1
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Wu WJ, Ma GC, Chang TY, Lee MH, Lin WH, Chen M. Outcome and etiology of fetal pleural effusion, fetal ascites and hydrops fetalis after fetal intervention: retrospective observational cohort from a single institution. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:536-543. [PMID: 37767652 DOI: 10.1002/uog.27501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 09/05/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVES Non-immune hydrops fetalis (NIHF) is the pathological accumulation of fluids in fetal compartments, without maternal isoimmunization. Fetal interventions (e.g. shunting, fetal paracentesis, fetal thoracocentesis, fetal pleurodesis) are used to alleviate fluid accumulations, but the outcome is uncertain because the underlying causes of NIHF vary. We aimed to explore the etiology and long-term outcome of NIHF after fetal intervention. METHODS This was a retrospective review of fetuses with NIHF, defined by the presence of fetal ascites, pleural or pericardial effusion, skin edema or cystic hygroma, or a combination of these features, who underwent intervention at our institution during the period 2012-2021. Clinical surveillance, genetic analysis and viral infection screening were used to define the etiology. Chart reviews and telephone interviews were conducted to assess the long-term outcomes. RESULTS In total, 55 fetuses were enrolled and 46 cases had final follow-up data after delivery. Etiology was identified in 33 cases, including four for which the underlying causes were not identified initially using small-gene-panel tests but which were later diagnosed with monogenic disorders by whole-exome sequencing (WES). Twenty-three cases with follow-up survived, having a follow-up period of 2-11 years at the time of writing, of which 17 were healthy. All 11 cases initially presenting as congenital chylothorax survived with favorable outcome. CONCLUSIONS The etiologies of NIHF are heterogeneous, and the long-term (spanning 2-11 years) outcome of fetal intervention varies, according to the underlying etiology, with cases caused by congenital chylothorax having the best prognosis. Genome-wide tests, such as WES, may be helpful in determining the underlying condition in cases caused by a genetic disorder, and this may affect fetal therapy approaches in the future. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- W-J Wu
- Department of Genomic Medicine and Center for Medical Genetics, Changhua Christian Hospital, Changhua, Taiwan
- Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua, Taiwan
| | - G-C Ma
- Department of Genomic Medicine and Center for Medical Genetics, Changhua Christian Hospital, Changhua, Taiwan
- Department of Medical Laboratory Science and Biotechnology, Central Taiwan University of Science and Technology, Taichung, Taiwan
| | - T-Y Chang
- Department of Genomic Medicine and Center for Medical Genetics, Changhua Christian Hospital, Changhua, Taiwan
- Department of Bioscience Technology, Chung Yuan Christian University, Taoyuan, Taiwan
| | - M-H Lee
- Department of Genomic Medicine and Center for Medical Genetics, Changhua Christian Hospital, Changhua, Taiwan
| | - W-H Lin
- Welgene Biotechnology Company, Nangang Business Park, Taipei, Taiwan
| | - M Chen
- Department of Genomic Medicine and Center for Medical Genetics, Changhua Christian Hospital, Changhua, Taiwan
- Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua, Taiwan
- Department of Obstetrics and Gynecology, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Medical Sciences, National Tsing Hua University, Hsinchu, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
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2
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Tan APP, Tan B, Wright A, Kong JY. Management dilemma in Thoracoamniotic Shunt Migrations. BMJ Case Rep 2023; 16:e255760. [PMID: 37758657 PMCID: PMC10537852 DOI: 10.1136/bcr-2023-255760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023] Open
Abstract
Shunt migration is a rare but significant complication of thoracoamniotic shunting, an intervention widely used for fetal pleural effusion. We describe a case of a term infant noted antenatally to have fetal hydrothorax that was managed with thoracoamniotic shunting but complicated by shunt migration. We also present the current literature on risk factors, complications and management of intrathoracic shunt migration. The majority of shunt migration cases are managed conservatively with no untoward postnatal sequelae, but surgical removal of the migrated shunt has been used for associated clinical complications, if visceral damage is suspected or if postnatal thoracic surgery is indicated for other reasons. We advocate an approach of conservative management for asymptomatic infants, where possible, to avoid unnecessary surgical and anaesthetic risks to very young, often already compromised children. However, further studies are still required to determine optimal management after shunt migration has occurred to ensure the best outcome.
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Affiliation(s)
| | - Bobby Tan
- KK Women's and Children's Hospital, Singapore
| | - Ann Wright
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - Juin Yee Kong
- Neonatology, KK Women's and Children's Hospital, Singapore
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3
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Zhu L, Wang Y, Song H, Wang X, Zhang M, Guo F. Case report: Minimally invasive removal of a dislodged thoracoamniotic shunt with an integral cystoscope in a preterm infant. Front Pediatr 2023; 11:1217667. [PMID: 37441567 PMCID: PMC10333579 DOI: 10.3389/fped.2023.1217667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/15/2023] [Indexed: 07/15/2023] Open
Abstract
Introduction Fetal pleural effusion is a rare condition that is associated with significant mortality. Although the insertion of fetal thoracoamniotic shunts can improve perinatal outcomes, there are several associated complications, such as intrathoracic dislodgement of the shunts. The optimal neonatal treatment for retained shunts remains uncertain. Case Description A male infant was born at 32 weeks of gestation. He had antenatal hydrothorax that was detected at 27 weeks of gestation and was managed by intrauterine thoracoamniotic shunting. However, the shunt catheter dislodged into the fetal chest, which caused reaccumulated pleural effusion and respiratory distress requiring ventilatory support after birth. After the patient's condition stabilized, minimally invasive removal of the retained catheter was performed on day 17 of life using an integral pediatric cystoscope via a 3-mm thoracic incision. The procedure took approximately 5 min. The postoperative course was uneventful, and the patient, who was discharged 39 days postnatally, is thriving at the 6-month follow-up. Conclusions We present a novel and effective approach to the management of an intrathoracic shunt using an integral cystoscope. This approach may offer a valuable alternative to traditional thoracoscopy in the neonatal period.
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Affiliation(s)
- Lichao Zhu
- Department of Pediatric Surgery, Shandong Provincial Hospital, Shandong University, Jinan, China
- Department of Pediatric Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yanze Wang
- Department of Pediatric Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Honghao Song
- Department of Pediatric Surgery, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Xiaoqing Wang
- Department of Pediatric Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Mingang Zhang
- Department of Pediatric Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Feng Guo
- Department of Pediatric Surgery, Shandong Provincial Hospital, Shandong University, Jinan, China
- Department of Pediatric Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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4
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Muntean A, Cazacu R, Ade-Ajayi N, Patel SB, Nicolaides K, Davenport M. The long-term outcome following thoraco-amniotic shunting for congenital lung malformations. J Pediatr Surg 2023; 58:213-217. [PMID: 36379747 DOI: 10.1016/j.jpedsurg.2022.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 10/11/2022] [Indexed: 11/15/2022]
Abstract
AIM OF THE STUDY Insertion of a thoraco amniotic shunt (TAS) during fetal life is a therapeutic option where there is a high risk of death secondary to large congenital lung malformations (CLM). The aim of this study is to present our center's long-term experience. METHODS Retrospective single center review of the period (Jan 2000-Dec 2020). We included all fetuses that underwent TAS insertion for CLM with detailed analysis of those live newborns managed in our center. Data are quoted as median (range). MAIN RESULTS Thirty one fetuses underwent 37 TAS insertions at a 25 (20-30) weeks gestational age. This was successful on 1st attempt in 30 (97%) fetuses. In 6 cases a 2nd shunt was required at 6.5 (2-10) weeks following the 1st insertion. Twenty-eight survived to be born. Sixteen (9 male) infants were delivered in our center at 39 (36-41) weeks gestational age and birth weight of 3.1 (2.6-4.2) kg. All infants underwent surgery at 2 (0-535) days (emergency surgery, n = 9; expedited n = 4; elective surgery, n = 3). Final histopathology findings were CPAM Type 1 (n = 14, n.b. associated with mucinous adenocarcinoma, n = 1), CPAM Type 2 (n = 1) and an extralobar sequestration (n = 1). Postoperative stay was 16 (1-70) days with survival in 15/16 (94%). One infant died at 1 day of life secondary to a combination of pulmonary hypoplasia and hypertension. Median follow up period was 10.7 (0.4-20.4) years. Nine (60%) children developed a degree of chest wall deformity though none have required surgical intervention. Clinically, 14/15 (93%) have otherwise normal lung function without limitations of activity, sporting or otherwise. One child has a modest exercise limitation (FVC - 70% predicted). CONCLUSIONS TAS insertion is associated with high perinatal survival and should be considered in fetuses at risk of hydrops secondary to large cystic lung malformation. Their long term outcome is excellent although most have a mild degree of chest wall deformity.
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Affiliation(s)
- Ancuta Muntean
- Departments of Paediatric Surgery, Kings College Hospital, London, UK
| | - Ramona Cazacu
- Harris Birthright Research Centre for Fetal Medicine, Kings College Hospital, London, UK
| | - Niyi Ade-Ajayi
- Departments of Paediatric Surgery, Kings College Hospital, London, UK
| | - Shailesh B Patel
- Departments of Paediatric Surgery, Kings College Hospital, London, UK
| | - Kypros Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, Kings College Hospital, London, UK
| | - Mark Davenport
- Departments of Paediatric Surgery, Kings College Hospital, London, UK.
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Muraoka J, Yoshimoto N, Ohsawa A, Matsuzawa S, Katsuragi S. Fetal Distress and Neonatal Death After Thoracoamniotic Shunting Therapy Due to Hydrops Associated With Transient Abnormal Myelopoiesis. Cureus 2022; 14:e28991. [PMID: 36225415 PMCID: PMC9541969 DOI: 10.7759/cureus.28991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2022] [Indexed: 11/13/2022] Open
Abstract
We present the case of a pregnant woman who developed fetal bradycardia, which required an emergency cesarean delivery immediately after thoracoamniotic shunting (TAS), resulting in neonatal death four hours after birth due to hemodynamic deterioration. A 35-year-old Japanese female was referred to our hospital at 30+0 weeks of gestation due to fetal hydrops. Blood and ultrasonography examinations suggested that transient abnormal myelopoiesis (TAM) due to trisomy 21 could contribute to the development of hydrops fetalis. We performed thoracocentesis and TAS replacement as well as chromosomal testing of the amniotic fluid. However, the fetus developed persistent bradycardia soon after the treatment, and a sonographic examination revealed a recurrence of fluid retention in the thoracic cavity. A 1,558-g male neonate received life-saving resuscitation after being born via emergency surgery. Blood analysis revealed the occurrence of TAM in utero. At autopsy, there were no injuries to the intrathoracic organs. The G-banded karyotype revealed trisomy 21 (47, XY, +21). Our case offers new perspectives on providing prenatal information about potential complications to family members and selecting fetuses for TAS in the case of trisomy 21 complicated with TAM.
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6
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Grandt J, Gottschalk I, Geipel A, Gembruch U, Simonini C, Weber E, Berg C, Müller A, Strizek B. Intrauterine Thoracoamniotic Shunting of Fetal Hydrothorax with the Somatex Intrauterine Shunt: Intrauterine Course and Postnatal Outcome. J Clin Med 2022; 11:jcm11092312. [PMID: 35566436 PMCID: PMC9100171 DOI: 10.3390/jcm11092312] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/10/2022] [Accepted: 04/19/2022] [Indexed: 12/10/2022] Open
Abstract
(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.
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Affiliation(s)
- Joleen Grandt
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany; (J.G.); (A.G.); (U.G.); (C.S.); (C.B.)
| | - Ingo Gottschalk
- Division of Prenatal Medicine, Gynecological Ultrasound and Fetal Surgery, Department of Obstetrics and Gynecology, University of Cologne, 50923 Cologne, Germany; (I.G.); (E.W.)
| | - Annegret Geipel
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany; (J.G.); (A.G.); (U.G.); (C.S.); (C.B.)
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany; (J.G.); (A.G.); (U.G.); (C.S.); (C.B.)
| | - Corinna Simonini
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany; (J.G.); (A.G.); (U.G.); (C.S.); (C.B.)
| | - Eva Weber
- Division of Prenatal Medicine, Gynecological Ultrasound and Fetal Surgery, Department of Obstetrics and Gynecology, University of Cologne, 50923 Cologne, Germany; (I.G.); (E.W.)
| | - Christoph Berg
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany; (J.G.); (A.G.); (U.G.); (C.S.); (C.B.)
- Division of Prenatal Medicine, Gynecological Ultrasound and Fetal Surgery, Department of Obstetrics and Gynecology, University of Cologne, 50923 Cologne, Germany; (I.G.); (E.W.)
| | - Andreas Müller
- Department of Neonatology and Pediatric Intensive Care, Children’s University Hospital Bonn, 53127 Bonn, Germany;
| | - Brigitte Strizek
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany; (J.G.); (A.G.); (U.G.); (C.S.); (C.B.)
- Correspondence: ; Tel.: +49-228-287-37115
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7
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Iwahata Y, Iwahata H, Hasegawa J, Homma C, Nishimura Y, Kondo H, Suzuki N. Hemothorax after fetal pleural effusion-thoracoamniotic shunting procedure due to transient myeloproliferative disorder. CASE REPORTS IN PERINATAL MEDICINE 2022. [DOI: 10.1515/crpm-2021-0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
To present a case of fetal hemothorax after two times of thoracoamniotic shunting (TAS) performed to pleural effusion with hydrops fetalis, resulting in non-reassuring fetal status due to hemothorax.
Case presentation
This is a case of bilateral pleural effusion with hydrops fetalis and polyhydramnios at 32 weeks gestation, in which unilateral fetal TAS was performed twice, resulting in non-reassuring fetal status due to hemothorax. After delivery, the infant was diagnosed with trisomy 21 and transient myeloproliferative disorder (TMD) with disseminated intravascular coagulation and congenital systemic lymphangiopathy.
Conclusions
In conclusion, since TAM case do not always show hemothrax, TAM is not inhibited but technical carefulness should be necessary.
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Affiliation(s)
- Yuriko Iwahata
- Department Obstetrics and Gynecology , St. Marianna University School of Medicine , Kawasaki , Japan
| | - Hideyuki Iwahata
- Department Obstetrics and Gynecology , St. Marianna University School of Medicine , Kawasaki , Japan
| | - Junichi Hasegawa
- Department Obstetrics and Gynecology , St. Marianna University School of Medicine , Kawasaki , Japan
| | - Chika Homma
- Department Obstetrics and Gynecology , St. Marianna University School of Medicine , Kawasaki , Japan
| | - Yoko Nishimura
- Department Obstetrics and Gynecology , St. Marianna University School of Medicine , Kawasaki , Japan
| | - Haruhiro Kondo
- Department Obstetrics and Gynecology , St. Marianna University School of Medicine , Kawasaki , Japan
| | - Nao Suzuki
- Department Obstetrics and Gynecology , St. Marianna University School of Medicine , Kawasaki , Japan
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8
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Chung MY, Leung WC, Tse WT, Ting YH, Law KM, Hui ASY, Wah YM, Lam HS, Poon LCY, Leung TY. The Use of Somatex Shunt for Fetal Pleural Effusion: A Cohort of 8 Procedures. Fetal Diagn Ther 2021; 48:440-447. [PMID: 34077935 DOI: 10.1159/000515849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/29/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Fetal pleural effusion may require in utero shunting which is associated with procedure-related complications. OBJECTIVE To evaluate the efficacy and complications of the newly designed Somatex shunt in treating fetal pleural effusion. METHODS Consecutive cases with primary fetal pleural effusion who were treated with the Somatex shunt between 2018 and 2019 were evaluated. Perinatal outcomes and complications were retrospectively analyzed. RESULTS There were 6 cases of unilateral and 1 case of bilateral pleural effusion, and hence a total of 8 pleuroamniotic shunting procedures were performed. The median gestational age at diagnosis and shunting was 20.7 and 22.6 weeks, respectively. All 8 procedures were successful, achieving complete in utero drainage. All but one were live births (85.7%) with a median gestational age of 38 weeks. The single case of in utero death occurred 4.7 weeks after successful shunting, and no cause could be identified after autopsy. The rates of preterm birth and premature rupture of membranes were 33.3% (2/6) and 16.7% (1/6), respectively. Four of the 8 procedures (50%) had minor shunt-related complications such as dislodgement and entrapment, occurring at a median of 7.7 weeks after shunting. None of the shunts became blocked. CONCLUSIONS The Somatex shunt is effective in relieving fetal pleural effusions with good survival rate. Overall, it was a safe instrument, though minor shunt complications occurred.
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Affiliation(s)
- Man Yan Chung
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Wing Cheong Leung
- Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Kowloon, Hong Kong, China
| | - Wing Ting Tse
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Yuen Ha Ting
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Kwok Ming Law
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Annie Shuk Yi Hui
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Yi Man Wah
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Hugh Simon Lam
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Liona Chiu Yee Poon
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Tak Yeung Leung
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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9
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Abbasi N, Windrim R, Keunen J, Seaward PGR, Van Mieghem T, Kelly EN, Langer JC, Ryan G. Perinatal Outcome in Fetuses with Dislodged Thoraco-Amniotic Shunts. Fetal Diagn Ther 2021; 48:430-439. [PMID: 33915545 DOI: 10.1159/000515694] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 03/04/2021] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Nimrah Abbasi
- Fetal Medicine Unit, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Rory Windrim
- Fetal Medicine Unit, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Johannes Keunen
- Fetal Medicine Unit, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Ontario Fetal Centre, Toronto, Ontario, Canada
| | - P G R Seaward
- Fetal Medicine Unit, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Tim Van Mieghem
- Fetal Medicine Unit, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Edmond N Kelly
- University of Toronto, Toronto, Ontario, Canada.,Ontario Fetal Centre, Toronto, Ontario, Canada.,Division of Neonatology, Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Jacob C Langer
- University of Toronto, Toronto, Ontario, Canada.,Ontario Fetal Centre, Toronto, Ontario, Canada.,Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Ontario Fetal Centre, Toronto, Ontario, Canada
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10
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Kelly EN, Seaward G, Ye XY, Windrim R, Van Mieghem T, Keunen J, Abbasi N, Chitayat D, Ryan G. Short- and long-term outcome following thoracoamniotic shunting for fetal hydrothorax. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:624-630. [PMID: 32068931 DOI: 10.1002/uog.21994] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/17/2020] [Accepted: 02/09/2020] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- E N Kelly
- Department of Paediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - G Seaward
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - X Y Ye
- Micare Research Centre, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - R Windrim
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - T Van Mieghem
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - J Keunen
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - N Abbasi
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - D Chitayat
- Prenatal Diagnosis and Medical Genetics Program, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - G Ryan
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Canada
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11
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Gámez-Varela A, Martínez-Rodríguez M, López-Briones H, Luna-García J, Chávez-González E, Villalobos-Gómez R, Hernandez-Andrade E, Cruz-Martínez R. Preoperative Cervical Length Predicts the Risk of Delivery within One Week after Pleuroamniotic Shunt in Fetuses with Severe Hydrothorax. Fetal Diagn Ther 2021; 48:297-303. [PMID: 33784701 DOI: 10.1159/000514912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/31/2021] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Alma Gámez-Varela
- Prenatal Diagnosis and Fetal Surgery Center, Medicina Fetal Mexico, Querétaro, Mexico
| | - Miguel Martínez-Rodríguez
- Prenatal Diagnosis and Fetal Surgery Center, Medicina Fetal Mexico, Querétaro, Mexico.,Department of Fetal Surgery, Hospital de Especialidades del Niño y la Mujer "Dr. Felipe Núñez-Lara,", Querétaro, Mexico
| | - Hugo López-Briones
- Prenatal Diagnosis and Fetal Surgery Center, Medicina Fetal Mexico, Querétaro, Mexico
| | - Jonahtan Luna-García
- Prenatal Diagnosis and Fetal Surgery Center, Medicina Fetal Mexico, Querétaro, Mexico
| | | | - Rosa Villalobos-Gómez
- Prenatal Diagnosis and Fetal Surgery Center, Medicina Fetal Mexico, Querétaro, Mexico
| | - Edgar Hernandez-Andrade
- Department of Obstetrics and Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, Texas, USA
| | - Rogelio Cruz-Martínez
- Prenatal Diagnosis and Fetal Surgery Center, Medicina Fetal Mexico, Querétaro, Mexico.,Universidad Autónoma del Estado de Hidalgo (UAEH), Hidalgo, Mexico.,Department of Fetal Surgery, Hospital de Especialidades del Niño y la Mujer "Dr. Felipe Núñez-Lara,", Querétaro, Mexico
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12
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Sampat K, Losty PD. Fetal surgery. Br J Surg 2021; 108:632-637. [PMID: 33720314 DOI: 10.1093/bjs/znaa153] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/26/2020] [Accepted: 12/01/2020] [Indexed: 11/13/2022]
Abstract
Fetal medicine is a super-specialty enterprise and a technology-driven field. The growth and interest in fetal surgery can be largely attributed to advances in fetal imaging and bespoke instruments for in utero intervention. Previously fatal fetal conditions are now being treated using open surgery, minimally invasive procedures, and percutaneous fetal technologies. Several fetal conditions, including myelomeningocele and twin-to-twin transfusion syndrome, have been tested rigorously in RCTs. However, as the specialty of fetal surgery grows, a robust evidence base with long-term follow-up is obligatory for every procedure. This article offers an overview of fetal surgery and antenatal intervention. As more cutting edge therapies come into clinical practice, growing public opinion and medical ethics will play a significant role in the future of this multidisciplinary specialty.
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Affiliation(s)
- K Sampat
- Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK
| | - P D Losty
- Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK.,Institute of Child Health, Alder Hey Children's Hospital, Liverpool, UK
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13
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Cruz-Martínez R, Sosa Sosa C, Martínez-Rodríguez M, Gámez-Varela A, Villalobos-Gómez R, López-Briones H, Luna-García J, Chávez-González E, Juárez-Martínez I. 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. Fetal Diagn Ther 2021; 48:209-216. [PMID: 33677452 DOI: 10.1159/000513748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/13/2020] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Rogelio Cruz-Martínez
- Prenatal Diagnosis and Fetal Surgery Center, Fetal Medicine Mexico and Fetal Medicine Foundation of Mexico, Queretaro, Mexico, .,Instituto de Ciencias de la Salud (ICSa), Universidad Autónoma del Estado de Hidalgo (UAEH), Hidalgo, Mexico, .,Department of Fetal Surgery, Hospital de Especialidades del Niño y la Mujer "Dr. Felipe Núñez-Lara,", Queretaro, Mexico,
| | - Cristian Sosa Sosa
- Prenatal Diagnosis and Fetal Surgery Center, Fetal Medicine Mexico and Fetal Medicine Foundation of Mexico, Queretaro, Mexico
| | - Miguel Martínez-Rodríguez
- Prenatal Diagnosis and Fetal Surgery Center, Fetal Medicine Mexico and Fetal Medicine Foundation of Mexico, Queretaro, Mexico.,Department of Fetal Surgery, Hospital de Especialidades del Niño y la Mujer "Dr. Felipe Núñez-Lara,", Queretaro, Mexico
| | - Alma Gámez-Varela
- Prenatal Diagnosis and Fetal Surgery Center, Fetal Medicine Mexico and Fetal Medicine Foundation of Mexico, Queretaro, Mexico
| | - Rosa Villalobos-Gómez
- Prenatal Diagnosis and Fetal Surgery Center, Fetal Medicine Mexico and Fetal Medicine Foundation of Mexico, Queretaro, Mexico
| | - Hugo López-Briones
- Prenatal Diagnosis and Fetal Surgery Center, Fetal Medicine Mexico and Fetal Medicine Foundation of Mexico, Queretaro, Mexico
| | - Jonahtan Luna-García
- Prenatal Diagnosis and Fetal Surgery Center, Fetal Medicine Mexico and Fetal Medicine Foundation of Mexico, Queretaro, Mexico
| | - Eréndira Chávez-González
- Prenatal Diagnosis and Fetal Surgery Center, Fetal Medicine Mexico and Fetal Medicine Foundation of Mexico, Queretaro, Mexico
| | - Israel Juárez-Martínez
- Prenatal Diagnosis and Fetal Surgery Center, Fetal Medicine Mexico and Fetal Medicine Foundation of Mexico, Queretaro, Mexico
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14
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Hara A, Hidaka N, Nitahara K, Sakai A, Kido S, Kato K. Intrathoracic shunt displacement with massive pleural effusion after successful shunt placement in a hydropic fetus with multilocular macrocystic congenital pulmonary airway malformation. JOURNAL OF CLINICAL ULTRASOUND : JCU 2021; 49:149-153. [PMID: 32562426 DOI: 10.1002/jcu.22886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/30/2020] [Accepted: 06/05/2020] [Indexed: 06/11/2023]
Abstract
We successfully performed shunting for a fetus with a multilocular macrocystic lung mass with hydrops at 22 weeks' gestation. Complete resolution of hydrops was achieved; however, at 35 weeks' gestation, the fetus developed acute massive pleural effusion. Fetal ultrasound examination revealed that one end of the shunting tube had migrated downward in the thoracic cavity, which led to fluid draining from the lung cyst. The baby was delivered at term and was discharged following neonatal intensive care management. Intrathoracic displacement of the shunt can occur, followed by massive pleural effusion due to drainage of cystic fluid.
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Affiliation(s)
- Asako Hara
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nobuhiro Hidaka
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenta Nitahara
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Atsuhiko Sakai
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Saki Kido
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kiyoko Kato
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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15
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Sharma D, Tsibizova VI. Current perspective and scope of fetal therapy: part 1. J Matern Fetal Neonatal Med 2020; 35:3783-3811. [PMID: 33135508 DOI: 10.1080/14767058.2020.1839880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Deepak Sharma
- Department of Neonatology, National Institute of Medical Science, Jaipur, India
| | - Valentina I Tsibizova
- Almazov National Medical Research Centre, Health Ministry of Russian Federation, Saint Petersburg, Russia
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16
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Valenzuela I, van der Merwe J, De Catte L, Devlieger R, Deprest J, Lewi L. Foetal therapies and their influence on preterm birth. Semin Immunopathol 2020; 42:501-514. [PMID: 32785752 DOI: 10.1007/s00281-020-00811-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/26/2020] [Indexed: 12/12/2022]
Abstract
Foetal therapy aims to improve perinatal survival or to prevent severe long-term handicap. Foetal medicine opens a new territory by treating the foetus as a patient. The mother has nothing to gain in terms of health benefits, yet she is inherently also undergoing treatment. In utero foetal interventions can be divided into ultrasound-guided minimally invasive procedures, fetoscopic procedures and open hysterotomy procedures, which carry an inherent risk of ruptured membranes and preterm birth. In this review, we summarise the conditions that may benefit from foetal therapy and review the current therapies on offer, each with their associated risk of ruptured membrane and preterm birth. We also look into some risk limiting and preventative strategies to mitigate these complications.
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Affiliation(s)
- Ignacio Valenzuela
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
| | - Johannes van der Merwe
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Luc De Catte
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Roland Devlieger
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, United Kingdom
| | - Liesbeth Lewi
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium. .,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium.
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17
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Fetal therapies as standard prenatal care in Japan. Obstet Gynecol Sci 2020; 63:108-116. [PMID: 32206649 PMCID: PMC7073354 DOI: 10.5468/ogs.2020.63.2.108] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/25/2019] [Accepted: 09/09/2019] [Indexed: 11/09/2022] Open
Abstract
With recent advances in fetal medicine, various attempts have been made to save fetuses facing perinatal death or devastating consequences despite optimal management after birth. The concept of the fetus as a patient has been established through the application of in utero treatments. This paper reviews fetal therapies in order to highlight the role of perinatal medicine as standard prenatal care. Fetal therapies consist of medical therapy, percutaneous ultrasound-guided surgery, fetoscopic surgery, and open fetal surgery. In the 1980s, with advances in ultrasound imaging, percutaneous ultrasound-guided surgeries such as vesicoamniotic shunting for lower urinary tract obstruction and thoracoamniotic shunting (TAS) for fetal hydrothorax (FHT) were started. In the 1990s, fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) was introduced, and later, a fetoscopic approach for congenital diaphragmatic hernia was also established. The revival of open fetal surgery, introduced in the 1980s by pediatric surgeons, began in the 2010s after a successful clinical study for myelomeningocele. Although many fetal therapies are still considered experimental, some have proven effective, such as FLS for TTTS, TAS for primary FHT, and radiofrequency ablation (RFA) for twin reversed arterial perfusion (TRAP) sequence. These three fetal therapies have been approved for coverage by Japan National Health Insurance as a result of clinical studies performed in Japan. FLS for TTTS, TAS for primary FHT, and RFA for TRAP sequence have become standard prenatal care approaches in Japan. These three minimally invasive fetal therapies will help improve the perinatal outcomes of fetuses with these disorders.
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18
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Phithakwatchara N, Nawapun K, Viboonchart S, Jaingam S, Wataganara T. Simulation‐based fetal shunting training. Prenat Diagn 2019; 39:1291-1297. [DOI: 10.1002/pd.5599] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 10/18/2019] [Accepted: 10/19/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Nisarat Phithakwatchara
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyFaculty of Medicine Siriraj Hospital Bangkok Thailand
| | - Katika Nawapun
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyFaculty of Medicine Siriraj Hospital Bangkok Thailand
| | - Sommai Viboonchart
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyFaculty of Medicine Siriraj Hospital Bangkok Thailand
| | - Suparat Jaingam
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyFaculty of Medicine Siriraj Hospital Bangkok Thailand
| | - Tuangsit Wataganara
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyFaculty of Medicine Siriraj Hospital Bangkok Thailand
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19
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Weissbach T, Kushnir A, Rasslan R, Rosenblatt O, Yinon Y, Berkenstadt M, Weisz B, Mazaki Tovi S, Kassif E. Fetal pleural effusion: Contemporary methods of genetic evaluation. Prenat Diagn 2019; 39:751-757. [PMID: 31169934 DOI: 10.1002/pd.5497] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 05/13/2019] [Accepted: 05/16/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the contribution of chromosomal microarray (CMA) and other advanced genetic tests to the genetic evaluation of fetal pleural effusion (FPE) and to identify parameters that might assist in predicting genetic abnormality. METHODS A retrospective study of FPE cases referred between 2013 and 2018 was conducted. Cases that underwent genetic evaluation were divided into two groups, chromosomally normal and genetically abnormal. The types and prevalence of genetic abnormalities were reported. Clinical and sonographic parameters were compared. Univariate and multivariate analyses were performed to determine an association between different parameters and genetic abnormality. RESULTS Sixty-two cases were included in the study. Forty-eight cases were genetically assessed (karyotype, CMA, whole exome sequencing, Noonan panel, or a combination). A clinically significant genetic abnormality was detected in 29.17% (14/48) of cases. Aneuploidy and single gene disorders were found in 78.6% (11/14) and 21.4% (3/14) of abnormal cases. Four additional cases had microdeletion/duplications detected, yet none were of clinical significance. Multivariate analysis indicated that the presence of anomalies was statistically associated with genetic abnormality (95% CI, 1.144-168.2; 0.039). CONCLUSION In our cohort, CMA did not demonstrate an additional clinical yield over karyotyping. The presence of anomalies was independently associated with underlying genetic abnormality.
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Affiliation(s)
- Tal Weissbach
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anya Kushnir
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rana Rasslan
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orgad Rosenblatt
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Yinon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Berkenstadt
- The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - Boaz Weisz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shali Mazaki Tovi
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Kassif
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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20
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Shamshirsaz AA, Erfani H, Aalipour S, Shah SC, Nassr AA, Stewart KA, Rezaei A, Sanz Cortes M, Espinoza J, Belfort MA. Primary fetal pleural effusion: Characteristics, outcomes, and the role of intervention. Prenat Diagn 2019; 39:484-488. [PMID: 31009092 DOI: 10.1002/pd.5462] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/10/2019] [Accepted: 04/12/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND We aimed to present the natural history and outcomes of fetal primary pleural effusions (PPE). METHODS Fetuses with prenatal diagnosis of PPE delivered between January 2011 and June 2018 were included. Fetal PPE were separated into groups: resolved, stable, or progressive. Progressive PPE was diagnosed, using fetal echocardiography, by the new onset of fetal hydrops or impaired cardiac function. Data were reported as median [range] and n (%). RESULTS Among 189 fetuses with antenatal diagnosis of pleural effusion, 30 had a PPE. A total of 26.7% (n = 8), 26.7% (n = 8), and 40.0% (n = 12) were classified as resolved, stable, and progressive, respectively; two were lost to follow-up. In 14 cases (50%), there were bilateral pleural effusions. Of the 12 cases in the progressive group, four (33.3%) had amnioreduction, six (50.0%) had thoracentesis, and eight (66.7%) had shunt placement performed. There were two fetal deaths, both in the progressive group, one of which received amnioreduction and the other underwent both thoracentesis and shunt placement prior to demise. CONCLUSION In more than half of fetuses with prenatal PPE, the effusion remained stable or spontaneously resolved, and the perinatal outcomes were generally favorable. This information will be useful in optimizing the counseling and care of these patients.
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Affiliation(s)
- Alireza A Shamshirsaz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Hadi Erfani
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Soroush Aalipour
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Sohum C Shah
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Ahmed A Nassr
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Kelsey A Stewart
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Atefeh Rezaei
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Magdalena Sanz Cortes
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Jimmy Espinoza
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Michael A Belfort
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
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21
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Abbasi N, Ryan G. Fetal primary pleural effusions: Prenatal diagnosis and management. Best Pract Res Clin Obstet Gynaecol 2019; 58:66-77. [PMID: 30737016 DOI: 10.1016/j.bpobgyn.2019.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 01/07/2019] [Accepted: 01/08/2019] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Nimrah Abbasi
- Fetal Medicine Unit, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Canada.
| | - Greg Ryan
- Fetal Medicine Unit, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Canada.
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22
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Nassr AA, Erfani H, Fisher JE, Ogunleye OK, Espinoza J, Belfort MA, Shamshirsaz AA. Fetal interventional procedures and surgeries: a practical approach. J Perinat Med 2018; 46:701-715. [PMID: 28599395 DOI: 10.1515/jpm-2017-0015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 04/19/2017] [Indexed: 12/25/2022]
Abstract
Abstract
The identification of congenital birth defects and fetal malformations continues to increase during the antenatal period with improved imaging techniques. Understanding of how to treat specific fetal conditions continues to improve outcomes from these treatment modalities. In an effort to further improvement in this field, we provide a review that begins with a brief background of fetal surgery including the history of fetal surgery, ethics surrounding fetal surgery, and considerations of how to treat the fetus during intervention. A synopsis of the most commonly encountered disease processes treated by fetal intervention/surgery including definitions, treatment modalities, and outcomes following fetal intervention/surgery is then provided. Within the sections describing each disease process, methodology is described that has helped with efficiency and success of procedures performed at our institution.
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Affiliation(s)
- Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA.,Women's Health Hospital, Assiut University, Assiut, Egypt
| | - Hadi Erfani
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - James E Fisher
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Oluseyi K Ogunleye
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, 6651 Main Street, Houston, TX 77030, USA,
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23
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Chon AH, Chmait HR, Korst LM, Llanes A, Ouzounian JG, Chmait RH. Long-Term Outcomes After Thoracoamniotic Shunt for Pleural Effusions With Secondary Hydrops. J Surg Res 2018; 233:304-309. [PMID: 30502263 DOI: 10.1016/j.jss.2018.08.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/19/2018] [Accepted: 08/03/2018] [Indexed: 01/21/2023]
Abstract
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.
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Affiliation(s)
- Andrew H Chon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Hikmat R Chmait
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Lisa M Korst
- Childbirth Research Associates, North Hollywood, California
| | - Arlyn Llanes
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ramen H Chmait
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California.
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24
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Selovic A, Belci D. Influence of distribution of mother's abdominal body fat on first trimester fetal growth. J Matern Fetal Neonatal Med 2018; 33:449-454. [PMID: 29950128 DOI: 10.1080/14767058.2018.1494715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: Fetal growth in the first trimester is estimated by measuring the crown to rump length of the fetus (CRL). There are no data on the relation between fetal growth and fat distribution in pregnant women. The objective was to investigate the influence of fat distribution in pregnant women on fetal growth in the first trimester of pregnancy.Methods: This was a controlled observation using a random sampling method. Newly registered pregnant women were included in the sample during a 12-18-month period. The study included 400 pregnant women from Bjelovarsko-bilogorska County, Croatia. Participants were divided into three groups according to their pregravid BMI values, normal weight (n = 254), overweight (n = 103), and obese (n = 43). In the 12th week of pregnancy, the CRL was measured by transvaginal ultrasound. The subcutaneous and preperitoneal fat was measured by transabdominal ultrasound, using the Suzuki method. The correlation was tested by the Pearson's coefficient, and a linear regression analysis was performed on the variables with good correlation.Results: In normal weight pregnant women, there is no correlation between the adipose tissue and fetal length, but there is a significant correlation between overweight and obese ones.Conclusion: The distribution of adipose tissue in obese and overweight pregnant women is associated with fetal length in the first trimester of pregnancy, with a stronger correlation between visceral fat and fetal length. The influence of this correlation on the overall fetal growth should be investigated by longitudinal monitoring of these variables during the entire pregnancy.
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Affiliation(s)
| | - Dragan Belci
- Gynecology and Obstetrics, Opca bolnica Pula, Pula, Croatia
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25
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Fetal intervention for congenital chylothorax is associated with improved outcomes in early life. J Surg Res 2018; 231:361-365. [PMID: 30278954 DOI: 10.1016/j.jss.2018.05.082] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/21/2018] [Accepted: 05/31/2018] [Indexed: 11/24/2022]
Abstract
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.
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26
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Gulati N, Morris RK, Williams D, Kilby MD. Prenatal thoraco-amniotic chest drain insertion to manage a case of fetal hydrops secondary to FOXC2. BMJ Case Rep 2018; 2018:bcr-2017-223902. [PMID: 29866673 DOI: 10.1136/bcr-2017-223902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Lymphoedema-distichiasis is an inherited autosomal dominant disorder of the lymphatic system. Rarely, it is associated with fetal hydrops; the risk and severity of which increases with successive generations. The causative gene is a member of the forkhead transcription factor family (FOXC2). We describe a fetus presenting with early-onset, rapidly progressing body wall oedema, bilateral pleural effusions and a pericardial effusion in a mother with known FOXC2 mutation. First trimester chorionic villus sampling confirmed FOXC2 mutation in the fetus when there was only a large nuchal translucency. As the phenotype progressed, the couple consented to in utero ultrasound-guided insertion of sequential bilateral pleuro-amniotic chest drains (at 23 weeks) which successfully drained the pleural effusions. The fetus was delivered at 39 weeks gestation by elective caesarean section in good condition. The shunts were removed postnatally, and the baby was discharged after 7 days. This is the first case described of a fetus with severe early-onset fetal hydrops secondary to FOXC2 mutation successfully treated by the prenatal insertion of bilateral pleuro-amniotic shunts.
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Affiliation(s)
- Nidhi Gulati
- Obstetrics and Gynaecology, Burton Hospitals NHS Foundation Trust, Staffordshire, UK
| | - Rachel Katie Morris
- Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.,Institute of Metabolism and System Research, University of Birmingham, Edgbaston, UK
| | - Denise Williams
- West Midlands Genetic Centre, Birmingham Women's & Children's Foundation Trust, Birmingham, UK
| | - Mark David Kilby
- Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.,Institute of Metabolism and System Research, University of Birmingham, Edgbaston, UK
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27
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Suyama F, Ozawa K, Ogawa K, Sugibayashi R, Wada S, Sago H. Fetal lung size after thoracoamniotic shunting reflects survival in primary fetal hydrothorax with hydrops. J Obstet Gynaecol Res 2018; 44:1216-1220. [PMID: 29797505 DOI: 10.1111/jog.13657] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 03/21/2018] [Indexed: 11/28/2022]
Abstract
AIM To assess the role of lung size and abnormal Doppler findings in the umbilical artery (UA) in determining the outcomes of fetuses with primary fetal hydrothorax (FHT) associated with hydrops who underwent thoracoamniotic shunting (TAS). METHODS This was a retrospective study at a single center. We included cases of primary FHT with hydrops who underwent TAS at our hospital between 2004 and 2016. We assessed the relationship between mortality until 28 days after birth and ultrasound findings, including absent or reversed end-diastolic velocity (AREDV) in the UA and the lung-to-thorax transverse area ratio (LTR), before and after TAS. RESULTS Forty-one cases of primary FHT with hydrops underwent TAS. The median (range) gestational age at TAS was 28.5 (19.3-33.8) weeks. Bilateral pleural effusion was observed in 39 cases (95.1%). Among the 41 cases, 19 (46.4%) survived, 11 (26.8%) died in utero, and 11 (26.8%) died in the neonatal period. AREDV in the UA before and after TAS were not associated with mortality (P = 0.32 and 0.47, respectively). The odds ratio for mortality in LTR 0.2-0.3 before TAS was 0.62 (vs LTR < 0.2, P = 0.45) and that in LTR 0.2-0.3 and > 0.3 after TAS were 0.27 and 0.06, respectively (vs LTR < 0.2, P for trend <0.01). CONCLUSION A larger LTR after TAS was significantly associated with a better prognosis in hydropic primary FHT. The fetal lung size after the procedure may be a prognostic factor of primary FHT.
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Affiliation(s)
- Fumio Suyama
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Katsusuke Ozawa
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kohei Ogawa
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Rika Sugibayashi
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Seiji Wada
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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28
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Witlox RSGM, Klumper FJCM, Te Pas AB, van Zwet EW, Oepkes D, Lopriore E. Neonatal management and outcome after thoracoamniotic shunt placement for fetal hydrothorax. Arch Dis Child Fetal Neonatal Ed 2018; 103:F245-F249. [PMID: 28780497 DOI: 10.1136/archdischild-2016-311265] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 06/20/2017] [Accepted: 06/22/2017] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Ruben S G M Witlox
- Department of Paediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frans J C M Klumper
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan B Te Pas
- Department of Paediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik W van Zwet
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Paediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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29
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Thoracoamniotic shunting for fetal pleural effusion with hydropic change using a double-basket catheter: An insight into the preoperative determinants of shunting efficacy. Eur J Obstet Gynecol Reprod Biol 2018; 221:34-39. [DOI: 10.1016/j.ejogrb.2017.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 10/20/2017] [Accepted: 12/06/2017] [Indexed: 11/18/2022]
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30
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Dorsi M, Giuseppi A, Lesage F, Stirnemann J, De Saint Blanquat L, Nicloux M, Assaf Z, Khen Dunlop N, Kermorvant-Duchemin E, Magny JF, Ville Y, Lapillonne A. Prenatal factors associated with neonatal survival of infants with congenital chylothorax. J Perinatol 2018; 38:31-34. [PMID: 29048403 DOI: 10.1038/jp.2017.150] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 08/11/2017] [Accepted: 08/14/2017] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- M Dorsi
- Department of Neonatal Intensive Care, APHP Necker Hospital, Paris, France
| | - A Giuseppi
- Department of Neonatal Intensive Care, APHP Necker Hospital, Paris, France
| | - F Lesage
- Department of Pediatric Intensive Care, APHP Necker Hospital, Paris, France
| | - J Stirnemann
- Paris Descartes University (EA 7328), Sorbonne Paris Cite, France.,Department of Obstetrics, APHP Necker Hospital, Paris, France
| | | | - M Nicloux
- Department of Neonatal Intensive Care, APHP Necker Hospital, Paris, France
| | - Z Assaf
- Department of Neonatal Intensive Care, APHP Necker Hospital, Paris, France
| | - N Khen Dunlop
- Paris Descartes University (EA 7328), Sorbonne Paris Cite, France.,Department of Pediatric Surgery, APHP Necker Hospital, Paris, France
| | - E Kermorvant-Duchemin
- Department of Neonatal Intensive Care, APHP Necker Hospital, Paris, France.,Paris Descartes University (EA 7328), Sorbonne Paris Cite, France
| | - J-F Magny
- Department of Neonatal Intensive Care, APHP Necker Hospital, Paris, France.,Paris Descartes University (EA 7328), Sorbonne Paris Cite, France
| | - Y Ville
- Paris Descartes University (EA 7328), Sorbonne Paris Cite, France.,Department of Obstetrics, APHP Necker Hospital, Paris, France
| | - A Lapillonne
- Department of Neonatal Intensive Care, APHP Necker Hospital, Paris, France.,Paris Descartes University (EA 7328), Sorbonne Paris Cite, France
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31
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Peng YF, Zhong W, He QM, Wang Z, Yu JK, Zhang GL, Li DZ. Treatment of fetal congenital chylothorax: Report of eight cases at a mainland Chinese medical center. Taiwan J Obstet Gynecol 2017; 56:867-869. [PMID: 29241937 DOI: 10.1016/j.tjog.2017.10.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2017] [Indexed: 11/26/2022] Open
Affiliation(s)
- Yan-Fen Peng
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center Affiliated to Guangzhou Medical University, Guangzhou, China
| | - Wei Zhong
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center Affiliated to Guangzhou Medical University, Guangzhou, China
| | - Qiu-Ming He
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center Affiliated to Guangzhou Medical University, Guangzhou, China
| | - Zhe Wang
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center Affiliated to Guangzhou Medical University, Guangzhou, China
| | - Jia-Kang Yu
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center Affiliated to Guangzhou Medical University, Guangzhou, China
| | - Guang-Lan Zhang
- Prenatal Diagnosis & Fetal Medicine Center, Guangzhou Women and Children's Medical Center Affiliated to Guangzhou Medical University, Guangzhou, China
| | - Dong-Zhi Li
- Prenatal Diagnosis & Fetal Medicine Center, Guangzhou Women and Children's Medical Center Affiliated to Guangzhou Medical University, Guangzhou, China.
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32
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Johnson MP, Wilson RD. Shunt-based interventions: Why, how, and when to place a shunt. Semin Fetal Neonatal Med 2017; 22:391-398. [PMID: 28964685 DOI: 10.1016/j.siny.2017.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The broad categories of surgical fetal therapy can be separated into either open surgical techniques or minimally invasive endoscopic/ultrasound-guided techniques that require only puncture of the uterus with single or multiple small ports. Benefits of fetoscopic or ultrasound-guided fetal intervention include decreased uterine irritability, decreased incidence of preterm labor, and avoidance of risks associated with hysterotomy and commitment to cesarean delivery for future pregnancies. Fetal abnormalities potentially amenable to ultrasound-guided drainage techniques include thoracic fluid-filled lesions and lower urinary tract obstruction.
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Affiliation(s)
- Mark P Johnson
- The Center for Fetal Diagnosis and Therapy, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - R Douglas Wilson
- Departments of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
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33
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Nakayama A, Oshiro M, Yamada Y, Hattori T, Wakano Y, Hayashi S, Kokubo M, Takemoto K, Honda S, Ieda K, Yamamoto H, Kouwaki M, Yokoi K, Shinohara O, Kato T, Miyata M, Tanaka T, Hayakawa M. Prognostic factors of hydrops fetalis with pleural effusion. Pediatr Int 2017; 59:1053-1057. [PMID: 28672054 DOI: 10.1111/ped.13357] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 06/20/2017] [Accepted: 06/28/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Hydrops fetalis (HF) has a low survival rate, particularly in the case of preterm birth. In addition, the severity index of HF has not been fully investigated yet. The aim of this study was to clarify the prognostic factors of HF with pleural effusion. METHODS All live-born HF patients with pleural effusion, except for chromosomal abnormality or complex congenital heart disease, born from 2009 to 2013 in Aichi Prefecture in Japan were included. Prenatal, perinatal, and postnatal information was obtained from the medical records and was retrospectively analyzed. RESULTS Forty-one HF patients with pleural effusion were included, and 28 patients (68%) survived. On multivariate logistic stepwise analysis, gestational birth week (OR, 0.71; 95% CI: 0.52-0.96, P = 0.027) and standard deviation (SD) score of the birthweight (OR, 1.74; 95% CI: 1.01-2.99, P = 0.045) were significant factors for postnatal death. All patients with both ≥32 gestational weeks and <3.0 birthweight SD score survived. CONCLUSIONS Combined with the gestational weeks data, birthweight SD score may be useful to estimate the prognosis of HF with pleural effusion.
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Affiliation(s)
- Atsushi Nakayama
- Department of Pediatrics, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Makoto Oshiro
- Department of Pediatrics, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Yasumasa Yamada
- Division of Reproductive and Perinatal Medical Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Tetsuo Hattori
- Department of Neonatology, Anjo Kosei Hospital, Anjo, Japan
| | - Yasuhiro Wakano
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.,Department of Pediatrics, Ichinomiya Municipal Hospital, Ichinomiya, Japan
| | - Seiji Hayashi
- Department of Pediatrics, Okazaki City Hospital, Okazaki, Japan
| | - Minoru Kokubo
- Department of Pediatrics, Aichi Prefectural Welfare Federation of Agricultural Cooperatives Kainan Hospital, Yatomi, Japan
| | - Koji Takemoto
- Department of Pediatrics, Konan Kosei Hospital, Konan, Japan
| | - Shigeru Honda
- Department of Pediatrics, Komaki City Hospital, Komaki, Japan
| | - Kuniko Ieda
- Department of Pediatrics, Tosei General Hospital, Seto, Japan
| | - Hikaru Yamamoto
- Department of Neonatology, Toyota Memorial Hospital, Toyota, Japan
| | - Masanori Kouwaki
- Department of Pediatrics, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Kyoko Yokoi
- Department of Pediatrics, Nagoya City West Medical Center, Nagoya, Japan
| | | | - Takenori Kato
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masafumi Miyata
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Taihei Tanaka
- Department of Pediatrics, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | - Masahiro Hayakawa
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
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Current Strategy of Fetal Therapy II: Invasive Fetal Interventions. JOURNAL OF FETAL MEDICINE 2017. [DOI: 10.1007/s40556-017-0132-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Cao L, Du Y, Wang L. Fetal pleural effusion and Down syndrome. Intractable Rare Dis Res 2017; 6:158-162. [PMID: 28944136 PMCID: PMC5608924 DOI: 10.5582/irdr.2017.01028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 05/22/2017] [Accepted: 05/27/2017] [Indexed: 01/23/2023] Open
Abstract
Fetal pleural effusion is a rare abnormality that results from accumulation of fluid in the chest cavity. It can be classified as primary fetal hydrothorax and secondary fetal hydrothorax. The underlying causes of pleural effusion are still unknown, and the current treatment strategies are mainly based on symptoms. The prognosis of fetal pleural effusion varies significantly, ranging from spontaneous resolution to perinatal death. Recent advances in prenatal diagnostic methods and treatment such as thoracoamniotic shunting have significantly improved the survival rates for patients with or without hydrops.
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Affiliation(s)
- Li Cao
- Ultrasound Department, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Yan Du
- Office of Clinical Epidemiology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Ling Wang
- Laboratory for Reproductive Immunology, Hospital & Institute of Obstetrics and Gynecology, IBS, Fudan University Shanghai Medical College, Shanghai, China
- The Academy of Integrative Medicine of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-related Diseases, Shanghai, China
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Yumoto Y, Jwa SC, Wada S, Takahashi Y, Ishii K, Kato K, Usui N, Sago H. The outcomes and prognostic factors of fetal hydrothorax associated with trisomy 21. Prenat Diagn 2017; 37:686-692. [DOI: 10.1002/pd.5066] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 04/28/2017] [Accepted: 05/06/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Yasuo Yumoto
- Department of Obstetrics and Gynecology, Kyushu University Hospital; Kyushu University; Fukuoka Japan
| | - Seung Chik Jwa
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine; National Center for Child Health and Development; Tokyo Japan
| | - Seiji Wada
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine; National Center for Child Health and Development; Tokyo Japan
| | - Yuichiro Takahashi
- Department of Fetal-Maternal Medicine; Nagara Medical Center; Gifu Japan
| | - Keisuke Ishii
- Maternal Fetal Medicine; Osaka Women's and Children's Hospital; Izumi Japan
| | - Kiyoko Kato
- Department of Obstetrics and Gynecology, Kyushu University Hospital; Kyushu University; Fukuoka Japan
| | - Noriaki Usui
- Department of Pediatric Surgery; Osaka Women's and Children's Hospital; Izumi Japan
| | - Haruhiko Sago
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine; National Center for Child Health and Development; Tokyo Japan
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Wada S, Jwa SC, Yumoto Y, Takahashi Y, Ishii K, Usui N, Sago H. The prognostic factors and outcomes of primary fetal hydrothorax with the effects of fetal intervention. Prenat Diagn 2017; 37:184-192. [DOI: 10.1002/pd.4989] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 10/24/2016] [Accepted: 12/09/2016] [Indexed: 12/29/2022]
Affiliation(s)
- Seiji Wada
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine; National Center for Child Health and Development; Tokyo Japan
| | - Seung Chik Jwa
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine; National Center for Child Health and Development; Tokyo Japan
| | - Yasuo Yumoto
- Department of Obstetrics and Gynecology; Kyushu University Hospital, Kyushu University; Fukuoka Japan
| | - Yuichiro Takahashi
- Department of Fetal-Maternal Medicine; Nagara Medical Center; Gifu Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine; Osaka Medical Center and Research Institute for Maternal and Child Health; Izumi Japan
| | - Noriaki Usui
- Department of Pediatric Surgery; Osaka Medical Center and Research Institute for Maternal and Child Health; Izumi Japan
| | - Haruhiko Sago
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine; National Center for Child Health and Development; Tokyo Japan
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Lee CJ, Tsao PN, Chen CY, Hsieh WS, Liou JY, Chou HC. Prenatal Therapy Improves the Survival of Premature Infants with Congenital Chylothorax. Pediatr Neonatol 2016; 57:127-32. [PMID: 26315047 DOI: 10.1016/j.pedneo.2015.07.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 06/30/2015] [Accepted: 07/16/2015] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Chia-Jung Lee
- Department of Pediatrics, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Po-Nien Tsao
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University, Medical College, Taipei, Taiwan
| | - Chien-Yi Chen
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University, Medical College, Taipei, Taiwan
| | - Wu-Shiun Hsieh
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University, Medical College, Taipei, Taiwan
| | - Jyun-You Liou
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University, Medical College, Taipei, Taiwan
| | - Hung-Chieh Chou
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University, Medical College, Taipei, Taiwan.
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Hellmund A, Berg C, Geipel A, Bludau M, Heydweiller A, Bachour H, Müller A, Müller A, Gembruch U. Prenatal Diagnosis and Evaluation of Sonographic Predictors for Intervention and Adverse Outcome in Congenital Pulmonary Airway Malformation. PLoS One 2016; 11:e0150474. [PMID: 26978067 PMCID: PMC4792474 DOI: 10.1371/journal.pone.0150474] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 02/14/2016] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To describe antenatal findings and evaluate prenatal risk parameters for adverse outcome or need for intervention in fetuses with congenital pulmonary airway malformation (CPAM). METHODS In our retrospective study all fetuses with a prenatal diagnosis of CPAM detected in our tertiary referral center between 2002 and 2013 were analyzed. Sonographic findings were noted and measurements of mass-to-thorax-ratio (MTR), congenital pulmonary airway malformation volume-ratio (CVR) and observed to expected lung-to head-ratio (o/e LHR) were conducted and correlated to fetal or neonatal morbidity and mortality and/or need for prenatal intervention. RESULTS 67 fetuses with CPAM were included in the study. Hydropic fetuses were observed in 16.4% (11/67) of cases, prenatal intervention was undertaken in 9 cases; 7 pregnancies were terminated. The survival rate of non-hydropic fetuses with conservatively managed CPAM was 98.0% (50/51), the survival rate for hydropic fetuses with intention to treat was 42.9% (3/7). 10 (18.2%) children needed respiratory assistance. Fetuses with a CVR of <0.91 were significantly less likely to experience adverse outcome or need for prenatal intervention with sensitivity, specificity and positive/negative predictive value of 0.89, 0.71, 0.62 and 0.93, respectively. A MTR (mass-to-thorax-ratio) of < 0.51 had a positive predictive value of 0.54 and a negative predictive value of 0.96 of adverse events with a sensitivity of 0.95 and a specificity of 0.63. The negative predictive value for o/e LHR of 45% was 0.84 with sensitivity, specificity and positive predictive value of 0.73, 0.68 and 0.52, respectively. CONCLUSIONS The majority of cases with CPAM have a favorable outcome. MTR and CVR are able to identify fetuses at risk, the o/e LHR is less sensitive.
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Affiliation(s)
- Astrid Hellmund
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
- * E-mail:
| | - Christoph Berg
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
- Division of Prenatal Medicine and Gynecologic Sonography, Department of Obstetrics and Gynecology, University of Cologne, Cologne, Germany
| | - Annegret Geipel
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - Meike Bludau
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | | | - Haitham Bachour
- Division of Pediatric Surgery, University of Bonn, Bonn, Germany
| | - Andreas Müller
- Department of Neonatology, University of Bonn, Bonn, Germany
| | - Annette Müller
- Department of Pathology, University of Bonn, Bonn, Germany
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
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Jeong BD, Won HS, Lee MY, Shim JY, Lee PR, Kim A. Perinatal outcomes of fetal pleural effusion following thoracoamniotic shunting. Prenat Diagn 2015; 35:1365-70. [DOI: 10.1002/pd.4709] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 10/13/2015] [Accepted: 10/14/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Ba-Da Jeong
- Department of Obstetrics and Gynecology; University of Ulsan College of Medicine, Asan Medical Center; Seoul Korea
| | - Hye-Sung Won
- Department of Obstetrics and Gynecology; University of Ulsan College of Medicine, Asan Medical Center; Seoul Korea
| | - Mi-Young Lee
- Department of Obstetrics and Gynecology; University of Ulsan College of Medicine, Asan Medical Center; Seoul Korea
| | - Jae-Yoon Shim
- Department of Obstetrics and Gynecology; University of Ulsan College of Medicine, Asan Medical Center; Seoul Korea
| | - Pil-Ryang Lee
- Department of Obstetrics and Gynecology; University of Ulsan College of Medicine, Asan Medical Center; Seoul Korea
| | - Ahm Kim
- Department of Obstetrics and Gynecology; University of Ulsan College of Medicine, Asan Medical Center; Seoul Korea
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41
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O''Brien B, Kesby G, Ogle R, Rieger I, Hyett JA. Treatment of Primary Fetal Hydrothorax with OK-432 (Picibanil): Outcome in 14 Fetuses and a Review of the Literature. Fetal Diagn Ther 2015; 37:259-66. [DOI: 10.1159/000363651] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 05/10/2014] [Indexed: 11/19/2022]
Abstract
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.
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Abstract
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.
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Adams TM, Kunzier NB, Chavez MR, Vintzileos AM. Ultrasound-Guided Retrieval and Position Replacement of a Dislodged Fetal Pleuro-Amniotic Shunt: A Novel Approach for a Known Complication of Feto-Amniotic Shunting. Fetal Diagn Ther 2015; 39:78-80. [PMID: 25660293 DOI: 10.1159/000371576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 12/10/2014] [Indexed: 11/19/2022]
Abstract
Untreated fetal pleural effusion can cause significant perinatal morbidity and mortality. Treatment of pleural effusions with pleuro-amniotic shunting has been shown to improve outcomes. Pleuro-amniotic shunting is associated with complications including ruptured membranes, preterm labor and shunt dislodgement into either the amniotic cavity or the fetal thorax. Shunt dislodgement into the thoracic cavity can cause prenatal complications from the shunt itself or may necessitate neonatal surgery for removal. We present a case where a novel ultrasound-guided technique was used to replace the dislodged pleural shunt in utero, thereby effectively draining the effusion while simultaneously obviating the need for neonatal surgery and decreasing possible perinatal complications.
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Affiliation(s)
- Tracy M Adams
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Stony Brook University Hospital, Mineola, N.Y., USA
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Norton ME, Chauhan SP, Dashe JS, Dashe JS. Society for maternal-fetal medicine (SMFM) clinical guideline #7: nonimmune hydrops fetalis. Am J Obstet Gynecol 2015; 212:127-39. [PMID: 25557883 DOI: 10.1016/j.ajog.2014.12.018] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 12/12/2014] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Nonimmune hydrops is the presence of ≥2 abnormal fetal fluid collections in the absence of red cell alloimmunization. The most common etiologies include cardiovascular, chromosomal, and hematologic abnormalities, followed by structural fetal anomalies, complications of monochorionic twinning, infection, and placental abnormalities. We sought to provide evidence-based guidelines for the evaluation and management of nonimmune hydrops fetalis. METHODS A systematic literature review was performed using MEDLINE, PubMed, EMBASE, and Cochrane Library. The search was restricted to English-language articles published from 1966 through June 2014. Priority was given to articles reporting original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Evidence reports and guidelines published by organizations or institutions such as the National Institutes of Health, Agency for Health Research and Quality, American Congress of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine were also reviewed, and additional studies were located by reviewing bibliographies of identified articles. Grading of Recommendations Assessment, Development, and Evaluation methodology was employed for defining strength of recommendations and rating quality of evidence. Consistent with US Preventive Task Force guidelines, references were evaluated for quality based on the highest level of evidence. RESULTS AND RECOMMENDATIONS Evaluation of hydrops begins with an antibody screen (indirect Coombs test) to determine if it is nonimmune, detailed sonography of the fetus(es) and placenta, including echocardiography and assessment for fetal arrhythmia, and middle cerebral artery Doppler evaluation for anemia, as well as fetal karyotype and/or chromosomal microarray analysis, regardless of whether a structural fetal anomaly is identified. Recommended treatment depends on the underlying etiology and gestational age; preterm delivery is recommended only for obstetric indications including development of mirror syndrome. Candidates for corticosteroids and antepartum surveillance include those with an idiopathic etiology, an etiology amenable to prenatal or postnatal treatment, and those in whom intervention is planned if fetal deterioration occurs. Such pregnancies should be delivered at a facility with the capability to stabilize and treat critically ill newborns. The prognosis depends on etiology, response to therapy if treatable, and the gestational age at detection and delivery. Aneuploidy confers a poor prognosis, and even in the absence of aneuploidy, neonatal survival is often <50%. Mirror syndrome is a form of severe preeclampsia that may develop in association with fetal hydrops and in most cases necessitates delivery.
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Affiliation(s)
| | | | | | - Jodi S Dashe
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
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Van Mieghem T, Hodges R, Jaeggi E, Ryan G. Functional echocardiography in the fetus with non-cardiac disease. Prenat Diagn 2013; 34:23-32. [DOI: 10.1002/pd.4254] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 09/23/2013] [Accepted: 10/07/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Tim Van Mieghem
- Fetal Medicine Unit, Mount Sinai Hospital; University of Toronto; Toronto Canada
| | - Ryan Hodges
- Fetal Medicine Unit, Mount Sinai Hospital; University of Toronto; Toronto Canada
| | - Edgar Jaeggi
- Fetal Cardiac Program, Pediatric Cardiology, Hospital for Sick Children; University of Toronto; Toronto Canada
| | - Greg Ryan
- Fetal Medicine Unit, Mount Sinai Hospital; University of Toronto; Toronto Canada
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Miyoshi T, Katsuragi S, Ikeda T, Horiuchi C, Kawasaki K, Kamiya CA, Sasaki Y, Osato K, Neki R, Yoshimatsu J. Retrospective review of thoracoamniotic shunting using a double-basket catheter for fetal chylothorax. Fetal Diagn Ther 2013; 34:19-25. [PMID: 23595018 DOI: 10.1159/000348776] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 02/05/2012] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Takekazu Miyoshi
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Osaka, Japan.
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Inoue S, Odaka A, Baba K, Kunikata T, Sobajima H, Tamura M. Thoracoscopy-assisted removal of a thoracoamniotic shunt double-basket catheter dislodged into the fetal thoracic cavity: report of three cases. Surg Today 2013; 44:761-6. [DOI: 10.1007/s00595-013-0565-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 09/24/2012] [Indexed: 12/01/2022]
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48
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Petersen S, Kaur R, Thomas JT, Cincotta R, Gardener G. The Outcome of Isolated Primary Fetal Hydrothorax: A 10-Year Review from a Tertiary Center. Fetal Diagn Ther 2013; 34:69-76. [DOI: 10.1159/000351855] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 04/30/2013] [Indexed: 11/19/2022]
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49
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Gembruch U, Geipel A, Müller A, Bartmann P, Berg C. Intrauterine minimalinvasive Therapie. Monatsschr Kinderheilkd 2012. [DOI: 10.1007/s00112-012-2729-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ruano R, Ramalho AS, de Freitas RCM, Campos JADB, Lee W, Zugaib M. Three-dimensional ultrasonographic assessment of fetal total lung volume as a prognostic factor in primary pleural effusion. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2012; 31:1731-1739. [PMID: 23091243 DOI: 10.7863/jum.2012.31.11.1731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES The purpose of this study was to predict perinatal outcomes using fetal total lung volumes assessed by 3-dimensional ultrasonography (3DUS) in primary pleural effusion. METHODS Between July 2005 and July 2010, total lung volumes were prospectively estimated in fetuses with primary pleural effusion by 3DUS using virtual organ computer-aided analysis software. The first and last US examinations were considered in the analysis. The observed/expected total lung volumes were calculated. Main outcomes were perinatal death (up to 28 days of life) and respiratory morbidity (orotracheal intubation with mechanical respiratory support >48 hours). RESULTS Twelve of 19 fetuses (63.2%) survived. Among the survivors, 7 (58.3%) had severe respiratory morbidity. The observed/expected total lung volume at the last US examination before birth was significantly associated with perinatal death (P < .01) and respiratory morbidity (P < .01) as well as fetal hydrops (P < .01) and bilateral effusion (P = .01). CONCLUSIONS Fetal total lung volumes may be useful for the prediction of perinatal outcomes in primary pleural effusion.
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Affiliation(s)
- Rodrigo Ruano
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universidade de São Paulo, 255 Avenida Dr Enéias de Carvalho Aguiar, 10° Andar, 05403-900 São Paulo-SP, Brazil.
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