Differential diagnosis of hydrops fetalis

Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association

BACKGROUND

The goal of this statement is to review available literature and to put forth a scientific statement on the current practice of fetal cardiac medicine, including the diagnosis and management of fetal cardiovascular disease.

METHODS AND RESULTS

A writing group appointed by the American Heart Association reviewed the available literature pertaining to topics relevant to fetal cardiac medicine, including the diagnosis of congenital heart disease and arrhythmias, assessment of cardiac function and the cardiovascular system, and available treatment options. The American College of Cardiology/American Heart Association classification of recommendations and level of evidence for practice guidelines were applied to the current practice of fetal cardiac medicine. Recommendations relating to the specifics of fetal diagnosis, including the timing of referral for study, indications for referral, and experience suggested for performance and interpretation of studies, are presented. The components of a fetal echocardiogram are described in detail, including descriptions of the assessment of cardiac anatomy, cardiac function, and rhythm. Complementary modalities for fetal cardiac assessment are reviewed, including the use of advanced ultrasound techniques, fetal magnetic resonance imaging, and fetal magnetocardiography and electrocardiography for rhythm assessment. Models for parental counseling and a discussion of parental stress and depression assessments are reviewed. Available fetal therapies, including medical management for arrhythmias or heart failure and closed or open intervention for diseases affecting the cardiovascular system such as twin-twin transfusion syndrome, lung masses, and vascular tumors, are highlighted. Catheter-based intervention strategies to prevent the progression of disease in utero are also discussed. Recommendations for delivery planning strategies for fetuses with congenital heart disease including models based on classification of disease severity and delivery room treatment will be highlighted. Outcome assessment is reviewed to show the benefit of prenatal diagnosis and management as they affect outcome for babies with congenital heart disease.

CONCLUSIONS

Fetal cardiac medicine has evolved considerably over the past 2 decades, predominantly in response to advances in imaging technology and innovations in therapies. The diagnosis of cardiac disease in the fetus is mostly made with ultrasound; however, new technologies, including 3- and 4-dimensional echocardiography, magnetic resonance imaging, and fetal electrocardiography and magnetocardiography, are available. Medical and interventional treatments for select diseases and strategies for delivery room care enable stabilization of high-risk fetuses and contribute to improved outcomes. This statement highlights what is currently known and recommended on the basis of evidence and experience in the rapidly advancing and highly specialized field of fetal cardiac care.

Middle cerebral artery peak systolic velocity and ductus venosus velocity in the investigation of nonimmune hydrops

PURPOSE

This study was performed to investigate the cause of nonimmune hydrops fetalis by measuring the peak systolic velocity (PSV) in the middle cerebral artery (MCA) and velocity waveforms of the ductus venosus (DV) with Doppler.

METHODS

This cross-sectional study was done on 19 pregnancies referred to three university teaching hospitals for further investigation of nonimmune hydrops fetalis in 2007 and 2008. The MCA-PSV and DV velocity waveforms were recorded in all fetuses. Anemia was investigated in cases with MCA-PSV values greater than 1.50 MoM (multiple of the median). Cardiovascular causes and chromosomal abnormalities were investigated in fetuses with abnormal DV velocity.

RESULTS

Four of 19 fetuses had MCA-PSV values greater than 1.50 MoM. The causes of anemia were cytomegalovirus, parvovirus B19 infections, congenital heart disease, and Turner syndrome. Four cases had reversed flow in the DV; three of them had congenital heart disease on echocardiography; and one had a normal echocardiogram, but an abnormal karyotype was detected.

CONCLUSION

Assessment of the MCA-PSV and DV velocity waveforms during sonographic examination of fetuses with nonimmune hydrops fetalis may improve our knowledge about the etiology of this condition.

Gender differences in the induction of chromosomal aberrations and gene mutations in rodent germ cells

Germ cell mutagenicity testing provides experimental data to quantify genetic risk for exposed human populations. The majority of tests are performed with exposure of males, and female data are relatively rare. The reason for this paucity lies in the differences between male and female germ cell biology. Male germ cells are produced throughout reproductive life and all developmental stages can be ascertained by appropriate breeding schemes. In contrast, the female germ cell pool is limited, meiosis begins during embryogenesis and oocytes are arrested over long periods of time until maturation processes start for small numbers of oocytes during the oestrus cycle in mature females. The literature data are reviewed to point out possible gender differences of germ cells to exogenous agents such as chemicals or ionizing radiation. From the limited information, it can be concluded that male germ cells are more sensitive than female germ cells to the induction of chromosomal aberrations and gene mutations. However, exceptions are described which shed doubt on the extrapolation of experimental data from male rodents to the genetic risk of the human population. Furthermore, the female genome may be more sensitive to mutation induction during peri-conceptional stages compared to the male genome of the zygote. With few exceptions, germ cell experiments have been carried out under high acute exposure to optimize the effects and to compensate for the limited sample size in animal experiments. Human exposure to environmental agents, on the other hand, is usually chronic and involves low doses. Under these conditions, gender differences may become apparent that have not been studied so far. Additionally, data are reviewed that suggest a false impression of safety when responses are negative under high acute exposure of male rodents while a mutational response is induced by low chronic exposure. The classical (morphological) germ cell mutation tests are not performed anymore because they are animal and time consuming. Nevertheless, information is needed to place genetic risk extrapolations on more solid grounds and thereby to prevent an increased genetic burden to future generations. It is pointed out that modern molecular methodologies are available now to experimentally address the open questions.

Fetal middle cerebral artery peak systolic velocity in the investigation of non-immune hydrops

OBJECTIVE

In some cases of non-immune hydrops there is congenital or acquired fetal anemia. The aim of this study was to investigate the potential value of fetal middle cerebral artery peak systolic velocity (MCA-PSV) in the assessment and management of non-immune hydrops due to anemia.

METHODS

Fetal MCA-PSV and fetal hemoglobin concentration, in blood obtained by cordocentesis, were measured in 16 singleton pregnancies referred to our unit for further investigations because of a diagnosis of non-immune hydrops fetalis. In all cases a detailed ultrasound examination demonstrated moderate or severe ascites, with or without skin edema, and pericardial or pleural effusions. Furthermore, there were no obvious malformations to account for the hydrops. In each fetus the measured MCA-PSV and hemoglobin concentration were expressed as delta values (the difference in SD from the normal mean for gestation). Regression analysis was used to determine the significance of the association between delta MCA-PSV and delta fetal hemoglobin concentration. In addition, we searched our database to identify the sonographic features and hemoglobin concentration of fetuses with congenital infection.

RESULTS

In the 16 cases of non-immune hydrops there were seven with parvovirus B19 infection, one each of alpha-thalassemia and primary cardiomyopathy and seven with no obvious explanation for the hydrops. There was a significant association between delta MCA-PSV and delta hemoglobin concentration (delta hemoglobin = (delta MCA-PSV + 0.1437)/-0.4154; R(2) = 0.7202; P < 0.0001). In 10 of the cases the fetal hemoglobin concentration was more than 4 SD below the normal mean for gestation and in all these cases the MCA-PSV was more than 2 SD above the normal mean for gestation. Our computer search identified an additional nine fetuses with parvovirus B19 infection and in all cases the predominant sonographic finding was ascites and the hemoglobin concentration was more than 4 SD below the normal mean. In contrast, only 3/14 fetuses with cytomegalovirus, toxoplasmosis, coxsackie B or Treponema infection had ascites and only 2/14 had a hemoglobin deficit of 4-6 SD.

CONCLUSION

In the management of non-immune hydrops, measurement of fetal MCA-PSV can help identify the subgroup with fetal anemia.

Prenatal diagnosis and management of nonimmune hydrops fetalis

We examined the incidence, aetiological factors and outcome in 40 cases of nonimmune hydrops fetalis (NIH) and suggest a rational approach to management. The incidence of NIH was 1 in 830 deliveries during the last 10-year period. In spite of extensive antenatal and postnatal investigation no cause could be established in 14 (35%) cases. A probable aetiological factor was found in 65% of cases. These included viral infection (7), cardiovascular (6), twin-to-twin transfusion (3), chromosomal abnormality (3), other malformation syndromes (4), renal dysplasia (1), laryngeal atresia (1) and severe fetomaternal haemorrhage (1). Five of the 40 fetuses survived, 2 treated antenatally for tachyarrhythmia, 2 had spontaneous resolution and the fifth fetus had repeated intrauterine transfusions because of human parvovirus B19-induced anaemia. After diagnosis of nonimmune hydrops fetalis, early referral to a tertiary centre is to be encouraged for investigation and provision of intensive perinatal care. Investigation allows parents to be counselled appropriately that the mortality is no longer 100% and a steadily growing number may be amenable to some form of fetal therapy.

Antenatal diagnosis and outcome in hydrops fetalis

The records of 15 cases of hydrops fetalis consecutively delivered at our institution were reviewed to determine the accuracy of antenatal diagnosis and whether antenatal diagnostic techniques yielded information useful in predicting outcome. All 15 cases were detected antenatally, five were due to rhesus haemolytic disease and 10 were non-immune hydrops. All the infants required active resuscitation. Ten infants eventually died, two had immune hydrops fetalis and 8 non-immune hydrops. Seven infants had pleural effusions, all had been detected antenatally. The presence of pleural effusions did not influence mortality. All structural abnormalities were accurately detected in those patients seen prior to labour and there were no survivors in the group of infants so affected. We conclude that the mortality of non-immune hydrops fetalis remains high and that antenatal diagnosis of this condition is accurate and provides useful prognostic information.

Developmental anomalies derived from exposure of zygotes and first-cleavage embryos to mutagens

Results of continuing studies indicate that the mouse zygote and two-cell embryo stages are a window of susceptibility in the experimental induction of congenital anomalies with certain mutagenic agents. The mechanisms by which the mutagens initiate the pathogenesis of these developmental defects are not known. However, in certain cases there is evidence that a nonconventional, perhaps epigenetic, mechanism is involved. Detailed characterization of the spectrum of anomalies induced and comparison of responses at the various stages exposed allowed classification of the mutagens generally into two groups. One group is characterized by being effective only in the early stages of zygote development and capable of producing a relatively high incidence of fetal death and hydrops. The other group affects all of the zygote stages studied as well as the two cell-embryo, but does not increase the incidence of fetal death and hydrops. Except for hydrops, chemicals in the two groups do not differ in terms of the types of anomalies present among malformed live fetuses, which bear a resemblance to a subset of common, sporadic human developmental anomalies that are of unknown etiology. This similarity raises the possibility that certain human developmental defects may have their origins in events that happen in the zygote and early pre-implantation stages.

Prenatal diagnosis of human parvovirus B19 in nonimmune hydrops fetalis by polymerase chain reaction

OBJECTIVE

Nonimmune hydrops fetalis is a potentially lethal condition reflecting the clinical manifestation of several pathologic processes. Recently maternal infection by human parvovirus B19 has been reported to result in nonimmune fetal hydrops. We sought to develop a rapid and sensitive test to detect the presence of this agent in utero.

STUDY DESIGN

Using a cloned isolate of the virus, we developed an assay based on enzymatic amplification of a segment of the human parvovirus B19 genome that allows direct detection of this agent in samples of fetal blood and amniotic fluid.

RESULTS

The method detected as few as 100,000 genome equivalences and was specific for the viral genome alone. We used this assay to evaluate nine fetuses initially seen with nonimmune hydrops. Three cases were found to be positive for the human parvovirus B19 genome.

CONCLUSION

The method is powerful in that it is rapid, sensitive, and simple. This assay may have general applicability in evaluation of nonimmune hydrops and in documentation of the natural history of fetal human parvovirus infections.

Absent thumb, immune disorder, and congenital anemia presenting with hydrops fetalis

A patient is described who presented with severe congenital anemia, hydrops fetalis, immune disorder, and absent thumbs. No toxic, infectious, or metabolic cause was found to explain these symptoms. Immunologic and cytogenetic studies excluded several syndromes that combine radial ray anomalies with hematological involvement. After careful study of the literature, it is concluded that the disorder described here represents a new syndrome that can be added to a growing list of hematological-radial syndromes.

Colour Doppler imaging of intracranial vasculopathy in severe infantile sialidosis

Neonatal ascites is usually attributed to prenatal infections, lysosomal storage disease and anomalies of the genitourinary tract, gastrointestinal tract or cardiovascular system. We report one case of neonatal ascites associated with infantile sialidosis. Cerebral sonography showed stripe-like intracerebral echogenicities in the region of the basal ganglia. Colour Doppler imaging demonstrated blood flow within the echogenicities confirming the suspected diagnosis of intracranial vasculopathy.

Placentomegaly with massive hydrops of placental stem villi, diploid DNA content, and fetal omphaloceles: possible association with Beckwith-Wiedemann syndrome

Marked placental hydrops is generally associated with hydatidiform mole. Diagnosis of hydatidiform mole requires both villous hydrops and trophoblast hyperplasia. This report describes four cases with massive hydrops of placental stem villi without associated trophoblast hyperplasia. All four had diploid DNA content by flow cytometry. Fetal omphalocele was present in three; and one had diagnostic Beckwith-Wiedemann syndrome (BWS). In two others, there were pathologic features suggestive of BWS. The fourth fetus had multiple anomalies by ultrasound; autopsy examination of the fragmented fetus failed to disclose additional pathology. The association of massive placental hydrops involving stem villi, fetal omphalocele, and diploid DNA content is unusual. These fetal and placental findings may suggest possible BWS in some cases and allow for antenatal diagnosis of affected fetuses, clinical evaluation of additional family members, and planning for neonatal care.

Beta-glucuronidase deficiency as a cause of prenatally diagnosed non-immune hydrops fetalis

We describe a case of beta-glucuronidase deficiency presenting as a non-immune hydrops fetalis diagnosed at 26 weeks of gestation. The deficiency was disclosed on cultured amniotic fluid cells and in fetal plasma and was confirmed post-abortion. In a second pregnancy, a normal beta-glucuronidase activity was found in extracts of chorionic villi obtained at 10 weeks of gestation. The pregnancy is continuing uneventfully. We conclude that it is of great importance to verify the presence of metabolic disease whenever the major causes of hydrops fetalis have been excluded.

Hydrops revisited: literature review of 1,414 cases published in the 1980s

This paper reviews 47 series of hydrops fetalis (804 cases) and 610 individual cases published since 1980. From this large number of cases, guidelines are derived for prenatal diagnosis and management.

Fetal pathology produced by ethylene oxide treatment of the murine zygote

Exposure of female mice to ethylene oxide by inhalation 1 or 6 h after mating produced not only multitemporal death of conceptuses but also high rates of abnormalities among surviving fetuses. In contrast, only marginal effects were observed when females were exposed 9 or 25 h after mating. The abnormalities found among 17 day gestation live fetuses were predominated by hydrops and eye defects, which, together, constitute 54% of all anomalies. Most of the remaining anomalies were distributed among 5 other types: small size, cleft palate, and cardiac, abdominal wall, or extremity and/or tail defects. In a follow-up study, the fetuses of females treated 6 h postmating were examined at 11-15 days gestation and the progression of fetal death and of malformations was studied. Results indicate that the expression of most fetal anomalies does not become apparent until late in gestation. Several of these induced anomalies are similar to common human sporadic birth defects. This new class of experimentally induced fetal anomalies provides a new avenue for investigating zygotic biology and a system for studying the progression of aberrant development.

The pathologist's perspective of genetic disease. Malformations and dysmorphology

The pathologic approach to the study of malformations and congenital abnormalities emphasizes the importance of careful dissection and pathologic studies. Concepts and terms of morphogenesis as defined by the International Working Group are presented. The developmental field is the central concept of a malformation. Malformation syndromes, disruptions, sequences, deformations, dysplasias, and associations are presented. The significance of fetal hydrops and short umbilical cord is discussed. Pathologic studies in chromosome defects suggest pathologic markers for some chromosome abnormalities.

Cardiac abnormalities and nonimmune hydrops fetalis: a coincidental, not causal, relationship

Few conditions associated with nonimmune hydrops fetalis have had a demonstrable causal relationship. Congenital heart disease is often said to be a cause of nonimmune hydrops fetalis and antenatal closure of the foramen ovale is the cardiac abnormality most frequently reported in association with hydrops. In order to examine the role of congenital heart disease in hydrops, and, in particular, that of antenatal closure of the foramen ovale, we reviewed all autopsy cases with hydrops fetalis over an 11 year period and compared cardiac anomalies with those of nonhydropic controls. The incidence of various congenital heart malformations was not significantly different among these groups, suggesting that factors in addition to cardiac anomalies must be considered in the pathogenesis of nonimmune hydrops fetalis.

TC-83 Venezuelan equine encephalitis vaccine exposure during pregnancy

A human pregnancy exposed to TC-83 live attenuated Venezuelan equine encephalitis (VEE) virus vaccine resulted in hydrops fetalis and fetal demise. Maternal seroconversion and the finding of a diffuse mononuclear cell infiltrate on postmortem examination are suggestive of a causative role for TC-83 vaccine.

Hydrops foetalis in sheep

Hydrops foetalis was observed in foetuses from a sheep flock in southern New South Wales over 4 years. Ewes showed marked abdominal distension and most died at parturition, being unable to deliver large affected foetuses. These had birth weights up to 18 kg and exhibited severe generalised oedema of subcutaneous tissues, fluid accumulation in the serous cavities and oedema of the placenta. Microscopically, there was a generalised extramedullary haemopoiesis and massive oedema, consistent with a chronic foetal anaemia. No infectious or environmental factors could be incriminated in the outbreak. The clinical and pathological findings resemble those of the homozygous alpha-thalassaemia in infants associated with haemoglobin Bart's.

Fetal ascites. A report of 3 autopsy cases

Three rare autopsy cases of fetal ascites were presented and the etiology of each case was described. Case 1 was a male neonate, delivered by cesarean section at 32 weeks' gestation, and died of respiratory failure. The abdomen was remarkably distended with 1020 ml of ascites. The etiology of Case 1 remained unknown even after macroscopic and microscopic examinations. We considered this as "idiopathic" fetal ascites. Case 2 was a female neonate, delivered at 31 weeks' gestation, with marked abdominal distension and cyanosis. Autopsy revealed 435 ml of ascites, and she was considered to have had "polysplenia syndrome" with cardiovascular malformations. Intrauterine heart failure due to cardiac anomalies was thought to be the cause of this ascites. In case 3 embryotomy was carried out under the diagnosis of fetal ascites by ultrasound examination at 22 weeks' gestation. An urachal cyst connected to the dilated urinary bladder and deficiency of musculature of the abdominal wall composed of loose connective tissue with calcification were observed. The abdominal wall was ruptured and 1,960 ml of ascites was measured. Polycystic kidney with renal dysplasia was also found. Case 3 showed "Prune-Berry syndrome" and fetal ascites may have arisen from these anomalies.

Listeriosis: a cause of non-immune hydrops fetalis

A case of prenatally diagnosed non-immune hydrops fetalis, that was later shown to be caused by listeriosis, is presented, and the clinical course, as well as the appropriate diagnostic and therapeutic procedures are described. We conclude, that listeriosis should be excluded, whenever a non-immune hydrops fetalis is associated with septicemia, influenza-like illness and fever of unknown origin.

The Farber lecture. Prenatal and perinatal death: the future of developmental pathology

It seems evident that most of "humanity" dies before, not after birth and that perhaps only one-third survive from earliest beginnings until birth or the end of the first year of life. As many as 50% of all human ova may have a chromosome abnormality with over 99% mortality, making this type of genetic defect not just the commonest cause of death prenatally and the cause of a substantial proportion of the malformations of abortuses and fetuses, but the commonest cause of death in humans altogether. This study, along with numerous studies before it, is the most convincing justification for doing autopsies on pre- and perinatally dead embryos and fetuses. With appropriate supervisory collaboration from a university pediatric pathology unit, such studies can be done efficiently at secondary-care centers, including some in rather remote locations. Thus, there exists no excuse anymore for not doing such studies which, in a high proportion of cases, will give the parents and attending physicians an explanation of the events and observed abnormalities with a chance in all cases at correct diagnostic and genetic counseling, appropriate monitoring of the next pregnancy, and an improved possibility of population monitoring for teratogens and substantial increases in the mutation rate. These immediate benefits to patients and the quality of medical care are the major, but not the only, justification for doing fetal pathology. Literally thousands of new discoveries still await the investigator with a prepared mind and will afford many research opportunities to those with an interest in normal and abnormal human development. And if it can be resolved in present-day pathology training programs how to attract greater numbers of interested residents and fellows into the field and to motivate them to take the additional training to become expert in developmental and genetic analysis, then "developmental" pathology will be facing a very bright future indeed.

Prenatal treatment of fetal hydrops associated with the hypertelorism-dysphagia syndrome (Opitz-G syndrome)

Non-immunological fetal hydrops diagnosed prenatally presents a difficult diagnostic and therapeutic problem. In the case presented, fetal hydrops was recognized at 19 weeks gestation and no specific cause was found prenatally in spite of extensive investigations. The fetal hydrops was treated in utero by thoracocentesis and an intravenous infusion of albumin carried out at fetoscopy. After birth the infant was recognized to have the hypertelorism-dysphagia syndrome (or Opitz-G syndrome, McK no. 30710). This autosomal dominant syndrome consists of hypertelorism, laryngeal abnormalities, swallowing difficulties, hyprospadias and an imperforate anus. Fetal hydrops has been reported on one previous occasion in this syndrome. The intrauterine treatment given in this case may have been successful in reducing the neonatal complications of the Opitz-G syndrome.

Intrauterine aplastic anemia and fetal hydrops: a case report

Fetal hydrops developed in the 8-day interval between two ultrasonographic examinations of a pregnant woman who had presented with a revealed placental abruption. Chronic ulcerative colitis had been treated with oral prednisone and sulfasalazine until the second month of pregnancy and then with prednisone only. An autolysed hydropic fetus was delivered at 26 weeks gestation. No hematopoietic tissue was identified in the small pale fetal liver, in the bone marrow, or in other organs. No cause for hydrops other than the aplastic anemia was identified.

alpha-Thalassemia hydrops fetalis: clinical and ultrasonographic considerations

Five pregnant Southeast Asian women presenting during a 14-month period with microcytic anemia, preeclampsia, and size-date discrepancies were all ultimately diagnosed as carrying fetuses with homozygous alpha-thalassemia hydrops fetalis. The perinatal complications of this hemoglobin disorder are unique to persons of this ethnic background and include uniform fatality for the affected infant, maternal preeclamptic morbidity, and retained placenta. In this report the obstetric ultrasound findings are presented and the clinical manifestations are discussed, with recommendations made to reduce this emerging public health problem in the United States.

Vascular abnormalities in a fetus with multiple pterygia

We describe a 16-week fetus with a lethal multiple pterygium syndrome and hydrops. No bony abnormalities were noted on radiographic or anatomical examination. A prominent meshwork of dilated, thin-walled vessels was present in the subcutis over the entire body. This abnormal vascularity may have caused pterygium formation and death of the fetus.

Nonimmune hydrops fetalis: a challenge in perinatal pathology

Autopsies were performed in 40 cases of nonimmune hydrops fetalis during the period from 1975 to 1983. In 25 cases specific anatomic diagnoses, including hematologic disorders, infections, chromosomal abnormalities, congenital anomalies, and tumors, were made. In the majority the diagnosis of hydrops fetalis was made prenatally by ultrasonography. The mean gestational age at delivery was 30 weeks; 23 infants were stillborn, and 17 died during the neonatal period. Body weights were consistently increased; peripheral edema and ascites were present in all cases and pleural effusions in all but two cases. Hepatosplenomegaly, cardiomegaly, and pulmonary hypoplasia were frequent findings. The most consistent microscopic changes involved endocrine organs. Islet cell hyperplasia and Leydig cell hyperplasia were common, and thyroid hyperplasia was found occasionally. The fetal zone of the adrenal cortex was often thick and composed of swollen, vacuolated cells. Enhanced extramedullary erythropoiesis was observed in all cases. Thirty-nine placentas were examined; 34 were edematous (mean weight, 547 g), with villous edema, excess erythroblastemia and normoblastemia, and occasional intravillous hematopoiesis. Nonimmune hydrops fetalis has a range of known causes. Thorough autopsy, including placental examination, is the most useful approach for determining the etiology. In 23 cases the probable or possible cause was established in this manner. Antibody studies should also be performed in all cases to exclude an immunologic etiology. Synthesis of clinical, serologic, and pathologic data offers prospects for rational management and prediction of recurrence.

Fetoscopy in the assessment of unexplained fetal hydrops

Pure fetal blood samples, obtained fetoscopically from 30 patients with unexplained fetal hydrops at 16 to 32 weeks gestation were investigated for cytogenetic, haematological, biochemical and virological properties. In two patients with oligohydramnios, the fetoscope was introduced transabdominally into the fetal peritoneal cavity and sampling was undertaken from the intra-abdominal portion of the umbilical vein; in all the other patients an umbilical cord vessel was sampled. Ten (33%) of the fetuses had chromosomal abnormalities, one an erythroblastic process, possibly erythroleukaemia, one alpha-thalassaemia and one cytomegalovirus infection. Blood-film abnormalities were seen in 23 (88%) of 26 fetuses that had this examination. Biochemical analysis of fetal plasma was undertaken in 18 fetuses and hypoproteinaemia was found in all cases. One fetus was subsequently found to have a paroxysmal tachyarrhythmia that responded to digitilization. Three (10%) of the fetuses survived.

Twin transfusion syndrome: successful in utero treatment with digoxin

A pregnancy complicated by twin transfusion syndrome is presented. When signs of cardiac failure (edema, ascites and hydramnios) persisted in the recipient twin, maternal digoxin therapy was instituted at 27 weeks' gestation. The signs of failure resolved, and the twins were delivered electively by cesarean section at 34 weeks. At birth, the syndrome was confirmed by examination of the infants and placenta. Both infants survived. Digoxin therapy is recommended for fetal heart failure from circulatory overload in twin transfusion.

The relationship of fetal plasma protein concentration and hemoglobin level to the development of hydrops in rhesus isoimmunization

Fetoscopic samples of pure fetal blood were obtained at 18 to 25 weeks' gestation from seven hydropic and 10 nonhydropic fetuses affected by rhesus isoimmunization, and the fetal plasma albumin, plasma total protein, and hemoglobin concentrations were determined. All fetuses with sonographic evidence of hydrops had a hemoglobin of 3.8 gm/dl or less, whereas all but one of those without hydrops had a hemoglobin greater than 4.0 gm/dl. The plasma total protein was less than 2 standard deviations below the mean of the normal range in all hydropic fetuses and in six of 10 of those without hydrops. Hypoalbuminemia was found in six of the seven hydropic fetuses and in two of the nonhydropic fetuses. Ascitic fluid total protein and albumin concentrations were also determined in four hydropic fetuses, and the values in three were found to be more than 50% of the corresponding plasma levels.

A lethal autosomal recessive syndrome of multiple congenital contractures

We describe 16 cases of a lethal syndrome with multiple congenital contractures from ten families. The main clinical findings included intrauterine growth retardation with marked fetal hydrops, multiple contractures, and facial abnormalities, especially micrognathia. At autopsy, pulmonary hypoplasia and muscular atrophy were present. There was a paucity of anterior horn motor neurons in the four studied cases. We think that the cases represent the same clinical entity, probably caused by homozygosity of an autosomal recessive gene. The syndrome resembles the Pena-Shokeir I syndrome, but seems to differ in some respects, including length of survival and presence of hydrops. Prenatal diagnosis of this syndrome is possible after the 16th week of pregnancy with ultrasound.

Diseases causing fetal and neonatal ascites

Causes of fetal ascites are reviewed, and 3 new cases are reported. A protocol is suggested for intrauterine investigation of the spectrum of diseases causing fetal ascites. There is some overlap with causes of hydrops fetalis.

Investigation of nonimmune hydrops fetalis

Fifty pregnancies complicated by fetal ascites and generalized edema are reviewed and their prenatal findings, obstetric management, and fetal outcome are discussed. From the myriad of maternal, fetal, and placental problems which are known to cause nonimmune hydrops fetalis, many different causes of the disorder could be identified in 84% of all patients studied by extensive prenatal and postnatal workup. Therefore, in only 16% of the cases was the nonimmune hydrops fetalis labeled "idiopathic." The most common demonstrable causes of the disorder in this series were cardiac anomalies, followed by chromosomal disorders, congenital malformations, alpha-thalassemia, and the twin-twin transfusion syndrome. A systematic approach to the prenatal diagnostic workup of nonimmune hydrops fetalis is outlined, starting with the least invasive techniques (ultrasound, echocardiography, complete blood count, Kleihauer-Betke analysis, TORCH testing, and so forth) followed by more invasive techniques (amniocentesis and fetoscopy). Although the detection and prognostic evaluation of nonimmune hydrops fetalis are greatly improved by applying these techniques, the overall prognosis for most fetuses with nonimmune hydrops fetalis is still very poor, and only a few conditions causing the disorder, such as prenatally detected cardiac arrhythmias or selected cases of urinary tract obstruction, are amenable to treatment in utero.

Neuraminidase deficiency presenting as non-immune hydrops fetalis

A newborn infant with oedema, ascites and hepatosplenomegaly is described. In ascites fluid foamy macrophages were found, in a liver biopsy cytoplasmic inclusions and membrane-bound vacuoles were seen. Furthermore the child excreted excessive amounts of sialic acid-rich oligosaccharides in the urine, and therefore a neurovisceral degenerative disorder was assumed. The diagnosis of sialidosis was confirmed by enzymatic assay in cultured fibroblasts, in which a complete deficiency of the lysosomal enzyme neuraminidase could be demonstrated. After recurrent septicaemias the child became dystrophic and died at the age of 6 months. Our case is compared with sialidosis observed by other authors, the wide phenotypic diversity within this biochemical defect is emphasised. The occurrence of hydrops fetalis in lysosomal storage diseases is discussed.

Syndrome of multiple pterygia, camptodactyly, facial anomalies, hypoplastic lungs and heart, cystic hygroma, and skeletal anomalies: delineation of a new entity and review of lethal forms of multiple pterygium syndrome

Three unrelated stillborn infants (cases 1-3) are presented here with a distinct constellation of multiple anomalies: namely, multiple pterygia involving chin-to-sternum, cervical, axillary, antecubital, crural and/or popliteal areas, flexion contractures of multiple joints, small chest, hydrops, characteristic abnormal facial appearance with hypertelorism, markedly flattened nasal bridge with hypoplastic nasal alae, cleft palate, micrognathia, apparently low-set malformed ears, short neck with a cystic hygroma at the back of the neck and head, and pulmonary and cardiac hypoplasia. Radiographic studies, in addition, showed scalp edema, microbrachycephaly, flattened mandibular angle, lack of normal curvature at the cervico-thoracic junction, marked bony fusion of posterior spinous processes of older fetuses (cases 1, 2), thin crowded ribs, markedly hypoplastic scapulae, hypoplastic iliac wings, ischia and pubic bones, undermodeling of tubular bones, and radio-ulnar synostosis. Histologic studies of the skeletal system showed cartilaginous and bony fusion of the spinous processes (cases 1, 2), fusion of epiphyseal cartilages of distal humerus and proximal ulna, a poorly developed joint space, an abnormal growth plate, and weak safranin staining of the resting cartilages (cases 1, 2). To the best of our knowledge, this pattern of anomalies constitutes a previously undescribed syndrome. Prenatal diagnosis of this entity is possible by ultrasonographic studies on the basis of nonimmune fetal hydrops, a cystic hygroma at the back of the head and neck, diminished fetal activity, short and fixed limbs, and/or maternal hydramnios. Three additional cases (cases 4-6) are also presented to show a possible heterogeneity of this syndrome.

Nonimmune hydrops fetalis: antenatal diagnosis and management

An 8-year (1975-1982) study of 26 cases of nonimmune fetal hydrops revealed the main causes to be: anomalies (11/26), tachyarrhythmias (4/26), and twin-to-twin transfusion (4/26). The perinatal mortality was 19/26 (76%). Based on this series, and a review of the literature, a plan for the antenatal diagnosis and management of these cases is outlined.

Nonimmunologic hydrops fetalis

Twenty cases of nonimmunologic hydrops fetalis were reviewed. The incidence of nonimmunologic hydrops fetalis was 1/2,029 (20 cases in 40,588 deliveries). The diverse etiologies of nonimmunologic hydrops fetalis are demonstrated. The incidence of erythroblastosis fetalis caused by Rh isoimmunization declined markedly. The perinatal mortality rate was 14/18 or 78%. Prematurity, the presence of congenital anomalies, and the severity of hydrops fetalis contribute to this poor prognosis. However, a better understanding of the pathophysiology of hydrops fetalis, along with early detection by ultrasonography, preterm delivery with the liberal use of cesarean section, and availability of high-risk perinatal units, may enable us to improve the prognosis. A precise diagnosis should be attempted by careful antenatal and postnatal evaluation, so that accurate genetic counseling can be offered.

Congenital ascites as a presenting sign of lysosomal storage disease

Neonatal ascites is usually attributed to hematologic, genitourinary, gastrointestinal tract, or congenital heart disease. When these lesions have been excluded, metabolic storage disorders should be considered in the differential diagnosis. We report eight cases of neonatal ascites associated with different types of lysosomal storage disease: infantile sialidosis, Salla disease, GM1 gangliosidosis, and Gaucher disease. In each case there was a history of sibling of perinatal death resulting from the disease. In three cases the diagnosis of ascites was made in utero by ultrasound examination. These diseases are characterized by excretion in the fetal urine of abnormal catabolic products or by measurement of decreased activity of specific lysosomal hydrolases in cultured amniocytes. Thin-layer chromatography of the oligosaccharides in amniotic fluid may be indicated when a diagnosis of persistent fetal ascites has been established.

Primary restrictive foramen ovale

A newborn infant with primary restrictive foramen ovale, tubular hypoplasia of the aortic arch, and some other developmental defects is described. This combination resulted in fetal hydrops, as was shown by ultrasonography. The child died 24 h after birth due to low output syndrome and extensive bronchopneumonia. The pathogenesis of this clinical entity is discussed.

Non-immunologic hydrops fetalis: a review of 27 cases

Twenty seven babies with severe non-haemolytic hydrops fetalis were born during a 7 1/4 year period (1/1400 total births). Thirteen were live born and admitted to the intensive care nursery, but only three survived. The survivors differed from those live born infants who died in the neonatal period in that the cause of the hydrops was discovered antenatally, their serum concentrations of total protein and albumin were normal, and they had no structural anomaly. A scheme of investigation of the severely hydropic fetus in the antenatal period is outlined and the role of active obstetric management is evaluated.

Evaluation of a protocol for post-mortem examination of stillbirths

A variety of procedures have been recommended for post-mortem examination of stillbirths to determine the cause of the loss of the pregnancy and to provide an estimate of the risk of recurrence. We studied the relative usefulness of several such techniques, including gross and microscopical autopsy, photography, radiography, bacterial cultures, and chromosome studies. In 44 (35 per cent) of 124 cases of stillbirth or early neonatal death, structural physical abnormalities were evident at autopsy. In 35 of the 44 cases the abnormalities were due to chromosomal, single-gene, or polygenic disorders. The single most useful examination was the gross autopsy. Analysis of the various procedures suggests that when resources are limited, gross autopsy, photography, radiography, and bacterial cultures should be performed in all cases of stillbirth and early neonatal death, but that karyotyping and histopathology may be used selectively. This approach should minimize the use of expensive, low-yield procedures without compromising the ability to provide information for purposes of genetic counseling.

Nonimmune fetal hydrops and Down syndrome

Six infants with nonimmune fetal hydrops (NIFH) were found to have trisomy 21 (Down syndrome). A cardiac malformation was present in three of these infants. The manifestations of Down syndrome was obscured by the generalized edema at birth. The association of Down syndrome and NIFH emphasizes the need for chromosome analysis in the workup of infants or fetuses with NIFH.