Parvovirus B19 in Pregnancy

Importance

Although the risk of parvovirus B19 infection during pregnancy and subsequent risk of adverse fetal outcome are low, understanding management practices is essential for proper treatment of fetuses with nonimmune hydrops fetalis. In addition, continued investigation into delivery management, breastfeeding recommendations, and congenital abnormalities associated with pregnancies complicated by parvovirus B19 infection is needed.

Objective

This review describes the risks associated with parvovirus B19 infection during pregnancy and the management strategies for fetuses with vertically transmitted infections.

Evidence Acquisition

Original articles were obtained from literature search in PubMed, Medline, and OVID; pertinent articles were reviewed.

Results

Parvovirus B19 is a viral infection associated with negative pregnancy outcomes. Up to 50% of people of reproductive age are susceptible to the virus. The incidence of B19 in pregnancy is between 0.61% and 1.24%, and, overall, there is 30% risk of vertical transmission when infection is acquired during pregnancy. Although most pregnancies progress without negative outcomes, viral infection of the fetus may result in severe anemia, congestive heart failure, and hydrops fetalis. In addition, vertical transmission carries a 5% to 10% chance of fetal loss. In pregnancies affected by fetal B19 infection, Doppler examination of the middle cerebral artery peak systolic velocity should be initiated to surveil for fetal anemia. In the case of severe fetal anemia, standard fetal therapy involves an intrauterine transfusion of red blood cells with the goal of raising hematocrit levels to approximately 40% to 50% of total blood volume. One transfusion is usually sufficient, although continued surveillance may indicate the need for subsequent transfusions. There are fewer epidemiologic data concerning neonatal risks of congenital parvovirus, although case reports have shown that fetuses with severe anemia in utero may have persistent anemia, thrombocytopenia, and edema in the neonatal period.

Conclusions and Relevance

Parvovirus B19 is a common virus; seropositivity in the geriatric population reportedly reaches 85%. Within the pregnant population, up to 50% of patients have not previously been exposed to the virus and consequently lack protective immunity. Concern for parvovirus B19 infection in pregnancy largely surrounds the consequences of vertical transmission of the virus to the fetus. Should vertical transmission occur, the overall risk of fetal loss is between 5% and 10%. Thus, understanding the incidence, risks, and management strategies of pregnancies complicated by parvovirus B19 is essential to optimizing care and outcomes. Further, there is currently a gap in evidence regarding delivery management, breastfeeding recommendations, and the risks of congenital abnormalities in pregnancies complicated by parvovirus B19. Additional investigations into optimal delivery management, feeding plans, and recommended neonatal surveillance are needed in this cohort of patients.

Changing epidemiology of parvovirus B19 in the Netherlands since 1990, including its re-emergence after the COVID-19 pandemic

Parvovirus B19V (B19V) infection during pregnancy can be complicated by potentially life-threatening fetal hydrops, which can be managed by intrauterine transfusion (IUT). This study investigates the long-term temporal patterns in the epidemiology of B19V and evaluates the impact on fetal hydrops, by combining data on B19V infections from the Dutch Sentinel Surveillance system in the period 1990 to 2023, Dutch blood banking data and hospital data on fetal hydrops. Using wavelet analysis, we identified annual epidemic cycles in the Netherlands in the period 1990-2019 and we identified superimposed multiannual cycles in the period 1990-2009. After 2009, no multiannual cycle could be identified, although the incidence fluctuated and correlates with number of IUT performed. As of 2020, weekly reports of B19V infection demonstrated a historically low incidence and B19V-DNA positive blood donors were nearly absent. From May 2020 to May 2023, no IUT for B19V-related hydrops was performed. In the spring of 2023, B19V infections re-emerged, reaching pre-pandemic epidemic levels. Due to the changes in B19V epidemiology over the last 30 years and the near-absence of B19V during the COVID-19 pandemic, the resulting low immunity levels may lead to rebound outbreaks. Alertness to severe complications such as fetal hydrops is warranted.

Maternal outcomes of a cohort of pregnancies affected by non-immune hydrops fetalis

OBJECTIVE

To describe the maternal outcomes of a prospective cohort of non-immune hydrops fetalis (NIHF) pregnancies with negative standard-of-care evaluations.

METHODS

This study was a secondary analysis of a prospective cohort study of NIHF pregnancies with negative work-ups (infection, alloimmune anemia, fetomaternal hemorrhage, and chromosomal disorders). Outcomes were obstetric complications, including pre-eclampsia, mirror syndrome, preterm birth, polyhydramnios, postpartum hemorrhage, and maternal mental health.

RESULTS

Forty pregnancies were included. Four patients developed pre-eclampsia (4/40, 10.0%); three occurred postpartum. None was diagnosed with mirror syndrome. Of the 31 continued pregnancies, 16 (51.6%) resulted in early fetal death or stillbirth and 15 (48.4%) resulted in live births. Of the 15 live births, 8 (53.3%) were delivered by primary cesarean delivery; 5 (62.5%) were for hydrops fetalis. Eleven live births (73.3%) were delivered preterm; 9 (81.8%) were indicated, most commonly for fetal indications (7/9, 77.8%). Polyhydramnios occurred in 14/40 (35.0%) cases. Where EBL was recorded (n=37), there were 5 (13.5%) cases of postpartum hemorrhage and an additional 3 (8.1%) had uterine atony without hemorrhage. Eighteen patients (18/40, 45.0%) had new-onset or exacerbated depression or anxiety symptoms.

CONCLUSION

Our study identified several important adverse outcomes of pregnancies complicated by NIHF with negative standard-of-care evaluations, including a high rate of postpartum pre-eclampsia and worsened mental health. We identified a higher rate of cesarean delivery and preterm birth, both primarily for fetal indications. We also observed the known relationship between polyhydramnios, hemorrhage, and atony, but noted that this risk included pregnancies concluding in dilation and evacuation. Counseling after a diagnosis of NIHF should include these adverse outcomes.

Molecular characteristics of thalassemia and hemoglobin variants in prenatal diagnosis program in northern Thailand

Molecular analysis of globin genes is an essential process for prenatal diagnosis (PND) of severe thalassemia. This study aimed to describe the molecular characteristics of thalassemia and hemoglobin (Hb) variants in PND program in northern Thailand. The type and frequency of globin gene mutations from 1290 couples at risk of fetal severe thalassemia diseases that were tested at Thalassemia Laboratory at Chiang Mai University from 2012 to 2017 were retrospectively reviewed. The PND program detected 444 (34.4%), 196 (15.2%) and 642 (49.8%) couples at risk of fetal Hb Bart's hydrops fetalis, beta-thalassemia major (BTM) and beta-thalassemia/Hb E disease, respectively. Coinheritance of more than one type of thalassemia was common and eight (0.6%) couples were at risk of two types of severe thalassemia. There were two types of alpha⁰-thalassemia; 893 (99.7%) Southeast Asian and 3 (0.3%) Thai deletions. Twenty beta-globin gene mutations were found with 94.3% of beta⁰-thalassemia. The codon 41/42 (- TTCT), codon 17 (A>T), IVS-I-1 (G>T) and codon 71/72 (+ A) comprised 90% of beta-thalassemia mutations. The study shows a high percentage of couples at risk of fetal Hb Bart's hydrops fetalis and BTM. The percentage of beta⁰-thalassemia is higher than those seen in other regions of Thailand.

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

OBJECTIVES

Polyhydramnios and placentomegaly are commonly observed in nonimmune hydrops fetalis (NIHF); however, whether their ultrasonographic identification is relevant for prognosis is controversial. We evaluated outcomes of fetal or neonatal death and preterm birth (PTB) in cases of NIHF alone and in those with polyhydramnios and/or placentomegaly (P/PM).

METHODS

We conducted a retrospective cohort of singletons with NIHF evaluated between 1994 and 2013. Nonimmune hydrops fetalis was defined as 2 or more abnormal fluid collections, including ascites, pericardial effusion, pleural effusion, and skin edema. Primary outcomes were intrauterine fetal demise (IUFD) and neonatal death. Secondary outcomes were PTB (<37, < 34, and <28 weeks) and spontaneous PTB. Outcomes were compared between cases of NIHF alone and NIHF with P/PM.

RESULTS

A total of 153 cases were included; 21% (32 of 153) had NIHF alone, and 79% (121 of 153) had NIHF with P/PM. There was no significant difference in neonatal death (38.1% versus 43.0%; P = .809) between the groups. Intrauterine fetal demise was seen more frequently in NIHF alone (34.4% versus 17.4%; P = .049). Nonimmune hydrops fetalis-with-P/PM cases were more likely to deliver before 37 weeks (80.0% versus 57.1%; P = .045) and before 34 weeks (60.0% versus 28.6%; P = .015) and to have spontaneous PTB (64.4% versus 33.3%; P = .042). Adjusted odds ratios accounting for the etiology of NIHF supported these findings, with the exception of IUFD.

CONCLUSIONS

Compared to NIHF alone, pregnancies with NIHF and P/PM had a lower risk of IUFD and were at increased risk of PTB (<37 and <34 weeks) and spontaneous PTB. This information may help providers in counseling patients with NIHF and supports the need for close antenatal surveillance.

[NEW APPROACH IN DIAGNOSTIC ALGORITHM OF AN INFECTIOUS AGENTS (PARVOVIRUS B19 AND CHLAMYDIA TRACHOMATIS) INVOLVED IN THE DEVELOPMENT OF PATHOLOGICAL PREGNANCY]

Viral infections during pregnancy, along with some form of accompanying pregnancy diseases such as diabetes, cardiovascular, gastrointestinal, kidney and others, are a major cause of arising complications and mortality of mother and fetus.

AIM

To improved the laboratory diagnostic approach in the study of women with pathological pregnancy, including improve treatment and prognostic character of the outcome of pregnancy, with the inclusion of two infectious agent parvovirus B19 and Chlamydia trachomatis. To determine types of anemia in pregnant women with parvovirus B19 and Chlamydia trachomatis infection and to select the correct therapeutic approach.

MATERIALS AND METHODS

A total 36 serum samples from pregnant women with anemia (n = 22), nonimmune hydrops fetalis (n = 8) and fetal ascites (n = 6) were tested. The study included three newborns (n = 3), tested on the occasion of a possible maternal-fetal infections. The serological (indirect ELISA tests) and molecular (B19V-PCR test) methods were used. In anemic pregnant women were evaluated iron homeostasis parameters with CLIA, AAS and NEPH methods.

RESULTS

In 6/36 (16.66%) patients B19V-IgM positive result was detected. Among the study patients with anemia, non-immune hydrops fetalis and fetal ascites incidence of proven B19V-IgM antibodies was 18.18% (4/22), 12.5% (1/8) and 16.66% (1/6), respectively. Protective B19-IgG antibodies in 25/39 (64.10%) samples were found. A positive PCR signal was showed in all patients with positive B19V-IgM, and 1 patient with anemia and positive B19V-IgG result. The three newborns were positive for B19V-IgG antibodies (maternal) and negative for acute viral infection. Present Chlamydia trachomatis infection in 6/36 (16.66%) and past infection in 5/36 (13.89%) patients was demonstrated. The anemia was evaluated as iron-deficiency according to low hepcidin levels 2.54 ± 0.4 μg/I compared to pregnant control group which included women without anemia 25.9 ± 2.8 μg/I.

CONCLUSION

In view of the varied transmission B19V and the wide range of complications arising as a result of chlamydia, screening for these viral agents of pregnant women and women of childbearing age is an important approach for monitoring of pregnancy.

Estimating the risk of parvovirus B19 infection in blood donors and pregnant women in Japan

BACKGROUND

Seroepidemiological study of parvovirus B19 has not taken place for some 20 years in Japan. To estimate the risk of parvovirus B19 infection in Japan among blood donors and pregnant women in this century, a seroepidemiological survey and statistical modeling of the force of infection were conducted.

METHODOLOGY/PRINCIPAL FINDINGS

The time- and age-specific seroprevalence data were suggestive of strong age-dependency in the risk of infection. Employing a piecewise constant model, the highest forces of infection of 0.05 and 0.12 per year were observed among those aged 0-4 and 5-9 years, respectively, while estimates among older individuals were less than 0.01 per year. Analyzing the antigen detection data among blood donors, the age-specific proportion positive was highest among those aged 30-39 years, agreeing with the presence of dip in seroprevalence in this age-group. Among pregnant women, up to 107 fetal deaths and 21 hydrops fetalis were estimated to have occurred annually across Japan.

CONCLUSIONS

Seroepidemiological profiles of PVB19 infection in Japan was characterized with particular emphasis on the risk of infection in blood donors and the burden of infection among pregnant women. When a vaccine becomes available in the future, a similar seroepidemiological study is expected to play a key role in planning the appropriate immunization policy.

Hemolytic disease of the fetus and newborn with late-onset anemia due to anti-M: a case report and review of the Japanese literature

Hemolytic disease of the fetus and newborn (HDFN) attributed to M/N-incompatibility varies from asymptomatic to lethally hydropic. Case reports are rare, and the clinical significance of anti-M is not completely understood. A challenging case of HDFN due to anti-M prompted an investigation of the Japanese literature, in order to characterize the clinical spectrum of M/N-incompatibility pregnancies in Japan and report results to English-language readers. Japanese reports of HDFN attributed to M/N incompatibility were compiled. Abstracted data include maternal antibody titers at delivery, fetal direct antiglobulin test, hemoglobin, total bilirubin, reticulocyte count at birth, and therapeutic interventions. We investigated characteristics of HDFN due to M/N-incompatible pregnancies in Japan after encountering a case of severe HDFN along with late-onset anemia in an infant born to a woman carrying IgG anti-M with a titer of 1. In total, thirty-three babies with HDFN due to anti-M and one due to anti-N have been reported in Japan since 1975. The median maternal antibody titer was 64 at delivery and was 16 or less in 10 of 34 women (29%). Five of 34 babies (15%) were stillborn or died as neonates. Twenty-one of 29 survivors (72%) had severe hemolytic anemia and/or hydrops fetalis. The reticulocyte count of neonates with anemia stayed below the reference interval. Sixteen (55%) developed late-onset anemia and 14 (48%) were transfused with M-negative RBCs. Significant positive correlation (P < .05) between the hemoglobin value and the reticulocyte count within 4 days of birth was obtained in 16 babies with anti-M HDFN. In the Japanese population, 21 of 34 cases of M/N-incompatible HDFN (72%) have manifested as severe hemolytic anemia and/or hydrops fetalis. Low reticulocyte count in neonates with late-onset anemia is consistent with suppressed erythropoiesis due to anti-M.

[Clinical study of 12 cases with obstetric mirror syndrome]

OBJECTIVE

To discuss the clinical features, management, pregnancy outcome and prognosis of obstetric mirror syndrome.

METHODS

The clinical data of 12 cases with obstetric mirror syndrome at Shenzhen Maternity and Child Healthcare Hospital from April 2008 to December 2010 were collected to retrospectively analyze the clinical features, management, pregnancy outcome and prognosis.

RESULTS

(1) ETIOLOGY: 12 cases with obstetric mirror syndrome included 9 cases of Bart's hydrops fetalis, 2 cases with fetal complicated congenital cardiac anomalies, and 1 case of unknown etiology. (2) Gestational age at diagnosis and at delivery: gestational age at diagnosis ranged from 28 to 36 weeks [mean (31.5 ± 4.7) weeks], and gestational age at delivery ranged from 28(+3) to 38 weeks [mean (32.9 ± 2.9) weeks]. There were no significant differences between the gestational age at diagnosis and at delivery in consistence with severe preeclampsia group and mild preeclampsia group [(31.8 ± 2.3) weeks vs. (30.9 ± 7.2) weeks, (32.5 ± 2.3) weeks vs. (33.5 ± 3.9) weeks, P > 0.05]. (3) The patients with obstetric mirror syndrome can present a preeclampsia-like syndrome: maternal extremity edema in 12 cases, headache and visual disturbance in 1 case, proteinuria in 11 cases, elevated blood pressure in 5 cases, elevated uric acid in 9 cases, hypoproteinemia in 12 cases, elevated creatinine in 3 case, elevated liver enzyme in 1 case, thrombocytopenia in 2 cases. The major complications included 1 case of HELLP syndrome, acute pulmonary edema, placental abruption, amnionic fluid embolism, DIC respectively, 3 cases of acute kidney failure and 6 cases of postpartum hemorrhage. (4) Sonographic findings: 1) Hydrops fetalis: fetal ultrasound revealed pleural fluid, fetal ascites, skin edema, scalp edema, encephalocolele enlargement, hydropericardium and increased cardio-chest ratio. 2) Placenta megaly: the placental pathological examination revealed edematous and large in 12 cases. Placental thickness was beyond 4 cm in all cases [(6.3 ± 1.9) cm]. 3) Hydramnios: hydramnios could be found in 11 cases [amniotic fluid index (19.7 ± 3.1) cm]. (5) Postnatal conditions:all blood pressure and laboratory findings including urine protein normalized within 5 to 7 days after delivery. (6) Pregnancy outcome:all 12 patients survived, however the perinatal mortality rate was 100%. Two of 12 cases with mirror syndrome underwent cesarean section, and 10 were vaginal delivery, of which 1 need uterine artery embolisom due to postpartum hemorrhage.

CONCLUSIONS

Obstetric mirror syndrome seems to simulate preeclampsia although there are distinguishing features, such as hemodilution, placental edema, and polyhydramnios. When the specific cause of obstetric mirror syndrome can not be identified and corrected, the decision for delivery should be made as soon as possibly.

Risk of fetal hydrops and non-hydropic late intrauterine fetal death after gestational parvovirus B19 infection

BACKGROUND

Risk assessment of parvovirus B19 (B19)-associated fetal complications following gestational B19 infection remains controversial.

OBJECTIVES

To determine the risk of fetal hydrops or non-hydropic late intrauterine fetal death following acute maternal B19 infection at defined gestational weeks.

STUDY DESIGN

Observational cohort study of pregnant women with serologic evidence of acute B19 infection. If available, fetal or neonatal tissue samples from cases complicated by fetal loss or hydrops were investigated for the presence of B19 DNA by polymerase chain reaction (PCR) and/or in situ hybridization (ISH).

RESULTS

Of 236 women with known pregnancy outcome, 228 had a live birth and 8 a fetal loss. The observed rate of fetal hydrops for all pregnant women was 4.2% (10/236) (95% confidence interval [CI], 2.1-7.7) and 10.6% (10/94) (95% CI, 5.2-18.7) for those infected between 9 and 20 weeks gestation. Tissue samples from 8 hydrops cases were investigated by PCR or ISH and all were B19 DNA positive. Fetal death occurring during or after gestational week 22 was only observed in one case which was associated with B19-derived fetal hydrops.

CONCLUSIONS

Our findings demonstrate that although adverse fetal outcome is a rare complication of gestational B19 infection, a relevant risk of fetal hydrops exists particularly for women infected between 9 and 20 weeks' gestation. Cases of B19-derived non-hydropic late intrauterine fetal death were not observed in the present study.

Relationship between obstetric history and Rh(D) alloimmunization severity

BACKGROUND

To evaluate the relationship between obstetric history and Rh(D) alloimmunization severity, employing the gestational age at the first intrauterine fetal transfusion (IUT) as an indicator of this severity.

METHODS

From 1996 to 2006, Rh(D) alloimmunized pregnancies submitted to IUT had their data assessed. Gestational age at the first IUT was modeled as a linear outcome. The associations between obstetric history variables, anti-Rh(D) antibodies titer and gestational age at the first IUT were analyzed. Statistics are presented with 95% confidence intervals (P < 0.05).

RESULTS

A total of 82 non-hydropic anemic fetuses, ensuing in 92.7% (n = 76) of perinatal survival, were submitted to IUT. Nineteen (23,2%) pregnant women did not present with any previous stillbirth, neonatal death, IUT, hydrops or neonatal exchange transfusion (group 1); and 63 (76.8%) reported at least one of these events (group 2). Gestational age at the first IUT differed significantly between the groups (P = 0.0001). For group 1, it ranged from 24 to 35 weeks (median 32.5 weeks), whereas for group 2 it ranged from 19 to 34 weeks (median 27 weeks). In the multivariated analysis, previous neonatal death (P = 0.040), previous IUT (P = 0.000) and previous neonatal exchange transfusion (P = 0.036) were independently associated with the gestational age at the first IUT.

CONCLUSIONS

The evaluation of the obstetrical history is an important diagnostic tool for predicting Rh(D) alloimmunization severity. Alloimmunized pregnant women who reported previous neonatal death(s), neonatal exchange transfusion(s) or IUT(s) should receive a closer fetal surveillance due to the risk of a higher rate of fetal hemolysis and the need of an earlier IUT.

Predictors of fetal outcome in pregnant trauma patients: a five-year institutional review

Injury Severity Score (ISS) and lactate are controversial in predicting fetal outcome. A retrospective review was conducted to determine whether ISS and lactate are valuable in predicting fetal survival in injured pregnant patients. Injured pregnant women were identified by ICD-9 codes from our Trauma Registry, Emergency Department Registry, and hospital medical records. Records were reviewed for demographic data, mechanism of injury, ISS, Glascow Coma Scale, lactate, vital signs, and maternal/fetal outcome. To determine statistical analysis, chi2 and t test analysis was performed. From 2001 to 2005, 294 women reported injuries. Most patients (51.7%) were discharged from the Emergency Department, yet 18 per cent were admitted to Trauma Surgery. The average maternal and gestational age was 23.4 years and 19.6 weeks, respectively. Seventy-two (33.3%) patients were in the first trimester. The majority of patients (88.1%) were involved in blunt trauma, and 10 (3.9%) had poor fetal outcome (nine fetal deaths and one hydrops fetalis). There were no maternal deaths. Maternal age, first trimester, elevated lactate, and high ISS were significant risk factors for poor fetal outcome (P = 0.044, P = 0.0173, P = 0.0001, and P = 0.0001, respectively). Specific parameters (ISS, lactate, maternal age, and gestational age) may be helpful in predicting poor fetal outcome and directing patient management.

Prognostic factors and clinical features in liveborn neonates with hydrops fetalis

The purpose of this study was to delineate the etiology and the clinical features of liveborn neonates with hydrops fetalis, and to explore the prognostic factors for survival. Medical records of 28 liveborn neonates with hydrops fetalis between April 1995 and March 2005 were reviewed retrospectively. Demographic data, clinical manifestations, laboratory findings, and outcomes were analyzed. Most patients presented with pleural effusions (21 of 28) and ascites (22 of 28). The majority of patients had hydrops due to cardiovascular diseases (seven of 28), hematologic disorders (six of 28), lymphatic malformations (six of 28), and idiopathic origins (six of 28). The overall survival rate was 50% and was highest (83%) in infants with lymphatic malformations. By univariate analysis, risk factors for mortality are earlier ages at diagnosis and at birth, low Apgar scores, need for resuscitation in the delivery room, low serum albumin level, and severe acidemia. After using stepwise multiple logistic regression analysis, the most significant factors associated with fatality were younger gestational age at birth and lower serum albumin level. Hydrops fetalis remains a complex condition with a high mortality rate. Hydrops resulting from lymphatic malformations has a favorable outcome. Preterm birth at less than 34 weeks and serum albumin concentration lower than 2 g/dL are two poor prognostic factors for survival.

Prevalência de anticorpos IgG antiparvovírus B19 em gestantes durante o atendimento pré-natal e casos de hidropisia fetal não imune atribuídos ao parvovírus B19, na Cidade do Rio de Janeiro

Com o objetivo de medir a prevalência de anticorpos IgG contra o parvovírus B19 em gestantes com até 24 semanas de idade gestacional e detectar a ocorrência de casos de hidropisia fetal não-imune atribuídos a esse vírus, coletamos 249 amostras de soro em uma maternidade de referência na cidade do Rio de Janeiro, entre junho de 2003 e março de 2005. As gestantes foram acompanhadas até o termo da gestação, sendo detectados 17 casos de hidropisia fetal. Quatro casos foram atribuídos ao parvovírus B19 e dois destes ocorreram em gestantes residentes na zona oeste da cidade, em fevereiro de 2005. Resultados positivos para anticorpos IgG antiparvovírus B19 foram encontrados em 172 (71,6%) gestantes (IC 95% 65,5-77,7%), sendo esta prevalência de anticorpos comparável à encontrada em outras cidades brasileiras. A única variável associada com aquisição prévia de anticorpos IgG foi número de gestações anteriores maior que um(p= 0,02, IC 95% 0,36-0,94).

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.

Pleural effusions in the neonate

INTRODUCTION

Pleural effusions are rare in the neonate and may be associated to several clinical conditions. Only a few series of pleural effusions in the fetus and newborn are described in the literature.

AIM

This study was undertaken to determine more accurately the causes and prognostic significance of pleural effusions in a population of high-risk neonates.

MATERIALS AND METHODS

A retrospective chart review of 62 neonates admitted to the neonatal intensive care unit of six medical centers in the north of Portugal, between 1997 and 2004, that presented the diagnosis of pleural effusion.

RESULTS

33M/29F newborns; preterms 47 (76%); GA 33 (25-40) wk; BW 1830 (660-4270) g; C-section 39 (63%). Pleural effusions were congenital in 20 (32%) newborns and acquired in 42 (68%). Congenital pleural effusions occurred as fetal hydrops in 11 (18%) patients and as chylothorax in 9 (15%). In four cases of hydrops, the cause was a congenital chylothorax. Congenital chylothorax (n=13) was the most common (65%) congenital pleural effusion in this study. The incidence of congenital chylothorax was 1:8.600 deliveries and male:female ratio was 2:1. Mortality occurred in five newborns due to pulmonary hypoplasia. Traumatic (iatrogenic) were the most frequent (n=31) acquired pleural effusions. These included 8 (13%) cases of hemothorax and 8 (13%) cases of total parenteral nutrition leakage. Pleural effusions after intra-thoracic surgery were mainly (79%) chylothoraces. There were 11 (26%) non-iatrogenic acquired pleural effusions. No mortality was associated with acquired pleural effusions.

CONCLUSIONS

Congenital pleural effusions usually occur as hydrops or congenital chylothorax. Traumatic (iatrogenic) are the most frequent acquired pleural effusions in a tertiary NICU. Pleural effusions after intra-thoracic surgery are mainly chylothoraces. Non-iatrogenic acquired pleural effusions are associated to several clinical conditions, and mortality is usually associated to the underlying condition.

Spontaneous antenatal resolution of canine hydrops fetalis diagnosed by ultrasound

A previously unreported syndrome of transient mid-gestational hydrops fetalis identified by ultrasound was diagnosed in 16 litters of 16 different dogs between November 1999 and May 2002. During this study period, a total of 161 canine pregnancies were diagnosed by ultrasound. A 17th litter of eight fetuses developed similar ultrasonographic changes concurrently with maternal systemic mastocytosis and subsequently spontaneously aborted. No pups were born with clinical signs of hydrops fetalis. Fetal resorption in the affected litters was 7/95 (7.4 per cent) and 8/95 (8.4 per cent) aborted. Of the fetuses that survived to term, there were 7/88 (8 per cent) stillbirths. Neonatal mortality rate in the affected litters was 15 per cent (11/73) and the incidence of congenital abnormalities was 7/73 (9.6 per cent). Pugs were significantly (22.8 times) more likely to be affected than other breeds.

Karyotype and outcome of fetuses diagnosed with cystic hygroma in the first trimester in relation to nuchal translucency thickness

OBJECTIVES

To determine the incidence and to examine the karyotype and the outcome of fetuses diagnosed with cystic hygroma (CH) at 11-14 weeks of gestation.

METHODS

The presence of bilateral cystic anechoic cavities in the neck, nuchal translucency (NT), malformations and hydrops was prospectively recorded in 6894 ultrasound examinations in the first trimester, between 2001 and 2004.

RESULTS

Forty-two fetuses (0.62%) were diagnosed with CH in the first trimester of pregnancy and 60% of these had an abnormal karyotype. NT was > or = 3 mm in 83% and hydrops was present in 40% of the cases. The karyotype was abnormal in 25 (69%) of these, showing trisomy 18 and 45,XO more often than trisomy 21. NT was <3 mm in seven cases (17%); no hydrops was present and only one had an abnormal karyotype (47 + 18). Eight babies with CH without aneuploidy or hydrops were born alive, seven among them were without malformations and are developing normally at 1 to 18 months of age, the remaining one presented with CHARGE syndrome.

CONCLUSIONS

CH is an independent entity from NT and its association with increased NT carries a poor prognosis.

α-Thalassemia: Hb H Disease and Hb Barts Hydrops Fetalis

alpha-Thalassemia mutations are one of the most common mutations of man, and they cause Hb H disease and Hb Barts hydrops fetalis. Hb H disease is not necessarily a benign disorder as has been generally thought. Furthermore, in southern China and in Southeast Asia, there are 2-3 times more fetuses afflicted with the invariably fatal Hb Barts hydrops fetalis than with the beta-thalassemia major or intermedia. These findings underscore the public health importance of these hereditary disorders, and they call for better education, diagnosis, treatment, prevention, and research for these diseases.

Fetal morbidity and mortality after acute human parvovirus B19 infection in pregnancy: prospective evaluation of 1018 cases

OBJECTIVE

To determine more precisely the incidence of fetal complications following maternal parvovirus B19 infection at various gestational ages.

METHODS

An observational prospective study of 1018 pregnant women whose acute B19 infection was serologically confirmed in our laboratory.

RESULTS

The observed rate of fetal death throughout pregnancy was 6.3% (64/1018) (95% confidence interval [CI]: 4.9, 8.0). The fetal death rate for those infected within the first 20 weeks of gestation (WG) was 64/579 (11.0%). Fetal death was only observed when maternal B19 infection occurred before the completed 20 WG. The observed stillbirth proportion was 0.6% (6/960). Three of six stillbirth cases presented with fetal hydrops. The overall risk of hydrops fetalis was 3.9% (40/1018) (95% CI: 2.8, 5.3). Three of 17 cases with non-severe hydrops and 13 of 23 cases with severe hydrops received intrauterine transfusion(s). The proportion of fetuses with severe hydrops that survived following fetal transfusions was 11/13 (84.6%). All of the non-transfused fetuses with severe hydrops died.

CONCLUSION

Our data demonstrate a relevant B19-associated risk of fetal death, which is largely confined to maternal B19 infection in the first 20 WG. Timely intrauterine transfusion of fetuses with severe hydrops fetalis reduces the risk of fetal death. Parvovirus B19-associated stillbirth without hydropic presentation is not a common finding.

Simple non-invasive prenatal detection of Hb Bart's disease by analysis of fetal erythrocytes in maternal blood

OBJECTIVE

To investigate a simple non-invasive technique for early detection of Hemoglobin (Hb) Bart's disease.

METHOD

Maternal blood smears from 8 known Hb Bart's pregnancies and 40 at-risk pregnancies were investigated. Maternal peripheral blood smears were stained with fluorescence-labeled monoclonal antibodies against alpha- and embryonic zeta-globin chains.

RESULTS

Fetal nonnucleated red blood cells, stained with anti-zeta but not with anti-alpha globin antibodies were found in 15 out of 16 affected pregnancies but were not detected in 23 out of 24 unaffected pregnancies.

CONCLUSION

Results showed that non-invasive immunofluorescence staining of maternal blood is a feasible approach for screening Hb Bart's disease before ultrasound manifestation in affected pregnancies.

Congenital chylothorax: lymphopenia and high risk of neonatal infections

AIM

To describe the clinical course of patients with congenital chylothorax focusing on infectious complications. Congenital chylothorax is a common manifestation of non-immune hydrops fetalis (NIHF). The drainage of chyle leads to loss of cellular and plasmatic factors that influence the patient's immune response and increase the risk of infections.

METHODS

In a retrospective analysis of 24 preterm infants with NIHF treated between 1998 and 2002, congenital chylothorax was diagnosed in 7 patients.

RESULTS

All 7 patients were treated conservatively with pleural drainage over a median period of 22 d (range 10-36 d). Lymphopenia was found in all patients (median of minimal lymphocyte counts 285/microl, range 80-770). The nadir was on day 5 (2-6 d). Lymphopenia lasted for 12 d median (range 4-39 d) and was significantly correlated with the duration of lymph drainage (p = 0.001). Cell-surface analysis of peripheral blood lymphocytes was performed in two patients. Both patients had a decreased number of total T cells. Four out of seven (57%) patients developed nosocomial infections. This incidence of nosocomial infections in patients with congenital chylothorax is about three times higher than that in other neonatal patients. None of the children suffered from fungal or viral infection. Although there was a very high incidence of infections, no correlation between lymphopenia and the occurrence of infections could be shown.

CONCLUSION

Drainage of congenital chylothorax results in the loss of lymphocytes and bears a high risk of infections.

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.

Management of asymptomatic neonatal cystic adenomatoid malformations

BACKGROUND/PURPOSE

Although much is known about the prenatal course of cystic adenomatoid malformations (CCAM), the postnatal course of asymptomatic lesion is less well documented. The authors studied the pre- and postnatal course and treatment of asymptomatic CCAM.

METHODS

The authors reviewed the files of all patients referred to Necker-Enfants Malades hospital with an antenatal diagnosis of CCAM and asymptomatic at birth.

RESULTS

Files of 29 patients were studied. The first x-ray film was considered normal in 12 cases (41.3%). Computed tomography was normal in 4 cases and showed cystic lung malformations in the other patients. Postnatally, clinical manifestations occurred in 3 patients (10.3%). CCAM vanished in 6 cases. Surgical resection of CCAM was performed in 17 cases (58.6%). All the patients currently are asymptomatic.

CONCLUSIONS

CCAM can shrink or vanish during pregnancy and antenatal ultrasound findings are not predictive of the postnatal course. Thus, all infants with prenatal diagnosis of CCAM require postnatal evaluation. Normal radiographic findings at birth do not rule out CCAM persistence on CT. The treatment of asymptomatic CCAM is controversial. Surgery may be advocated because of the low morbidity and the prevention of late complications, above all, cancer. The surgical indications of small (<3 cm) and asymptomatic lesions should be discussed on a case-by-case basis with the parents.

Congenital diaphragmatic hernia and hydrops: a lethal association?

BACKGROUND/PURPOSE

Nonimmune hydrops in the fetus is a finding that often portends death. The association and prognosis of fetuses with congenital diaphragmatic hernia (CDH) and hydrops is not known.

METHODS

A retrospective review of all prenatally diagnosed cases and referrals of CDH was performed. Variables analyzed included gestational age at diagnosis and delivery, side of hernia, presence of associated anomalies and hydrops, and neonatal outcome.

RESULTS

Since 1993, 474 prenatal referrals for CDH have been made. One hundred seventy-five were evaluated; 15 fetuses had hydrops (9%). Five patients had CDH, hydrops, and associated lethal anomalies. In the remaining 10 patients, 6 of the diaphragmatic defects were right-sided and 4 were left-sided. All except one had a major portion of the liver herniated into the chest. Six fetuses had prenatal intervention. Five neonates died shortly after birth. There were 5 long-term survivors; all received prenatal intervention.

CONCLUSIONS

The association of CDH and hydrops is rare but often results in fatality. Hydrops appears to be associated with liver in the hernia, right-sided lesions, and lethal anomalies. Fetal intervention can be performed successfully in patients with CDH and hydrops, and may improve long-term survival rate in this group.

Clinical, hormonal, and hematologic characteristics of bovine calves derived from nuclei from somatic cells

Although healthy animals are born after nuclear transfer with somatic cells nuclei, the success of this procedure is generally poor (2%-10%) with high perinatal losses. Apparently normal surviving animals may have undiagnosed pathologies that could develop later in life. The gross pathology of 16 abnormal bovine fetuses produced by nuclear transfer (NT) and the clinical, endocrinologic (insulin-like growth factors I and II [IGF-I and IGF-II], IGF binding proteins, post-ACTH stimulation cortisol, leptin, glucose, and insulin levels), and biochemical characteristics of a group of 21 apparently normal cloned calves were compared with those of in vitro-produced (IVP) controls and controls resulting from artificial insemination. Oocytes used for NT or IVP were matured in vitro. NT to enucleated oocytes was performed using cultured adult or fetal skin cells. After culture, Day 7, grade 1-2 embryos were transferred (one per recipient). All placentas and fetuses from clones undergoing an abnormal pregnancy showed some degree of edema due to hydrops. Mean placentome number was lower and mean placentome weight was higher in clones than in controls (69.9 +/- 9.2 placentomes with a mean weight of 144.3 +/- 21.4 g in clones vs. 99 and 137 placentomes with a mean individual weight of 34.8 and 32.4 g in two IVP controls). Erythrocyte mean cell volume was higher at birth (P < 0.01), and body temperature and plasma leptin concentrations were higher and T4 levels were lower during the first 50 days and the first week (P < 0.05), respectively, in clones. Plasma IGF-II concentrations were higher at birth and lower at Day 15 in clones (P < 0.05). Therefore, apparently healthy cloned calves cannot be considered as physiologically normal animals until at least 50 days of age.

Transient hydropic signs in the donor fetus after fetoscopic laser coagulation in severe twin-twin transfusion syndrome: incidence and clinical relevance

OBJECTIVE

To evaluate the incidence, characteristics, and impact on perinatal outcome of the development of hydropic signs in the donor fetus after laser coagulation for severe twin-twin transfusion syndrome in the second trimester.

METHODS

Forty cases of second-trimester severe twin-twin transfusion underwent fetoscopic laser coagulation of placental anastomoses and were followed up with serial ultrasound up to 14 days after therapy. Ultrasound scans were performed just before, and on days 1, 3, 5 and 14 after therapy, and fetuses were monitored for the presence of hydropic signs (skin edema, pleural effusion, ascites and pericardial effusion). Response to therapy and perinatal outcome in terms of neonatal survival were recorded for all cases.

RESULTS

Four recipients (10%) and three donors (7.5%) died over the first 72 h after therapy. During the study period, two recipients (5.5%) developed frank hydrops fetalis, and eventually died in utero. Ten donors (27.0%) developed one or more hydropic signs. In nine (90%), signs were mild or moderate and transient (mean, 3.2 days), while in one case hydrops worsened and the fetus eventually died. No donors with transient hydrops died in utero, and two died postnatally due to extreme prematurity. Gestational age at procedure and deepest amniotic fluid vertical pocket were similar between hydropic and non-hydropic donors. Discrepancy in estimated fetal weight at procedure was significantly lower in donors developing hydrops (9.6 (SD, 6.4) vs. 17.8 (14.4)%,P = 0.018). In pregnancies with hydropic donors, gestational age at delivery (33.1 (3.4) vs. 29.7 (3.5) weeks,P = 0.015) and birth weight for recipient (2392 (423) vs. 1631 (576) g, P < 0.001) and donor (1908 (774) vs. 1281 (583) g,P = 0.021) were significantly higher. The development of transient hydrops had no influence on neonatal survival at 28 days nor on the rate of clinical resolution of intertwin transfusion.

CONCLUSIONS

Transient hydropic signs may develop in a proportion of donor fetuses after laser coagulation for severe twin-twin transfusion syndrome. This phenomenon is normally not associated with a poor prognosis, and possibly indicates an hemodynamic adaptation response following interruption of the transfusion process.

Management of anti-Rhesus-D antibodies in pregnancy: a review from 1994 to 1998

OBJECTIVE

To review our management of anti-Rhesus-D antibodies in pregnancy over a 5-year period in order to assess possible changes in the management or prognosis which may have developed with time.

METHOD

Retrospective analysis of prospectively collected data from 31 pregnancies with maternal anti-D levels >4 IU/ml and in which the fetus was Rhesus positive.

RESULTS

There were a total of 30 amniocenteses, 8 cordocenteses, and 54 fetal blood transfusions performed. When undertaken as the first procedure, the mean gestational age at amniocentesis was 30 weeks as compared with 25 weeks for fetal blood sampling/transfusion (p < 0.05). The median anti-D level at the first procedure was 24 IU/ml for amniocentesis and 64 IU/ml for fetal blood sampling. Of the 54 blood transfusions, 43 were intravascular, 4 were intraperitoneal, and 7 transfusions were both intravascular and intraperitoneal.

CONCLUSIONS

Intravascular as opposed to intraperitoneal transfusions were found to be the main method of transfusion in the later years in this study, a finding which was expected with improved sonographic equipment. Apart from this, management and prognosis of anti-D red cell isoimmunisation in pregnancy have remained relatively stable since the 1980s. Amniocentesis was useful in the management of such pregnancies, especially as an initial procedure in the cases with a lower initial anti-D level. In this series 90% of the fetuses requiring blood transfusion, but were without hydrops, survived, whereas this was about 70%, if they had become hydropic (this latter figure was reduced by 2 hydropic deaths before 20 weeks' gestation in the same very severely affected woman).

Alpha-thalassaemia prenatal diagnosis by two PCR-based methods

In Cyprus all couples carrying alpha0-thalassaemia mutations are detected in the course of the thalassaemia carrier screening program and prenatal diagnosis is offered to all of them. Prenatal diagnosis for alpha-thalassaemia is routinely done by two independent molecular methods. With the first method, the mutations of the parents are directly determined by gap-PCR and then the chorionic villus sample (CVS) is examined for the presence of these mutations. With the other method, a (CA)n repeat polymorphic site located between the psialpha1- and alpha2-globin genes is used for determining the presence or absence of the normal and mutant alleles. In the period from 1995 to 1999, molecular analysis of 46 couples in which haematological data were consistent with deletion of two alpha-globin genes in both partners indicated that only 13 of them were actually at risk for haemoglobin (Hb) Bart's hydrops fetalis and prenatal diagnosis was provided in 16 pregnancies. The molecular diagnosis was possible in all cases with the use of both gap-PCR and (CA)n repeat polymorphisms analysis. No misdiagnosed cases for alpha-thalassaemia have been reported to date.

Congenital parvovirus B19 infection: experience of a recent epidemic

OBJECTIVE

We report the management and outcome of 6 cases of non-immune fetal hydrops secondary to parvovirus B19 infection presenting over a 5-month period.

METHODS

The Queen Mothers Hospital is a tertiary referral centre for fetal medicine. All cases were suspected on the basis of ultrasound evidence of hydrops. Two cases were managed conservatively owing to the presence of an active fetus with evidence of resolving hydrops. Fetal blood sampling intra-uterine transfusion and drainage of ascitic fluid were performed in 3 cases. The 6th case unfortunately resulted in an intra-uterine death prior to fetal blood sampling.

RESULTS

Maternal parvovirus specific B19 was identified in all cases. Fetal parvovirus B19 IgM was identified in the 3 cases in whom fetal blood sampling was performed. A single intra-uterine transfusion was performed in these 3 cases; fetal hydrops resolved in 2 of these pregnancies progressing to the birth of a healthy baby at term, whereas 1 case was complicated by intra-uterine death. Fetal hydrops resolved in both cases managed conservatively, leading to the birth of a healthy baby at term.

CONCLUSIONS

Parvovirus B19 infection should always be suspected in cases of non-immune hydrops. Conservative management will be appropriate in some cases and should involve weekly ultrasonography. The outlook for pregnancies presenting with gross hydrops remains guarded, even if intra-uterine transfusion is performed successfully.

Parvovirus B19 infection and its significance in pregnancy

Parvovirus B19 causes prolonged epidemics of erythema infectiosum, particularly in primary school-aged children. Infection causes clinically significant anaemia in individuals with high red cell turnover, including the fetus. Approximately 40% of women of childbearing age are susceptible, and annual seroconversion rates vary from 1.5% during endemic periods to 10-15% during epidemics. Infection occurs in around 50% of susceptible women exposed at home and 20-30% following occupational exposure (for example, at a primary school). Maternal infection in the first half of pregnancy is associated with 10% excess fetal loss and hydrops fetalis in 3% of cases (of which up to 60% resolve spontaneously or with appropriate management). No congenital abnormalities or long-term sequelae have been attributed to parvovirus B19 infection. The overall risk of serious adverse outcome from occupational exposure to parvovirus B19 infection during pregnancy is low (excess early fetal loss in 2-6/1,000 pregnancies and fetal death from hydrops in 2-5/10,000 pregnancies). It is not recommended that susceptible pregnant women be excluded routinely from working with children during epidemics.

Hydrops fetalis: lysosomal storage disorders in extremis

In recent years there has been an increased recognition that hydrops fetalis may be an extreme presentation of many of the lysosomal storage disorders. Hydrops fetalis, the excessive accumulation of serous fluid in the subcutaneous tissues and serous cavities of the fetus, has many possible etiologies, providing a diagnostic challenge for the physician. Ten different lysosomal storage disorders have now been diagnosed in infants with hydrops fetalis, including mucopolysaccharidosis (MPS) VII and IVA, type 2 Gaucher disease, sialidosis, GMI gangliosidosis, galactosialidosis, Niemann-Pick disease type C, disseminated lipogranulomatosis (Farber disease), infantile free sialic acid storage disease (ISSD), and mucolipidosis II (I-cell disease). Frequently, these inborn errors of metabolism are recognized only after the unfortunate recurrence of hydrops fetalis in several pregnancies of a family. Making the diagnosis relies on the physician having a high index of suspicion and ordering appropriate testing, which can often be performed prenatally. In several of these disorders, including MPS VII, infantile galactosialidosis, type 2 Gaucher disease, and ISSD, hydrops fetalis is a relatively common presentation. A greater physician awareness of hydrops fetalis as a presentation of lysosomal disease will facilitate establishing a diagnosis in cases that would have previously been considered idiopathic and will enable a better estimation of the incidence of this association. Lysosomal disorders are among the few causes of nonimmune hydrops fetalis in which an accurate recurrence risk can be ascertained. With an early and accurate diagnosis, genetic counseling and family planning can be offered in these difficult cases.

Serologic study of human parvovirus B19 infection in pregnancy in Japan

OBJECTIVES

To clarify the relationship between hydrops fetalis and parvovirus outbreaks in the community, seroprevalence of B19 antibody among women of childbearing age, and adverse effects of intrauterine B19 infection.

METHODS

Sera were collected from 168 cases of hydrops fetalis which were diagnosed between 1987 and 1997 in Miyagi prefecture, Japan, from 232 healthy pregnant women in 1987 and 277 healthy pregnant women in 1997 in Miyagi, and from 48 women infected with B19 during pregnancy. The sera were examined for B19 IgG and IgM antibodies by enzyme-linked immunosorbent assay and for B19 DNA by polymerase chain reaction. The number of cases of erythema infectiosum in Miyagi had been monitored each month.

RESULTS

Thirteen of the 168 cases of hydrops fetalis were found to be caused by intrauterine B19 infection and 12 of the 13 cases clustered in two periods of outbreaks of erythema infectiosum in the community. The positive rates of B19 IgG antibody between 1987 and 1997 were significantly different: 33% in 1987 and 46% in 1997. Nine of the 48 women infected during pregnancy showed adverse effects of the fetus: eight hydrops fetalis and one early abortion with positive B19 DNA. The fetal death rate (>12 weeks of gestation) among them was 15% (7/48), far higher than the calculated 1% among the general population. The nine mothers with adverse fetal outcomes had contact with the infectious source at the 16 weeks of gestation or earlier.

CONCLUSIONS

These data clearly showed a relationship between hydrops fetalis and parvovirus outbreaks in the community, and it may be important to follow the seroprevalence for an extrapolated period time to predict occurrence of hydrops fetalis caused by B19. Also the data indicated that the gestational week infection occurred is the most important determinant of an adverse effect to the fetus as described previously.

Prenatal diagnosis of thalassemia in Songklanagarind Hospital in southern Thailand

A thalassemia screening program for pregnant women has been established in Songklanagarind Hospital since 1992. After genetic counseling, a total of 5078 pregnant women accepted entry into a screening program for thalassemia. Couples at risk who should receive prenatal diagnosis were 2.8%. Total cases who accepted prenatal diagnosis were 135. Total clinical cases were 40 (29.6%) with achievement by prenatal diagnosis of 33 cases (82.5%). Genetic amniocentesis is the most acceptable method for prenatal diagnosis. Five cases (12.5%) were misdiagnosed due to contamination of maternal blood cells in amniotic fluid cases. Questionable results were reported in 2 cases (5%). Abortion occurred in one case (0.7%). Improvement of surgical technic in prenatal diagnosis reduced the complications and contamination of maternal cells. This program shows the feasibility of prevention and control of thalassemia disease in southern Thailand.

The incidence of, and factors leading to, parvovirus B19-related hydrops fetalis following maternal infection; report of 10 cases and meta-analysis

OBJECTIVES

to clarify the approximation of the frequency of B19-related nonimmune hydrops fetalis (NIHF), and to know the critical period during which maternal infection led to NIHF.

METHODS

we investigated the characteristics of 10 cases of antenatal B19 infection diagnosed over the past 10 years in Miyagi prefecture, Japan, and performed a meta-analysis of these cases and those previously reported in the literature.

RESULTS

NIHF caused by intrauterine B19 infection was diagnosed between 11 and 23 weeks of gestation in 10 women over the past 10 years in Miyagi prefecture, Japan. The source of infection was the mother's older child in six out of 10 cases, and children at a kindergarten where the mothers worked in two cases. The interval between the onset of infection and the diagnosis of NIHF ranged from 2 to 6 weeks. B19 infection was responsible for 10 (15.2%) in 66 cases of aetiology unknown NIHF in this study, and for 57 (19.1%) of 299 cases of non-malformed or aetiology-unknown NIHF by meta-analysis of the literature. Meta-analysis of the 165 reported cases of antenatal B19 infection, including the 10 cases described above, showed that there was a 10.2% excess risk of fetal death in women infected with B19 during pregnancy and a 12.40% excess risk in women infected during the first 20 weeks of pregnancy. Transplacental transmission was confirmed in 69 (24.1%) of 286 cases. The mean gestational age at diagnosis of NIHF was 22.8 +/- 5.1 weeks. The mean interval between the onset of maternal infection and diagnosis of NIHF was 6.2 +/- 3.7 weeks.

CONCLUSIONS

these approximations will be useful for counselling and management for pregnant women. The critical period during which maternal infection led to NIHF correlated with the hepatic period of hematopoietic activity. These findings suggest that parvovirus B19 may have an affinity for erythroid lineage cells at the hepatic stage of hematopoiesis, which may strongly influence the clinical features of feto-maternal B19 infection.

Immediate and long term outcome of human parvovirus B19 infection in pregnancy

OBJECTIVE

To estimate more precisely the risk of fetal loss and congenital abnormalities after maternal parvovirus B19 infection, and to assess the long term outcome for surviving infants.

DESIGN

Prospective cohort study of pregnant women with confirmed B19 infection with follow up of the surviving infants. The rate of fetal loss in the study cohort was compared with that in pregnant women with varicella.

SETTING

Cases reported by laboratories in England and Wales between 1985-1988 and 1992-1995.

SAMPLE

Four hundred and twenty-seven pregnant women with B19 infection and 367 surviving infants of whom 129 were followed up at 7-10 years of age.

METHODS

Questionnaires to obstetricians and general practitioners on outcome of pregnancy and health of surviving infants. Maternal infection confirmed by B19-specific IgM assay and/or IgG seroconversion.

RESULTS

The excess rate of fetal loss in women with B19 infection was confined to the first 20 weeks of gestation and averaged 9%. Seven cases of fetal hydrops followed maternal infections between 9 and 20 weeks of gestation (observed risk 2.9%, 95% CI 1.2-5.9). No abnormalities attributable to B19 infection were found at birth in surviving infants (observed risk 0%, upper 95% CI 0.86%). No late effects were found at 7-10 years.

CONCLUSIONS

Around 1 in 10 women infected before 20 weeks of gestation will suffer a fetal loss due to B19. The risk of an adverse outcome of pregnancy after this stage is remote. Infected women can be reassured that the maximum possible risk of a congenital abnormality due to B19 is under 1% and that long term development will be normal.

Multiple marker screening test: identification of fetal cystic hygroma, hydrops, and sex chromosome aneuploidy

The goal of this study was to determine if the multiple marker screening test (maternal serum alpha-fetoprotein, unconjugated estriol, human chorionic gonadotrophin, and maternal age) detects fetal Turner syndrome or just cystic hygroma/hydrops. Multiple marker screening tests from 4 groups were compared: 1) Turner syndrome with hydrops/ hygroma group (n = 10) = fetuses with cystic hygroma/hydrops and a 45X karyotype, 2) Turner syndrome without hydrops/hygroma (n = 9) = sonographically unremarkable fetal Turner syndrome or Turner mosaic, 3) hydrops group (n = 8) = all cases of fetal cystic hygroma/hydrops excluding Turner syndrome, 4) sex chromosome aneuploidy group (n = 16) = other sonographically normal fetal sex chromosome aneuploidies. Positive screening tests (Down syndrome risk > or = 1:190 or MSAFP > or = 2.5 MOM) were found in 60% (6/10) of the Turner syndrome with hydrops/hygroma group, but only 11% (1/9) of the Turner syndrome without hydrops/hygroma group (P = .04). The incidence of positive screening tests in the Hydrops group was 75% (6/8), while it was only 12.5% (2/16) in the other sex chromosome aneuploidy group. We conclude that the multiple marker screening test identifies fetuses with cystic hygroma/hydrops, and may do so independently of the etiology of the hydrops.

A study by means of a new assay of the relationship between an outbreak of erythema infectiosum and non-immune hydrops fetalis caused by human parvovirus B19

An enzyme-linked immunosorbent assay (ELISA), used to detect IgG and IgM antibody specific for human parvovirus B19, was established by use of human parvovirus B19 capsid protein VP-1 expressed in Escherichia coli. Paired samples of serum derived from 44 mothers and single samples derived from 24 babies having unexplained non-immune hydrops fetalis (NIHF), were tested by means of the assay. Five cases (11%) of NIHF were suspected of having been induced by intrauterine human parvovirus B19 infection because the samples of maternal serum were positive for parvovirus B19 IgM antibody. Four of the five cases arose during an outbreak of erythema infectiosum. According to our study and previous reports over 90% of NIHF caused by parvovirus B19 intrauterine infection have become clinically overt in the second trimester of pregnancy during a period ranging from 15 to 27 weeks of gestation.

Antenatal diagnosis of sacrococcygeal teratoma with hydrops fetalis; a case report

Fetal sacrococcygeal teratoma (SCT) with hydrops fetalis is known to have a poor prognosis. We report a case of SCT with hydrops fetalis which was diagnosed antenatally at 30 weeks gestation. After delivery by cesarean section, the tumor was removed and the infant is alive one year after surgery with no sign of recurrence. However, he has profound brain damage, perhaps caused by hypoxia secondary to the perinatal hypovolemia. This case demonstrates that a 30 weeks' gestation, survival is possible in fetal cases of SCT with hydrops fetalis, and illustrates the importance of perinatal circulatory management.

Diagnosis and incidence of fetal parvovirus infection in an autopsy series: II. DNA amplification

This study evaluates the practical utility of the polymerase chain reaction (PCR) as a diagnostic method for intrauterine fetal parvovirus infection in cases of hydrops fetalis. Paraffin-embedded, formalin-fixed fetal tissues from cases of hydrops fetalis were assessed for parvovirus B19 by histology and PCR in conjunction with 32P hybridization. Of 673 fetal and neonatal autopsies performed at Women and Infants' Hospital for the years 1985 through 1990, 32 cases were determined to have hydrops fetalis, of which five were positive for parvovirus infection by both histology and the PCR. PCR was not used in seven (22%) of the 32 hydrops cases because 1 microgram of DNA was not available for study. Histology was as sensitive as PCR in detecting parvovirus B19 in fetal autopsy tissues from cases of hydrops fetalis, and could be used reliably in each case to diagnose parvovirus infection. In our hands, histology is as sensitive as PCR and less labor-intensive. We would reserve PCR for cases without inclusions and with a strong suspicion of parvovirus infection, or for fluids in which histological analysis is not available.

Leukemia in Down syndrome: a review

The incidence of leukemia is higher in children with Down syndrome (DS) than in normals. In approximately 50% of cases the type of leukemia is acute megakaryoblastic leukemia (AMKL) and it occurs during the first 4 years of life. The leukemic cell also has features of erythroid progenitors and therefore appears to be a precursor cell with biphenotypic properties. In addition, newborns with DS frequently develop transient leukemia (TL), which is characterized by the presence of megakaryoblasts in the blood which disappear during the first 1-3 months of life. The incidence of this disorder is unknown although preliminary studies suggest that megakaryoblasts may be found frequently in the blood of DS newborns. TL does not occur in normal newborn infants. Although TL disappears spontaneously, many of these children will develop AMKL at 1-4 years of age. Recent surveys suggest that 20-30% of newborns with TL will develop AMKL. Preliminary evidence suggests that TL is a clonal proliferation, can be fatal, and may occur in a specific subgroup of DS children. The observations in this report are drawn from our own experience, reports in the literature, and data accumulated in the Canadian Down Syndrome Leukemia Registry.

[Hydrops fetalis of non-immunological origin. Study of 24 cases and review of the literature]

Twenty-four cases of Schriddes' disease of non-immunological origin were observed between 1973 and 1990 in the Gynecology-Obstetrics Service at Angers (France). These cases are analyzed and the results are compared with those published in the literature. This disorder must be diagnosed before birth. Three examinations are currently essential for foetal assessment: obstetrical ultrasound, ultrasonic cardiography and amniocentesis. As a result of improved antenatal diagnosis, the question of the indications for in-utero treatment and medical termination of pregnancy now arises. Despite progress in neonatal resuscitation, the prognosis generally remains very poor.

Severe fetal hydrops resulting from ABO incompatibility

Severe fetal hydrops was diagnosed at 34 weeks' gestation. Funipuncture revealed a normal 46,XX karyotype and a hematocrit of 20%. Cesarean delivery was performed. Neonatal blood testing showed blood type B positive, positive direct and indirect Coombs, and an anti-B antibody titer of 1:64. The maternal blood group was O positive with a titer of 1:65,536 immunoglobulin G (IgG) anti-B antibody (after inactivation of IgM anti-B antibody). This report documents a rare case of fetal hydrops resulting from ABO incompatibility with neonatal survival.

The changing pattern of fetal hydrops

Fetal hydrops (hydrops fetalis) remains a significant cause of fetal and neonatal mortality. The decreased incidence of rhesus iso-immunisation due to prophylaxis with rhesus immune globulin (anti-D), improved antenatal ultrasound screening, and advances in neonatal intensive care have greatly altered the clinical outlook in this condition. A retrospective review of all 27 liveborn cases of hydrops in the Royal Maternity Hospital, Belfast in the period 1974-89 showed that in the last five years 40% of cases were non-immune in origin. The mortality rate fell from 100% in the first part of the study to 50% in the second.