Nonimmune hydrops fetalis: clinical experience and factors related to a poor outcome

Neonates with a prenatal diagnosis of hydrops fetalis: A 10-year experience in a tertiary care center

INTRODUCTION

Hydrops fetalis (HF) is a rare condition with a high mortality. This study analysed the obstetric and perinatal outcomes of antenatally diagnosed HF according to its aetiology and the possibility of intrauterine treatment (IUT).

PATIENTS AND METHODS

We carried out a retrospective review of the health records of 164 pregnant women with a prenatal diagnosis of HF in a tertiary care centre between 2011-2021. We analysed prenatal interventions, clinical findings, aetiologies and obstetric and live-born infant outcomes.

RESULTS

An invasive prenatal study had been performed in 79.3% cases. The most common aetiologies were genetic disorders (31%), TORCH and parvovirus B19 infections (9.7%) and structural heart diseases (9.1%). Intrauterine treatment was performed in 25.6%, and 74.4% of pregnancies were terminated. Pregnancies with a prenatal diagnosis of genetic or chromosomal disorders had higher rates of elective termination compared to other aetiologies (P < .01). Among all pregnancies, only 25.6% resulted in live births (LBs), most of them preterm. Perinatal and 1-year survival rates were higher in the group that received IUT (P < .001). Among the LBs, structural heart diseases had the worst survival rates, while the aetiology with the best outcomes was tachyarrhythmia. Survival at 1 year of life among those born alive was 70%, but 58.6% of these infants had significant morbidity at discharge.

CONCLUSIONS

Despite advances in the management of FH, the poor obstetric prognosis, perinatal mortality and morbidity of survivors is still significant. These data are important for the purpose of counselling families when HF is diagnosed antenatally.

Assessment of the fetal lungs in utero

Antenatal diagnosis of abnormal pulmonary development has improved significantly over recent years because of progress in imaging techniques. Two-dimensional ultrasound is the mainstay of investigation of pulmonary pathology during pregnancy, providing good prognostication in conditions such as congenital diaphragmatic hernia; however, it is less validated in other high-risk groups such as those with congenital pulmonary airway malformation or preterm premature rupture of membranes. Three-dimensional assessment of lung volume and size is now possible using ultrasound or magnetic resonance imaging; however, the use of these techniques is still limited because of unpredictable fetal motion, and such tools have also been inadequately validated in high-risk populations other than those with congenital diaphragmatic hernia. The advent of advanced, functional magnetic resonance imaging techniques such as diffusion and T2* imaging, and the development of postprocessing pipelines that facilitate motion correction, have enabled not only more accurate evaluation of pulmonary size, but also assessment of tissue microstructure and perfusion. In the future, fetal magnetic resonance imaging may have an increasing role in the prognostication of pulmonary abnormalities and in monitoring current and future antenatal therapies to enhance lung development. This review aims to examine the current imaging methods available for assessment of antenatal lung development and to outline possible future directions.

Non-immune hydrops fetalis: Two case reports

BACKGROUND

Fetal hydrops is a serious condition difficult to manage, often with a poor prognosis, and it is characterized by the collection of fluid in the extravascular compartments. Before 1968, the most frequent cause was the maternal-fetal Rh incompatibility. Today, 90% of the cases are non-immune hydrops fetalis. Multiple fetal anatomic and functional disorders can cause non-immune hydrops fetalis and the pathogenesis is incompletely understood. Etiology varies from viral infections to heart disease, chromosomal abnormalities, hematological and autoimmune causes.

CASE SUMMARY

A 38-year-old pregnant woman has neck lymphoadenomegaly, fever, cough, tonsillar plaques at 14 wk of amenorrhea and a rash with widespread itching. At 27.5 wk a fetal ultrasound shows signs of severe anemia and hydrops. Cordocentesis is performed with confirmation of severe fetal anemia and subsequent fetal transfusion. The karyotype is 46, XX, array-comparative genome hybridization (CGH) negative, and infectious tests are not conclusive. In the following days there is a progressive improvement of the indirect signs of fetal anemia. At 33.6 wk, for relapse of severe fetal anemia, further fetal transfusions are necessary and an urgent cesarean section is performed. On the day 12 of life, for the detection of anemia, the newborn is subjected to transfusion of concentrated red blood cells and begins treatment with erythropoietin. Later there is a normalization of blood chemistry values and the baby does not need new transfusions. A 29-year-old pregnant woman, with Sjogren's syndrome and positive Anti-Ro/SSA antibodies, is subjected to serial fetal ecocardio for branch block. At 26.5 wk there is a finding of fetal ascites. Infectious disease tests on amniotic fluid are negative as well as quantitative fluorescent polymerase chain reaction, Array CGH. At cordocentesis Hb is 1.3 mmol/L, consequently fetal transfusion is performed. Also in this case, due to continuous episodes of relapse of fetal anemia with consequent transfusions, at 29.4 wk a cesarean section is performed. On day 9 of life, a treatment with erythropoietin is started in the newborn, but the baby needs three blood transfusions. The search for autoantibodies in the baby found SS-A Ro60 positive, SSA-Ro52 positive and SS-B negative. The hemoglobin values normalized after the disappearance of maternal autoantibodies.

CONCLUSION

An attempt to determine the etiology of hydrops should be made at the time of diagnosis because the goal is to treat underlying cause, whenever possible. Even if the infectious examinations are not conclusive, but the pregnancy history is strongly suggestive of infection as in the first case, the infectious etiology must not be excluded. In the second case, instead, transplacental passage of maternal autoantibodies caused hydrops fetalis and severe anemia. Finally, obstetric management must be aimed at fetal support up to an optimal timing for delivery by evaluating risks and benefits to increase the chances of survival without sequelae.

Obstetrician patterns of steroid administration for the prenatal management of congenital pulmonary airway malformations

BACKGROUND

Congenital pulmonary airway malformation (CPAM) is the most common prenatally-diagnosed lung malformation. This lesion, classified as macrocystic or microcystic, can lead to significant fetal compromise. Management options include observation, maternal antenatal steroid administration, and fetal surgical intervention. Current evidence suggests that microcystic (but not macrocystic) lesions and those with a cyst volume ratio (CVR) >1.6 are responsive to steroid therapy. The objective of this study was to identify patterns of prenatal steroid administration for the management of CPAMs and to identify characteristics of CPAMs prompting steroid administration.

METHODS

An 18-question survey was distributed to obstetricians from the Pregnancy-Related Care Research Network (PRCRN) and the North American Fetal Therapy Network (NAFTNet), from January to April 2019, to capture antenatal steroid prescribing patterns.

RESULTS

Response rates were 28.3% (138/487) for PRCRN and 63.3% (19/30) for NAFTNet. Among PRCRN members, 16.8% administered prenatal steroids, with most (77.2%) doing so for both microcystic and macrocystic CPAMs; corresponding percentages for NAFTNet members were 90.9% and 52.6%. Two thirds (65.6%) of obstetricians who administer steroids do so for a CVR > 1.6, without evidence of mediastinal shift or hydrops fetalis.

CONCLUSIONS

There is a lack of consensus among obstetricians as to the CPAM characteristics that should prompt administration of prenatal steroids. Many surveyed obstetricians do not use cyst type or CVR to guide decision-making regarding steroid therapy.

Non-immune fetal hydrops: etiology and outcome according to gestational age at diagnosis

OBJECTIVE

Fetal hydrops is associated with increased perinatal morbidity and mortality. The etiology and outcome of fetal hydrops may differ according to the gestational age at diagnosis. The aim of this study was to evaluate the cause, evolution and outcome of non-immune fetal hydrops (NIFH), according to the gestational age at diagnosis.

METHODS

This was a retrospective cohort study of all singleton pregnancies complicated by NIFH, at the Fetal Medicine Unit at St George's University Hospital, London, UK, between 2000 and 2018. All fetuses had detailed anomaly and cardiac ultrasound scans, karyotyping and infection screening. Prenatal diagnostic and therapeutic intervention, gestational age at diagnosis and delivery, as well as pregnancy outcome, were recorded. Regression analysis was used to test for potential association between possible risk factors and perinatal mortality.

RESULTS

We included 273 fetuses with NIFH. The etiology of the condition varied significantly in the three trimesters. Excluding 30 women who declined invasive testing, the cause of NIFH was defined as unknown in 62 of the remaining 243 cases (25.5%). Chromosomal aneuploidy was the most common cause of NIFH in the first trimester. It continued to be a significant etiologic factor in the second trimester, along with congenital infection. In the third trimester, the most common etiology was cardiovascular abnormality. Among the 152 (55.7%) women continuing the pregnancy, 48 (31.6%) underwent fetal intervention, including the insertion of pleuroamniotic shunts, fetal blood transfusion and thoracentesis. Fetal intervention was associated significantly with lower perinatal mortality (odds ratio (OR), 0.30 (95% CI, 0.14-0.61); P < 0.001); this association remained significant after excluding cases with a diagnosis of anemia or infection (OR, 0.29 (95% CI, 0.13-0.66); P = 0.003). In 104 fetuses not undergoing active fetal intervention, the gestational age at diagnosis was the only parameter that was significantly associated with the risk of perinatal mortality (OR, 0.92 (95% CI, 0.85-0.99); P = 0.035), while the affected body cavity and polyhydramnios were not (P > 0.05).

CONCLUSIONS

An earlier gestational age at diagnosis of NIFH was associated with an increased risk of aneuploidy and worse pregnancy outcome, including a higher risk of perinatal loss. Fetal therapy was associated significantly with lower perinatal mortality. © 2020 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Prognostic factors of hydrops fetalis with pleural effusion

BACKGROUND

Hydrops fetalis (HF) has a low survival rate, particularly in the case of preterm birth. In addition, the severity index of HF has not been fully investigated yet. The aim of this study was to clarify the prognostic factors of HF with pleural effusion.

METHODS

All live-born HF patients with pleural effusion, except for chromosomal abnormality or complex congenital heart disease, born from 2009 to 2013 in Aichi Prefecture in Japan were included. Prenatal, perinatal, and postnatal information was obtained from the medical records and was retrospectively analyzed.

RESULTS

Forty-one HF patients with pleural effusion were included, and 28 patients (68%) survived. On multivariate logistic stepwise analysis, gestational birth week (OR, 0.71; 95% CI: 0.52-0.96, P = 0.027) and standard deviation (SD) score of the birthweight (OR, 1.74; 95% CI: 1.01-2.99, P = 0.045) were significant factors for postnatal death. All patients with both ≥32 gestational weeks and <3.0 birthweight SD score survived.

CONCLUSIONS

Combined with the gestational weeks data, birthweight SD score may be useful to estimate the prognosis of HF with pleural effusion.

Biochemical analysis of ascites fluid as an aid to etiological diagnosis: a series of 100 cases of nonimmune fetal ascites

OBJECTIVE

The aim of this study is to analyze the contribution of biochemistry and cytology of fetal ascites fluid to the etiological diagnosis of ascites after ultrasonographic scan, maternal blood sampling, and fetal karyotyping.

METHOD

This is a retrospective study of 100 consecutive cases of nonimmune fetal ascites in which ascites fluid was sampled. All women underwent referral ultrasound scan and fetal karyotyping. All cases of fetal ascites were studied by biochemistry (total protein, β2 -microglobulin, IgM, gamma-glutamyl transpeptidase, aspartate aminotransferase, aminopeptidase M, and intestinal isoform of alkaline phosphatase) and cytology (lymphocyte count and vacuolated cells).

RESULTS

The etiology of ascites was diagnosed at ultrasound scan in only 50% of cases. We observed significantly (P < 0.001) low levels of total protein in ascites of urinary origin, high levels of digestive enzymes in ascites of digestive origin, and high β2 -microglobulin in infectious ascites. Vacuolated cells were observed in all ten storage metabolic diseases.

CONCLUSION

Sampling of fetal ascites fluid for biochemical and cytological examination provides important additional information. We propose a two-step management: (1) detailed ultrasound scan examination, maternal blood analysis, and fetal karyotyping and (2) biochemical and cytological analyses. On the basis of such an approach, 63% and 96% of etiologies would have been identified in our series after the first and second steps, respectively. © 2014 John Wiley & Sons, Ltd.

Primary Congenital Lymphedema Complicated by Hydrops Fetalis: A Case Report and Review of the Literature

Introduction. Primary congenital lymphedema is a rare disorder associated with insufficient development of lymphatic vessels. Usually most patients present with lower extremity edema seen sonographically. Rarely primary congenital lymphedema may be associated with severe lymphatic dysfunction resulting in hydrops fetalis. Case. A 27-year-old primigravida with a family history of leg swelling throughout multiple generations was diagnosed early in the third trimester with hydrops fetalis. Delivery was undertaken at 32 weeks for nonreassuring fetal status and the infant expired at approximately 45 minutes of life. Primary congenital lymphedema was confirmed via molecular testing of the vascular endothelial growth factor receptor-3 gene. Discussion. The diagnosis of PCL is suspected prenatally when ultrasound findings coincide with a positive family history of chronic lower limb lymphedema. Isolated PCL is rarely associated with significant complications. Rarely, however, widespread lymphatic dysplasia may occur, possibly resulting in nonimmune hydrops fetalis.

Lysosomal storage disorder in non-immunological hydrops fetalis (NIHF): more common than assumed? Report of four cases with transient NIHF and a review of the literature

Background

Lysosomal storage disorders (LSD) are a rare cause of non immunological hydrops fetalis (NIHF) and congenital ascites. The reported incidence is about 1%. The incidence of idiopathic NIHF is estimated to be about 18%.

Patients and methods

We report four cases with transient hydrops fetalis resulting from LSD and performed a literature review on LSD with NIHF and congenital ascites in combination.

Results

At present, 12 different LSDs are described to be associated with NIHF or congenital ascites. Most patients had a family history of NIHF, where the preceding sibling had not been examined. A diagnostic approach to the fetus with NIHF due to suspected LSD either in utero or postnatal is suggested. Transient forms of NIHF and/or ascites in association with MPS IVA, MPS VII and NPC are described for the first time in this publication.

Conclusions

LSD should be considered in transient hydrops. Enzymatic studies in chorionic villous sample or amniotic cultured cells, once the most common conditions associated with fetal ascites or hydrops have been ruled out, are important. This paper emphasizes the fact that LSD is significantly higher than the estimated 1% in previous studies, which is important for genetic counseling as there is a high risk of recurrence and the availability of enzyme replacement therapy for an increasing number of LSD.

Nonimmune hydrops fetalis part I: etiology and pathophysiology

Nonimmune hydrops fetalis (NIHF) is a condition in which excess fluid has accumulated in the fetal interstitial spaces as a result of one or more nonimmune factors. A plethora of maternal, placental, and fetal disease processes have been associated with NIHF. Knowledge of the various etiologies of NIHF and how the disease process affects fluid homeostasis is important for planning patient care and counseling families of patients diagnosed with nonimmune hydrops fetalis. This article discusses the mechanisms governing fluid distribution in the extracellular spaces, examines the various etiologies associated with NIHF, and describes the pathogenesis of NIHF for each etiologic category.

Fetal Anasarca

Fetal anasarca, defined by the presence of generalized subcutaneous edema measuring >5 mm tissue thickness, is a rare sonographic finding associated with end-stage hydrops fetalis and impending fetal death.This literature review describes the etiology, diagnosis, treatment, and prognosis for both immune and nonimmune hydrops fetalis. Medical technology and treatment have favorably affected fetal mortality associated with hydrops fetalis. Sonography is a noninvasive procedure that is heavily used in the management of hydrops fetalis. Sonographic guidance is equally important in the diagnosis and treatment. Sonographer recognition of early signs that may precipitate fetal anasarca is vital to continued favorable maternofetal outcome.

Nonimmune hydrops fetalis part II: does etiology influence mortality?

Hydrops fetalis is a condition in which there is an excess of total body fluid, primarily within the fetal interstitial spaces. Etymologically, hydrops fetalis is a Latin term meaning "edema of the fetus." In addition to generalized edema, the fetus has at least one of the following: ascites, pericardial effusion, pleural effusion(s), and an abnormally thick (>6 cm) placenta. Hydrops is classified as nonimmune hydrops fetalis (NIHF) when it occurs without evidence of isoimmunization.

Nonimmune hydrops fetalis in two cases of consanguineous parents and associated with hereditary spherocytosis and hemophagocytic hystiocytosis

Nonimmune hydrops fetalis may occur as a result of different etiological conditions and in about one-third of cases no cause could be identified. Here, we report two cases of nonimmune hydrops fetalis associated with hereditary spherocytosis and hemophagocytic hystiocytosis. We think that babies with hydrops fetalis born of consanguineous parents should be examined for hereditary diseases, and that these rare causes should be taken into account in problematic cases.

Proinflammatory macrophage migratory inhibition factor and interleukin-6 are concentrated in pleural effusion of human fetuses with prenatal chylothorax

OBJECTIVES

To study the role of selected cytokines and growth factors involved in the pathogenesis of fetal chylous pleural effusion.

METHODS

Seventeen fetuses with prenatal chylothorax at gestational age (GA) 17-29 weeks were enrolled as the study group during the period 2003-2005. Their pleural effusion (n = 17) and amniotic fluid (n = 17) were drawn when disease set in. Eleven fetuses received cordocentesis because of suspected fetal anemia. Forty-one normal fetuses without adverse perinatal outcome at GA 17-29 weeks received amniocentesis and were enrolled in the reference group. Levels of hepatocyte growth factor (HGF), stromal-derived factor-1(SDF-1), vascular endothelial growth factor (VEGF), interleukin-8 (IL-8), macrophage migratory inhibition factor (MIF), and interleukin-6 (IL-6) were determined in the samples from both groups (amniotic fluid, pleural fluid, and cord blood from the study group and amniotic fluid from the reference group) by enzyme-linked immunoassay (EIA).

RESULTS

No significant differences were observed in the amniotic fluids between the study group and the reference group regarding levels of IL-6, IL-8, MIF, SDF-1, HGF and VEGF. In the study group, levels of IL-8, VEGF and SDF-1 (all pro-angiogenic) showed no significant differences between the amniotic fluid, cord blood and pleural effusion. The level of HGF (proangiogenic) was significantly higher in the amniotic fluid than in the cord blood or the pleural effusion, but there were no significant differences between the levels in the pleural fluid and in the cord blood. Interestingly, the levels of MIF and IL-6 (both are proinflammatory) in the amniotic fluid and in the pleural effusion were much higher than the levels in the cord blood.

CONCLUSION

Our study demonstrated that the levels of pro-inflammatory proteins (MIF and IL-6) that we tested were higher in the fetal pleural effusion than in the fetal circulation, a phenomenon not observed in the levels of proangiogenic proteins (HGF, SDF-1, VEGF, IL-8). This result implies that inflammation-related proteins may be more relevant than the angiogenesis-related proteins in the local environment of accumulating pleural effusion, a prominent feature of prenatal chylothorax.

Antenatal Ultrasonographic Appearance of Isolated Fetal Ascites

BACKGROUND

Isolated fetal ascites can be caused by many heterogeneous disorders and is associated with a variety of conditions. Cloacal anomalies are rare abnormalities with a highly variable array of sonographic symptoms, which make them difficult to diagnose antenatally. We present a case with isolated fetal ascites without hydronephrosis caused by a cloacal malformation.

CASE

A 28-year-old woman, gravida 2, para 1, was referred to our unit at 18 weeks gestation with a hyperdense structure in the fetal liver. Cordocentesis revealed a normal karyotype and negative viral titers. Isolated fetal ascites occurred for the first time at 23 weeks gestation. Serial ultrasounds showed progressive fetal ascites with no hydronephrosis at any time and no other malformations apart from the previously diagnosed hyperechogenic liver structure. After the insertion of an abdomino-amniotic shunt, a temporary reduction of the sonographically detectable ascites could be achieved. Cesarean delivery was necessary due to a pathological CTG at 33 weeks of gestation. The baby was born with a markedly distended abdomen. Postnatal radiologic examination showed two fistulae between the cloaca and the notedly dilated vagina and the rectum respectively. At the age of 3 months a vaginoplasty was performed, which involved creating a correctly positioned vaginal opening, reconstruction of the urethra and rectum as well as occlusion of the two fistulae.

CONCLUSION

In view of the examinations, performed before and after delivery, it has to be assumed that fetal urine drained via the cloaca through the fallopian tubes into the abdomen. In contrast to usual appearance of cloacal malformations no hydronephrosis was detected and the kidney function was normal at all times. To our knowledge, this is the first published case of isolated fetal ascites without hydronephrosis caused by a cloacal malformation.

Middle cerebral artery peak systolic and ductus venosus velocity waveforms in the hydropic fetus

OBJECTIVE

The purpose of this study was to assess whether Doppler assessment of the middle cerebral artery (MCA) peak systolic velocity (PSV) and ductus venosus (DV) velocity waveforms during sonography of hydropic fetuses may specify the cause of fetal hydrops.

METHODS

A level II sonographic examination was performed in 16 hydropic fetuses, and the MCA PSV and DV velocity waveforms were assessed. The MCA PSV values divided hydropic fetuses into anemic (group 1) and nonanemic (group 2) fetuses. In group 2 fetuses, the DV was defined as normal or abnormal. Sonographic examination and Doppler assessment of these vessels specified the cause of hydrops and indicated the use of specific investigations for diagnosing the etiology of fetal hydrops.

RESULTS

Seven of 16 fetuses had MCA PSV values greater than 1.50 multiples of the median (group 1). Nine of 16 fetuses had normal MCA PSV values (group 2); among them, 7 of 9 had either absent or reversed flow in the DV, and 2 had a normal DV. In group 1, the cause of fetal anemia was investigated by maternal serum tests, and 5 cordocentesis procedures were performed. In group 2, 7 of 9 fetuses had reversed flow in the DV, which suggested a cardiac abnormality confirmed by echocardiography. Five cordocentesis procedures were performed for fetal karyotype, and in 2 fetuses, the cause of hydrops was idiopathic.

CONCLUSIONS

Our data suggest that assessment of the MCA PSV and DV velocity waveforms in the hydropic fetus may further our knowledge of the etiology of hydrops and may indicate which investigations among the many available should be used for diagnosing the cause of fetal hydrops.

Hydrops fetalis: an unusual prenatal presentation of hereditary congenital lymphedema

OBJECTIVES

To report a rare case of primary congenital lymphedema (PCL) presenting as hydrops fetalis.

METHODS

The patient presented at 33(+4) weeks' gestation with polyhydramnios, massive bilateral hydrothorax, skin edema, scalp edema and minimal ascites. In utero thoracocentesis was performed and delivery was induced. Follow-up at 12 months of age revealed moderate bilateral foot edema with otherwise normal development.

RESULTS

The diagnosis of PCL was suspected on the basis of the family history. DNA analysis revealed a novel missense mutation, E1106K, in the tyrosine kinase domain of the vascular endothelial growth factor receptor 3 gene (VEGFR3/FLT4).

CONCLUSION

PCL should be considered in the differential diagnosis of hydrops fetalis. Knowledge of the favorable course, variable clinical presentation, therapy options and genetic basis should contribute to better pregnancy counseling and management.

Hemophagocytic lymphohistiocytosis presenting with nonimmune hydrops fetalis

Hydrops fetalis is a condition of diverse etiologies. An association between hemophagocytic lymphohistiocytosis (HLH) and hydrops fetalis has not been reported in the English literature. We describe an intrauterine case of HLH in an infant who presented with hydrops fetalis at 32 weeks gestation. We suggest that HLH should be considered in the differential diagnosis of nonimmune hydrops fetalis, especially in the presence of cytopenias.

Nonimmune fetal ascites: a series of 79 cases

OBJECTIVE

The purpose of this study was to analyze the precision of ultrasonography in defining the cause and prognosis in fetal ascites.

STUDY DESIGN

We conducted a retrospective study of 79 cases of fetal ascites.

RESULTS

The mortality rate was 57% overall and ranged from 100% (7/7 cases) for metabolic storage disease to 0% (0/3 cases) in chylous ascites. Ascites before 24 weeks of gestation or combined with fetal hydrops indicates poor prognosis (respectively, 78.6% vs 45% mortality rate after 24 weeks; P<.01; and 77% vs 50.8% without hydrops; P<.02). Ascites was organic in 45 cases, infectious in 13 cases, idiopathic in 12 cases, and genetic in 9 cases. The cause was defined ultrasonographically in 28 of the 45 organic ascites and in 8 of the 25 isolated ascites. Urinary cause was the most frequent and the most successfully specified cause (14/15 cases).

CONCLUSION

Routine ultrasonography detects fetal ascites, but the cause is extremely variable and difficult to specify. When associated with fetal hydrops, the prognosis is poor.

Sonographic markers of hemoglobin Bart disease at midpregnancy

OBJECTIVE

To evaluate the efficacy of various sonographic markers at midpregnancy in predicting fetal hemoglobin Bart disease.

METHODS

Four hundred eighty-eight pregnancies at risk of having fetuses with hemoglobin Bart disease were recruited for prenatal diagnosis with cordocentesis at 18 to 21 gestational weeks. Before cordocentesis, the sonographic markers, including cardiothoracic ratio, placental thickness, pericardial effusion, pleural effusion, ascites, subcutaneous edema, cord edema, dilated umbilical vein, and amniotic fluid index, were assessed and recorded. The definite fetal diagnosis was based on blood analysis. The efficacy of each sonographic marker in predicting hemoglobin Bart disease was evaluated by sensitivity and specificity.

RESULTS

Among 488 pregnancies undergoing prenatal diagnosis, 100 fetuses were proved to be affected by hemoglobin Bart disease. The cardiothoracic ratio gave the highest sensitivity, 95.0%, with specificity of 96.1%, followed by placental thickness. Signs of hydrops fetalis were observed in 33.0% of cases; they did not increase the sensitivity of the cardiothoracic ratio but strongly reinforced the diagnosis when they appeared.

CONCLUSIONS

At midpregnancy, sonographic markers can effectively differentiate normal pregnancies from those with fetal hemoglobin Bart disease. Among couples at risk with no sonographic markers, the risk of having an affected child is nearly eliminated. The most sensitive marker was the cardiothoracic ratio, followed by placental thickness.

Analysis of outcome in hydrops fetalis in relation to gestational age at diagnosis, cause and treatment

OBJECTIVE

To examine fetal outcome in hydrops fetalis in relation to gestational age at diagnosis and following investigation and treatment.

METHODS

All cases of hydrops fetalis presenting to the Fetal Medicine Unit during the last seven years, between 1993 and 1999, were identified from the Fetal Medicine Database. During this time 87 of 13,980 patients who attended the Fetal Medicine Unit had hydrops fetalis. The cases were examined for gestational age at presentation according to etiology and fetal survival following investigation and treatment. The fetal survival rates for non-immune cases of hydrops before and after 24 weeks were compared.

RESULTS

The cause of hydrops was determined antenatally in 71 of the 87 (82%) cases. Of the 51 cases presenting before 24 weeks' gestation, 23 (45%) were due to chromosomal abnormality. After 24 weeks, fetal tachyarrhythmias and hydrothorax were the most common causes and accounted for 14 (38%) of the 36 cases. Thirty-four cases (39%) of hydrops received intrauterine treatment. The survival rates excluding chromosomal abnormalities in the non-immune cases before and after 24 weeks' gestation were 31% and 48%, respectively, and were not significantly different.

CONCLUSIONS

The survival rate in cases of hydrops fetalis may be improved with appropriate prenatal investigation and therapy. The etiology of hydrops is different before and after 24 weeks, and even when cases of chromosomal abnormality are excluded the survival rate is similar before and after 24 weeks.

Noncardiac thoracic anomalies

FHT is a rare diagnosis that may be an isolated finding or associated with multiple fetal anomalies, congenital infection or isoimmunization. The natural history of the lesion is variable. The effusion may regress spontaneously; remain stable in size; or progress to involve both sides of the chest and produce fetal hydrops, pulmonary hypoplasia, and fetal or neonatal demise. Hydrops is associated with significant fetal mortality. Antenatal decompression of the hydrothorax with pleuroamniotic shunting or thoracocentesis may result in a significant decrease in perinatal morbidity and mortality. Persistent hydrothorax can usually be treated with noninvasive measures in the newborn period.

Hydrops fetalis

Although most NIH fetuses have poor prognosis, it is imperative to attempt to identify the underlying cause to present parents with the best estimate for prognosis and future outcomes. Identification of a disorder with a good prognosis may prevent unnecessary termination of pregnancy and give a chance for therapy. Identification of a disorder with poor prognosis may still provide information that may be unavailable after delivery regarding this and future pregnancies.

Nonimmune hydrops fetalis

Nonimmune hydrops fetalis (NIHF) is a term that defines an edematous fetus that does not have erythroblastosis fetalis from isoimmunization. All of the other reasons that a fetus develops NIHF are included in this category. The causes of NIHF range from diseases to structural anomalies to genetic abnormalities. The mere presence of NIHF is a poor prognostic indicator, even with the etiology unknown. Some causes of NIHF are treatable with intrauterine therapies. These currently include cordocentesis to administer intrauterine transfusions or medications and fetal surgery. Prenatal testing to establish an etiology or follow the progress of the fetus is extensive, expensive, and stressful. The mortality rate remains high. Education, counseling, and support of the patient and family are the work of the prenatal period. Delivery room management of the infant with NIHF requires a resuscitation team with a specific plan of care to maximize chances of survival.

Management of parvovirus infection in pregnancy and outcomes of hydrops: a survey of members of the Society of Perinatal Obstetricians

OBJECTIVE

Our purpose was to investigate the evaluation and management of parvovirus infection during pregnancy.

STUDY DESIGN

Surveys were mailed to members of the Society of Perinatal Obstetricians residing in the United States and Canada in July 1997. They were asked about their evaluation and management of parvovirus infection, including whether they repeated and confirmed serologic studies, what their initial and follow-up evaluations included, whether they had had any cases of parvovirus-associated hydrops in the past 2 years, and if so, what were the management and outcomes of the hydropic fetuses.

RESULTS

Surveys were mailed to 1623 members of the Society of Perinatal Obstetricians and 541 completed surveys were returned. Sixty-eight percent of the respondents repeated and confirmed serologic studies. Eighty-nine percent used ultrasonography in their initial management of pregnant patients with recent parvovirus infection, 7.5% used amniocentesis for polymerase chain reaction, and 2% used fetal blood sampling. The outcomes of the 539 cases of parvovirus-induced hydrops included spontaneous resolution in 34%, death without intrauterine transfusion in 30%, resolution after intrauterine transfusion in 29%, death after intrauterine transfusion in 6%, and pregnancy termination in 1%. Almost all cases of nonimmune hydrops reported occurred between 16 and 32 weeks.

CONCLUSIONS

Approximately one third of the cases of parvovirus-induced nonimmune hydrops resolved spontaneously, whereas 83.5% of hydropic fetuses transfused survived.

Parvovirus B19 infections in pregnancy

Parvovirus B19 is the viral agent that causes the childhood exanthum erythema infectiosum, or fifth disease. Approximately 50% of pregnant women are seropositive for this agent and thus immune to primary infection. However, acute infection may develop in seronegative pregnant women exposed to B19. Acute B19 infections during pregnancy have been associated with miscarriage and hydrops fetalis. This latter condition is amenable to fetal therapy via intrauterine transfusion.

Extracorporeal life support for nonimmune hydrops fetalis

BACKGROUND/PURPOSE

Most babies born with idiopathic nonimmune hydrops fetalis (NIHF) suffer generalized cardiopulmonary collapse and die despite maximal medical therapy. With reported survival rates of less than 10%, many centers consider NIHF an unsalvageable situation and the babies who have this condition, untreatable. In this study, the authors questioned if the aggressive use of extracorporeal life support (ECLS) could salvage this condition and improve the chances of survival for babies born with NIHF.

METHODS

The Extracorporeal Life Support Organization's (ELSO) neonatal registry was searched for all available information on babies treated for hydrops fetalis. The ELSO records of all hydropic babies were then reviewed to exclude those babies who had identifiable causes of hydrops. Survival statistics were then calculated for the remaining core group of idiopathic NIHF babies before separating them into two groups based on survival. A detailed analysis comparing the survivors with nonsurvivors was then performed.

RESULTS

A total of 28 hydropic babies were identified in the ELSO registry. Four babies were excluded from analysis because of identifiable causes of hydrops (two with congenital diaphragmatic hernia, one with Rh incompatibility, and one with fetal anemia). Of the remaining 24 babies who had NIHF, 54% (13 babies) survived the neonatal period and were discharged from the hospital. Analysis comparing the survivors with the nonsurvivors in our study showed that the groups were similar in their gestational ages, birth weights, Apgar scores and the time to initial intubation. The most distinguishing factor of survival in our study was that the survivors, on average, received ECLS support 3 days sooner than nonsurvivors (mean, 17.5 +/- 1.3 hours of life for survivors v 105 +/- 36.6 hours for nonsurvivors, P < or = .05).

CONCLUSION

Idiopathic NIHF should no longer be considered an untreatable condition but a new indication for ECLS that, when begun early, may significantly improve the chances of survival for these babies previously considered "unsalvageable."

Angiotensin mediated interaction of fetal kidney and placenta in the control of fetal arterial pressure and its role in hydrops fetalis

Fetal cardiovascular control is effected by an interaction of the fetal somatic and placental circulations. Three primary regulatory mechanisms are involved: transplacental transfer of extracellular fluid, driven by a difference in hydrostatic and oncotic pressures; modulation of fetal placental and somatic vascular resistances by means of blood pressure controlled production of angiotensin; and somatic autoregulation of flow. A systems analysis incorporates these and other fetal cardiovascular functions and this analysis was modelled for computer simulation. Given physiologically plausible values for known cardiovascular parameters in the fetal sheep, the model reproduced in detail a variety of experimental protocols with known outcomes; these included the normal fetus, the fetus after bilateral nephrectomy, the nephrectomized fetus infused with angiotensin, the intact fetus infused with NaCl solutions, the fetus with lymphatic obstruction and the severely anaemic fetus. The systems analysis demonstrated that fetal cardiac failure constituted the strongest stimulus for the formation of fetal oedema of any tested pathological intervention.

Hydrops fetalis: recent advances

Hydrops fetalis is a morbid condition caused by a wide variety of fetal, placental, and maternal diseases. Mortality is high and depends on the gestational age at the time of occurrence and underlying etiology. Although the condition was described more than 300 years ago, recent advances in obstetric ultrasound, prenatal diagnostics have made it possible to differentiate various etiologies involved. It is also possible to treat some of these fetuses prenatally. In utero medical and surgical therapy is presently done in some centers. However, the majority of cases diagnosed remain untreatable. Early diagnosis of untreatable cases allows parents to make informed choices about subsequent management. Recent advances are covered in this review.

Fetal Ebstein anomaly--a rare cause of non-immune hydrops

A rare case of fetal Ebstein anomaly presenting as non-immune hydrops fetalis at 28 weeks of gestation is reported along with its review of literature.

Antenatal sonographic features of 100 alpha-thalassemia hydrops fetalis fetuses

OBJECTIVE

To characterize the sonographic findings of alpha-thalassemia hydrops fetalis.

METHODS

Descriptive study of the ultrasound findings in 100 women with antenatal diagnosis of hydrops fetalis due to alpha-thalassemia.

RESULTS

Mean (+/- SD) maternal age was 27.5 + 5.7 years (17-41 years). Mean menstrual age was 31.3 +/- 4.7 weeks (22-42 weeks). All fetuses were stillborn or died very shortly after birth. The indications for sonographic examination included early onset of pre-eclampsia, large for date, decreased fetal movement and nonreactive NST, or bradycardia and premature contractions. The sonographic features found in more than 90% of cases included hepatosplenomegaly, cardiac enlargement, edematous placenta, and ascites. Other common findings were oligohydramnios (82%), subcutaneous edema (75%), decreased fetal movement (74%), cord edema (63%), and enlarged umbilical vessel (62%). Pericardial or pleural effusion was seen in only 15% of cases. None of the fetuses showed any morphological abnormality. Early findings (22-28 weeks) included evidence of a thickened placenta and/or minimal ascites and/or slight cardiomegaly.

CONCLUSIONS

The sonographic characteristics of alpha-thalassemia hydrops fetalis ranged from no obvious morphological abnormalities to evidence of fluid retention. These typical abnormal findings generally did not appear until the late second trimester or early third trimester.

Prognostic factors and prenatal management in non immune hydrops fetalis are still a dilemma

Seventeen cases of non-immune hydrops fetalis (NIHF) were diagnosed prenatally at King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia over a period of 15 years (1979-1994). In nine patients (53%) a possible underlying mechanism was suspected. Of the six patients who survived beyond the first year of life, four had normal neurological and development follow-up. Family history was positive for NIHF in five cases (29%): two of these had a history of four siblings each who had been diagnosed with NIHF. All patients had prenatal ascites and subcutaneous oedema diagnosed by ultrasound. All five patients who had prenatal ascites, pericardial and pleural effusion died, while 9 of 11 (82%) patients who had prenatal pleural effusion and ascites also succumbed. Four of five (80%) patients with congenital anomalies died. One patient required intrauterine blood transfusion because of fetal anemia with subsequent partial resolution of the hydrops. Two patients received digitalis transplacentally for treatment of congestive heart failure secondary to congenital heart disease without response. We conclude that the presence of prenatal pericardial and pleural effusion or congenital anomalies carries a very poor prognosis in patients with NIHF.

The delivery room resuscitation of the hydropic neonate

Hydrops fetalis is a relatively rare disorder that will be encountered occasionally in all obstetric centers. The prognosis for infants with hydrops fetalis is poor, with mortality reported in the range of 50% to 98%. The effectiveness of delivery room resuscitation and the ability to achieve early adequate gas exchange in affected infants may be related to survival. Successful resuscitation requires an understanding of transitional neonatal physiology and the potential impact of hydrops fetalis, an experienced and well-prepared resuscitation team, meticulous attention to technical aspects of resuscitation, and careful assessment and monitoring of the infant during resuscitation.

Non-immune hydrops fetalis associated with impaired fetal movement: a case report and review

Non-immune hydrops fetalis (NIHF) is due to many different causes. Fetal hypomobility has been alluded to as a possible cause. We present a preterm fetus with NIHF secondary to fetal hypomobility. Fetal movements were undetected after the 20th week of gestation. The infant was born 8 weeks later and was edematous, had pleural effusions, and no spontaneous movements. He died on day four of life. Diffuse massive central nervous system (CNS) destruction found on post-mortem examination was thought to be the origin of the hypomobility. As all other causes of NIHF were eliminated, we propose that the NIHF in this infant was due to the hypomobility. This case then gives support to the assertion that fetal hypomobility is another cause of NIHF. The cause of the CNS catastrophy remains unelucidated.

Brain lesions of fetal onset in encephalopathic infants with nonimmune hydrops fetalis

Nonimmune hydrops fetalis (NIHF) comprised 79% (45/57) of all infants with hydrops fetalis at our institution over a 6-year period. Thirty-seven infants with NIHF were liveborn. One or more electroencephalograms were performed on 40% of liveborn infants (15/37); the majority (87%) were moderately to markedly abnormal, including burst suppression, lack of background, multifocal sharp waves, excessive discontinuity, and disorganization reflecting significant neonatal encephalopathies. Postmortem neuropathologic examinations were performed in 86% of infants with NIHF who died or were stillborn, 81% of whom demonstrated intrauterine brain insults including microcalcifications, cerebral and/or cerebellar hypoplasia, microcephaly, encephalomalacia, cavitary lesions, astrocytosis, polymicrogyria, and severe neuronal loss. Cranial ultrasonography failed to document the diverse pathologic lesions that were later noted on postmortem examination. Ten infants survived the neonatal period, but 6 were neurologically abnormal at the time of discharge. Infants with NIHF are at risk for antepartum brain injury, and electroencephalographic abnormalities reflect in part a fetal brain disorder. A prospective clinical study is needed to fully assess the prevalence, incidence, spectrum of central nervous system involvement, contribution of intrapartum and neonatal stress, and long-term outcome in surviving infants with NIHF.

Antenatal diagnosis and outcome in hydrops fetalis

The records of 15 cases of hydrops fetalis consecutively delivered at our institution were reviewed to determine the accuracy of antenatal diagnosis and whether antenatal diagnostic techniques yielded information useful in predicting outcome. All 15 cases were detected antenatally, five were due to rhesus haemolytic disease and 10 were non-immune hydrops. All the infants required active resuscitation. Ten infants eventually died, two had immune hydrops fetalis and 8 non-immune hydrops. Seven infants had pleural effusions, all had been detected antenatally. The presence of pleural effusions did not influence mortality. All structural abnormalities were accurately detected in those patients seen prior to labour and there were no survivors in the group of infants so affected. We conclude that the mortality of non-immune hydrops fetalis remains high and that antenatal diagnosis of this condition is accurate and provides useful prognostic information.

Prenatal diagnosis of human parvovirus B19 in nonimmune hydrops fetalis by polymerase chain reaction

OBJECTIVE

Nonimmune hydrops fetalis is a potentially lethal condition reflecting the clinical manifestation of several pathologic processes. Recently maternal infection by human parvovirus B19 has been reported to result in nonimmune fetal hydrops. We sought to develop a rapid and sensitive test to detect the presence of this agent in utero.

STUDY DESIGN

Using a cloned isolate of the virus, we developed an assay based on enzymatic amplification of a segment of the human parvovirus B19 genome that allows direct detection of this agent in samples of fetal blood and amniotic fluid.

RESULTS

The method detected as few as 100,000 genome equivalences and was specific for the viral genome alone. We used this assay to evaluate nine fetuses initially seen with nonimmune hydrops. Three cases were found to be positive for the human parvovirus B19 genome.

CONCLUSION

The method is powerful in that it is rapid, sensitive, and simple. This assay may have general applicability in evaluation of nonimmune hydrops and in documentation of the natural history of fetal human parvovirus infections.

Hydrops revisited: literature review of 1,414 cases published in the 1980s

This paper reviews 47 series of hydrops fetalis (804 cases) and 610 individual cases published since 1980. From this large number of cases, guidelines are derived for prenatal diagnosis and management.

The influence of pleural effusion on pulmonary growth in the human fetus

The present study was performed to clarify the relation of cause and effect between pleural effusion and hypoplastic lung in the human fetus. In six cases with a duration of less than two weeks between the initial diagnosis of pleural effusion and delivery, lung weights were within the mean weight +/- 1.5 S.D. In fourteen cases with a duration of more than two weeks between diagnosis and delivery, seven cases had lungs with weights of less than -2.0 S.D. and twelve had lungs of less than -1.5 S.D. in weight. The incidence of lung weights less than -1.5 S.D. or -2.0 S.D. was significantly higher in cases with a diagnosis-delivery duration of more than two weeks, compared to those with a duration of less than two weeks. These results suggest that the development of hypoplastic lung in fetuses with pleural effusion may depend on the length of the presence of pleural effusion.

Abnormal antenatal ultrasound findings and subsequent handicap

The modern ultrasound technique in its various modes, real-time B-mode, M-mode, continuous and pulsed wave Doppler ultrasound, makes it possible to study in detail the fetal anatomy and function in utero. Fetometry allows for the evaluation of fetal size and growth and for detecting growth-retarded or macrosomic fetuses. Ultrasound seems, at present, to be the best method available in the detection of the growth-retarded fetus who is at risk of developing perinatal complications and subsequent handicap. Ultrasound can also be used when fetal growth retardation is suspected on clinical grounds. An absolute prerequisite for the proper use of ultrasound fetometry is the estimation of gestational age in early pregnancy. The high resolution of modern ultrasound scanners allows the antenatal detection of even minor fetal structural abnormalities. When lethal malformations are detected early in pregnancy, selective termination of pregnancy can be considered. Fetal abnormality detected in late pregnancy allows for optimal timing and mode of delivery leading to improved management and outcome, thus lowering the risks of subsequent handicap. Ultrasound examination of the extrafetal structures, e.g. umbilical cord, placenta and amniotic fluid volume, may add valuable clinical information. The finding of severe oligohydramnios is associated with increased perinatal mortality and morbidity. Fetal circulation can be evaluated by using the combination of real-time and pulsed Doppler ultrasound or, alternatively, by employing continuous wave Doppler ultrasound alone. Pathological changes in the blood velocity waveforms recorded from the fetal and umbilical arteries may signify very early signs of fetal hypoxia. The method has the potential of becoming a useful clinical method for fetal surveillance. The guidelines for a proper application in the perinatal medicine of the Doppler method have, however, not yet been established. In fetuses with cardiac arrhythmia and/or cardiac malformation, the Doppler investigation of the fetal circulation can be used to evaluate the haemodynamic alterations and, in cases of intrauterine treatment, to supervise and monitor the therapeutic effects. Fetal motor function can be followed and quantified with real-time ultrasound. Abnormal motor activity might indicate bad perinatal outcome. The predictive capacity of the test is increased when several variables are combined (e.g. the fetal biophysical profile score).(ABSTRACT TRUNCATED AT 400 WORDS)

Intrauterine treatment of idiopathic hydrops fetalis

Seven fetuses with idiopathic hydrops fetalis (IHF) were treated in utero by injecting albumin into the fetal abdominal cavity and by removal of accumulated fluid from the serous cavities. Signs of hydrops fetalis disappeared in utero in one, and skin edema significantly decreased in another. In the other five, signs of hydrops fetalis remained unchanged in utero. The hourly fetal urine production rate (HFUPR) increased after albumin injection in three of five. The interval between the initial diagnosis and delivery ranged from 3 to 14 weeks. Gestational age at the time of delivery ranged from 33 to 40 weeks. There were no stillbirths. Two of three without pleural effusion survived, but four with pleural effusion died of respiratory failure during the neonatal period due to pulmonary hypoplasia. These results indicate that albumin injection into the fetal abdomen in utero deserves further attention and that other therapeutic methods should be established to enhance the development of the lungs in cases of intrauterine treatment of IHF with pleural effusion.

Pleural effusions and pulmonary hypoplasia

Nine cases of fetuses with pleural effusions are presented in which the diagnosis was made by ultrasound before the thirtieth week of gestation. A ratio of lung span to hemithorax diameter was calculated and ranged from 0.44 to 0.77 (mean 0.60). At autopsy, pulmonary hypoplasia was confirmed in all cases by criteria based on the ratio of lung weight to total body weight. Because pleural effusions occurring in the midtrimester can be detected and may lead to pulmonary hypoplasia, consideration should be given to definitive in utero therapy when no other major fetal abnormality is detected.