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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Isolated unilateral severe fetal hydrothorax: spontaneous resolution after birth

Hydrothorax is the accumulation of fluid in the pleural space. A large fetal pleural effusion (hydrothorax) was identified within the right hemithorax in a 22-year-old woman at 39 weeks of gestation. Because the fetal hydrothorax was detected at 39 weeks of gestation, we did not perform any intervention antenatally. A male fetus was delivered by an elective cesarean section at 39 weeks of gestation. He did not require intubation, ventilation or resuscitation in the operating room, and had a good health status. The baby was followed-up in the neonatal intensive care unit. Six days after the birth, the pleural effusion (hydrothorax) was completely resolved spontaneously. Conservative management may be regarded as an option for isolated fetal hydrothorax in uncomplicated, stable cases without hydrops.

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

BACKGROUND

Primary hydrothorax is a congenital anomaly affecting 1 in 10,000-15,000 pregnancies. The natural history of this condition is variable with some fetuses having spontaneous resolution and others showing progression. The associated pulmonary hypoplasia leads to increased perinatal morbidity and mortality. Optimal prenatal intervention remains controversial.

METHODS

After obtaining the Institutional Review Board approval, a retrospective review of all patients evaluated for a fetal pleural effusion in the Fetal Diagnosis and Treatment Center at The University of Michigan, between 2006 and 2016 was performed. Cases with secondary etiologies for an effusion or when families decided to pursue elective termination were excluded.

RESULTS

Pleural effusions were identified in 175 patients. Primary hydrothorax was diagnosed in 15 patients (8%). The effusions were bilateral in 13/15 cases (86%) and 10/15 (66%) had hydrops at presentation. All 15 patients with primary hydrothorax underwent prenatal intervention. Thoracentesis was performed in 14/15 cases (93%). Shunt placement was performed in 10/15 cases (66%). Shunt migration was seen in four patients (40%) and all of these underwent prenatal shunt replacement. Overall survival was 76%. The rates of prematurity and preterm premature rupture of membranes were 69% and 35%, respectively.

CONCLUSIONS

Fetal intervention for the treatment of primary hydrothorax is effective, and it appears to confer a survival advantage. Both the fetuses and the mothers tolerated the procedures well. Preterm labor and preterm premature rupture of membranes remain an unsolved problem. Further studies are needed to understand the mechanisms behind the development of fetal hydrothorax.

Fetal pleural effusion and Down syndrome

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.

Iatrogenic Congenital Diaphragmatic Hernia following Prenatal Pleuroamniotic Shunting

We report a case of an iatrogenic congenital diaphragmatic hernia (CDH) following left pleuroamniotic shunting at 20 weeks gestation for severe left pleural effusion. The infant developed respiratory difficulty after birth and was diagnosed with left CDH on imaging with the intraoperative findings confirming the hernia to be at an unusual site and likely secondary to the shunting.

Mid-term follow-up of neonatal pleural effusion

OBJECTIVES

To investigate the clinical course and mid-term prognosis of neonates admitted with pleural effusion.

METHODS

Case records of 38 neonates admitted with pleural effusion were retrieved and analyzed.

RESULTS

16 (42%) patients had congenital and 22 (58%) patients had acquired causes of pleural effusion. The most common causes of congenital pleural effusion and acquired pleural effusion were chylothorax (18%) and congestive heart failure (13%), respectively. Poorer outcome was observed with fetal hydrops, preterm birth (<34 weeks) and associated defects.

CONCLUSION

Most of the neonates with pleural effusion have good outcome in the mid-term follow-up.