Outcomes of fetuses with primary hydrothorax that undergo prenatal intervention (prenatal intervention for hydrothorax)

Management dilemma in Thoracoamniotic Shunt Migrations

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.

Clinical features and outcomes of congenital chylothorax: a single tertiary medical center experience in China

Objective

Congenital chylothorax (CC) is an uncommon congenital disease. The objective of this study was to analyze the clinical features, treatment, and outcome of infants with CC in a Chinese tertiary medical center.

Methods

CC was defined as a non-traumatic pleural effusion with ≥ 80% lymphocytes detected before birth or within 28 days after birth. Clinical data were collected in CC infants discharged from June 2017 to March 2021.

Results

A total of 24 CC infants were discharged during the study period, accounting for 67% of congenital pleural effusions. The median gestational age at birth was 36⁺⁴ weeks (range 29⁺⁵–41 weeks) and the birth weight was 3025 g (range 1850–4250 g). Twenty-one infants were diagnosed antenatally. The median gestational age at the time of diagnosis was 30⁺³ weeks (range 24–36⁺⁶ weeks). Nine infants presented with hydrops fetalis; 18 were bilateral. Prenatal interventions were performed in 13 fetuses. Nine infants (38%) had birth asphyxia. Compared with the infants without hydrops fetalis, the infants with CC and hydrops fetalis had lower Apgar scores at 1 and 5 min (P < 0.05) and a lower gestational age at birth (P < 0.05). Postnatally, 17 infants required continuous pleural drainage for 10 days (range 2–30 days). Analysis of the pleural effusion showed a higher cell count, lymphocyte fraction, and protein content after enteral feeding (P < 0.05). Fifteen infants required mechanical ventilation; 9 did not require any respiratory support. Ten infants received a delayed feeding strategy and 17 received a medium-chain triglyceride (MCT) formula. Only 1 infant received octreotide therapy. Twenty-one infants survived and 3 died. The main cause of death was pulmonary dysplasia. The duration of hospital stay in survivors was 21.5 days (range 10–43) days. For infants with CC and hydrops fetalis, prenatal therapy shortened the duration of pleural drainage and the length of hospital stay (P < 0.05).

Conclusion

CC is the most common cause of congenital pleural effusions. The poor prognosis is mainly associated with prematurity, hydrops fetalis, and pulmonary dysplasia. Prenatal intervention may improve the outcome of infants with hydrops fetalis.

Lymphatic anomalies in congenital heart disease

Congenital heart disease can lead to various lymphatic complications including traumatic leaks, lymphatic overproduction, conduction abnormalities or lymphedema. Advancements in the imaging of central lymphatics and guided interventions have improved outcomes in these children. Dynamic contrast-enhanced magnetic resonance (MR) lymphangiography allows for the assessment of abnormal lymphatic drainage. This technique is preferred for evaluating lymphatic conditions such as plastic bronchitis, chylothorax, chyloptysis, chylopericardium, protein-losing enteropathy and chylous ascites, among other lymphatic disorders. In this review, we discuss lymphatic abnormalities encountered on MRI in children with congenital heart disease. We also briefly review treatment options.

Imaging of fetal lymphangiectasias: prenatal and postnatal imaging findings

Lymphangiectasias are lymphatic malformations characterized by the abnormal dilation and morphology of the lymphatic channels. The classification and treatment of these disorders can be challenging given the limited amount of literature available in children. Various imaging modalities are used to confirm suspected diagnosis, plan the most appropriate treatment, and estimate a prognosis. Prenatal evaluation is performed using both prenatal US imaging and fetal MRI. These modalities are paramount for appropriate parental counseling and planning of perinatal care. During the neonatal period, chest US imaging is a useful modality to evaluate pulmonary lymphangiectasia because other modalities such as conventional radiography and CT display nonspecific findings. Finally, the recent breakthroughs in lymphatic imaging with MRI have allowed us to better classify lymphatic disorders. Dynamic contrast-enhanced lymphangiography, conventional lymphangiography and percutaneous lymphatic procedures offer static and dynamic evaluation of the central conducting lymphatics in children, with excellent spatial resolution and the possibility to provide treatment. The purpose of this review is to discuss the normal and abnormal development of the fetal lymphatic system and how to best depict it by imaging during the prenatal and postnatal life.

In utero congenital chylothorax treatment with fetal thoracoamniotic shunt: Case report

BACKGROUND

Fetal pleural effusions are a rare fetal anomaly that may result from congenital chylothorax. Severe cases lead to chest compression with resulting pulmonary hypoplasia and possible neonatal demise. Fetal thoracoamiontic shunt (TAS) placement may decrease the amount of pleural effusion and improve lung expansion.

CASE

A 30-year-old primigravida at 29 2/7 weeks' gestation presented with fetal bilateral pleural effusions with no identifiable genetic or structural abnormalities. TAS placement accomplished decompression of the left fetal chest. The neonate was delivered at 33 3/7 weeks and required minimal respiratory support with no apparent long term complications at discharge.

CONCLUSION

This case demonstrated that fetal intervention with TAS placement can improve neonatal outcomes. Referral to an MFM specialist capable of TAS should be considered for isolated fetal bilateral pleural effusion.

Determination of the cytokine levels in fetal pleural effusion and their association with fetal/neonatal findings

OBJECTIVES

Few studies have investigated the distribution of multiple cytokines in fetal pleural effusion, and its clinical implications are uncertain. This study aimed to determine cytokine levels in fetal pleural effusion and their clinical role in affected fetuses.

METHODS

We obtained fetal pleural fluid samples from 18 infants and investigated the profiles of 40 cytokines using multiplex immunoassay. Relationships among cytokines were estimated by Spearman correlation analysis. Possible associations of cytokine levels with fetal adverse outcomes, including perinatal demise and neurodevelopmental impairment, were studied using univariate logistic regression analysis.

RESULTS

Several pro-inflammatory cytokines and CCL chemokines were highly correlated with each other. In contrast, CXCL chemokines had relatively weak correlations with other cytokines. The levels of IL-1β, IL-2, and CCL20 were significantly associated with the occurrence of fetal adverse outcomes. Based on our findings, IL-1β had the strongest causal link to adverse outcomes among the cytokines [odds ratio (OR): 19.74; 95% confidence interval (CI): 1.14-341.9; p = 0.040].

CONCLUSIONS

Cytokine levels in fetal pleural effusion varied considerably among cases with or without adverse outcomes. These results provide important information for further clarifying the pathophysiology of fetal pleural effusion and a novel clinical implication that could predict the occurrence of adverse outcomes.

Primary fetal pleural effusion: Characteristics, outcomes, and the role of intervention

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.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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