Antenatal diagnosis of cystic hygroma or nuchal pad--report of 92 cases with follow up of survivors

Outcome of 45,X fetuses with cystic hygroma: A systematic review

This objective of this systematic review was to estimate live birth rate and explore prognostic indicators in fetuses with 45,X karyotype and a posterior cystic hygroma (CH). Electronic databases were searched and studies reporting pregnancy outcomes (termination, spontaneous abortion, demise, or live birth) for fetuses with 45,X karyotype and a CH diagnosed on ultrasound were included. For cases of survival, CH characteristics, presence of hydrops fetalis, or concomitant anomalies, delivery details, and postnatal outcomes were summarized. A total of 95 studies, including 535 cases, met inclusion criteria: 285 (53.3%) pregnancies were terminated, 72 (13.5%) had spontaneous abortion or demise, 164 (30.7%) had unspecified pregnancy failure, and 14 (2.6%) were live births. Among live births with data available, all CH measured 2-7 cm, more than half were septate, and almost all regressed in size or eventually disappeared. Hydrops fetalis was noted in five cases. Of the eight live births with neonatal outcomes available, three neonates died shortly after birth and five survived past the neonatal period. This review suggests that diagnosis of CH in a 45,X fetus is associated with an estimated live birth rate of 2.6%, but only 1% survive to infancy. Prognosis appears to improve with CH regression.

[Increased nuchal translucency with normal karyotype]

Nuchal translucency (NT) measurement in first trimester screening between 11 and 14 weeks' gestation has now been clearly identified as a marker for aneuploidies and in particular for trisomy 21. Even in the absence of aneuploidy increased fetal nuchal translucency has been shown to be a marker for fetal heart malformations and numerous other fetal defects and genetic syndromes when the measure is>or=95th centile which is around 3,5 mm for each gestational age. Fetuses with NT thickness above the 99th centile and normal karyotype have a high risk of adverse prenatal outcome and this increase in risk is exponential as the nuchal translucency measurement increases. However, among children born alive with normal ultrasound at 22 weeks of gestation, there was no significant association between NT thickness and development at 2 years as assessed by clinical examination and ASQ scores, when with a control population. Counselling should emphasize that when the karyotype is normal and no fetal structural malformation was missed prenatally following resolution of nuchal thickening, the prognosis is not impaired at the age of 2.

Long-term outcome of children born after a first-trimester measurement of nuchal translucency at the 99th percentile or greater with normal karyotype: a prospective study

OBJECTIVE

This study was undertaken to assess the long-term outcome of children born after a first-trimester measurement of nuchal translucency (NT) at the 99th percentile or greater during routine first-trimester screening in an unselected population.

STUDY DESIGN

One hundred sixty-two infants were born alive. Clinical examination as well as a questionnaire to the parents (Ages and Stages Questionnaires [ASQ]) at the age of 2 years were obtained in 160 children. Our study population was compared with an external control group made of the 370 term control children.

RESULTS

The prevalence of abnormal clinical pediatric examination and ASQ results at 2 years were not associated with NT thickness. Comparison with an external control group did not demonstrate an increased incidence of developmental delay.

CONCLUSION

Parents should be informed that when the fetus is shown to be normal by ultrasound at 22-24 weeks of gestation the risk of adverse neonatal outcome or developmental delay in early childhood is not increased.

Management of antenatally detected fetal airway obstruction

Five cases of antenatally diagnosed fetal airway obstruction have been cared for at the John Hunter Children's Hospital, Newcastle, Australia. A multidisciplinary team manages them during the perinatal period. We present our technique at the time of delivery, which aims to afford us the greatest flexibility in managing both the mother, her child's airway, and the underlying lesion. We begin with an ex utero intrapartum technique (EXIT) and favor routine rigid bronchoscopy to secure the neonate's airway without preliminary attempts at endotracheal intubation.

Suivi à long terme des enfants avec clarté nucale augmentée et caryotype normal

The aim of this study was to investigate outcome at the age of two years for infants without known chromosomal anomalies who presented increased nuchal translucency (NT) at first trimester ultrasound examinations. One hundred fifty-one infants with NT measuring 3mm or more, between 12 and 16 weeks gestation, were followed for at least 24 months. A homogeneous pediatric examination was applied. Among these 151 infants, thirteen (8%) had a major isolated malformation. Five infants (3.3%) had chromosomal anomalies which were unrecognized on fetal karyotype owing to tissue mosaic in two and to cryptic chromosomal anomalies in three. At the age of two years, 16 children (10%) presented psychomotor retardation as part of a genetic syndrome, half of them had an associated cardiac malformation. We did not find any specific ultrasound characteristics which could be used to distinguish fetuses with impaired neurological prognosis. Newborns who presented NT at the first trimester ultrasound examination constitute a high risk population, particularly for psychomotor retardation which is not always recognized during the neonatal period. Careful pediatric follow up is required during childhood.

Population-based study of the outcome following the prenatal diagnosis of cystic hygroma

OBJECTIVE

To identify the population prevalence, pregnancy outcome, and the pattern of associated anomalies with a prenatal diagnosis of cystic hygroma.

DESIGN

We analysed the pregnancy outcomes from 99 cases of prenatally diagnosed cystic hygroma reported to the Trent Congenital Anomalies Register from 1 January 1997 to 31 December 1999, by means of an outcome reporting form completed by the notifying centre.

RESULTS

We identified a population prevalence of 1 in 1775 livebirths for prenatally diagnosed cystic hygroma. There were 64 terminations of pregnancy, 19 spontaneous pregnancy failures, and 16 livebirths. Of the 87 pregnancies karyotyped, 53 (61%) demonstrated aneuploidy with Turner syndrome being the most common, 29 (33%). There were a large variety of structural malformations identified, however, only 14 out of 83 terminations of pregnancy and spontaneous pregnancy failures had post-mortem examinations. Termination of pregnancy for Turner syndrome not complicated by identified structural malformations was the norm. Of the 16 livebirths, only 6 were normal at birth, 1 other has had successful hygroma surgery. Four of the liveborn infants have since died.

CONCLUSIONS

The 'normal outcome' rate from pregnancies complicated by prenatally diagnosed cystic hygroma is less than 10% in this study (6/99). Prenatal diagnosis of cystic hygroma requires careful assessment of the fetus, with regard to both karyotyping and ultrasound. Post-mortem examination should be encouraged after termination of pregnancy, or spontaneous pregnancy loss. This is important not just to the current pregnancy but also for future pregnancies.

Outcome of cystic hygroma in fetuses with normal karyotypes depends on associated findings

OBJECTIVE

To determine the associated diagnostic findings which are linked with adverse fetal outcome in nuchal cystic hygroma.

STUDY DESIGN

Based on a series of 32 cases, we determined the sonographic morphology of the hygroma, associated structural anomalies, karyotypes and autopsy findings. Intrauterine fetal death, spontaneous abortion and abnormal karyotypes were assigned as adverse outcome parameters.

RESULTS

The mean gestational age at diagnosis was 14.4 weeks (range 10-21). There were 18 nonseptated and 14 septated hygromas. Besides hygroma, associated sonographic detectable structural anomalies were observed in 17 cases (53.1%). The greatest number of associated sonographic anomalies were hydrops (31.3%), generalised skin oedema (6.3%) and pterygium colli (6.3%). Cytogenetic analysis revealed an abnormal karyotype in 13 of 26 (50%) invasive procedures. Turner syndrome and Trisomy 18 (both 15.4%) were the most frequent cytogenetic abnormalities. Autopsy was performed in 24 cases and 16 cases (66.7%) had an associated autopsy finding to hygroma colli. The most frequent associated autopsy findings were limb and craniofacial anomalies (both 25%). Only 3 (9.4%) mothers gave birth to healthy newborns. The overall fetal adverse outcome rate was 68.8% (22 cases).

CONCLUSIONS

Fetuses with NCH are at high risk for adverse outcome and detailed prenatal diagnosis including invasive procedures should be offered. According to the presented autopsy findings, to determine fetal outcome in NCH cases with normal karyotypes, detailed sonography should be concentrated beside the exclusion of fetal heart defects and existence of hydrops fetalis, on the skeletal, urogenital and craniofacial anomalies, as these might cause severe morbidity.

Noonan syndrome: a cryptic condition in early gestation

Noonan syndrome is one of the most common of genetic syndromes and manifests at birth, yet it is usually diagnosed during childhood. Although prenatal diagnosis of Noonan syndrome is usually not possible, in a few cases the ultrasonographic findings suggested the diagnosis in utero. Reported sonographic clues include septated cystic hygroma, hydrothorax, polyhydramnios, and cardiac defects, such as pulmonic stenosis and hypertrophic cardiomyopathy. During a 6-year period, 46,224 live-born infants were delivered at the Chaim Sheba Medical Center. Seven newborn infants and four fetuses were found to have Noonan syndrome. One fetus showed transient nuchal translucency of 4 mm and bilateral neck cysts at the 13th gestational week. Both findings resolved spontaneously by the 18th gestational week, but during the third trimester this fetus developed hydrothorax, skin edema, and polyhydramnios. In the three other fetuses, first- and second-trimester ultrasonographic findings were normal, and the diagnosis of Noonan syndrome was suggested only during the third trimester. All three fetuses had polyhydramnios and skin edema. A cardiac malformation, hydrothorax, and a large head were present in one fetus. Sonographic facial findings were investigated. In all four fetuses posteriorly angulated, apparently low-set ears and depressed nasal bridge were identified. Wide nasal base was seen in two fetuses. In two fetuses, persistent opening of the fetal mouth was interpreted as fetal hypotonia. One fetus developed progressive postnatal hypertrophic cardiomyopathy and in one case, pulmonic stenosis became apparent at age 6 months. This small series suggests that Noonan syndrome has an evolving phenotype during in utero and postnatal life. Amelioration of early nuchal region findings and late onset of the more "typical" ultrasonographic changes may limit early prenatal detectability.

The outcome after perinatal management of infants with potential airway obstruction

Masses in the head and neck are being detected prenatally with increasing frequency, necessitating the need for management of potential upper airway obstruction at delivery. Establishment of the airway at delivery and its maintenance thereafter are critical. This should optimally be performed with the baby still attached to the placental circulation. The importance of multidisciplinary team management, including a high risk obstetrician, neonatologist, pediatric otolaryngologist, pediatric thoracic surgeon, and an anesthetist, cannot be overemphasized. Endotracheal intubation is attempted first, if unsuccessful then is followed by insertion of a rigid bronchoscope. Tracheotomy should be reserved for airway obstructions, which are not amenable to endotracheal intubation or in babies in whom exchange from a bronchoscope to endotracheal tube cannot be safely performed. The management of six infants with prenatally diagnosed potential airway obstruction is presented. Morbidity and mortality still ultimately depend on the severity of the existent anomalies.