Non-Immune Hydrops Fetalis: Do Placentomegaly and Polyhydramnios Matter?

Partial molar pregnancy with hydrops fetalis causing intrauterine fetal demise: A case report

Key Clinical Message

Timely prenatal diagnosis, regular checkups, and comprehensive counseling are vital in preventing and managing complications in high-risk pregnancies like partial molar pregnancy with hydrops fetalis.

Abstract

A live singleton fetus with partial molar pregnancy is a rare condition. We report a case of partial mole with hydrops fetalis causing intrauterine fetal demise (IUFD) in the third trimester. Our case involves a 20-year primigravid without prior antenatal checkups who presented to outpatient department at 31 weeks and 5 days of gestation with lower abdominal pain, backache, vaginal spotting, and decreased fetal movement. Ultrasound revealed partial mole, hydrops fetalis, and IUFD. The patient underwent induced delivery expelling a 1900 gm female fetus with no viability and a placenta containing 650 gm of molar tissue. Placental tissue with cystic component was confirmed as molar tissue by histopathological examination. She was discharged a few days afterward and had undetectable beta-human chorionic gonadotropin levels after a month. Prenatal diagnosis, counseling, rigorous antepartum surveillance, and appropriate postpartum follow-up are essential for the best possible mother and fetal outcomes.

Genetic disorders and pregnancy outcomes of non-immune hydrops fetalis in a tertiary referral center

OBJECTIVES

Non-immune hydrops fetalis (NIHF) is a non-specific symptom associated with a wide range of disorders. The prognosis of NIHF depends on the underlying etiology. In this study, we investigated the incidence of chromosomal abnormalities and Bart's hydrops fetalis in pregnancies associated with NIHF in South China.

METHODS

We conducted a retrospective review of NIHF pregnancies referred to the Fujian Provincial Maternity and Children's Hospital between 2014 and 2018, excluding pregnancies with maternal alloimmunization. Routine karyotyping was performed on all 129 enrolled patients, and chromosomal microarray analysis was performed for 35 cases with a normal karyotype. In addition, α-thalassemia genotyping was performed to confirm the presence of Bart's hydrops fetalis.

RESULTS

Chromosomal abnormalities were detected in 29.5% (38/129) of the cohort, including 37 cases with aneuploidy and one case with unbalanced structural rearrangement. Chromosomal microarray analysis performed on the 35 cases with a normal karyotype did not reveal any additional pathogenic variants. The proportions of chromosomal abnormalities declined with trimester progression, with frequencies of 65%, 30.1%, and 8.3% in the first, second, and third trimesters, respectively (p < 0.05). Bart's hydrops fetalis was detected in 34.9% (45/129) of the cohort. Among the 46 (35.6%) cases with unknown etiology, 23 cases had other ultrasonic abnormalities characterized by poor outcomes, whereas seven cases with multiple cavity effusions that resolved or remitted prior to birth showed normal development during the 3-4 years of follow-up.

CONCLUSIONS

In South China, Bart's hydrops fetalis and chromosomal abnormalities are the most common genetic etiologies of NIHF. Generalized skin edema and accompanying ultrasonic abnormalities are predictive of adverse outcomes, highlighting the need for intensive monitoring and better pregnancy management of NIHF patients.

Understanding Preterm Birth in Pregnancies Complicated by Nonimmune Hydrops Fetalis

OBJECTIVE

 Nonimmune hydrops fetalis (NIHF) is associated with poor perinatal outcomes including preterm birth (PTB). However, the frequency and causes of PTB in this population are not well understood. We hypothesized that NIHF frequently results in PTB due to medically indicated delivery for fetal distress.

STUDY DESIGN

 This was a secondary analysis of a prospectively enrolled cohort of pregnancies with NIHF that underwent exome sequencing if standard testing was nondiagnostic. The primary outcome was frequency of PTB at <37 weeks' gestation. Secondary outcomes were reasons for PTB, fetal predictors of PTB, and frequency of neonatal death following PTB.

RESULTS

 Fifty-six cases were included, with a median gestational age at delivery of 32.8 weeks (interquartile range [IQR]: 30.3-35.0). Overall, 86% (48/56) were delivered preterm. Among 48 PTBs, 18 (38%) were spontaneous, 9 (19%) were medically indicated for maternal indications (primarily preeclampsia), and 21 (44%) were medically indicated for fetal indications (nonreassuring antenatal testing or worsening effusions). Neither fetal genetic diagnosis nor polyhydramnios was associated with PTB.

CONCLUSION

 More than four-fifths of pregnancies with NIHF result in PTB, often due to nonreassuring fetal status. These data are informative for counseling patients and for developing strategies to reduce PTB in pregnancies with NIHF.

KEY POINTS

· Pregnancies complicated by nonimmune hydrops fetalis often result in preterm birth.. · Preterm birth in these cases is most often medically indicated for fetal benefit.. · Fetal genetic conditions and polyhydramnios may be associated with preterm birth in cases of NIHF..

Preoperative Cervical Length Predicts the Risk of Delivery within One Week after Pleuroamniotic Shunt in Fetuses with Severe Hydrothorax

OBJECTIVE

The objective of this study was to assess the predictive performance of preoperative cervical length (CL) for delivery within 1 week after pleuroamniotic shunting (PAS) in fetuses with severe hydrothorax.

METHODS

A prospective cohort of fetuses with severe hydrothorax referred to our fetal surgery center in Querétaro, Mexico from January 2012 to July 2020. Severe fetal hydrothorax was diagnosed as an accumulation of fluid within the fetal pleural space accompanied with severe bilateral lung compression, mediastinal shift, polyhydramnios, and/or hydrops. Transvaginal CL was measured immediately before PAS, and a short cervix was defined as that <25 mm. The interval from fetal intervention to delivery, prevalence of preterm prelabor rupture of membranes (PPROMs), and associations with delivery within the first week after PAS according to a short or a normal CL, were evaluated.

RESULTS

Thirty-five pregnancies with severe fetal hydrothorax treated with PAS were evaluated. Median gestational age at PAS was (weeks + days) 31+2 (range, 26+0-36+1). Two (5.7%) and 7 (20.0%) cases delivered within the first 24 h and 1 week after PAS, respectively. Ten (28.6%) women had a short cervix before PAS, while 25 (71.4%) had normal preoperative CL. Women with a short cervix showed lower mean interval between fetal intervention and delivery (2.4 vs. 5.5 weeks, p = 0.01), and higher prevalence of PPROM (50 vs. 12%, p = 0.01), as compared to women with a nonshort cervix. Preoperative short cervix was associated with significantly higher risk of delivery within the first 24 h (20.0 vs. 0%, respectively, p < 0.05) and 1 week after PAS (50.0 vs. 8.0%, respectively, p < 0.01) compared with pregnancies with normal preoperative CL.

CONCLUSION

In pregnancies with severe fetal hydrothorax candidates for pleuroamniotic shunt, identification of a short cervix before fetal intervention can predict delivery within 1 week after the surgical procedure.

Placental Chorioangioma with Nonimmune Hydrops Fetalis

A 38-year-old woman was found to have a large placental chorioangioma. The fetus was studied using ultrasound. The pregnancy became complicated by hydrops fetalis, polyhydramnios, and abruptio placenta. The infant delivered at 29 weeks' gestational age. The neonatal course was complicated by nonimmune hydrops fetalis, respiratory distress syndrome, anemia, pulmonary hemorrhage, intraventricular hemorrhage, necrotizing enterocolitis, and bronchopulmonary dysplasia. The infant was discharged home with breastfeeding and off oxygen at 50 days of life. This case represents the multidisciplinary approach to the pregnancy complicated by a large placental chorioangioma and the resulting premature neonate with nonimmune hydrops fetalis.

Nonimmune hydrops fetalis: identifying the underlying genetic etiology

PURPOSE

Numerous etiologies may lead to nonimmune hydrops fetalis (NIHF), and the underlying cause often remains unclear. We aimed to determine the proportion of NIHF cases in which the etiology was clearly determined in a large, contemporary, and diverse cohort, as well as to describe the etiologies with a focus on genetic causes.

METHODS

Retrospective review of NIHF cases between 2015 and 2017 from the five University of California Fetal-Maternal Consortium sites. Singleton pregnancies with prenatally diagnosed NIHF were included, and cases with maternal alloimmunization were excluded. Cases were categorized as being of confirmed, suspected, or unknown etiology.

RESULTS

Sixty-five NIHF cases were identified. Forty-six percent (30/65) remained of unknown etiology, while 9.2% (6/65) had a suspected etiology and 44.6% (29/65) were of confirmed etiology. Among confirmed cases, 11 resulted from aneuploidy; 7 from fetal structural anomalies; 2 each from fetal arrhythmia, Noonan syndrome, and generalized lymphatic dysplasia; and 1 each from arthrogryposis, parvovirus, neonatal alloimmune thrombocytopenia, fetal goiter, and Kasabach-Merritt syndrome.

CONCLUSION

In this contemporary, multicenter study, the cause of prenatally diagnosed NIHF was confirmed in only 44% of cases, and a genetic etiology was found in only 25% of those that received standard of care genetic testing.