Non-immunologic hydrops fetalis: a review of 27 cases

Myogenic tumors in children and adolescents

Neoplasms of striated and smooth muscle in children are a diverse group of neoplasms that have some unique aspects in contrast to these tumors in adults. Rhabdomyosarcoma is the most common soft tissue sarcoma of infancy and childhood and is relatively common in adolescents. In contrast, smooth muscle tumors are relatively rare, and the various types of rhabdomyoma and smooth and skeletal muscle hamartomas are very uncommon. In recent years, the understanding of the pathologic and genetic aspects of rhabdomyosarcoma has been enhanced by adjunct techniques, such as immunohistochemistry and cytogenetic or molecular genetic analysis. The current classification of rhabdomyosarcoma emphasizes the histologic-prognostic correlations. This article reviews the clinicopathologic features of striated and smooth muscle tumors with an emphasis on the unique aspects of these neoplasms in children and adolescents and the differential diagnosis.

Nonimmune hydrops fetalis part I: etiology and pathophysiology

Nonimmune hydrops fetalis (NIHF) is a condition in which excess fluid has accumulated in the fetal interstitial spaces as a result of one or more nonimmune factors. A plethora of maternal, placental, and fetal disease processes have been associated with NIHF. Knowledge of the various etiologies of NIHF and how the disease process affects fluid homeostasis is important for planning patient care and counseling families of patients diagnosed with nonimmune hydrops fetalis. This article discusses the mechanisms governing fluid distribution in the extracellular spaces, examines the various etiologies associated with NIHF, and describes the pathogenesis of NIHF for each etiologic category.

Nonimmune hydrops fetalis part II: does etiology influence mortality?

Hydrops fetalis is a condition in which there is an excess of total body fluid, primarily within the fetal interstitial spaces. Etymologically, hydrops fetalis is a Latin term meaning "edema of the fetus." In addition to generalized edema, the fetus has at least one of the following: ascites, pericardial effusion, pleural effusion(s), and an abnormally thick (>6 cm) placenta. Hydrops is classified as nonimmune hydrops fetalis (NIHF) when it occurs without evidence of isoimmunization.

Mutations and polymorphisms of the gene of the major human blood protein, serum albumin

We have tabulated the 77 currently known mutations of the familiar human blood protein, serum albumin (ALB). A total of 65 mutations result in bisalbuminemia. Physiological and structural effects of these mutations are included where observed. Most of the changes are benign. The majority of them were detected upon clinical electrophoretic studies, as a result of a point mutation of a charged amino acid residue. Three were discovered by their strong binding of thyroxine or triiodothyronine. A total of 12 of the tabulated mutations result in analbuminemia, defined as a serum albumin concentration of <1 g/L. These were generally detected upon finding a low albumin concentration in patients with mild edema, and involve either splicing errors negating translation or premature stop codons producing truncated albumin molecules. A total of nine mutations, five of those with analbuminemia and four resulting in variants modified near the C-terminal end, cause frameshifts. Allotypes from three of the point mutations become N-glycosylated and one C-terminal frameshift mutation shows O-glycosylation.

Severity of Non-Immune Hydrops Fetalis at Birth Continues to Predict Survival despite Advances in Perinatal Care

OBJECTIVES

To describe the aetiology and short-term outcome of live-born infants with non-immune hydrops fetalis (NIH), to identify predictors of mortality and to establish whether there has been any change in mortality over a 14-year period.

METHODS

A retrospective case note review of all liveborn neonates with NIH.

RESULTS

30 infants were identified. Twenty (66%) had an identifiable aetiology. Ten (33%) survived to discharge. Survivors had significantly higher Apgar scores at 1 and 5 min (both p<0.001). Mortality did not differ between the time periods 1990-1999 and 2000-2004.

CONCLUSIONS

NIH continues to be associated with a significant mortality despite advances in perinatal care. Poor condition at birth is a strong predictor of death.

Spontaneous antenatal resolution of canine hydrops fetalis diagnosed by ultrasound

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

Fetal and neonatal cardiac tumors

Primary tumors of the heart are uncommon in the fetus and neonate. Nevertheless, the widespread use of new imaging techniques has contributed significantly to earlier diagnosis, treatment, and thus improved survival. The clinical findings, imaging studies, pathology, and outcome of 224 fetuses and neonates with cardiac tumors collected from the literature are evaluated and discussed. Most tumors are benign, and of these rhabdomyoma is the most common, followed by teratoma, fibroma, oncocytic cardiomyopathy, vascular tumors, and myxoma. Malignant and metastatic tumors are described but are rare. Murmurs, arrhythmias, cyanosis, respiratory distress, and cardiac failure are the main presenting signs of cardiac tumors in the perinatal period. Disturbances in hemodynamic function are correlated with the size and location of the tumor. Cardiac vascular tumors have the best outcome, whereas malignant tumors have the worst. The purpose of this review is to concentrate on the fetus and neonate in an attempt to determine the various ways cardiac tumors differ clinically and morphologically in this age group from those occurring in older children and adults and to show that certain types of tumors have a better prognosis than others.

Left ventricular outflow obstruction in rhabdomyoma of infancy: meta-analysis of the literature

Primary heart tumors are exceptional in infants and children. Most common is the rhabdomyoma, often associated with tuberous sclerosis (Bourneville's disease). This tumor is generally believed to have no hemodynamic effects in the majority of cases. Recently, severe obstruction of the left ventricular outflow tract by a solitary tumor was diagnosed during pregnancy and emergency surgery was needed soon after birth.

Transplacental treatment of fetal tachycardia: implications of drug transporting proteins in placenta

Sustained fetal tachyarrhythmia (> 180 bpm) is a potentially life-threatening condition for the unborn. Digoxin is commonly used as an initial monotherapy. Flecainide, sotalol, and verapamil are also used as a monotherapy or a combination therapy with digoxin. The treatment success rate with digoxin is about 50%. Presence of hydrops is associated with poor placental transfer of digoxin. Although transplacental pharmacotherapy has been available, it is a challenging task to maximize fetal drug exposure, while minimizing drug exposure of the mother. In addition, clear evidence behind drug of choice and treatment algorithm is lacking. Whereas prospective clinical studies with rigorous design remain to be seen, our knowledge on placental drug transport at a molecular level has been steadily increasing. For example, an ATP-dependent membrane protein, known as P-glycoprotein, is expressed in placenta, decreasing fetal exposure to maternal digoxin. Pharmacological manipulation of drug transporters may open a door to ultimate optimization of the transplacental pharmacotherapy.

Broadsheet number 56: Mechanisms of fetal loss

The most significant task of the pathologist examining a fetal death is, if possible, the provision of an explanation for the event, which will allow the clinical attendants to counsel the family in an informed and relevant manner. In some cases, no adequate explanation will be possible, though many conditions will be excluded and the importance of this exercise is worth emphasising. Often, however, a combination of fetal, maternal or placental conditions can be found and a full or partial explanation offered, and it is the purpose of this broadsheet to highlight some of these conditions and provide suggestions as to sources of further practical help.

The delivery room resuscitation of the hydropic neonate

Hydrops fetalis is a relatively rare disorder that will be encountered occasionally in all obstetric centers. The prognosis for infants with hydrops fetalis is poor, with mortality reported in the range of 50% to 98%. The effectiveness of delivery room resuscitation and the ability to achieve early adequate gas exchange in affected infants may be related to survival. Successful resuscitation requires an understanding of transitional neonatal physiology and the potential impact of hydrops fetalis, an experienced and well-prepared resuscitation team, meticulous attention to technical aspects of resuscitation, and careful assessment and monitoring of the infant during resuscitation.

A case of spontaneous resolution of nonimmune hydrops fetalis

Spontaneous intrauterine resolution of severe nonimmune hydrops fetalis has been rarely reported in the literature. A case of severe fetal hemolytic anaemia with hydrops fetalis but subsequent spontaneous resolution is reported along with a discussion of possible aetiologies.

Hydrops fetalis caused by fetal Kasabach-Merritt syndrome

There have been only 2 previous reports of nonimmunologic hydrops fetalis (NIHF) caused by fetal Kasabach-Merritt syndrome, both of which were pathological studies. This is the first clinical case report of NIHF due to fetal Kasabach-Merritt syndrome that was prenatally diagnosed by sonography, computerized tomography, and percutaneous umbilical blood sampling.

Fetal hydrops

Seventy-two fetuses or neonates with non-immune hydrops were examined between 1983 and 1988. The commonest association was chromosome abnormality; 11 fetuses had a 45,X karyotype and 11 autosomal trisomy. Chromosome abnormality was suspected in a further 20 on necropsy findings but chromosome culture was not possible or unsuccessful. In 11 cases there was histological evidence of infection; seven babies had major structural anomalies and six affected fetuses were twins. In six (8%) the cause of hydrops was not determined compared with eight (16%) of cases examined between 1976 and 1982. Hydrops was diagnosed more frequently while the fetus was alive, before 20 weeks' gestation, and associated with chromosome anomaly than found previously.

Cardiac rhabdomyoma. Rare cause of fetal death

Two cases of nonimmune hydrops fetalis and fetal death associated with cardiac rhabdomyoma are reported. Case 1 presented with fetal supraventricular tachycardia, and cardiac rhabdomyoma was accurately diagnosed by fetal echocardiography. Autopsy revealed multiple rhabdomyomata involving the right atrial free wall, the sinoatrial node, and the left ventricle. The left circumflex coronary artery was extrinsically compressed by adjacent tumor tissue, causing left ventricular myocardial infarction. Case 2 had a unique, pedunculated, ball-like rhabdomyoma that almost totally occluded the mitral orifice. The causes of fetal death in patients with cardiac rhabdomyoma are analyzed and the possibility of fetal surgical management is proposed.

Nonimmunologic hydrops fetalis: an etiopathogenetic approach through the postmortem study of 59 patients

Aiming at increasing our understanding of the various causative factors of nonimmunologic hydrops fetalis (NIHF) and their pathogenetic mechanisms, we have reviewed 59 cases of this condition from a total number of 4,175 pediatric post-mortem studies performed at the Department of Pathology of the Hospital La Paz from 1967 to 1987. We found eight cases (13.5%) without clinical, biochemical, or post-mortem findings justifying the development of hydrops fetalis, seven cases (12%) associated with certain pathologic findings that by themselves do not explain the development of hydrops and, finally, 44 cases (74.5%) in whom pathological findings may explain the development of the condition. Notwithstanding the etiological diversity of this last group, in 31 of these cases (70%), some common pathogenetic features may be recognized, basically a failure of the right ventricle of the heart in the fetus or newborn, due to a primary heart condition, to intracardiac tumors, or to obstructive phenomena at the level of the right venous drainage. In our opinion, whenever NIHF is diagnosed or suspected, causes of right cardiovascular failure should be investigated, since about 50% of all cases seem to be due to this pathogenetic mechanism.

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

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

Hydrops fetalis due to abnormal lymphatics

A case of generalised lymphatic abnormality that presented with hydrops fetalis is described. This seems to be the first such case reported.

Intrauterine supraventricular tachyarrhythmias and transplacental digitalisation

Six newborn infants with intrauterine supraventricular tachyarrhythmias (five cases of atrial flutter and one of supraventricular tachycardia) are described. Transplacental digitalisation was attempted in three cases. Supraventricular tachycardia associated with hydrops fetalis, detected in a fetus at a gestation of 31 weeks, was successfully converted to normal sinus rhythm eight days after the mother began treatment with digoxin. The serum concentration of digoxin in cord blood almost equalled the maternal concentration in three cases. In the remaining three cases treatment with digitalis was effective in converting tachyarrhythmias to sinus rhythm after delivery. With maintenance digoxin therapy, the prognosis of fetal tachyarrhythmias seems to be good, once conversion to sinus rhythm has been accomplished.

The obstetric management of non-immunological hydrops

During the past 8 years, non-Rhesus hydrops has been observed in 31 pregnancies extending beyond 28 weeks gestation. Only three of the babies survived. Antenatal diagnosis is possible by ultrasound examination and although 27 of our patients had at least one indication for this procedure, only 22 were so investigated and in 13, fetal hydrops was demonstrated. Twenty-three were delivered before 36 weeks gestation, 10 by caesarean section of whom none survived; 16 babies were stillborn. Fourteen infants had major cardiovascular anomalies and six had other major malformations. In five infants, infection was thought to be causally related to fetal hydrops and in only four could no cause for the hydrops be found. In five pregnancies the cause of hydrops was discovered antenatally; this influenced subsequent management and two of the five survived. The unexpected appearance of a very abnormal fetal heart rate pattern requires the exclusion of fetal anomaly and non-immunological hydrops. When a diagnosis of non-immune hydrops is made its underlying cause should be sought without delay so that specific treatment may be instituted in the few cases where this is appropriate. A high incidence of complications of the third stage of labour should be anticipated. Subsequent pregnancies are likely to be normal.

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

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

Cardiac rhabdomyoma presenting as fetal hydrops

Fetal hydrops and possible congenital heart disease with atrioventricular block was diagnosed one day before birth in a male infant of 35 weeks' gestation. Echocardiography and angiocardiography soon after birth revealed a cardiac tumor. The child died three days after birth. Necropsy showed tuberous sclerosis involving the heart (type-I rhabdomyoma), kidneys, retina, and central nervous system.