular disruption phenotypes: arthrogryposis, terminal transverse reductions of limbs, aplasia cutis of the scalp. Neurological disorders (as Möbius syndrome) are also frequently observed.

In cases of administration of the misoprostol during pregnancy, all these anomalies should be considered and the further diagnostic process should be focused on them.

Images 1, 2: The images compare the normal right upper extremity of the fetus and the left one with acheiria.

Images 3, 4: 3D images comparing the normal right upper extremity (image 3) of the fetus and the left one with acheiria (image 4).

Image 5: Postnatal X-ray showing the acheiria of the left hand.

Video 1: The video shows the left upper extremity of the fetus with acheiria.