Refractory supraventricular fetal tachycardia as a cause of non-immune hydrops: management conundrum

Supraventricular tachyarrhythmia (SVT) is the most common form of fetal tachyarrhythmias. The presentation can vary from ill-defined, non-sustained episodes of tachyarrhythmia to frank non-immune hydrops. The standard of care is transplacental therapy by treating the mother with oral antiarrhythmic drugs, followed by direct fetal therapy in refractory cases. We report a case of primigravida in her late 20s, who presented at 28.1 weeks of gestation with fetal hydrops and SVT. She was initially managed with oral digoxin and flecainide, but due to worsening hydrops, risk of fetal demise and extreme prematurity, further management by direct fetal therapy was given in terms of intramuscular digoxin and intraperitoneal flecainide. Following which, the fetus had a favourable outcome. This case highlights the possible role of direct fetal therapy in refractory cases of SVT.

Prenatally Diagnosed Large Lung Lesions: Timing of Resection and Perinatal Outcomes

INTRODUCTION

Fetuses with large lung lesions including congenital cystic adenomatoid malformations (CCAMs) are at risk for cardiopulmonary compromise. Prenatal maternal betamethasone and cyst drainage for micro- and macrocystic lesions respectively have improved outcomes yet some lesions remain large and require resection before birth (open fetal surgery, OFS), at delivery via an Ex Utero Intrapartum Treatment (EXIT), or immediately post cesarean section (section-to-resection, STR). We sought to compare prenatal characteristics and outcomes in fetuses undergoing OFS, EXIT, or STR to inform decision-making and prenatal counseling.

METHODS

A single institution retrospective review was conducted evaluating patients undergoing OFS, EXIT, or STR for prenatally diagnosed lung lesions from 2000 to 2021. Specimens were reviewed by an anatomic pathologist. Lesions were divided into "CCAMs" (the largest pathology group) and "all lung lesions" since pathologic diagnosis is not possible during prenatal evaluation when care decisions are made. Prenatal variables included initial, greatest, and final CCAM volume-ratio (CVR), betamethasone use/frequency, cyst drainage, and the presence of hydrops. Outcomes included survival, ECMO utilization, NICU length of stay (LOS), postnatal nitric oxide use, and ventilator days.

RESULTS

Sixty-nine percent (59 of 85 patients) of lung lesions undergoing resection were CCAMs. Among patients with pathologic diagnosis of CCAM, the initial, largest, and final CVRs were greatest in OFS followed by EXIT and STR patients. Similarly, the incidence of hydrops was significantly greater and the rate of hydrops resolution was lower in the OFS group. Although the rate of cyst drainage did not differ between groups, maternal betamethasone use varied significantly (OFS 60.0%, EXIT 100.0%, STR 74.3%; p = 0.0378). Notably, all OFS took place prior to 2014. There was no difference in survival, ventilator days, nitric oxide, NICU LOS, or ECMO between groups. In multiple variable logistic modeling, determinants of survival to NICU discharge among patients undergoing resection with a pathologic diagnosis of CCAM included initial CVR <3.5 and need for <3 maternal betamethasone doses.

CONCLUSION

For CCAMs that remain large despite maternal betamethasone or cyst drainage, surgical resection via OFS, EXIT, or STR are viable options with favorable and comparable survival between groups. In the modern era there has been a shift from OFS and EXIT procedures to STR for fetuses with persistently large lung lesions. This shift has been fueled by the increased use of maternal betamethasone and introduction of a Special Delivery Unit during the study period and the appreciation of similar fetal and neonatal outcomes for STR vs. EXIT and OFS with reduced maternal morbidity associated with a STR. Accordingly, efforts to optimize multidisciplinary perinatal care for fetuses with large lung lesions are important to inform patient selection criteria and promote STR as the preferred surgical approach in the modern era.

LEVEL OF EVIDENCE

Level IV.

Treatment of severe fetal Ebstein's anomaly with prenatal non-steroidal anti-inflammatory therapy

INTRODUCTION

Prenatally diagnosed Ebstein's anomaly with tricuspid valve dysplasia (EA/TVD) is a rare and high-risk congenital heart malformation with limited effective treatments. We report a case of severe fetal EA with hydrops treated with modest doses of non-steroidal anti-inflammatory drug (NSAID) therapy, resulting in reversal of hydrops and a favorable fetal outcome.

CASE PRESENTATION

Fetal heart defects included an inferiorly displaced tricuspid valve, severe tricuspid regurgitation, significantly dilated right atrium, and hypoplastic pulmonary valve with moderate regurgitation resulting in a circular shunt across the ductus arteriosus. Maternal indomethacin therapy was initiated at 31+5 weeks gestation due to the development of fetal hydrops as demonstrated by the presence of a pericardial effusion and ascites. Indomethacin therapy resulted in the desired restriction of the ductus arteriosus and resolution of fetal hydrops. Maternal therapy was transitioned to ibuprofen and serial fetal echocardiograms ensured continued ductal restriction. Delivery occurred via cesarean at 36+3 weeks. The neonate did not require immediate cardiac surgical intervention and was discharged home with close follow-up.

DISCUSSION/CONCLUSION

A lower dose of prenatal NSAID therapy effected successful ductal restriction and hemodynamic mitigation of the circular shunt, resulting in reversal of hydrops and avoidance of postnatal cardiac surgical intervention.

Congenital syphilis with hydrops fetalis: report of four cases in a general referral hospital in Bogota, Colombia between 2016- 2020

Objective

To report four cases of hydrops fetalis secondary to congenital syphilis and carry out a review of the literature to answer the question, What is the antibiotic regimen used in cases of gestational syphilis with hydrops fetalis as a complication?

Materials and Methods

Four cases of congenital syphilis with hydrops fetalis are presented. Maternal age ranged between 17 and 28 years, gestational age at the time of diagnosis varied between 25 and 30 weeks, and two of the mothers had not initiated prenatal care at that time. Treatment with crystalline penicillin for gestational syphilis was given immediately 6 to 12 weeks before delivery in three cases and partners were prescribed treatment with benzathine penicillin. As for the neonates, two had no active infection or sequelae and one of them was considered to have congenital syphilis based on non-treponemal test titers. In one case, the patient was unable to receive syphilis treatment before delivery and her newborn had signs of active infection. A review of the literature was conducted in the Medline, LILACS and Google Scholar databases using the search terms “hydrops fetalis,” “Lues”, “syphilis – prenatal diagnosis - ultrasound - penicillin – treatment”. The search included case reports and case series or cohorts of newborns with gestational syphilis and hydrops fetalis. Information regarding treatment in the mothers and in the newborns was extracted.

Results

Overall, 119 articles were identified. Of these, 13 met the inclusion criteria, three were discarded because the full text could not be accessed. Ten studies with a total of 16 reported cases of hydrops fetalis secondary to congenital infection were reported. Of these, three presented with severe fetal anemia and required intrauterine transfusion; 5 cases received intrauterine penicillin treatment. In four cases the mother received weekly intramuscular injections of benzathine penicillin for 3 weeks, one received additional intravenous crystalline penicillin for 13 days, while another one received intravenous crystalline penicillin for 14 days. Treatment during gestation was not given in a total of 11 cases; and 6 of the 16 cases (37.5%) resulted in perinatal death.

Conclusion

Delays in prenatal care and late diagnosis and treatment of gestational syphilis are important causes of persistent congenital syphilis. Randomized studies are required to identify the best treatment in fetuses with congenital syphilis 30 days before delivery and in fetuses with systemic compromise during the second half of gestation.

Resolution of Fetal Hydrops Dependent on Sustained Fetal Supraventricular Tachycardia after Digoxin Therapy

We present a special case of fetal supraventricular tachycardia detected at 34 weeks gestation. Fetal hydrops was noted on ultrasound upon admission. Normal fetal heart rate was maintained for three weeks by maternal administration of digoxin. A live infant was delivered via caesarian section at 37 weeks gestation. This clinical case demonstrated that pharmacological treatment can be effective and helps to prolong pregnancy safely.

Sotalol as an effective adjunct therapy in the management of supraventricular tachycardia induced fetal hydrops fetalis

Sustained fetal supraventricular tachycardia (SVT) complicated by hydrops fetalis carries a significant risk of morbidity and mortality. While there is no clear consensus on first- and second-line therapy options for the management of fetal SVT with or without hydrops fetalis, there exists significant nonrandomized experience with a number of antiarrhythmic agents that has founded the basis for management. Furthermore, recently published meta-analyses and ongoing multicenter prospective studies have aimed to bridge the gap in the literature. We report two cases of sustained fetal SVT with severe secondary hydrops fetalis managed successfully with flecainide-sotalol combination therapy in one case and sotalol-digoxin combination therapy in the second and review the literature for the management of fetal SVT.

Resolution of hydrops fetalis caused by atrioventricular block: good postnatal evolution with terbutaline treatment

INTRODUCTION

Complete atrioventricular block (CAVB) is rarely seen, as it occurs in only 1:11 000 to 1:20 000 newborns. There is a serious risk of mortality in CAVB, mainly in those cases associated with hydrops, fetal cardiac frequency ≤ 55 beats/minute, and premature delivery.

CASE REPORT

Case of complete atrioventricular block with a poor prognosis (hydrops fetalis and foetal cardiac frequency < 5 beats/minute) caused by anti-La and anti-Ro antibodies. Intrauterine symptoms improved after treatment with terbutaline, permit- ting foetal viability and successful postnatal treatment with a cardiac pacemaker.

DISCUSSION

In case of complete atrioventricular block of cause autoimmune with poor prognosis should be treated with positive inotropic drugs, anticholinergics or b-mimetic in the attempt to maintain adequate ventricular frequency, and thus prevent hydrops fetalis from occurring.

Microcystic congenital pulmonary airway malformation with hydrops fetalis: steroids vs open fetal resection

BACKGROUND/PURPOSE

Congenital pulmonary airway malformations (CPAM) are rare lesions often diagnosed during routine prenatal ultrasound. The presence of hydrops fetalis is an indicator of poor prognosis. Here we present a retrospective review of fetuses undergoing either open fetal surgery or steroids for predominantly microcystic CPAM with hydrops fetalis.

METHOD

A retrospective review of patients undergoing open fetal surgery or steroids for CPAM at our institution was performed. The primary outcome was survival.

RESULTS

A retrospective review of all patients referred to our institution with the diagnosis of CPAM was performed. Fetuses with predominantly microcystic CPAM and the presence of hydrops fetalis treated with steroid or surgery were included. Thirteen patients were treated with steroids, and 11 patients underwent open fetal surgery. In the steroid group 12 (92%) of 13 fetuses survived to delivery versus 9 (82%) of 11 in the open fetal surgery group. Only 5 (56%) of 9 of the patients in the open fetal surgery group survived to neonatal discharge compared to 10 (83%) of 12 in the steroid group.

CONCLUSIONS

In the present retrospective study, improved survival was seen in fetuses with hydrops fetalis and predominantly microcystic CPAM treated with steroids when compared with open fetal surgery. Steroids should be considered for first-line therapy in these cases.

Perinatal treatment of refractory atrial flutter with hydrops fetalis: a case report

OBJECTIVE

Highlight the management of a critically ill premature hydropic baby with refractory atrial flutter (AF) and successful outcome without neurologic sequel at 1 year of follow-up.

CASE

A 23-year-old pregnant woman, G1PO, presented with fetal tachycardia at 32 weeks.

RESULTS

Ultrasound revealed a hydropic fetus with fetal atrial rate (FHR) of 440 bpm and A:V block of 2:1. Transplacental therapy resulted in a temporary response with the combination of digoxin and flecainide, and subsequently digoxin plus sotalol. Termination of pregnancy at 34 weeks was performed for postnatal treatment, giving birth to a premature hydropic baby, weighing 3320 grams. At birth flecainide failed to control the AF Therefore, intravenous adenosine was started and successful conversion to normal sinus rhythm was temporally achieved. Finally, conversion to normal sinus rhythm with amiodarone plus digoxin was satisfactorily achieved and then long-term control with only oral flecainide. The hydropic signs gradually disappeared without any significant sequelae. The baby was healthy at one year of follow-up without any neurological sequelae.

CONCLUSION

This case may be evidence that combined therapy with amiodarone and digoxin is probably effective in treatment of refractory AF with hydropic changes, at least in some cases.

Prenatal management with digoxin and sotalol combination for fetal supraventricular tachycardia: case report and review of literature

Sustained fetal supraventricular tachycardia (SVT) with a heart rate of approximately 210 bpm may lead to increased atrial and venous pressures and congestive heart failure. There is no clear consensus regarding the best drug-treatment regimens for fetal SVT. However, considerable nonrandomized experience in the transmaternal treatment of fetal SVT is available with a number of antiarrhythmic agents. We report a case of fetal supraventricular tachyarrhythmia with hydrops detected at 32 weeks that was managed with combination of oral digoxin and sotalol and review management guidelines available in the literature.

Can digoxin and sotalol therapy for fetal supraventricular tachycardia and hydrops be successful? A case report

BACKGROUND

Neonatal survival and prognosis are closely linked with development of hydrops in cases of sustained fetal tachycardia. Several antiarrhythmic medications are available for conversion to sinus rhythm.

CASE

An 18-year-old woman had an audible fetal arrhythmia at 25 weeks' gestation. Fetal echocardiography revealed supraventricular tachycardia with worsening cardiac function at 28 weeks. Digoxin therapy was initiated and sotalol was later added for new-onset hydrops. The medications were then adjusted, and the fetus' heart rate converted to sinus rhythm with resolution of the hydrops. The patient was then managed as an outpatient with antenatal testing, serial laboratory studies and electrocardiograms until 39 weeks.

CONCLUSION

Digoxin and sotalol therapy can be successful in blocking likely nodal reentry in sustained fetal supraventricular tachycardia, thus allowing resolution of hydrops with a favorable outcome.

[Treatment of foetal supraventricular tachycardia with antiarrhythmic medication administered through the umbilical vein]

Foetal supraventricular tachycardia (SVT) with hydrops foetalis is associated with a high morbidity and mortality rate. If SVT with hydrops foetalis persists despite transplacental therapy, direct foetal treatment can be initiated. One foetus was found to have SVT with hydrops foetalis during the 29th week of pregnancy, and the condition persisted despite transplacental treatment. Amiodarone was administered directly via the umbilical vein, and the SVT resolved. A second foetus was found to have SVT with hydrops foetalis during the 28th week of pregnancy. The condition persisted despite maternal antiarrhythmic medication. Direct treatment of the foetus with amiodarone was successful. Amiodarone is the treatment of choice for direct foetal therapy for SVT, and can be administered safely via the umbilical vein. Direct foetal therapy should be considered for the treatment of foetal SVT with hydrops foetalis that occurs in the first 31 weeks of pregnancy and persists despite adequate transplacental therapy.

Effect of Maternal Betamethasone Administration on Prenatal Congenital Cystic Adenomatoid Malformation Growth and Fetal Survival

OBJECTIVE

To evaluate the effect of prenatal steroid treatment on the growth of congenital cystic adenomatoid malformations (CCAM) and survival in affected fetuses not amenable to other percutaneous ultrasound-guided prenatal interventions.

METHODS

A retrospective review of patients with a CCAM or hybrid lesion treated with two maternal prenatal betamethasone injections was performed. Patients receiving cyst aspiration or thoracoamniotic shunting at the time of or after steroid administration were excluded. Growth rates and survival data were compared to historical non-steroid treated controls.

RESULTS

Eleven patients were treated with prenatal steroids (10 microcystic and 1 macrocystic). Survival was 100% in fetuses with hydrops (5/5) or a CCAM volume ratio (CVR) >1.6 (7/7) at the time of steroid administration. This compares to a mortality of 100 and 56.2% respectively in historical non-treated controls. Resolution of hydrops was seen in 80% (4/5) of steroid-treated patients. CCAM growth rates were variable after steroid administration. However, when compared to historical data where CVR and CCAM volume have been documented to increase until 28 weeks' gestation, the CVR and CCAM volume growth rates decreased in 72.73% and 50% of patients respectively from the time of steroid administration to 28 weeks' gestation.

CONCLUSIONS

In the fetus with a CCAM, the presence of hydrops fetalis or a CVR >1.6 is indicative of poor fetal outcome without prenatal intervention. The observed effect of antenatal steroid treatment on CCAM growth is variable, but its potential to improve survival in these high-risk groups is encouraging and warrants further controlled evaluations.

Alcohol Injection for the Intrauterine Treatment of Chorioangioma in a Pregnancy with Transfusion Resistant Fetal Anemia: A Case Report

Chorioangiomas are usually small, clinically inevident, benign vascular lesions of the placenta, but larger ones may cause serious perinatal and neonatal complications. There is need for in utero intervention in these fetuses. Several interventions are described to relieve pathophysiologic insult on fetus. Alcohol injection is one of the therapeutic interventions. In this case, we present a patient with chorioangioma and early onset of hydrops fetalis and polyhydramnios at 24th week of gestation. Successful intratumoral injection of absolute ethyl alcohol relieved hydrops fetalis and polyhydramnios. Unfortunately, pregnancy ended at 28th week and a 1,330 g fetus was delivered.

Prenatal diagnosis and management for a large fetal cardiac tumor complicated with hydrops fetalis

Fetal cardiac tumor is a rare disease, and its prognosis varies in relation to the complications such as arrhythmia and out-flow obstruction. Hydrops fetalis is one of severe complications that result in an unfavorable outcome. A case is presented herein of a large fetal cardiac tumor diagnosed at 28 weeks gestation. At 30 weeks gestation, the fetus complicated with hydrops fetalis because of impaired cardiac function. Increased peak systolic velocity in the ascending aorta and marked reversed flow in the ductus venosus were observed. Oral digoxin therapy was administered to the mother as a cardiotonic agent and the hydropic condition was immediately diminished. After normal delivery, the cardiac tumor gradually decreased in size and the infant developed normally, but required an antiarrhythmic drug. The case indicates that the in utero digoxin therapy could be a choice for hydrops fetalis caused by cardiac tumor.

Atrioventricular block detected in fetal life: associated anomalies and potential prognostic markers

OBJECTIVES

To assess the spectrum of anomalies associated with fetal heart block and to identify possible prognostic markers.

METHODS

Retrospective review of all cases of second- or third-degree heart block identified in two tertiary referral centers in Germany (Bonn and Lübeck) and one in the USA (Baltimore).

RESULTS

Sixty fetuses with heart block were identified in the study period. Thirty-two had complex cardiac malformations, 31 of them associated with left isomerism. The outcomes of these fetuses were 22 terminations of pregnancy (TOP), three intrauterine fetal deaths (IUFD), three neonatal deaths (NND), two childhood deaths (CD) and there were two survivors. In 20 cases without complex cardiac malformations maternal antinuclear-antibodies were detected. Their outcomes were 2 TOP, 1 IUFD, 1 NND and 16 survived. The remaining eight cases had neither complex cardiac malformations nor associated maternal antibodies. Their outcomes were 1 TOP, 2 IUFD, 2 NND and 3 survived. After exclusion of terminated cases, hydrops as well as the presence of cardiac defects was significantly associated with non-survival (P < 0.01). The cardiothoracic circumference ratio was significantly higher in hydropic fetuses and significantly negatively correlated with survival in immune-mediated cases (P < 0.01). Atrial and ventricular frequencies and their evolution did not accurately predict fetal or neonatal outcome. Sympathomimetic treatment in seven cases was not associated with favorable fetal outcome in cases of hydrops or cardiac malformations.

CONCLUSIONS

The most important marker predicting adverse outcome in cases of heart block is fetal hydrops, followed by the association with complex cardiac malformations. Cases without cardiac malformations have a significantly better prognosis, especially in the absence of severe cardiomegaly.

Antenatal Treatment of Chylothorax and Cystic Hygroma with OK-432 in Nonimmune Hydrops fetalis

OBJECTIVES

To present our experience of using OK-432 in treating fetal cystic hygroma and chylothorax complicated with nonimmune hydrops fetalis.

METHODS

OK-432 (Picibanil) was injected into the fetal pleural cavity or fetal cystic hygroma.

RESULTS

Patient 1: A 23-year-old, gravida 2, para 1, was found to have a recurrent fetal chylothorax at GA 29 weeks. Serial amnioreduction and thoracocentesis was performed at GA 31, 32, 33, and 34 weeks. Intrapleural OK-432 injection was performed twice at GA 33 and 34 weeks. Cyanosis and respiratory distress were noted immediately after birth (GA 34 weeks). The baby expired despite of aggressive neonatal resuscitation. Patient 2: A 26-year-old, gravida 2, para 1, was found to have a cystic hygroma of her fetus at GA 17 weeks. Karyotype of the cystic fluid and the amniocytes were 46, XY. Fetal ascites developed at GA 22 weeks. OK-432 injection into the tumour was performed at GA 23 weeks. Stabilization of the cystic hygroma was noted throughout the pregnancy (about 3.5 cm in diameter). Serial fetal paracentesis and/or amnioreduction were performed. Karyotype of the ascites was again 46, XY. Maternal dietary modification with medium chain triglyceride was also prescribed. Chylothorax developed and the baby was born by cesareans at GA 32 weeks. Resolution of pleural effusion, ascites, and regression of cystic hygroma were noted since the 2nd day after birth. The baby had survived beyond 4 months of age at submission.

CONCLUSION

Combination of antenatal OK-432 injection, maternal dietary modification, serial thoracocentesis plus paracentesis, together with amnioreduction and tocolysis, appeared to contribute to the success of antenatal treatment. Fetal pulmonary expansion may determine the immediate neonatal survival.

Unexpected intrauterine death following resolution of hydrops fetalis after betamethasone treatment in a fetus with a large cystic adenomatoid malformation of the lung

Without intervention, the development of hydrops fetalis secondary to cystic adenomatoid malformation of the lung (CAML) implies a 100% mortality rate. Conversely, four CAML cases with in-utero resolution of hydrops fetalis after prenatal betamethasone therapy with good clinical outcome have been reported in the literature. The mechanism is speculated to be the effect of corticosteroid in improving lung maturation. Here we present another CAML case with resolution of hydrops fetalis after prenatal betamethasone therapy but which was followed by later intrauterine death. We speculate that the resolution of the CAML lesion itself may be more important in determining the clinical outcome than the resolution of hydrops. The association between prenatal betamethasone therapy and resolution of hydrops may be related to a different mechanism other than improvement of lung maturation.

Neurological outcome of children who were treated for fetal tachycardia complicated by hydrops

OBJECTIVE

Fetal tachycardia is a condition associated with congestive heart failure and development of fetal hydrops, which may result in neurological morbidity and mortality. The aim of this study was to investigate the long-term outcome of hydropic fetuses.

METHODS

This was a retrospective study on cognitive and neurological functioning of 11 infants, aged 6 months to 12 years, who experienced fetal tachycardia complicated by hydrops.

RESULTS

Seven fetuses had supraventricular tachycardia (SVT), three had atrial flutter (AF) and one had ventricular tachycardia (VT). Nine fetuses converted to sinus rhythm within a mean time of 8.2 days of presentation; resolution of hydrops was achieved in six of these patients in a mean time of 8.8 days. Mean gestational age (GA) at birth was 35 + 4 weeks. Neonatal cranial ultrasound was normal in seven infants and all but one of these were normal at follow-up: one infant who initially had no abnormalities developed multiple cerebral lesions as a result of a malignant long QT syndrome (LQTS) and died at the age of 2 years. Three infants had periventricular echogenicity (PVE) on neonatal cranial ultrasound, associated with a pseudocyst in one infant. The remaining infant showed a parenchymal hemorrhage of antenatal onset, seen as a porencephalic cyst at birth. One of these infants was normal at follow-up, one died 2 days after birth and two infants had neurological abnormalities at follow-up, consisting of mild hemiplegia with normal cognitive function in one, and a cognitive developmental delay in the other.

CONCLUSIONS

In this study, neurological outcome was good in eight out of 11 infants. Initiation of therapy should not be withheld or delayed on the assumption of poor neurological outcome.

Role of amiodarone in the treatment of fetal supraventricular tachyarrhythmias and hydrops fetalis

We report three consecutive hydropic fetuses with fetal tachyarrhythmias treated with amiodarone-two in combination with digoxin and one with digoxin, procainamide, and propranolol. Sinus rhythm was achieved in one case and ventricular rate control was achieved in two cases. All fetuses treated with amiodarone gradually improved. Observed side effects of amiodarone were a maternal rash in one mother and transient neonatal hypothyroidism in one infant. We conclude that amiodarone might be effective and safe for fetal tachyarrhythmias and impending hydrops. The small number of patients suggests that a multicenter cooperative approach is required in order to determine if this is correct.

Fetal supraventricular tachycardia diagnosed and treated at 13 weeks of gestation: a case report

Supraventricular tachycardia (SVT) is the most commonly encountered clinically significant tachycardia in the fetus. When SVT is sustained, congestive heart failure and fetal hydrops may ensue, due to both systolic and diastolic dysfunction. Sonographic diagnosis is usually incidental during the second or third trimester. Treatment goals are cardioversion to sinus rhythm and reversal of cardiac dysfunction. We describe a case of fetal SVT diagnosed at 13 weeks of gestation. Treatment with digoxin and flecainide was successful; the heart rate returned to sinus rhythm within one day, and fetal hydrops resolved within 8 days of treatment. We suspect that as more first-trimester examinations are performed, more cases with SVT will be diagnosed. We discuss the treatment protocol, and suggest that co-administration of two drugs that act synergistically may be more efficient than monotherapy, which is currently used as the first line of treatment. In addition, we discuss the potentially deleterious effect of heart failure encountered at an early developmental stage on the central nervous system. More data need to be collected in order to substantiate a clear recommendation regarding optimal management.

Resolution of hydrops fetalis in congenital cystic adenomatoid malformation after prenatal steroid therapy

BACKGROUND/PURPOSE

Development of hydrops fetalis in fetuses with congenital cystic adenomatoid malformations (CCAM) is a significant risk factor for fetal or neonatal demise. In rare cases, resolution of CCAM has occurred, presumably owing to lesion maturation or involution. Steroid therapy, utilized for lung maturity, has been postulated to accelerate this process. The natural history of hydropic fetuses with CCAM after receiving steroid therapy is presented.

METHODS

The authors prospectively followed up with 3 patients who had antenatally diagnosed CCAM and nonimmune hydrops fetalis with predicted mortality. All patients declined or were not candidates for fetal intervention and were treated with standard prenatal betamethasone to increase lung maturity.

RESULTS

Three fetuses had CCAM and nonimmune hydrops fetalis diagnosed prenatally. After a course of prenatal steroids during the second trimester, all 3 patients had resolution of their hydrops and were delivered at term without respiratory distress.

CONCLUSIONS

Nonimmune hydrops fetalis in fetuses with congenital cystic adenomatoid malformation is a harbinger for fetal demise. The resolution of hydrops in these patients after receiving steroid therapy is an interesting and compelling observation. Because the mechanism of this process is speculative, further studies are needed to elucidate the relationship between antenatal steroids and maturation of congenital cystic adenomatoid malformation.

Successful treatment of supraventricular tachycardia exhibiting hydrops fetalis with flecainide acetate. A case report

BACKGROUND

The efficacy of flecainide acetate for the treatment of fetal supraventricular tachycardia with hydrops fetalis and changes in venous blood flow patterns in the fetus during treatment are reported.

CASE

Oral flecainide administration was started at 30 weeks of gestation. Cardioversion was achieved 6 days after treatment. Sustained abnormal venous Doppler indices were shown and complete normalization of venous returns was observed 6 days after cardioversion. A vigorous male baby was born, and he is now 1 year of age and in good condition with no medication.

CONCLUSION

Reversible cardiac dysfunction was observed even after cardioversion in the fetus with supraventricular tachycardia, which could be assessed precisely by venous Doppler analysis.

Fetal supraventricular tachycardia: a role for amiodarone as second-line therapy?

OBJECTIVE

The aim of this study was to evaluate the role of amiodarone for the prenatal treatment of hydropic fetuses with supraventricular tachycardia.

METHODS

A group of 26 hydropic fetuses with supraventricular tachycardia was studied retrospectively.

RESULTS

Twenty-five fetuses received transplacental treatment. The overall prenatal conversion rate was 60%. Nine fetuses were converted to sinus rhythm using either flecainide (n = 7) or amiodarone (n = 2) as first line therapy, whilst digoxin alone or in association with sotalol failed to restore sinus rhythm in all cases. After first-line therapy, supraventricular tachycardia persisted in 10 fetuses. Nine fetuses received amiodarone alone or in association with digoxin as second-line therapy, five of whom were converted to sinus rhythm. Among the 11 live neonates treated by amiodarone in utero, 2 (17%) presented an elevated thyroid stimulating hormone at day 3-4. These two infants received thyroid hormone substitution therapy and had a normal outcome.

CONCLUSION

When first-line therapy fails to restore sinus rhythm in hydropic fetuses with supraventricular tachycardia, amiodarone therapy should be considered as it allows a substantial number of fetuses to be converted prenatally.

[Protocols for the treatment of supraventricular tachycardias in the fetus]

The protocols mentioned are used by Utrecht University Hospital for the treatment of foetal supraventricular tachycardias. In the case of atrial flutters the pregnant woman is treated with sotalol administered orally and, if no sinus rhythm is obtained nor a reduced ventricular rhythm occurs, subsequently with digoxin. If there is no hydrops foetalis then this is also the treatment regimen for other forms of foetal supraventricular tachycardia. In the case of hydrops foetalis the treatment is more aggressive: digoxin intravenously or flecanide orally; if the rhythm does not convert into a sinus rhythm nor a reduced ventricular rhythm occurs then both of these medications are administered; if that also proves to be insufficient then direct foetal therapy can be considered.

The resolution of fetal hydrops using combined maternal digoxin and dexamethasone therapy in a case of isolated complete heart block at 30 weeks gestation

The development of hydrops fetalis in cases of isolated complete heart block is associated with a very poor prognosis. Various pharmacological strategies have been proposed, involving both direct fetal access and transplacental therapy, with inconsistent results in small numbers of subjects. The optimal antenatal management will remain uncertain until multicentre controlled trials are organised. We report the complete resolution of fetal hydrops at 30 weeks of gestation using combination of maternal digoxin and dexamethasone therapy, despite persistence of the complete heart block. A Caesarean section was performed at 37 weeks of gestation due to evidence of fetal intrauterine growth restriction. The baby girl is now 8 months of age and remains well, with a heart rate of 45-50 beats per minute on no medication and without pacing.

Adenosine triphosphate for cardioversion of supraventricular tachycardia in two hydropic fetuses

OBJECTIVE

We performed a retrospective study to check the effectiveness of adenosine triphosphate (Striadyne) for cardioversion of fetal supraventricular tachycardia (SVT) and to evaluate neonatal outcome after prenatal treatment of severe SVT with fetal hydrops.

METHODS

Two hydropic fetuses with SVT were treated with Striadyne injection into the umbilical vein, as an additional treatment to the digoxin given intravenously to the mother. Both fetuses were in severe condition, with ultrasound, Doppler and laboratory signs of fetal distress and congestive heart failure.

RESULTS

Sinus rhythm was obtained in both cases for different periods of time, without side effects of Striadyne. The children survived. There were severe cardiac and neurologic problems after delivery.

CONCLUSIONS

Striadyne was an effective drug in converting SVT to the sinus rhythm in hydropic fetuses. Digoxin was useless in these fetuses in spite of the therapeutic level which was obtained in both mothers. We suppose that fetal SVT causing fetal hydrops could be the reason of brain damage, and intensive antiarrhythmic treatment seemed to be necessary.

Two cases of atrial flutter with fetal hydrops: successful fetal drug therapy

We describe two cases of fetal atrial flutter associated with severe fetal hydrops which were unresponsive to digoxin but were successfully treated with flecainide acetate. Two cases of fetal atrial flutter were identified in fetuses with severe fetal hydrops on 3rd trimester ultrasonogram(28 weeks' gestation and 30 weeks' gestation). Following failed digoxin monotherapy, flecainide acetate was added to digoxin. On the 7th day and 13th day after combined therapy, fetal heart rate converted to normal sinus rhythm without recurrence. Our cases showed that the combined therapy of digoxin and flecainide acetate can effectively treat fetal atrial flutter associated with fetal hydrops unresponsive to digoxin monotherapy.

Successful prenatal digoxin therapy for Ebstein's anomaly with hydrops fetalis. A case report

BACKGROUND

Ebstein anomaly is a rare tricuspid valve anomaly. Some fetuses with Ebstein's anomaly have concurrent severe cardiac function impairment, which results in hydrops fetalis. Most of these fetuses are inevitably terminally ill. No reports have demonstrated the potential prenatal therapy for fetuses under such conditions.

CASE

Ebstein's anomaly and hydrops fetalis were detected at 28 weeks' gestation. Tricuspid regurgitation with congestive heart failure was observed. From 28 to 34 weeks' gestation, intrauterine therapy with digoxin, 0.75 mg/d, was administered. The fetal hydrops status improved gradually, while the tricuspid valve regurgitation persisted. At 36 weeks' gestation the fetus was delivered normally. During the neonatal phase, digoxin was continued and gradually tapered off. The tricuspid valve regurgitation and cardiomegaly gradually improved.

CONCLUSION

The favorable outcome in this case supports the positive effect of prenatal digoxin therapy for Ebstein's anomaly with hydrops fetalis. In such conditions, upon the appearance of hydrops and congestive cardiac failure, immediate digoxin therapy may be useful. This successful trial encouraged us to manage such fetuses more aggressively.

Congenital cystic adenomatoid malformation of the lung and fetal hydrops--a case with favourable outcome

We present a case of congenital cystic adenomatoid malformation of the lung (CCAM) diagnosed at 23 weeks of gestation with concomitant fetal hydrops. The sonographical picture of CCAM disappeared in the third trimester of pregnancy and fetal hydrops resolved under medication with digitalis to the mother. The neonate showed mild dyspnea; the prenatal diagnosis of CCAM was confirmed by chest X-ray and computed tomography. The affected lung segments were dissected at 5 days of age. The diagnosis of CCAM type III was confirmed histologically.

Ultrasound recognition and treatment of fetal supraventricular tachycardia with hydrops: a case report

To manage fetal tachyarrhythmia induced hydrops, both a correct diagnosis and adequate intrauterine therapy are fundamentally important. We present a 32-week-gestational-age hydropic fetus with supraventricular tachycardia who responded dramatically after transplacental administration of high dose digoxin (1 mg intravenously daily). The baby was born at 36 weeks' gestation followed by a successful postnatal conversion. Prenatal fetal echocardiography is emphasized in determining appropriate treatment and monitoring fetal well-being which in this case resulted in a good outcome.

Fetal tachycardias: management and outcome of 127 consecutive cases

OBJECTIVE

To review the management and outcome of fetal tachycardia, and to determine the problems encountered with various treatment protocols.

STUDY DESIGN

Retrospective analysis.

SUBJECTS

127 consecutive fetuses with a tachycardia presenting between 1980 and 1996 to a single tertiary centre for fetal cardiology. The median gestational age at presentation was 32 weeks (range 18 to 42).

RESULTS

105 fetuses had a supraventricular tachycardia and 22 had atrial flutter. Overall, 52 fetuses were hydropic and 75 non-hydropic. Prenatal control of the tachycardia was achieved in 83% of treated non-hydropic fetuses compared with 66% of the treated hydropic fetuses. Digoxin monotherapy converted most (62%) of the treated non-hydropic fetuses, and 96% survived through the neonatal period. First line drug treatment for hydropic fetuses was more diverse, including digoxin (n = 5), digoxin plus verapamil (n = 14), and flecainide (n = 27). The response rates to these drugs were 20%, 57%, and 59%, respectively, confirming that digoxin monotherapy is a poor choice for the hydropic fetus. Response to flecainide was faster than to the other drugs. Direct fetal treatment was used in four fetuses, of whom two survived. Overall, 73% (n = 38) of the hydropic fetuses survived. Postnatally, 4% of the non-hydropic group had ECG evidence of pre-excitation, compared with 16% of the hydropic group; 57% of non-hydropic fetuses were treated with long term anti-arrhythmics compared with 79% of hydropic fetuses.

CONCLUSIONS

Non-hydropic fetuses with tachycardias have a very good prognosis with transplacental treatment. Most arrhythmias associated with fetal hydrops can be controlled with transplacental treatment, but the mortality in this group is 27%. At present, there is no ideal treatment protocol for these fetuses and a large prospective multicentre trial is required to optimise treatment of both hydropic and non-hydropic fetuses.

[Management of hemodynamically significant fetal arrhythmias]

Between January 1, 1993, and April 30, 1996, authors treated 23 fetuses with severe rhythm disturbances in their Department. The correct diagnosis was made by fetal echocardiography. They had 15 tachyarrhythmic and 8 bradyarrhythmic patients. They found hydrops fetus at 7 patients because of atrial flutter (2 fetuses), supraventricular tachycardia (4 fetuses) and severe bradycardia (1 fetus). They treated successfully 13 patients with antiarrhythmic therapy given to the mother. They had 1 intrauterine death (treated because of bradycardia) and 1 neonatal death (hydropic because of supraventricular tachycardia). The causes of severe bradycardia were maternal antibody (3 fetuses), cardiac malformation (3 fetuses) and large number of blocked atrial extrasystoles. The prognosis of fetal tachycardia is good even in cases of fetal hydrops. The prognosis of bradycardia due to heart abnormalities is poor.

In utero management of hydrops fetalis caused by critical aortic stenosis

Hydrops fetalis is rarely associated with congestive heart failure caused by obstructive left-sided heart lesions. There are rare cases of live born neonates with critical congenital valvar aortic stenosis and hydrops reported in the literature, all with fatal outcomes. This report describes, to the best of our knowledge, the first two newborns who were diagnosed prenatally to have hydrops fetalis caused by critical valvar aortic stenosis, who were treated prenatally with digoxin and who postnatally had successful percutaneous balloon aortic valvuloplasty. Both patients had not only left but right ventricular dysfunction. We speculate that right ventricular dysfunction was a contributing factor in the development of hydrops in these patients and in utero medical therapy with digoxin is associated with resolution of the hydrops before delivery.

[Fetal supraventricular tachycardia with anasarca complicating benign extrasystole: treatment with flecainide. Apropos of a case]

We report a case of fetal supraventricular tachycardia with intra-uterine cardiac failure, who complicate benign premature beats. It was treated with oral administration of flecainide acetate (Flecaine) to the mother. This treatment was rapidly effective. The fetus converted to sinus rhythm in 5 days and the ascites had completely resolved in 10 days. We conclude, that fetus with premature beats must be observed every 15 days, and we believe that flecainide acetate can be used as the "first line agent" to the fetal supraventricular tachycardias with cardiac failure.

Digitalization of the mother in treating hydrops fetalis in monochorionic twin with Ebstein's anomaly. Case report

Hydrops fetalis thought to be due to Ebstein's anomaly was seen at 22 weeks' gestation in one of two fetuses with a monochorionic placenta. Hydrops was treated with maternal digitalization and resolved by the 28th week of gestation. Hydrops did not recur while maternal digitalization continued. A clinical diagnosis of twin-to-twin transfusion syndrome required termination of the pregnancy at 33 weeks of gestation. The twin with Ebstein's anomaly died 22 hours after birth. The other twin survived and was normal at 19 months of age. Thus, administration of digitalis to the mother controlled hydrops fetalis in one fetus, and ultimately led to the survival of the healthy infant.

Direct fetal therapy for hydrops secondary to congenital atrioventricular heart block

BACKGROUND

The outcome for the fetus with hydrops fetalis secondary to complete congenital heart block is almost uniformly poor. Transplacental fetal therapy with inotropic drugs may be unreliable in the hydropic fetus. We describe our experience of direct fetal therapy with digoxin and furosemide in three cases.

CASES

In the first two cases, fetal hydrops secondary to congenital heart block was detected at 33 and 31 weeks. Direct fetal therapy with digoxin and furosemide was given and the mothers received digoxin concurrently. The neonates were born normally at 35 weeks and 33 weeks; one required ventricular pacing, but both are currently alive and well. In the third case, fetal hydrops was detected at 24 weeks, when furosemide was used alone for direct fetal therapy. The mother developed chorioamnionitis at 29 weeks and was delivered by cesarean; the infant died of cardiac failure after 48 hours.

CONCLUSION

Initial direct fetal therapy with digoxin and furosemide followed by transplacental treatment with digoxin and direct fetal therapy with diuretics might improve the perinatal salvage of hydropic fetuses with congenital heart block. Treatment must be individualized because development of infection and preterm labor might defeat the objective.

Successful treatment of recurrent non-immune hydrops secondary to fetal hyperthyroidism

BACKGROUND

Non-immune fetal hydrops is a heterogeneous disorder with a mortality rate of 50-98%. Resolution of non-immune fetal hydrops is rare but has been reported to occur spontaneously or after targeted therapeutic measures.

CASE

A euthyroid gravida with Graves disease presented with a history of three prior perinatal deaths between 26 and 28 weeks' gestation, all associated with fetal hydrops. In the current pregnancy, the fetus developed hydrops at 24 weeks' gestation. Fetal hyperthyroidism, with high-output cardiac failure, was diagnosed with fetal blood sampling. After maternal therapy with propylthiouracil, resolution of the non-immune hydrops were documented and a healthy neonate subsequently delivered to term. The neonate developed transient hyperthyroidism after delivery, which required treatment for 10 weeks.

CONCLUSION

Non-immune hydrops occurring as a result of fetal hyperthyroidism with high output cardiac failure is treatable with propylthiouracil.

Successful outcome of idiopathic nonimmune hydrops fetalis treated by maternal digoxin

Nonimmune hydrops fetalis (NIHF), occurring in 1 in 2,500-3,000 live births has a reported mortality rate of 50-98%. A similar mortality rate for intrauterine death of fetuses with NIHF probably exists. Many fetal pathological entities have been implicated as causing the condition, but to date, treatment has only been found for cases of fetal tachycardia complicated with hydrops. During a routine ultrasonographic survey of a woman at 32 weeks of gestation, we detected a fetus with severe ascites. There was no apparent etiology, and although no tachycardia was evident, low dosage transplacental digoxin therapy was immediately initiated. The hydropic condition completely resolved within 17 days and at 39 weeks of gestation, a perfectly normal baby was born after a spontaneous and uneventful labor. This is the first report of successful treatment of idiopathic NIHF with maternal digoxin.

[Nonimmune fetal edema]

The authors present the diagnosis and treatment of a fetus with hydrops secondary to severe maternal anemia. The mother was treated with blood transfusion, digoxin, spironolactone, iron and folic acid. In the two weeks of treatment the hydrops was controlled and the mother had a normal delivery at the 34th week of gestation. The newborn presented with an Apgar 7-9, Hb of 8 gm% and a normal evolution.

Prune-belly syndrome in a female, complicated by intestinal malrotation after successful antenatal treatment of hydrops fetalis

The authors report a female case of prune-belly syndrome having an antenatal sonographic diagnosis of hydrops fetalis and treated prenatally with transplacental digitalis administration. The findings of this case suggest that the clinical entity includes various phenotypes or aberrants having different origins.

Conjugated hyperbilirubinemia in a newborn infant after maternal (transplacental) treatment with flecainide acetate for fetal tachycardia and fetal hydrops

An infant with intrauterine supraventricular tachycardia and fetal hydrops, successfully treated with administration of flecainide acetate to the mother had conjugated hyperbilirubinemia shortly after birth. An extensive evaluation failed to disclose a known cause. We believe that in utero exposure to flecainide acetate resulted in conjugated hyperbilirubinemia in this infant.

[Fetal supraventricular tachycardia and nonimmune fetal hydrops]

A case of non-immunitary hydrops fetalis, following supraventricular tachycardia, in a fetus of 29 weeks of a 28-year-old woman at the first pregnancy, who evolved with systemic hypertension and amniorrhexis, being submitted to cesarean deliver. The child needed bilateral thoracic drainage and oro-tracheal intubation for treatment of respiratory failure. Treated with digoxin and diuretic, the newborn went home at the 56th day of life. The authors emphasize the importance of the intrauterine diagnosis of the arrhythmia for the success of the treatment.

Medical therapy for the hydropic fetus with congenital complete atrioventricular block

Early delivery, immediate ventricular pacing, and inotropic support have failed to improve the outcome of hydropic fetuses with congenital complete atrioventricular block. On detection of hydrops, two fetuses were treated with maternally administered digoxin and furosemide with prompt and sustained resolution of intrathoracic fluid accumulations. Clearance of serosal fluid collections may prevent pulmonary hypoplasia and improve cardiac function. Before proceeding with premature delivery in such patients, a brief trial of transplacental anti-congestive therapy is indicated.

Nonimmune hydrops fetalis associated with maternal infection with syphilis

Intrauterine infection with syphilis was diagnosed by reactive maternal serologic studies, ultrasonographic findings, and exclusion of other causes in three hydropic fetuses at 31, 34, and 35 weeks' gestation. With penicillin therapy and preterm delivery all infants survived through the perinatal period. Intrauterine infection that follows syphilis is a potentially treatable cause of nonimmune hydrops.