Hydrops fetalis due to abnormal lymphatics

Recurrent Non-immune Fetal Hydrops: A Case Report

Introduction: Recurrent non-immune fetal hydrops (NIH) has been reported in the literature but is a rare entity, with fewer than 6 reported cases so far. It has been postulated to be related to a recessive gene. Clinical Picture: We report a case of recurrent fetal hydrops in a multigravida with no medical history of note. She presented in her current pregnancy with a significant history of having 4 (out of 7) previous pregnancies affected by hydrops. Treatment: All the affected pregnancies resulted in mid-trimester pregnancy termination (MTPT) following diagnosis in the second trimester. Previous investigations for hydrops did not yield any obvious cause. Outcome: Her most recent pregnancy was unaffected. We discuss the possible differential diagnoses and the likelihood of autosomal recessive metabolic diseases being the aetiological factor. Conclusion: Rare causes of fetal hydrops need to be excluded in cases of recurrent non-immune hydrops with no obvious aetiology following routine investigations. Key words: Hydrops fetalis, Lysosomal storage disorders, Non-immune, Thalassaemia, Ultrasonography

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.

Umbilical pressure measurement in the evaluation of nonimmune hydrops fetalis

OBJECTIVE

Nonimmune hydrops fetalis continues to have a perinatal mortality rate > 50%. Although many abnormalities are associated with nonimmune hydrops fetalis, the direct mechanism by which the hydrops occurs is often obscure, even after delivery. There are at least three possible mechanisms for hydrops: heart failure (whether primary or a secondary effect of obstructed venous return), lymphatic malformation, and liver or peritoneal disease. The development of safe access to the fetal circulation by cordocentesis allows for the measurement of the umbilical venous pressure, which is closely related to the fetal central venous pressure. The premise that nonimmune hydrops fetalis of cardiac origin could be distinguished from that of noncardiac origin was examined by measuring the umbilical venous pressure.

STUDY DESIGN

Umbilical venous pressure was measured during indicated diagnostic cordocentesis in three groups of fetuses: 20 with nonimmune hydrops fetalis, four with a cardiac malformation but without nonimmune hydrops fetalis, and eight with immune hydrops (fetal hemolytic disease). In 16 of 20 fetuses with nonimmune hydrops fetalis the serum total protein and albumin concentrations were also measured.

RESULTS

Presumed inadequate cardiac output, as indicated by an elevated umbilical venous pressure, was the mechanism of nonimmune hydrops fetalis in 13 of 20 (65%). The pathologic condition included arrhythmia, cardiothoracic abnormalities, severe polycythemia and hyperviscosity, viral infection, and severe anemia. Successful antenatal treatment normalized the umbilical venous pressure. Nonimmune hydrops fetalis secondary to noncardiac mechanisms did not progress in severity and was not amenable to antenatal therapy. Hypoproteinemia and hypoalbuminemia were found in only six of 16 cases and were similarly distributed between cardiac and noncardiac mechanisms.

CONCLUSIONS

This is the first report where the measurement of umbilical venous pressure was applied to the evaluation of nonimmune hydrops fetalis. Cardiac dysfunction was the most common mechanism causing hydrops. The finding of a normal umbilical venous pressure greatly reduces the likelihood that the heart is the cause of the hydrops, even when there is a coexistent heart malformation. This immediate information allows the practitioner either to focus on therapeutic interventions that might lower the umbilical venous pressure or to look for noncardiac causes for the hydrops.

Current topic: water volume of the ovine conceptus; point of view

The sheep is the only species for which there is sufficient information to justify an overview of maternofetal water transfer. Current information points to the following conclusions: (1) the site of water exchange between mother and conceptus is mainly the placenta; (2) the pressure that initiates transfer to the fetus is the osmotic pressure of solutes that are present in higher concentrations in fetal plasma than in maternal plasma, such as urea, fructose, amino acids, bicarbonate and lactate; (3) maternal ultrafiltrate thus attracted into the conceptus arrives there mostly denuded of electrolytes and is strongly hypotonic; thus it is the transfer of electrolyte that restrains the transfer of water; (4) maternofetal transfer of water is strongly facilitated by angiotensin I in the fetal circulation by a sequence of events that has not yet been elucidated; (5) the net combined osmotic and hydrostatic pressure that drives water across the placenta is of the order of only 20 to 80 mm Hg; (6) it is necessary to make a sharp distinction between transfer from mother to conceptus and transfer from one compartment to another compartment within the conceptus. Finally, the review lists certain precautions to be taken in the further study of water exchange between mother and conceptus.

Growth hormone deficiency in children with chromosomal abnormalities

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Generalised lymphangiomatosis with chylothorax

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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.