Isolated fetal hydrothorax with hydrops: a systematic review of prenatal treatment options

National registry of thoracoamniotic shunting using a double-basket catheter: A post-marketing surveillance registry of 295 patients with fetal hydrothorax

OBJECTIVE

We report on the 1-year outcomes of fetuses who underwent thoracoamniotic shunting (TAS) with a double-basket catheter for fetal hydrothorax (FHT) using a national post-marketing surveillance registry.

METHODS

This surveillance study was conducted for cases enrolled between 2011 and 2019. Preoperative, operative, and postoperative findings and outcomes had to be reported through the national surveillance website.

RESULTS

Forty-three institutes enrolled 295 patients. In 60 patients, associated abnormalities were diagnosed after birth. Among the 235 patients with isolated hydrothorax, the survival rate at 1 year of age was 70.5%. Among these patients, 89% did not require oxygen or other respiratory support. The 1-year survival rate in complicated cases was 27%. Trisomy 21 was the most common associated problem (40%). Catheter associated problems, including dislocation (25%), obstruction (24%), and preterm rupture of the membranes (6%) were observed, but there were no severe maternal complications. TAS before 29.5 weeks of gestation (odds ratio [OR] 0.16) and skin edema and ascites (OR 0.06) were risk factors for death at one year, whereas appropriate shunt location for >28 days (OR 4.2) was a protective factor.

CONCLUSION

We report a favorable survival rate in fetuses with isolated FHT treated with this double-basket catheter.

Intrauterine Thoracoamniotic Shunting of Fetal Hydrothorax with the Somatex Intrauterine Shunt: Intrauterine Course and Postnatal Outcome

(1) Background: Severe fetal hydrothorax can be treated by intrauterine thoracoamniotic shunting (TAS). The aim of this study was to assess perinatal outcome and complication rates of TAS with a novel Somatex intrauterine shunt. (2) Methods: This is a single-center retrospective study of all fetuses with hydrothorax treated with TAS using a Somatex shunt between 2014 and 2020. (3) Results: A total of 39 fetuses were included in the study. Mean gestational age at first intervention was 27.4 weeks (range 19–33). Of these, 51% (n = 20) of fetuses had fetal hydrops, which resolved in 65% (13/20) before delivery. The live birth rate was 97% (n = 38), and 74% (n = 29) survived the neonatal period. The rate of postnatal pulmonary complications was high, with 88% of neonates requiring any kind of ventilatory support. There were 23% (n = 9) genetic abnormalities (trisomy 21 and Noonan syndrome). (4) Conclusions: TAS with a Somatex shunt has a high technical success rate, leading to high neonatal survival rates. Pregnancy and neonatal outcome is comparable to TAS for fetal hydrothorax using different shunt types.

Survival of Hydrops Fetalis with and without Fetal Intervention

Objectives: To investigate the survival rate of hydrops fetalis after fetal interventions and neonatal intensive care. Methods: We reviewed the medical records of patients diagnosed with hydrops fetalis from January 2009 to December 2019 at Changhua Christian Children’s Hospital. All cases had abnormal fluid accumulation in at least two body compartments during pre- and postnatal examination. The primary outcome measure was the mortality rate. We also collected information regarding disease etiology, duration of hospital stay, Apgar score, gestational age at birth, initial hydrops fetalis diagnosis, fetal intervention, first albumin and pH levels, and maternal history. Results: Of the 42 cases enrolled, 30 survived and 12 died; the mortality rate was 28.6%. Furthermore, 22 cases received fetal intervention, while 20 cases did not; there was no significant difference in their survival rates (75% and 68%, respectively). Survival rate was associated with gestational age at birth, initial diagnosis time, birthweight, Apgar score, initial albumin and pH levels, and gestational hypertension. Only one case was immune-mediated. Among the nonimmune-mediated cases, the three most common etiologies were lymphatic dysplasia (12/42), idiopathic disorders (10/42), and cardiovascular disorders (5/42). Conclusions: Overall, hydrops fetalis was diagnosed early, and fetal intervention was performed in a timely manner. Preterm births were more frequent, and birthweight was lower in the cases that underwent fetal intervention than in those that did not, but there was no significant between-group difference in mortality. The initial diagnosis time, gestational age at birth, birthweight, Apgar score, and first albumin and pH levels were independently associated with mortality.

Perinatal Outcome in Fetuses with Dislodged Thoraco-Amniotic Shunts

OBJECTIVE

Fetal thoraco-amniotic shunts (TASs) can dislodge in utero, migrating internally into the fetal thorax or externally into the amniotic cavity. Our objective was to evaluate the perinatal and long-term outcome of fetuses with TAS dislodgement and conduct a review of the literature.

METHODS

This is a retrospective review of all TAS inserted for primary pleural effusions and macrocystic congenital pulmonary airway malformations (CPAMs) in a tertiary fetal medicine center (1991-2020). Antenatal history, procedural factors, and perinatal and long-term outcomes were reviewed in all fetuses with dislodged shunts and compared to fetuses with shunts that did not dislodge.

RESULTS

Of 211 TAS inserted at a mean gestational age of 27.8 weeks ± 5.47 (17.4-38.1 weeks), 187 (89%) were inserted for pleural effusions and 24 (11%) for macrocystic CPAMs. Shunts dislodged in 18 fetuses (8.5%), 17 (94%) of which were for pleural effusions. Shunts migrated into the chest wall/amniotic cavity or into the thorax among 7/18 (39%) and 11/18 (61%) fetuses, respectively. Eleven (61%) fetuses were initially hydropic, which resolved in 8 (72%) cases. Effusions were bilateral in 9 (50%), amnioreduction was required in 6 (33%), and fetal rotation in 8 cases (44%). Four (22%) fetuses underwent repeat shunting, 12 (67%) neonates required ventilatory support, and 2 (11%) neonates required chest tubes. There was no significant difference in technical factors or outcomes between infants with shunts that dislodged and those that did not. Among 11 intrathoracic shunts, 2 (18%) were removed postnatally and the remainder are in situ without any shunt-related or respiratory complications over a follow-up period of 9 months to 22 years.

CONCLUSION

TAS dislodged antenatally in 8.5% of fetuses, with 2/3 of shunts migrating into the thorax, and nearly 25% requiring re-shunting. Retained intrathoracic shunts were well tolerated and may not necessarily require surgical removal after birth.

Short- and long-term outcome following thoracoamniotic shunting for fetal hydrothorax

OBJECTIVES

To assess short- and long-term outcome in a cohort of fetuses diagnosed with hydrothorax (FHT) which underwent thoracoamniotic shunting in utero, and to examine the antenatal predictors of survival and of survival with normal neurodevelopmental outcome.

METHODS

This was a retrospective analysis of 132 fetuses that underwent thoracoamniotic shunting at our center between 1991 and 2014. Data were extracted from hospital obstetric and relevant neonatal intensive care and neonatal developmental follow-up databases. Outcomes included survival to discharge and survival with normal neurodevelopmental outcome beyond 18 months. Information on malformations, syndromes and genetic abnormalities were obtained from antenatal, postnatal and pediatric hospital records or by parent report. We compared pregnancy characteristics among those who survived vs non-survivors and among those with normal neurodevelopmental outcome vs those who were abnormal or died. We explored whether there was a trend in survival over the study period.

RESULTS

The mean gestational age at diagnosis of FHT was 25.6 weeks. The fetus was hydropic at diagnosis in 61% of cases, 69% had bilateral effusions and 55% had bilateral shunts inserted. Other diagnoses were present in 24% of cases, two-thirds of which were discovered only postnatally. There were 16 intrauterine and 30 neonatal deaths, with a 65% survival rate overall. The mean gestational age at delivery of liveborns was 35.4 (range, 26.9-41.6) weeks, and 88/116 (76%) were preterm (< 37 weeks). Of 87 liveborn at the treatment center, 75% experienced some respiratory and/or cardiovascular morbidity after birth, many with a lengthy hospital stay (mean, 36 (range, 1-249) days). Overall, 84% of survivors were developmentally normal beyond 18 months and outcomes were better when pleural effusions were isolated, 92% of these cases being neurodevelopmentally normal. There was no trend in survival or neurodevelopmental outcome over time. Despite the presence of FHT and neonatal respiratory issues, most (89%) of the 55 survivors with relevant follow-up had no long-term pulmonary complications. Gestational age at delivery was the only factor independently predictive of both survival and survival with normal neurodevelopmental outcome.

CONCLUSIONS

FHT is associated with other pathologies in a quarter of cases and carries a significant risk of prematurity, mortality and neonatal morbidity. The outcome is good in survivors but is best in isolated cases. Predictors of outcome at diagnosis are poor. Future improvement in diagnostics at time of identification of FHT may help to identify those that would benefit most from thoracoamniotic shunting. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Single Uterine Access for Bilateral Pleuroamniotic Shunting in Fetuses with Severe Hydrothorax by an Internal Rotational Maneuver: Feasibility and Outcomes between Successful and Failed Procedures

OBJECTIVE

The objective of this study was to describe the feasibility of single percutaneous uterine access for bilateral pleuroamniotic shunting (PAS) in fetuses with severe hydrothorax by using an internal rotational maneuver and to compare perinatal outcomes between successful and failed procedures.

METHODS

A prospective cohort of 25 fetuses with isolated bilateral hydrothorax and hydrops were referred to our fetal surgery center in Queretaro, Mexico during an 8-year period. Bilateral PAS was first attempted through a percutaneous single uterine access by internal rotation of the fetus, which was achieved by using the blunt tip of the same cannula, and in case of a failed procedure, a second uterine port was used to place the second shunt. The perinatal outcomes between successful (single uterine port) and failed (2 uterine ports) fetal procedures were compared.

RESULTS

Placing of bilateral shunts through a percutaneous single uterine access was feasible in 15/25 (60%) cases. Overall, median GA at delivery was 35.2 weeks with a survival rate of 64.0% (16/25). Three cases were excluded due to shunt dislodgement, leaving a final population of 22 fetuses; 13/22 (59.1%) and 9/22 (40.9%) managed using 1 and 2 uterine ports, respectively. The group with bilateral PAS placement through a successful single uterine port showed a significantly higher GA at birth (36.5 vs. 32.8 weeks, p = 0.001), lower surgical time (11.0 vs. 19.0 min, p = 0.01), longer interval between fetal intervention and delivery (5.7 vs. 2.7 weeks, p = 0.01), lower risk of preterm delivery (46.2 vs. 100%, p < 0.01), and lower rate of perinatal death (15.4 vs. 55.6%, p < 0.05) than the failed procedures requiring 2 uterine ports.

CONCLUSION

In fetuses with severe bilateral hydrothorax and hydrops, bilateral pleuroamniotic shunting through a successful single percutaneous uterine access is feasible in up to 60% of cases and is associated with better perinatal outcomes.

Staged Management of Congenital Chylothorax With Hydrops Fetalis: An Insight Into EXIT Related Procedures

Background: Idiopathic congenital chylothorax is a rare but serious disease. Advancement in perinatal care and the renovated treatment modalities have brought about significant improvement in patient outcome. Objective: To describe the clinical course of severe forms of idiopathic congenital chylothorax, focusing on the development of recent treatment modalities and their impacts. Design: A retrospective cohort by review of medical records in the NICU of a perinatal referral center in Taiwan. Study period was from January 2006 to June 2017. Neonates with the diagnosis of idiopathic congenital chylothorax with non-immune hydrops fetalis were enrolled. Clinical relevant including demographic data, perinatal interventions, post-natal course, and treatment outcome were described and analyzed. Results: Twenty-eight neonatal patients were included. The median gestational age at birth was 34 (range 27-36) weeks and median birth weight was 2,369 (range 1,430-3,608) g. Prenatal intervention was performed in 39.3% of the patients. Besides, 11 out of the 28 neonates developed tension pneumothorax in the first 24 h and 4 (36.4%) of them died. Sepsis was documented in two patients (7.1%). Overall survival rate was 71.4%. There were five patients enrolled during the last 2 years of the study period. EXIT with intubation was performed in two and octreotide was given to four of these most recent neonates, and all of them survived. Conclusion: Recent advances in the management of these neonates, specifically EXIT with intubation and use of octreotide. Both of them improved patient survival in our cohort, but the evidence of impact has yet to be validated.

Current perspective and scope of fetal therapy: part 1

Fetal therapy term has been described for any therapeutic intervention either invasive or noninvasive for the purpose of correcting or treating any fetal malformation or condition. Fetal therapy is a rapidly evolving specialty and has gained pace in last two decades and now fetal intervention is being tried in many malformations with rate of success varying with the type of different fetal conditions. The advances in imaging techniques have allowed fetal medicine persons to make earlier and accurate diagnosis of numerous fetal anomalies. Still many fetal anomalies are managed postnatally because the fetal outcomes have not changed significantly with the use of fetal therapy and this approach avoids unnecessary maternal risk secondary to inutero intervention. The short-term maternal risk associated with fetal surgery includes preterm labor, premature rupture of membranes, uterine wall bleeding, chorioamniotic separation, placental abruption, chorioamnionitis, and anesthesia risk. Whereas, maternal long-term complications include risk of infertility, uterine rupture, and need for cesarean section in future pregnancies. The decision for invasive fetal therapy should be taken after discussion with parents about the various aspects like postnatal fetal outcome without fetal intervention, possible outcome if the fetal intervention is done, available postnatal intervention for the fetal condition, and possible short-term and long-term maternal complications. The center where fetal intervention is done should have facility of multi-disciplinary team to manage both maternal and fetal complications. The major issues in the development of fetal surgery include selection of patient for intervention, crafting effective fetal surgical skills, requirement of regular fetal and uterine monitoring, effective tocolysis, and minimizing fetal and maternal fetal risks. This review will cover the surgical or invasive aspect of fetal therapy with available evidence and will highlight the progress made in the management of fetal malformations in last two decades.

Systematic review of pleural-amniotic shunt insertion vs. conservative management in isolated bilateral fetal hydrothorax without hydrops

OBJECTIVE

In the management of bilateral fetal hydrothorax where the fetus is non-hydropic and apparently otherwise normal, we wished to determine if pleural-amniotic shunt insertion was better than conservative management in terms of mortality.

METHODS

A systematic review was conducted between 1992 and 2017. Data extracted was inspected for heterogeneity. Where there was comparative data available, the odds ratio (OR) and confidence interval (CI) were calculated.

RESULTS

Seven studies were included in this systematic review. There was a paucity of comparative data where only 2 studies (28 cases) allowed for direct comparison. Within the limitations of the study, there was no difference between shunt insertion vs. conservative management in terms of stillbirth or miscarriage (OR = 1.00, 95% CI 0.12-8.34, heterogeneity I² = 0%, p = 1.00).

CONCLUSION

There is insufficient data available to determine whether the outcome is improved by pleural-amniotic shunt insertion compared with conservative management in cases of bilateral fetal hydrothorax where the fetus is non-hydropic and otherwise normal.

Fetal primary pleural effusions: Prenatal diagnosis and management

Fetal pleural effusions can be associated with significant perinatal morbidity and mortality. When diagnosed antenatally, referral to a tertiary fetal medicine center is recommended for a detailed ultrasound evaluation for additional structural abnormalities or features suggestive of congenital infections or fetal anemia. The effusions should be characterized as unilateral or bilateral, and presence of hydrops and/or mediastinal shift should be documented. Additional testing should include fetal echocardiography, maternal testing for blood group and screen, hemoglobinopathies, and congenital infections. Invasive genetic testing is recommended with infectious testing on amniotic or pleural fluid. Pleuroamniotic shunting is recommended for large primary pleural effusions with significant mediastinal shift or hydrops, as several large series have demonstrated improvement in perinatal survival, particularly in hydropic fetuses. Delivery should occur in a tertiary care center with neonatal expertise, and infants should be followed up long-term for respiratory and neurodevelopmental outcomes.

Long-Term Outcomes After Thoracoamniotic Shunt for Pleural Effusions With Secondary Hydrops

BACKGROUND

Congenital pleural effusion is a rare condition with an incidence of approximately one per 15,000 pregnancies. The development of secondary hydrops is a poor prognostic indicator and such cases can be managed with a thoracoamniotic shunt (TAS). Our objective is to describe postnatal outcomes in survivors after TAS placement for congenital pleural effusions.

MATERIALS AND METHODS

A retrospective study of all cases with fetal pleural effusions treated between 2006 and 2016. Patients with dominant unilateral or bilateral pleural effusions complicated by secondary hydrops fetalis received TAS placement. The results are reported as median (range).

RESULTS

A total of 29 patients with pleural effusion with secondary hydrops underwent TAS placement. The gestational age at the initial TAS placement was 27.6 (20.3-36.9) wk. Before delivery, hydrops resolved in 17 (58.6%) patients. The delivery gestational age was 35.7 (25.4-41.0) wk and the overall survival rate was 72.4%. Among the 21 survivors, 19 (90.5%) required admission to the neonatal intensive care unit for 15 (5-64) d. All 21 survivors had postnatal resolution of the pleural effusions. All 21 children were long-term survivors, with a median age of survivorship of 3 y 3 mo (9 mo-7 y 6 mo) at the time of last reported follow-up.

CONCLUSIONS

Thoracoamniotic shunting in fetuses with a dominant pleural effusion(s) and secondary hydrops resulted in a 72% survival rate. Nearly all survivors required admission to the neonatal intensive care unit. However, a majority did not have significant long-term morbidity.

Fetal intervention for congenital chylothorax is associated with improved outcomes in early life

BACKGROUND

Congenital chylothorax (CC) can have devastating consequences for neonates. We sought to determine the outcomes of cases treated at our institution and evaluate the role of fetal intervention.

MATERIALS AND METHODS

With Institutional Review Board approval, patients treated at our institution 09/2006-04/2016 with CC were reviewed. History and outcomes were compared between patients undergoing fetal intervention (fetal group) and patients who did not (control group).

RESULTS

Twenty-three patients were identified. Mean gestational age at birth was 35 wk. Overall mortality was 30% (7 patients). Nineteen patients (83%) were prenatally diagnosed, and 10 patients (43%) underwent fetal intervention. Birth weight was significantly lower in the fetal group compared to the control group (median interquartile range [IQR]; 2.5 [2.3-3.0] versus 3.3 [2.6-3.7] kg, P = 0.02). Apgar scores were significantly higher in the fetal group than the control group at 1 and 5 min (median [IQR]; 6 [4-8] versus 1 [1-2], P = 0.005 and 8 [7-9] versus 2 [2-6], P = 0.008, respectively). For those patients with prenatal diagnosis of CC and hydrops fetalis, thrombosis and lymphopenia were both improved in the fetal group (thrombosis 0% versus 40%, P = 0.03; lymphocyte nadir [median {IQR}] 1.5 [0.6-2.9] versus 0.1 [0.05-0.2], P = 0.02). Duration of support with mechanical ventilation was significantly shorter in the fetal group (median [IQR]; 1 [0-40] versus 41 [29-75] d, P = 0.04).

CONCLUSIONS

Fetal intervention for CC is associated with improved Apgar scores and decreased ventilator days and complications in patients with hydrops fetalis. Fetuses with chylothorax, especially those with hydrops, should be referred to a fetal center for evaluation.

Long-Term Neurodevelopmental and Respiratory Outcome after Intrauterine Therapy for Fetal Thoracic Abnormalities

INTRODUCTION

The aim of this study is to evaluate long-term neurodevelopmental and respiratory outcome after fetal therapy for fetal pleural effusion, congenital cystic adenomatoid malformation, and bronchopulmonary sequestration.

METHODS

Children ≥18 months of age underwent an assessment of neurologic, motor, and cognitive development. Medical records were reviewed to determine respiratory outcome. Behavioral outcome was assessed using the Child Behavioral Checklist.

RESULTS

Between 2001 and 2016, 63 fetuses with fetal hydrops secondary to thoracic abnormalities were treated at our center. Overall perinatal survival was 64% (40/63). Twenty-six children were included for follow-up (median age 55 months). Severe neurodevelopmental impairment (NDI) was detected in 15% (4/26). Three out of 4 children with severe NDI had associated causes contributing to the impairment. Overall adverse outcome, including perinatal mortality or NDI, was 55% (27/49). Fifteen percent (4/26) had severe respiratory sequelae. Parents did not report more behavioral problems than Dutch norms.

DISCUSSION

Our results suggest that severe NDI in this specific high-risk cohort occurs in 15%, which is above the range of the incidence of NDI reported in case series treated with other fetal therapies (5-10%). Large multicenter studies and an international web-based registry are warranted to prospectively gather outcome data at fixed time points.

Neonatal management and outcome after thoracoamniotic shunt placement for fetal hydrothorax

AIM

To evaluate the short-term neonatal outcome after fetal thoracoamniotic shunt placement for isolated hydrothorax.

METHODS

Retrospective evaluation of infants with isolated hydrothorax treated with thoracoamniotic shunt placement at our fetal therapy centre between 2001 and 2016.

RESULTS

In total 48 fetuses were treated with a thoracoamniotic shunt. All fetuses had signs of hydrops at the time of intervention. Median (IQR) gestational age at shunting was 28.7 (24.4-31.3) weeks. Forty-one of 48 (85%) fetuses were born alive at a median (IQR) gestational age of 34.4 (31.1-36.7) weeks. In one child the course of disease after birth was unknown (this child was excluded from further analyses). After birth, 24/40 (60%) children had signs of pleural effusion and 12/40 (30%) needed a thoracic shunt for continuous pleural drainage. Twenty-one (53%) children required mechanical ventilation, of whom 13 (33%) needed high-frequency ventilation as rescue therapy. Overall 30/40 (75%) infants survived the neonatal period. Neonatal survival rate was significantly higher when infants were born ≥32 weeks' gestation as compared with <32 weeks: 93% (26/28) versus 33% (4/12), p<0.01.

CONCLUSION

Postnatal course of hydropic fetuses treated with thoracoamniotic shunt for isolated hydrothorax is often complicated by respiratory failure and persistent pleural effusions. Neonatal survival is good provided delivery occurs at or after 32 weeks' gestation.

Prenatal factors associated with neonatal survival of infants with congenital chylothorax

OBJECTIVES

Congenital chylothorax is a rare disease and prognostic factors are key element in properly informing parents. This study aimed at determining the prenatal factors associated with neonatal survival in a cohort of liveborn infants with congenital chylothorax.

STUDY DESIGN

Observational monocentric cohort study including all liveborn neonates consecutively admitted for congenital chylothorax.

RESULTS

Neonatal mortality was 32% (16/50). Prematurity (or birth weight), persistence of hydrops at birth and the absence of thoracoamniotic shunt procedure were significantly associated with mortality, whereas prenatal diagnosis of pleural effusion, side of pleural effusion, hydrops fetalis and amniodrainage were not. In case of prenatal diagnosis of hydrops fetalis, the reversal in utero of hydrops fetalis was significantly associated with survival (P=0.001). In case of thoracoamniotic shunting, the interval between thoracoamniotic shunting intervention and delivery was significantly longer for patients who survived (P=0.03).

CONCLUSIONS

Thoracoamniotic shunting and reversal of hydrops significantly improves survival, whereas prematurity worsened outcome of liveborn infants with congenital chylothorax. Our data also suggest that the interval between thoracoamniotic shunting and birth appears to be crucial; the longer the interval, the more likely is the reversal of antenatal hydrops and neonatal survival.

Congenital chylothorax

Congenital chylothorax (CC) results from multiple lymphatic vessel anomalies or thoracic cavity defects and may accompany other congenital anomalies. Fetal chylothorax may increase the risk of death and complications from pleural space lymphatic fluid accumulation, which compromises lung development, pulmonary, and cardiovascular function and from complications arising from the loss of drained lymphatic contents. Prenatal interventions might improve survival in severe cases of fetal chylothorax. The neonatal treatment strategy is generally supportive with interventions that include thoracostomy drainage and attempts to decrease chyle flow using a stepwise approach that begins with the least invasive means. Evidence-based treatment choices are lacking and are much needed. Most cases of CC resolve with time even without specific lymphatic system studies to identify the exact pathology. Expertise in performing lymphatic studies is not universally available. Data on both efficacy and safety of the various therapeutic options are needed to determine the best approach to the treatment of CC.

Treatment of persistent congenital chylothorax with intrapleural injection of sapylin in infants

Test the therapeutic efficacy of Sapylin in resolving persistent Congenital Chylothorax (CC) in four infants who failed to respond to conservative medical therapy including Erythromycin and/or Octreotide management. All cases were cured and have no adverse reactions during follow-up. The result shows Sapylin is effective in reducing chylous production.

Prenatal Therapy Improves the Survival of Premature Infants with Congenital Chylothorax

BACKGROUND

Chylothorax is a rare condition among neonates, although it is considered clinically significant, as it is difficult to manage in these patients. In addition, the course of chylothorax varies widely. Therefore, we aimed to elucidate the clinical features and effect of prenatal therapy on the prognosis of congenital chylothorax in neonates.

METHODS

We retrospectively reviewed the medical records of all infants with congenital chylothorax who were admitted to National Taiwan University Hospital, Taipei, Taiwan between January 2000 and December 2012. Their demographic characteristics, as well as their antenatal, perinatal, and postnatal information, were collected for our analysis of the mortality risk.

RESULTS

We found 29 infants who were diagnosed with congenital chylothorax during the study period. The median gestational age at birth was 34 weeks (range, 28-41 weeks), and 71% of the infants presented with hydrops fetalis. Most cases of congenital chylothorax were bilateral (bilateral: 86.2%, unilateral: 13.79%), and the overall survival rate was 59.6%. Among the cases with a prenatal diagnosis at ≤ 34 weeks of gestation, infants who received prenatal therapy had a significantly higher survival rate, compared to infants who did not receive prenatal therapy (76.9% vs. 11%, respectively; p = 0.008).

CONCLUSION

We found that infants whose chylothorax was diagnosed ≤ 34 weeks of gestation, and who subsequently received prenatal therapy, experienced a better perinatal condition and exhibited improved postnatal outcomes.

Congenital lung lesions: Prenatal diagnosis and intervention

Congenital lung lesions are common sonographic findings in pregnancy, usually detected at the routine 20 weeks scan. The most common is cystic adenomatous malformation of the lung (CCAM). This usually causes few prenatal problems; however, fetal hydrops occurs in about 5%. Prenatal intervention for these is possible in many to allow survival to birth. Bronchoplumonary sequestration (BPS), with an aberrant "feeder" vessel arising from the aorta may co-exist but is detectable as a separate entity by visualization of this vessel. Symptomatic or curative prenatal intervention is again possible in the few severe cases where hydrops or pleural effusions develop. Pleural effusions may be due to a primary leak usually of chylous fluid: prenatal thoracoamniotic shunting may prevent pulmonary hyoplasia or cure the consequent fetal hydrops. More often, however, effusions are a consequence of an underlying abnormality, including many structural or chromosomal abnormalities that may also cause co-existing fetal hydrops. Congenital high airway obstruction (CHAOS) is commonly fatal but cases potentially amenable to prenatal intervention or to immediate perinatal management may be identified using ultrasound or MRI.

Treatment of Primary Fetal Hydrothorax with OK-432 (Picibanil): Outcome in 14 Fetuses and a Review of the Literature

Background: Primary fetal hydrothorax (PFHT) is an uncommon condition with an estimated prevalence of 1 in 10,000/15,000 pregnancies. Therapeutic interventions include thoracocentesis, thoraco-amniotic shunting (TAS), and pleurodesis using OK-432. Methods: A review of the literature was performed to identify all cases of PFHT treated with TAS and OK-432. All cases of PFHT referred to the Fetal Maternal Unit at Royal Prince Alfred Hospital between 2002 and 2012 were retrospectively reviewed. In the cohort of fetuses treated with OK-432, the main perinatal outcomes evaluated were termination of pregnancy, live birth, neonatal death, and fetal death in utero. Secondary outcomes included gestational age (GA) at diagnosis, GA at treatment, GA at resolution, birth weight, and GA at birth. The development of the children was screened using the Ages and Stages Questionnaires, Version 3 (ASQ-3, 2009). Results: Primary hydrothorax was diagnosed in 31 fetuses, of which 14 had treatment with OK-432. One pregnancy terminated after treatment with OK-432. Survival was 85% (11/13): 100% in fetuses treated with OK-432 without hydrops, and 78% in those treated with hydrops. This compares well to the cases of TAS in the literature with an average survival of 63%: 85% in fetuses without hydrops and 55% with hydrops. The mean GA at birth was 36+4 weeks and mean birth weight 3,007 g. Eight of the 9 children screened with ASQ-3 scored well within the normal range. Conclusion: OK-432 appears to be a valid treatment option in fetuses with PFHT, particularly in those diagnosed at early GAs.

Fetal surgery: principles, indications, and evidence

Since the first human fetal surgery was reported in 1965, several different fetal surgical procedures have been developed and perfected, resulting in significantly improved outcomes for many fetuses. The currently accepted list of fetal conditions for which antenatal surgery is considered include lower urinary tract obstruction, twin-twin transfusion syndrome, myelomeningocele, congenital diaphragmatic hernia, neck masses occluding the trachea, and tumors such as congenital cystic adenomatoid malformation or sacrococcygeal teratoma when associated with developing fetal hydrops. Until recently, it has been difficult to determine the true benefits of several fetal surgeries because outcomes were reported as uncontrolled case series. However, several prospective randomized trials have been attempted and others are ongoing, supporting a more evidence-based approach to antenatal intervention. Problems that have yet to be completely overcome include the inability to identify ideal fetal candidates for antenatal intervention, to determine the optimal timing of intervention, and to prevent preterm birth after fetal surgery. Confronting a fetal abnormality raises unique and complex issues for the family. For this reason, in addition to a maternal-fetal medicine specialist experienced in prenatal diagnosis, a pediatric surgeon, an experienced operating room team including a knowledgeable anesthesiologist, and a neonatologist, the family considering fetal surgery should have access to psychosocial support and a bioethicist.

The use of simulation in maternal-fetal medicine procedure training

Many fields of medicine now routinely employ simulation while educating all levels of medical trainees. Unfortunately, OB-GYN has been slow to incorporate these beneficial adjuncts to traditional medical education, but thankfully the use of simulation is now increasing. Maternal-Fetal medicine procedures such as amniocentesis, in-utero stent placement, chorionic villus sampling, percutaneous umbilical blood sampling, and cervical cerclage placements are an area where simulation has great potential benefit. Here we describe the currently available simulation models for these procedures and outline specific training curricula designed to aid trainees in obtaining procedural competency in each. Although initial experiences with these training models and the curricula centered around them have been positive, in many cases their use remains limited. Our hope is that this manuscript will encourage others to incorporate simulation into their training programs as we believe it will enhance medical training and improve patient safety.

Retrospective review of thoracoamniotic shunting using a double-basket catheter for fetal chylothorax

OBJECTIVE

From a single-center retrospective cohort with fetal chylothorax, we evaluated the factors related to the decision to use shunting, poor prognostic factors, and reported shunting outcomes with a new double basket-catheter device.

METHODS

A retrospective single-center study was performed in 35 cases of fetal chylothorax.

RESULTS

There were 35 cases of chylothorax: 23 with hydrops and 12 without hydrops. Twenty-one procedures were performed on 15 fetuses (11 with hydrops) with a single shunt in 11, two shunts in 3 and four shunts in 1. All 12 nonhydropic cases survived. In 23 hydropic cases, overall survival rates with and without thoracoamniotic shunting were 46 and 33%, respectively. The mortality rates of fetal hydropic cases with and without ascites were 93 and 11%, respectively. Fetal ascites, progression of fetal hydrops, and premature delivery at <33 weeks were significant risk factors for a poor prognosis. Progression of polyhydramnios after shunting was also associated with a poor prognosis. Obstruction of the catheter was observed in 38%. There were no direct fetal deaths associated with shunting.

CONCLUSION

Thoracoamniotic shunting should be considered for pleural effusion before development of fetal hydrops, or at least before the appearance of fetal ascites. A double-basket catheter tends to be obstructive, but may be less invasive for fetuses.

The case for intrauterine gene therapy

Single-gene disorders can cause perinatal mortality or severe permanent morbidity. Intrauterine gene therapy seeks to correct the genetic defect in the early stages of pathogenesis through delivery of a vector system expressing the therapeutic transgene to the fetus. Advantages of intrauterine gene therapy include prevention of irreversible organ damage, potentially inducing central tolerance and wider bio-distribution, including the brain after delivery of vector. Already, proof-of-cure has been demonstrated in knockout animal models for several diseases. Long-term outcomes pertaining to efficacy and durability of transgene expression and safety are under investigation in clinically relevant non-human primate models. Bystander effects in the mother from transplacental vector trafficking require further assessment. In this chapter, we discuss the candidate diseases amenable to intrauterine gene therapy, current state-of-the-art evidence, and potential clinical applications.

Genome-wide gene expression analysis implicates the immune response and lymphangiogenesis in the pathogenesis of fetal chylothorax

Fetal chylothorax (FC) is a rare condition characterized by lymphocyte-rich pleural effusion. Although its pathogenesis remains elusive, it may involve inflammation, since there are increased concentrations of proinflammatory mediators in pleural fluids. Only a few hereditary lymphedema-associated gene loci, e.g. VEGFR3, ITGA9 and PTPN11, were detected in human fetuses with this condition; these cases had a poorer prognosis, due to defective lymphangiogenesis. In the present study, genome-wide gene expression analysis was conducted, comparing pleural and ascitic fluids in three hydropic fetuses, one with and two without the ITGA9 mutation. One fetus (the index case), from a dizygotic pregnancy (the cotwin was unaffected), received antenatal OK-432 pleurodesis and survived beyond the neonatal stage, despite having the ITGA9 mutation. Genes and pathways involved in the immune response were universally up-regulated in fetal pleural fluids compared to those in ascitic fluids. Furthermore, genes involved in the lymphangiogenesis pathway were down-regulated in fetal pleural fluids (compared to ascitic fluid), but following OK-432 pleurodesis, they were up-regulated. Expression of ITGA9 was concordant with overall trends of lymphangiogenesis. In conclusion, we inferred that both the immune response and lymphangiogenesis were implicated in the pathogenesis of fetal chylothorax. Furthermore, genome-wide gene expression microarray analysis may facilitate personalized medicine by selecting the most appropriate treatment, according to the specific circumstances of the patient, for this rare, but heterogeneous disease.

Experimental treatment of bilateral fetal chylothorax using in-utero pleurodesis

OBJECTIVE

To assess the use and efficacy of in-utero pleurodesis for experimental treatment of bilateral fetal chylothorax.

METHODS

This was a study of 78 fetuses with bilateral pleural effusion referred to three tertiary referral centers in Taiwan between 2005 and 2009. Fetuses were karyotyped following amniocentesis and the lymphocyte ratio in the pleural effusion was determined following thoracocentesis. Forty-nine (62.8%) fetuses had a normal karyotype and were recognized to have fetal chylothorax; of these, 45 underwent intrapleural injection of 0.1KE OK-432 per side per treatment. We evaluated clinical (hydrops vs. no hydrops) and genetic (mutations in the reported lymphedema-associated loci: VEGFR3, PTPN11, FOXC2, ITGA9) parameters, as well as treatment outcome. Long-term survival was defined as survival to 1 year of age.

RESULTS

The overall long-term survival rate (LSR) was 35.6% (16/45); the LSR for non-hydropic fetuses was 66.7% (12/18) and for hydropic fetuses it was 14.8% (4/27). If we included only fetuses with onset of the condition in the second trimester, excluding those with onset in the third trimester, the LSR decreased to 29.4% (10/34). Notably, 29.6% (8/27) of hydropic fetuses had mutations in three of the four loci examined.

CONCLUSIONS

OK-432 pleurodesis appeared to be an experimental alternative to the gold-standard technique of thoracoamniotic shunting in non-hydropic fetal chylothorax. In hydropic fetuses, pleurodesis appeared less effective.

Indicated preterm birth for fetal anomalies

Between 2% and 3% of pregnancies are complicated by fetal anomalies. For most anomalies, there is no advantage to late preterm or early-term delivery. The risks of maternal or fetal complication are specific for each anomaly. Very few anomalies pose potential maternal risk. Some anomalies carry ongoing risks to the fetus, such as an increased risk of fetal death, hemorrhage, or organ damage. In a limited number of select cases, the advantages of late preterm or early-term birth may include avoiding an ongoing risk of fetal death related to the anomaly, allowing delivery in a controlled setting with availability of subspecialists and allowing direct care for the neonate with organ injury. The optimal gestational age for delivery cannot be determined for all pregnancies complicated by fetal anomalies. For most pregnancies complicated by anomalies, there is no change to obstetrical management regarding timing of delivery. For those that may benefit from late preterm or early-term delivery, variability exists such that each management plan should be individualized.

Congenital primary hydrothorax: effect of thoracoamniotic shunting on neonatal clinical outcome

BACKGROUND

Spontaneous regression in the foetal period has been described for congenital hydrothorax. Hydrothorax may become larger and bilateral with hydrops and pulmonary hypoplasia. Prenatal thoracentesis and thoracoamniotic shunting of massive hydrothorax are indicated to decrease perinatal morbidity. In the neonatal period, persistent hydrothorax may require intensive care.

OBJECTIVE

To investigate neonatal outcome after thoracoamniotic shunting for congenital primary hydrothorax with hydrops/ polydramnios.

METHODS

Retrospective study on the postnatal management of a cohort of 28 congenital primary hydrothorax cases after thoracoamniotic shunting (January 2000-August 2005).

RESULTS

Congenital hydrotorax without major structural anomalies complicated by polidramnios and/or hydrops<34 weeks' gestation were the criteria accepted for thoracoamniotic shunting. There were neither pregnancy terminations nor utero deaths. Although 64% of cases were complicated by severe neonatal respiratory insufficiency, neonatal mortality rate was low (21.4%) if compared with literature. Univariate analysis identified 'birth at gestational age (GA)<35 weeks' and 'time between prenatal shunting and birth' as predictive factors for needing of ventilation. Multivariate analysis identified 'birth at GA<35 weeks' as the only independent predictor for needing ventilation. (OR=0.08, CI 95%=0.01-0.96, p=0.046). No risk factors for death or adverse neurological outcomes were reported.

CONCLUSIONS

Congenital hydrothorax although corrected by thoracoamniotic shunting is complicated by severe respiratory distress. The neonatal outcome may be improved limiting degree of prematurity; the presence of thoracoamniotic shunt is not per se an indication of premature birth, at least until GA>35 weeks and adequate pulmonary maturity is reached.

Novel treatment for chylothorax after esophagectomy with 50% glucose pleurodesis

Chylothorax is characterized by the presence of chyle in the pleural space and cardiothoracic surgery accounts for nearly half of all the cases. Treatment of chylothorax has traditionally been nonoperative, with alternative medical therapies involving the administration of octreotide or pleurodesis. Pleurodesis with chemical agents has previously been reported, but never with 50% glucose and 0.1% xylocaine. Herein, we report a successful method of intrapleural instillation of 50% glucose and 0.1% xylocaine to treat chylothorax. Five patients treated with this method were all recovered rapidly. This method can generate extensive adherence and prevent the effusion of the chylous fluid with minor side effects.

Congenital chylothorax: from foetal life to adolescence

AIM

To analyse the main prenatal and postnatal features of congenital chylothorax (CC), and the outcome including mid-term follow-up.

METHODS

We searched our databases for CC diagnosed between 1990 and 2006. Data of 29 cases were retrieved and analysed. Follow-up until 3 years of age was available for all patients.

RESULTS

Most patients were diagnosed prenatally (94%) and most cases were complicated by foetal hydrops (66.7%). The overall survival rate at 3 years was 56%. A significantly poorer outcome was observed when foetal hydrops, preterm birth < 34 weeks, large effusions and/or early-onset pneumothorax were present. An important but not significant improvement in the survival rate was observed through the study period; while in 1990-1998, the survival rate was 41.7%, from 1999 to 2006 it was 66.7% (p = 0.19). In the mid-term follow-up, we did not observe any recurrence of CC and most infants remain asymptomatic. However, 27% of survivors were diagnosed as having asthma in early infancy.

CONCLUSION

CC still carries a significant risk of perinatal mortality. However, continuous advances in foetal and neonatal medicine are improving the prognosis of these patients, and nowadays most of them are likely to survive. Beyond the neonatal period, most survivors have an uneventful outcome.

Perinatal outcome following fetal chest shunt insertion for pleural effusion

OBJECTIVE

To evaluate perinatal outcome of fetuses with primary pleural effusions following pleuroamniotic shunting.

METHODS

This was a retrospective study of 88 fetuses with large pleural effusions referred to a tertiary fetal medicine unit between 1991 and 2008 which, after a thorough work-up, underwent pleuroamniotic shunting.

RESULTS

At presentation, 59 (67.0%) fetuses were hydropic and 67 (76.1%) had bilateral effusions. In 17 (19.3%) fetuses, pleural fluid was aspirated prior to shunting and in 71 (80.7%), shunts were inserted directly as the first procedure. Mean gestational age at shunting was 27.6 (range, 18-37) weeks and at delivery 34.2 (range, 19-42) weeks. Seventy-four (84.1%) babies were born alive, of whom 52 (70.3%) survived the neonatal period. Of 59 hydropic fetuses, 10 (16.9%) died @ in utero and 18 neonates (30.5%) died, resulting in perinatal survival of 52.5%, whereas of 29 non-hydropic fetuses, perinatal survival was 72.4%. Hydrops resolved following shunting in 28 fetuses, of whom 71% survived, compared to 35% survival in 31 fetuses where hydrops persisted (P = 0.006). Of 22 neonatal deaths, seven were related to pulmonary hypoplasia, five to genetic syndromes, two to aneuploidy and one to a congenital anomaly (truncus arteriosus). Overall 13 (14.8%) were diagnosed with a chromosomal, genetic or other condition, several of which could not have been diagnosed antenatally.

CONCLUSION

Carefully selected fetuses with primary pleural effusions can benefit from pleuroamniotic shunting, allowing hydrops to resolve with a survival rate of almost 60%.

Fetal surgery is a clinical reality

An increasing number of fetal anomalies are being diagnosed prior to birth, some of them amenable to fetal surgical intervention. We discuss the current clinical status and recent advances in endoscopic and open surgical interventions. In Europe, fetoscopic interventions are widely embraced, whereas the uptake of open fetal surgery is much less. The indications for each access modality are different, hence they cannot substitute each other. Although the stage of technical experimentation is over, most interventions remain investigational. Today there is level I evidence that fetoscopic laser surgery for twin-to-twin transfusion syndrome is the preferred therapy, but this operation actually takes place on the placenta. In terms of surgery on the fetus, an increasingly frequent indication is severe congenital diaphragmatic hernia as well as myelomeningocele. Overall maternal safety is high, but rupture of the membranes and preterm delivery remain a problem. The increasing application of fetal surgery and its mediagenicity has triggered the interest to embark on fetal surgical therapy, although the complexity as well as the overall rare indications are a limitation to sufficient experience on an individual basis. We plead for increased exchange between high volume units and collaborative studies; there may also be a case for self-regulation. Inclusion of patients into trials whenever possible should be encouraged rather than building up casuistic experience.

In-utero stenting: development of a low-cost high-fidelity task trainer

OBJECTIVE

To develop an in-utero stent placement training model.

METHODS

The in-utero stent task trainer was constructed using a formalin-preserved gravid pig uterus. Altering the size of the uterine segment, changing the fluid level in the uterus and addition of a large Ziploc freezer bag variably filled with differing amounts of ultrasound gel can vary the procedural skill required.

RESULTS

Thoracoamniotic and vesicoamniotic shunts can be simulated using this life-like model. The cost of eight to 10 learning stations is approximately US $ 60. Fetal position, maternal size and amniotic fluid status can be altered rapidly to increase the complexity of the procedure.

CONCLUSIONS

This low-cost and realistic task trainer can provide the opportunity to practice in-utero shunt procedures in a non-clinical environment. This model should enhance learning and reinforce acquired skills.

Treatment with OK-432 for persistent congenital chylothorax in newborn infants resistant to octreotide

Chylothorax is a relatively uncommon condition defined as an abnormal collection of lymphatic fluid within the pleural space. We are reporting the use of OK-432 for treatment of prolonged idiopathic congenital chylothorax in 2 newborn infants who failed to respond to conservative medical therapy, including octreotide injection.

Fetal pleural effusions

The clinical course of primary fetal hydrothorax is unpredictable. Whereas smaller unilateral effusions might remain stable or even regress, this is rarely the case with larger collections. Bilateral effusions, hydrops, preterm delivery and the lack of antenatal therapy are all associated with poor outcome. Once structural and chromosomal anomalies have been excluded, optimal management depends on gestational age, rate of progression, the development of hydrops and associated maternal symptoms. For very large effusions with mediastinal shift, hydrops and/or hydramnios, or when there is rapid enlargement of the effusion, fetal intervention is warranted. Survival can be maximized by pleuroamniotic shunting, which can reverse hydrops and hydramnios and prevent pulmonary hypoplasia. Pleuroamniotic shunting can also be used for the treatment of other large cystic lung lesions, such as a macrocystic congenital cystic adenomatoid malformation or bronchopulmonary sequestration, especially when associated with hydrops.