A 30-year-old Syrian woman in her fifth pregnancy was admitted to the Ob-Gyn Department at the Ziv Medical Center for counseling regarding fetal malformations at 32 weeks of gestation. She reported good general health, no known allergies, and smoking few cigarettes a day. Her past obstetric history comprised two normal pregnancies ending at term with spontaneous vaginal delivery. Her third pregnancy ended at 40 weeks in a cesarean section—a 3000 g malformed fetus was born but died shortly after birth with no further genetic or pathology work-up. The following pregnancy ended 1 year ago at term, delivering a healthy baby boy by cesarean section. She conceived with her current pregnancy while breastfeeding, so was unaware of the exact gestational age. She was told by a physician in Syria that there is “something wrong” with her fetus so she decided to come to the border and get assistance from the Israeli medical system.

On the ultrasound scan, we observed a breech-positioned live fetus, biometry measurements were 28 weeks and fetal weight estimation of 1340 g. Anhydramnios and severe ventriculomegaly were striking at first glance. Although the lateral ventricles measured 20 mm, the head biometry measured 26 weeks. The posterior fossa organs could not be defined and a large posterior defect in the cranium with retraction of the brain tissue and CSF into it; an encephalocele was defined. The spine was normal. In the abdomen, no stomach was detected, and two large symmetrical hyperechoic masses with many small cysts were demonstrated at the level of the kidneys compatible with cystic dysplasia. No bladder was observed although two vessels were defined at the anatomic position. The femur was mildly bowed. A detailed survey of the long bones and hands and feet was not feasible due to the lack of amniotic fluid and curved position of the fetus. After discussing the probable diagnosis with the mother and explaining that the fetus will probably die of renal dysplasia and lung hypoplasia, she opted for termination of pregnancy. In accordance with the Israeli law, she was transferred after genetic counseling to the nearest advanced pregnancy clinical ethics committee in order to consider termination of her pregnancy. The committee reviewed the sonographic data and approved the women’s request. Thus, she was transferred back to Ziv Hospital, and after informed consent, feticide was successfully performed. Considering two previous cesarean deliveries, she underwent a hysterotomy in order to evacuate the uterus and terminate the pregnancy. A male fetus weighing 1530 g was born. A large encephalocele and large abdomen were prominent. Unilateral postaxial polydactyly could be observed in the left hand and severe bilateral clubfoot (probably positional due to the oligohydramnios). The woman declined pathologic and genetic testing. On postoperative day 5, she was discharged and accompanied back to the Israeli-Syrian border.