A case of refractory hepatic hydrothorax due to pleuroperitoneal communication successfully controlled by diaphragmatic plication and subsequent peritoneovenous shunting

In general, control of hepatic hydrothorax is difficult, and patients have a poor prognosis. A case in which hepatic hydrothorax was well controlled for a long time after diaphragm plication and subsequent Denver shunt placement is reported. A 70-year-old man with decompensated liver cirrhosis presented with progressive exertional dyspnea. 5 years before admission, hepatic ascites associated with portal hypertension appeared, and a left pleural effusion subsequently developed. The pleural effusion was not controlled by salt restriction and diuretics. Based on the clinical findings, the existence of pleuroperitoneal communication was strongly suspected, and surgical diaphragmatic plication was performed. After the treatment, the pleural effusion did not accumulate, but ascites increased significantly, and conservative therapy was ineffective. For the treatment of massive ascites, a peritoneovenous shunt (Denver shunt®) was placed. Although more than 2 years have passed, the thoracoabdominal effusions have not accumulated, and the patient has been asymptomatic. The present case suggests that multidisciplinary treatment may improve the prognosis of patients with refractory thoracoabdominal effusions.

Left hepatic hydrothorax without ascites

Hepatic hydrothorax (HH) is a complication in patients with cirrhosis and portal hypertension. It predominantly presents in the right pleural cavity and usually associates with ascites. Few cases of HH occurring without detectable ascites have been reported. This case report comprehensively presents a case of a refractory left unilateral HH without ascites. The patient benefited from palliative care and the HH was managed using a semipermanent indwelling pleural catheter until she died 3 months after diagnosis.

A Case Report of Tension Hydrothorax Incited by Bowel Perforation

We report the case of a 34-year-old man who developed cardiac arrest due to tension hydrothorax from colonic perforation. Tension hydrothorax, an entity characterized by pleural effusion leading to mediastinal compression, has not been reported in association with intraabdominal inflammation. Our patient developed respiratory insufficiency after repair of colonic perforation, followed by respiratory failure and cardiac arrest. Transthoracic echocardiography provided rapid diagnosis during decompensation and prompted a lifesaving thoracostomy. Clinicians should consider tension hydrothorax as a rare cause of hemodynamic collapse, even in the absence of liver failure, and use bedside tools like transthoracic echocardiography to facilitate diagnosis and intervention.

Hydrothorax and air fluid levels in the right chest - a diagnostic dilemma

SUMMARY

A diaphragmatic defect that permits abdominal contents to herniate into the right side of the chest is rare. In adults with right-sided diaphragmatic hernias, few occur without a history of trauma, and even fewer are symptomatic. This case report illustrates such a case and the rare entity of an anterolaterally located hernia. Although uncommon and easily missed, consequences of diaphragmatic hernias can be disastrous. The importance of a combination of high clinical suspicion and the use of computed tomography (CT) to aid diagnosis, and the dangers of a surgical condition being incorrectly assessed and admitted to a non-surgical specialty are highlighted in this case.

A rare coincidence of a chylothorax and a hydrothorax caused by gastric adenocarcinoma - a case report

We present a case report of a 74-years old patient with a finding of bilateral pleural effusion due to a different fluid composition caused by gastric adenocarcinoma. The finding of a bilateral effusion, where the exudate fluid is of a different chemical composition, is a rare phenomenon. While the right-sided exudate had the characteristics of hydrothorax, the left-sided exudate had those of chylothorax. The initial suspicion of a lung tumor was not confirmed, and further examination surprisingly revealed gastric adenocarcinoma. The patient did not benefit from targeted oncological treatment for a long time and the chemotherapy was terminated after 3 cycles. The cause of right-sided hydrothorax is therefore attributed to hypalbuminemia and secondary pneumonia, left-sided chylothorax was a primo-manifestation of gastric adenocarcinoma. There is only a small number of similar case reports of patients with gastric tumor and chylothorax in the literature. While the recorded cases were mostly Asian ethnic patients, the course of their illness - including survival - was almost strikingly similar (and unfavorable).

Scintigraphic findings in end-stage liver disease on Tc-99m sestamibi SPECT/CT myocardial perfusion imaging

Technetium-99m sestamibi myocardial perfusion imaging is commonly employed non-invasive study for evaluation of coronary artery disease; however, incidental extracardiac scintigraphic findings observed may provide additional diagnostic information. The authors present the unusual scintigraphic findings in a case of decompensated liver disease with right hepatic hydrothorax, being planned for orthotopic liver transplant.

Hydrothorax, ascites and an abdominal mass: not always signs of a malignancy - Three cases of Meigs' syndrome

This case report presents three cases of Meigs' syndrome: a benign ovarian tumor with ascites and a hydrothorax. After removal of the ovarian tumor, the symptoms resolved and the patients became asymptomatic. In daily practice, Meigs' syndrome is at first sight often mistaken for ovarian cancer. With this case report we would like to emphasize that the clinical presentation of an ovarian tumor might be ovarian cancer, but can masquerade as something uncommon like Meigs' syndrome. In a time span of two years we encountered three cases.

Advanced gastrointestinal carcinoma with massive ascites and hydrothorax during pregnancy: A case report and review of the literature

RATIONALE

Gastrointestinal carcinoma is rare during pregnancy. It is usually diagnosed at an advanced stage because special gastrointestinal symptoms are generally overlooked during pregnancy, and there are many limitations and contraindications for using diagnostic tools during pregnancy.

PATIENT CONCERNS

We present a case of a 29-year-old patient with 27 weeks and 5 days of gestation due to massive ascites and hydrothorax.

DIAGNOSES

The patient was diagnosed with an advanced gastrointestinal cancer. Pathological report showed poorly differentiated tumor with the signet ring cell component.

INTERVENTIONS

Caesarean section was performed. At the same time, an abdominal exploration showed that the omentum was like biscuits . There were extensive and firm intestinal adhesions, and many tumor lesions were found on the surface of greater curvature of stomach, spleen, intestine, peritoneum, ascending colon and descending colon.

OUTCOMES

Gastrointestinal surgeon was invited during operation, and palliative gastrectomy was not performed because of extensive metastases. The patient died 30 days after caesarean section.

LESSONS

This study present a case with advanced gastrointestinal cancer during pregnancy. We suggest that endoscopic exam is recommended if the patient is highly suspicious.

Pleural Effusion Developing in Two Patients on Continuous Ambulatory Peritoneal Dialysis

Two patients with end-stage-renal-disease on continuous ambulatory peritoneal dialysis (CAPD) presented with pleural effusions. The aspirated fluid was categorised as transudate, based on alkaline pH, low protein and lactic dehydrogenase level. A striking feature of the pleural fluid was, its very high glucose content that resulted from translocation of dextrose containing peritoneal dialysate into the pleural space via a pleuroperitoneal connection. One patient was transferred to hemodialysis, which led to complete resolution of pleural effusion. The other patient was switched to automated peritoneal dialysis, using small dwell volumes with consequent reduction in size of the pleural effusion. Pleuroperitoneal leak should always be considered in the differential diagnosis of pleural effusion in CAPD patients. Although isotopic peritoneography can demonstrate reflux of the tracer in the pleural space, measurement of pleural fluid glucose is a simpler and reliable way of diagnosing pleuroperitoneal communication.

[DIFFERENTIATED TACTICS OF VIDEOTHORACOSCOPIC DIAGNOSIS OF THE PLEURAL EXUDATE SYNDROME]

Differentiated tactics of diagnostic videothoracoscopy (VTHS) in a pleural exudate syndrome, which ought to be treated with hydrothorax elimination and artificial pneumothorax creation, was proposed. Further roentgenological investigation permits to create a plan for the operation conduction and a certain anesthesia application. Criteria for the operation planning and the anesthesiological support choice were elaborated. Results of VTHS conduction in 261 patients in Department of Thoracic Surgery were analyzed. The differentiated tactics for the VTHS performance application have had saved the patients from the unnecessary endotracheal narcosis conduction, and reduced a pharmacological load on a patient, as well as a rate of contraindications for the operation usage and the stationary treatment duration.

[Aspiration of blood does not verify intravenous location of central venous catheters]

This case which involves a misplaced central venous catheter demonstrates the importance of certain recognition of intravenous placement before the administration of fluids and medicine.

Desmoid tumor of lung with pleural involvement - the case of unique location of aggressive fibromatosis

Desmoid tumors (DTs) are rare mesenchymal neoplasms with unpredictable natural history. There is a high risk of recurrence despite adequate surgical resection, however DTs do not have the capacity to metastasize. The estimated incidence in general population is 2-4 cases/million/year. They may occur at any age but most commonly in the third and fourth decades. Both sexes may be affected, but there is a slight female predominance. DTs can occur at any body site. The exact etiology remains unclear, but trauma, hormonal disturbances, pregnancy, genetic and hereditary factors are postulated to be in association with its' development. Potential to attain large size, infiltration and destruction of adjacent vital structures and tendency to recur are main management problems and important causes of morbidity and mortality. Wide excision is standard first-line treatment of primary or recurrent symptomatic desmoids. We present case of 33-years-old Caucasian female patient admitted to hospital with 2 months history of squeezing pain in right upper quadrant which appeared after meals. The patient was in general good condition. There were no abnormalities on basic laboratory tests on admission. CT of chest revealed hydrothorax to the level of the apex of the right lung and tumor sized 7 × 13 × 13 cm located in the lower lobe of right lung. Histopathological diagnosis of desmoid tumor of right lung was formulated. We report, to our knowledge for the first time in Poland, case of aggressive fibromatosis of lung with invasion of pleura.

Bronchopulmonary sequestration with massive pleural effusion: pleuroamniotic shunting vs intrafetal vascular laser ablation

OBJECTIVE

To assess the incidence of complications among a relatively large cohort of fetuses with bronchopulmonary sequestration (BPS) and the success of two different intrauterine treatment modalities.

METHODS

All cases with a prenatal diagnosis of BPS detected in a 10-year period (2002-2011) in two tertiary referral centers were reviewed retrospectively for intrauterine course and outcome. Up to May 2010 severe pleural effusions were treated with pleuroamniotic shunting. Thereafter, they were treated with ultrasound-guided laser coagulation of the feeding artery.

RESULTS

A total of 41 fetuses with BPS were included in the study. In 29 (70.7%) there was no pleural effusion or hydrops and they were treated conservatively. In 19/29 (65.5%) there was partial or complete regression of the lesion during the course of pregnancy. All were born alive (median age at delivery, 38.3 (interquartile range (IQR), 34.0-39.6) weeks) and 16 (55.2%) required sequestrectomy. Intrauterine intervention was performed in all 12 (29.3%) fetuses with pleural effusion. Seven fetuses were treated with pleuroamniotic shunting. One fetus with severe hydrops died in utero. There was no complete regression in any case of BPS in this group. Six infants were born alive (median age, 37.2 (IQR, 30.3-37.4) weeks), of which five (83.3%) required sequestrectomy. Five fetuses were treated with laser ablation of the feeding vessel. In all cases of BPS there was regression after laser ablation. All infants were delivered at term (median age, 39.1 (IQR, 38.0-40.0) weeks). One (20.0%) neonate required sequestrectomy after birth. Following intrauterine shunt placement complete regression of the lesion was significantly less frequent (0/7 (0%) with shunt placement vs 4/5 (80%) with intrafetal laser treatment) and gestational age at birth was significantly lower, compared to treatment with intrafetal laser. Complete regression of the lesion was also significantly more frequent in the laser group compared to cases without intervention.

CONCLUSION

In the absence of pleural effusion, the likelihood of spontaneous regression of BPS is high and the prognosis is therefore favorable. In cases with massive pleural effusion, treatment by laser ablation of the feeding vessel seems to be more effective than is pleuroamniotic shunting, with fewer complications. It might also reduce the need for postnatal surgery.

Right internal jugular venous cannulation complicated by tension hydrothorax

Central Venous Catheter (CVC) is a common procedure performed in patients' management, especially the critically ill ones. CVC has been used as main access in patients requiring large amount of fluid resuscitation, total parenteral nutrition or measuring the central venous pressure. Although most complications associated with central venous cannulation are minimal, local and easy to control, others may be critical and rapidly fatal if not recognized and treated immediately. One of the most serious incidents that can occur post CVC placement is delayed hydrothorax. It usually results from migration and perforation of the catheter through the SVC wall. In this report, we describe a case of tension hydrothorax that occurred a few hours after placement of CVC in the right internal jugular vein. In acutely ill patients that are already unstable, making the diagnosis of tension hydrothorax secondary to CVC placement requires high level of suspicion. Prompt pleural effusion drainage like in our case is crucial for favorable outcome.

Isolated bilateral severe fetal hydrothorax: complete resolution following a single postnatal thoracocentesis

Isolated pleural effusion is a rare condition in a fetus or neonate with high mortality. When there are no other findings of hydrops fetalis or documented etiology such as inflammatory, iatrogenic or cardiac problems exist, isolated pleural effusion is considered. Timely diagnosis and management not only avoids mortality but also results in excellent prognosis. For fetal hydrothorax, intrauterine management is usually recommended. For those who present late, postnatal management includes intubation, thoracocentesis, ventilation and supportive care. The authors present isolated bilateral severe hydrothorax in a preterm neonate that resulted in severe respiratory compromise at birth. A single postnatal thoracocentesis resulted in complete resolution. No definite etiology for hydrothorax could be established. He had normal growth and development during his follow up till 1 year of age.

Fetal lung volume measurements using 3D ultrasonography

PURPOSE

The aim of the study was to establish fetal lung, thoracic and heart volume nomograms using three-dimensional (3D) ultrasonographic measurements.

MATERIALS AND METHODS

For this purpose a total of 300 fetuses were examined between 18 and 34 weeks of gestation using Voluson 530 ME and Voluson 730 PRO (General Electic, USA) ultrasound devices with 5 MHz three-dimensional annular volume transducers. To determine fetal lung volume, each lung was measured separately using a transversal sectional plane in the multiplanar mode. Measurements were performed by area tracing around the fetal lung in cross-sectional planes in different slices. The distance between two represented slices was calculated by computer. Calculated volume data was plotted against gestational age in order to obtain nomograms of fetal lung, heart and thorax volumes.

RESULTS

Our nomograms revealed increasing lung, heart and thoracic volume growth between 22 and 34 weeks of gestation. Furthermore, we could demonstrate that there is a statistically significant difference between the growth of the right and left lung volume (right > left). In a group of 12 fetuses with skeletal dysplasias or hydrothorax pulmonary hypoplasia was suspected by ultrasound. Comparing two-dimensional (2D) sonographic measurements of oblique lung diameter and 3D lung volumetry, it was found that these two methods were complementary for the recognition of pulmonary hypoplasia before the 24 weeks of gestation.

CONCLUSION

Using 3D ultrasound it is easy to perform fetal lung volumetry especially before 30 weeks of gestation. The encouraging results suggest that this method could be useful for the early detection of pulmonary hypoplasia even before 24 weeks of gestation.

[Pleuroperitoneal communication in patients on peritoneal dialysis. One hospital's experience and a review of the literature]

Peritoneal dialysis is a treatment alternative in patients with advanced chronic kidney disease. The infusion of liquid into the peritoneal cavity leads to an increase in intra-abdominal pressure, which can sometimes produce leaks to the chest, giving rise to pleuroperitoneal communication. This is not a common complication, but it brings about high drop-out rates among patients using the technique. Diagnosis is easy and must be suspected in patients with sudden dyspnoea with low ultrafiltration and pleural effusion in the chest x-ray. Peritoneal rest and a temporary transfer to haemodialysis, and pleurodesis can be effective treatment strategies.

A rare case of congenital pulmonary lymphangiectasia, hydrothorax and ascites in a male embryo aborted at 20 weeks of gestation

A case of a male embryo aborted at the 20th week of gestation with extensive ascites, hydrothorax, pulmonary lymphangiectasia and pulmonary hypoplasia is presented together with the pathological findings, the etiology, differential diagnosis, course and therapy of this pathologic entity. Also a short review of the literature is discussed.

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

OBJECTIVE

To develop an in-utero stent placement training model.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Single-needle laser treatment with drainage of hydrothorax in fetal bronchopulmonary sequestration with hydrops

Bronchopulmonary sequestration (BPS) is sometimes associated with hydrothorax and hydrops in utero. In the absence of fetal hydrops, perinatal outcome is favorable and justifies expectant management. In the presence of fetal hydrops, perinatal outcome is reported to be extremely poor and intervention should be considered. Therapeutic options include open fetal surgery, minimally invasive coagulation of the blood supply and thoracoamniotic shunting. We present the first case of fetal hydrops and a large hydrothorax due to BPS treated successfully with one ultrasound-guided thin needle insertion, through which both laser coagulation of the feeding artery and drainage of the hydrothorax were performed. Following the procedure the hydrothorax and hydrops gradually disappeared and the BPS diminished in size. A healthy neonate was delivered uneventfully at term. We describe the case and discuss the different therapeutic options.

Hydrothorax treated in utero and monitored by fetal echocardiography

Primary fetal hydrothorax is a relatively rare disorder, occurring in 1 out of 15,000 pregnancies, but connected with high perinatal mortality. In the event of little or no progress of the effusion or stable clinical course, conservative management seems to be the most appropriate course of action. In nearly half of the cases, a placement of only one pleuroamniotic shunt enables a total regression of the primary fetal hydrothorax and, consequently, a favourable outcome. The remaining cases require the placement of yet another shunt. In the case of repeated shunt failure, the prognosis is very poor. In the following paper we have presented a fetus with a giant re-accumulating hydrothorax after thoracocentesis, treated by pleuroamniotic shunts and monitored by fetal echocardiography and cardiovascular profile score. Despite dramatic fetal presentation and rapid re-accumulation of the hydrothorax, monitoring by fetal echocardiography and cardiovascular profile score proved the repeated fetal needling and double shunting to be safe. If there are no complications such as premature rupture of the membranes and preterm delivery, fetal echocardiography is a sufficient way of monitoring fetal well-being and the results of intrauterine procedures.

Real-time contrast-enhanced ultrasound--a new simple tool for detection of peritoneal-pleural communications in hepatic hydrothorax

PURPOSE

Hepatic hydrothorax is defined as the accumulation of pleural effusion in a cirrhotic patient in the absence of pulmonary or cardiac disease. Peritoneal fluid can pass into the pleural space through diaphragmatic fenestrations. The demonstration of such passage is important to establish the diagnosis of hepatic hydrothorax and can be achieved by intraperitoneal injection of nuclear contrast agents. Our aim was to evaluate the ability of contrast enhanced ultrasound in the detection of peritoneal-pleural communications.

MATERIALS AND METHODS

Seven patients with cirrhotic ascites and pleural effusion were studied in order to make a diagnosis of hepatic hydrothorax. SonoVue was injected into the peritoneal cavity (9.8 mL), and the peritoneal and pleural cavities were monitored by ultrasound. All patients were then studied using a nuclear scan.

RESULTS

Passage of SonoVue from the peritoneal to the pleural cavities was seen in 5 patients. In 2 patients, no passage of contrast agent was detectable. Nuclear scan was consistent with contrast enhanced ultrasound in all patients.

CONCLUSION

This study shows that the presence of peritoneal-pleural communications can be demonstrated by real time contrast enhanced ultrasound, whose results are comparable to those of nuclear scan. Contrast enhanced ultrasound is cheaper and could theoretically be performed wherever ultrasound facilities are available.

Fetal hydrothorax resolving completely after a single thoracentesis: a report of 2 cases

BACKGROUND

Although fetal hydrothorax is uncommon, perinatal mortality from it is high. The clinical course of fetal hydrothorax is highly variable. Despite some cases of spontaneous resolution, fetal hydrothorax progresses to nonimmune hydrops because of impaired venous return and congestive cardiac failure due to compression in many cases. Although the effect of thoracoamniotic shunting is established, the procedure is invasive and involves some risks.

CASES

Two cases of fetal hydrothorax completely resolved after a single thoracentesis. In the first case, thoracentesis was performed in a fetus with bilateral isolated pleural effusion at the gestational age of 20 weeks. Fetal hydrothorax achieved complete resolution after a single thoracentesis was performed, and the perinatal outcome was good. In the second case, we performed thoracentesis in a fetus with a unilateral pleural effusion and skin edema at the gestational age of 17 weeks. Complete resolution was achieved after a single thoracentesis, and the outcome was uneventful.

CONCLUSION

Thoracentesis is a comparatively simple procedure for mothers and fetuses and should be the first choice for treating fetal hydrothorax.

Isolated severe hydrothorax with respiratory distress as a main manifestation of ovarian hyperstimulation syndrome preceded by respiratory tract infection caused by Haemophilus influenzae

INTRODUCTION

An isolated unilateral pleural effusion as the only presentation of ovarian hyperstimulation syndrome (OHSS) is very rare. This case is an unusual presentation of OHSS after a confirmed respiratory tract infection, with no other coexisting risk factors identified for this syndrome. We also imply that the presence of Haemophilus influenzae in bronchial fluid can increase local reaction to vasoactive cytokines.

CASE REPORT

A 32-year-old woman presented at the Department of Reproductive Medicine and Gynaecology of the Pomeranian Medical University after 10 years of infertility with diagnosed hyperprolactinemia followed by bromocriptine treatment. The patient had three IUIs but no pregnancy was achieved. Therefore, ICSI was proposed. After an ovarian hyperstimulation, oocyte aspiration gave 8 oocytes. Although ICSI was performed in all of the oocytes there were 3 fertilizations. The ET of 3 embryos was carried out following 3 days of culture. Three weeks before the gonadotropin administration and a week before GnRH administration the patient had a respiratory tract infection with the most typical syndromes. The infection was treated successfully with over-the-counter medications and antibiotic. Three days after ET the patient was admitted to the ICU with signs of severe dyspnoea. The chest X-ray showed a large pleural effusion over the right lung. Upon admission, thoracocentesis was preformed and 1600 ml of clear fluid was aspirated. The bronchial aspirate showed evidence of Haemophilus influenzae and leukocytes. After three days of standard treatment the chest X-ray revealed no pathology. The patient was discharged asymptomatic on the 4th day of treatment. Serum beta-hCG level was negative on day 12 after ET.

CONCLUSIONS

This case suggest that respiratory tract infection prior to stimulation may constitute a new independent risk factor for OHSS. However, the true relation between the respiratory tract infection and susceptibility to OHSS still awaits explanation. Recent or existing respiratory tract infection may be a relative contraindication for starting COH.

The use of carbon dioxide wedged hepatic venography to identify the portal vein: comparison with direct catheter portography with iodinated contrast medium and analysis of predictive factors influencing level of opacification

PURPOSE

This study was conducted to assess the value of wedged hepatic venography (WHV) with CO(2) as a contrast agent for identification of the portal venous system in patients with cirrhosis. Additionally, the predictive value of several parameters that potentially influence the level of portal vein opacification by CO(2) WHV was analyzed.

MATERIALS AND METHODS

In 163 patients, CO(2) WHV was performed before transjugular intrahepatic portosystemic shunt creation to opacify and map the portal vein for subsequent targeting by intrahepatic puncture technique. Concordance between CO(2) WHV and direct catheter portography with iodinated contrast medium was assessed by analysis of sensitivity parameters. Additionally, analysis of factors potentially influencing the opacification of the portal vein with use of CO(2) WHV was assessed.

RESULTS

CO(2) WHV was successfully performed in all 163 patients. In three patients (1.8%), CO(2) extravasation was noted, but without any clinical consequence. Sensitivity rates of CO(2) WHV for opacification of the right and left portal veins and the portal main trunk were 93.83% and 68.52%, respectively. Positive predictive factors (P < .05, Wilcoxon two-sample test) were high portosystemic gradient, spontaneous splenorenal shunt, esophageal varices, and reversed portal flow. One negative predictive factor was a patent umbilical vein.

CONCLUSIONS

CO(2) WHV is safe, highly efficient, and reliable in the identification of the right and left portal veins. CO(2) WHV is clearly less effective in opacifying the entire portal main trunk. With use of CO(2) WHV, the portal venous system is most distinctly opacified in patients presenting with a high portosystemic gradient, a spontaneous splenorenal shunt, esophageal varices, and reversed portal flow.

[Isolated hydrothorax of a fetus--description of the clinical situation]

A diagnostic procedure in the medical treatment of middle hydrothorax at haemodynamically efficient fetus has been presented in the research. Container of the liquid in the fetal thorax has been observed since the eleventh week of pregnancy. Infection by TORCH viruses has been excluded and typical 46,XX female karyotype has been found in the cytogenic test. A liquid in the pericardial sack (without any sings of the fetal heart defect) was observed in the ECHO examination from 23 to 37 week of pregnancy. Cesarean section was made after 37 weeks of pregnancy and the new-born baby was found to be in good condition, with body mass of 3130g and 9 points in the Apgar scale. The child cardiologist did not diagnose any heart disorders. Awaiting attitude, while monitoring the state of the fetus, seems to be the right course of action in cases of haemodynamically efficient fetus with isolated hydrothorax.

Hydromediastinum associated with a peripherally inserted central venous catheter in a newborn infant

We report a case of hydromediastinum in a newborn associated with a peripherally inserted central venous catheter. A 9-day-old male infant with total parenteral nutrition via a peripherally inserted central venous catheter had acute respiratory distress. A chest radiograph showed a widened mediastinal shadow and left pleural effusion, and sonography revealed fluid collection in the mediastinum and bilateral hydrothorax. Sonography is useful in the diagnosis of hydromediastinum when infants treated with peripherally inserted central venous catheters have acute respiratory distress.

[Late mediastinitis with bilateral hydrothorax after vessel perforation by a central venous catheter]

A central venous catheter was inserted into the right internal jugular vein of a 67-year-old woman to provide parenteral nutrition on the 7th day after surgery. Five days later, mediastinitis with bilateral hydrothorax had developed and was causing respiratory failure and systemic inflammatory response syndrome secondary to documented vascular perforation by the catheter. Four factors have been associated with increased risk of perforation: catheter rigidity and diameter, the angle between the tip of the catheter and the vessel wall, and insertion from the left. Three catheter positions have been described as safe when radiologically confirmed: the superior vena cava, the point where the superior vena cava meets the atrium, and the midpoint of the innominate vein. However, it should not be forgotten that a radiograph is 2-dimensional and a single image of a catheter tip can correspond to a variety of locations (superior vena cava, vena innominata, extravascular location, and more). Even when there is clinical and radiologic evidence of catheter positioning, vascular perforation should be suspected in patients with a central venous catheter and bilateral pleural effusion who present respiratory insufficiency and hemodynamic instability.

Neonatal hydrothorax following migration of a central venous catheter

The use of a central venous catheter may occasionally be associated with complications like sepsis, effusions and thrombosis. Migration of the central catheter is an unusual complication that often goes unrecognized. This case report is of a neonate who developed hydrothorax resulting from a migrating central line and highlights the need for a high level of clinical suspicion in diagnosing catheter related problems.

Predicting Outcome in Primary Fetal Hydrothorax

OBJECTIVE

This study examines the role of serial ultrasound in predicting fetal outcomes based on progress, resolution or stability of pleural effusions in primary fetal hydrothorax (PFHT).

METHODS

Records from consecutive cases of fetal pleural effusions referred to the fetal echocardiography unit over a 12-year period were reviewed. Study patients underwent thorough investigation to rule out secondary causes of pleural effusions. The clinical course was monitored with serial ultrasound studies every 2 weeks until delivery. Pleurocentesis and pleuroamniotic shunts were performed in select cases of PFHT. Fetal survival was the primary outcome variable.

RESULTS

Eighteen of 44 patients referred for perinatal evaluation of fetal pleural effusions met the study criteria for PFHT. Diagnosis was made at 28 +/- 7 weeks and fetuses delivered at 35 +/- 3 weeks' gestational age. Overall survival was 78%. Effusion progression, greater effusion ratios, earlier gestational age at delivery, and lower Apgar scores at birth were associated with poor outcome. Conservative management was appropriate for most cases.

CONCLUSIONS

Serial ultrasound studies to evaluate the clinical course of the pleural effusions are essential in the management of PFHT. Expectant management of stable and resolving effusions was appropriate in all cases.

[Pleuroamniotic shunting--case report]

Fetal hydrothorax refers to a collection of fluid within the fetal thorax that may be the result of chylous leak from the thoracic duct (primary hydrothorax) or generalized fluid retention associated with immune or no immune fetal hydrops (secondary hydrothorax). The authors' presents a case report occurred in 2002, of a pregnant woman that at 25 weeks' gestation that was referred to Maternidade Bissaya-Barreto-Coimbra because of a fetal hydrothorax at left, under tension and with cardiac decompensation signs. A fetal thoracocentesis was performed and the diagnosis was chylothorax. Because of a rapid reaccumulation of fluid a pleuroamniotic shunt was placed. The effusion and the cardiac decompensation signs regressed. The delivery was at 38 weeks' gestation. The newborn had been stable. Actually he has 10 months, is healthy and has a normal grow and development.