Diagnosis and management of non-immune hydrops in the newborn

Short-term and long-term outcomes of 214 cases of non-immune hydrops fetalis

Despite advances in diagnosis and management, non-immune hydrops fetalis (NIHF) has a high mortality rate. Perinatal survival depends on the underlying disorder and the gestational age at diagnosis. As prognostic information is limited, this study acquired data regarding the neurological development of perinatal survivors. We performed a retrospective chart review of 214 cases in which NIHF was diagnosed antenatally. We recorded maternal demographic characteristics and interventions and their effectiveness, as well as the short-term outcome (survival) and long-term outcome including developmental quotients. Among the affected fetuses, 91 (42.5%) survived the perinatal period. Fetuses with chylothorax, chyloascites, or meconium peritonitis, and those in whom therapy was effective, had high survival rates irrespective of the type of intrauterine intervention. The subsequent intact survival rate was 28/56 (50.0%), with intact defined as ratio of the number of infants with normal development to the number of all infants followed. In contrast to the perinatal survival rate, the intact survival rate decreased as gestational age at diagnosis advanced. These findings suggest that the long-term intact survival rate depends on the underlying cause of NIHF. Additionally, while survival was improved with intensive perinatal care during the perinatal period, aggressive perinatal intervention was not a prognostic factor for neurological outcome.

Zellweger syndrome with unusual findings: non-immune hydrops fetalis, dermal erythropoiesis and hypoplastic toe nails

The peroxisomal biogenesis disorders (PBDs) comprise the Zellweger spectrum disorders (i.e., Zellweger syndrome, neonatal adrenoleukodystrophy, and infantile Refsum disease) and rhizomelic chondrodysplasia punctata. Peroxisomal biogenesis disorders can be caused by mutations in any of 13 currently known PEX genes, which encode peroxins involved in peroxisomal protein import and/or assembly of the organelle. We report here on a Turkish patient who presented with unusual clinical findings, that included non-immune hydrops, dermal erythropoiesis and hypoplastic toenails, as well as common dysmorphic features of Zellweger syndrome. The patient has also pulmonary hypoplasia, which has been reported in only a few patients with Zellweger syndrome. A peroxisomal biogenesis disorder was confirmed by enzyme analysis and abnormal very long-chain fatty acid (VLCFA) profiles in plasma and fibroblast and immunofluorescence microscopy studies. Subsequent molecular genetic analysis revealed a homozygous c.856C>T mutation (R268X) in the PEX3 gene, which made this patient the third to have a defect in this gene. In contrast to those of the two previously reported patients, the cells of this patient still contained peroxisomal membrane structures (ghosts), seen by immunofluorescence microscopy analysis. The case presented here and the two previously reported cases point out that a PEX3 gene defect may present with fairly heterogeneous clinical findings. This case also raises a possibility that hydrops fetalis may be associated with a PEX3 gene defect and that peroxisomal disorders can be considered in the etiology of hydrops fetalis as well as other cell organelle disorders when one is considering yet undiscovered complementation groups in peroxisomal disorders.

The emerging pattern of hydrops fetalis--incidence, aetiology and management

OBJECTIVES

To analyse the incidence, aetiology and management of live born cases of hydrops fetalis in a Regional Perinatal Centre.

METHODS

We reviewed 35 cases of hydrops delivered over a six year period.

RESULTS

Non-immune hydrops accounted for 80% of the cases and the majority of babies required Level 1 intensive care. The mortality rate was 40%.

CONCLUSION

The pattern of hydrops is changing. Most of these babies now have non-immune hydrops and approximately two thirds are surviving.

Characterization of newborns with nonimmune hydrops fetalis admitted to a neonatal intensive care unit

PURPOSE

To determine the incidence and characteristics of nonimmune hydrops fetalis in the newborn population.

METHOD

A retrospective study of the period between 1996 and 2000, including all newborns with a prenatal or early neonatal diagnosis of nonimmune hydrops fetalis, based on clinical history, physical examination, and laboratory evaluation. The following were analyzed: prenatal follow-up, delivery type, gender, birth weight, gestational age, presence of perinatal asphyxia, nutritional classification, etiopathic diagnosis, length of hospital stay, mortality, and age at death.

RESULTS

A total of 47 newborns with hydrops fetalis (0.42% of live births), 18 (38.3%) with the immune form and 29 (61.7%) with the nonimmune form, were selected for study. The incidence of nonimmune hydrops fetalis was 1 per 414 neonates. Data was obtained from 21 newborns, with the following characteristics: 19 (90.5%) were suspected from prenatal diagnosis, 18 (85.7%) were born by cesarean delivery, 15 (71.4%) were female, and 10 (47.6%) were asphyxiated. The average weight was 2665.9 g, and the average gestational age was 35 3/7 weeks; 14 (66.6%) were preterm; 18 (85.0 %) appropriate delivery time; and 3 (14.3%) were large for gestational age. The etiopathic diagnosis was determined for 62%, which included cardiovascular (19.0%), infectious (9.5%), placental (4.8%), hematologic (4.7%), genitourinary (4.8%), and tumoral causes (4.8%), and there was a combination of causes in 9.5%. The etiology was classified as idiopathic in 38%. The length of hospital stay was 26.6 +/- 23.6 days, and the mortality rate was 52.4%.

CONCLUSIONS

The establishment of a suitable etiopathic diagnosis associated with prenatal detection of nonimmune hydrops fetalis can be an important step in reducing the neonatal mortality rate from this condition.

Two new cases of Cumming syndrome confirming autosomal recessive inheritance

We report on two stillborn sisters with generalized hydrops, campomelia, cervical lymphocele, and polycystic dysplasia of kidney, liver, and pancreas. This syndrome conforms to that first described by Cumming et al. [Am. J. Med. Genet. 25:783-790, 1986]. This observation provides additional support for the notion that this syndrome has an autosomal recessive pattern of inheritance.

Renal tubular abnormalities in hydrops fetalis: a histological and immunohistochemical study

An immunohistochemical study of renal tubule cell differentiation in hydrops fetalis was performed using antibodies against lysozyme, CD15, keratin, epithelial membrane antigen and Leu-7, and formalin-fixed, paraffin-embedded sections of tissue that was obtained at autopsy. In 3 cases among 17 cases of hydrops fetalis (17.6%) there was a marked decrease in the number of cells stained positively for lysozyme, suggesting abnormal differentiation of the cells of the proximal convoluted tubules. This is the first report concerning the abnormalities of the renal tubular epithelium in hydrops fetalis.

Postnatal resolution of non-chylous primary fetal hydrothorax

We describe two cases of non-chylous primary fetal hydrothorax not associated with hydrops or associated malformations. Repeated ultrasonographic examinations, to detect development of hydrops or progression of intrapleural effusion, were used to evaluate the need for intrauterine thoracocentesis and to decide the optimal time for delivery. Both infants did well after postnatal evacuation of the intrapleural fluid. Pre- and postnatal investigation to find the pathophysiological mechanism leading to hydrothorax were negative. We conclude, in agreement with previous work, that primary fetal hydrothorax is generally associated with a favourable outcome.

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.

Diagnosis and management of non-immune hydrops in the newborn

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Selective intubation in a case of cystic adenomatoid malformation

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