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2014-06-10-11 Successful thoracoamniotic shunting for isolated fetal pleural effusion © Muresan www.TheFetus.net

Successful thoracoamniotic shunting for isolated fetal pleural effusion


Marius Bogdan Muresan, MD.*, Maria Cezara Muresan, MD.**


*   Medical Center of Dr.Muresan, Timisoara, Romania. 
**  Department of Obstetrics and Gynecology, V. Babes medical University, Timisoara, Romania.

Definition

Hydrothorax is an accumulation of fluid within the pleural space of the thoracic cavity. Primary fetal hydrothorax may present with a wide spectrum of severity ranging from small, harmless effusions, to life-threatening thoracic compression.

Incidence

Estimated incidence of isolated fetal pleural effusions is about 1 in 10 - 15 000 pregnancies. The effusion may be bilateral or more commonly unilateral, and may be associated with other malformations, chromosomal abnormalities, anemia, heart defects, cardiac arrhythmias, and viral infections.

Prognosis

The clinical course of primary fetal hydrothorax is unpredictable. Whereas smaller unilateral effusions might remain stable or even regress, this is rarely the case with larger collections. Bilateral effusions, hydrops, preterm delivery and the lack of antenatal therapy are all associated with poor outcome.

Differential diagnosis

The differential diagnosis between the primary pleural effusion causing the fetal hydrops and the secondary one, caused by the hydrops, may be based on the finding of everted diaphragm that occurs in the case of primary effusion.

Management

Once structural and chromosomal anomalies have been excluded, optimal management depends on gestational age, rate of progression, the development of hydrops and associated maternal symptoms.

For very large effusions with mediastinal shift, hydrops and/or hydramnios, or when there is rapid enlargement of the effusion, fetal intervention is warranted.

Case report

A secundigravida had been sent to our department at 25 weeks of gestation due to fetal hydrothorax that was diagnosed in a private office.

Our examination confirmed the diagnosis of the isolated left-sided hydrothorax (see images 1-3, and video 1). The patient was negative for TORCH and parvovirus infections and the karyotype of the fetus was normal.

Images 1, 2, 3 and video 1: 25 weeks of gestation; the images show transverse scans of the fetal thorax (images 1, 2) and abdomen (image 3). Massive left-sided hydrothorax can be seen. The video demonstrates huge left-sided hydrothorax of the fetus.

 

 

At 26 weeks placing of the intrauterine thoracoamniotic shunt was indicated and performed (videos 2, 3).

Videos 2, 3: 27 weeks of gestation; the video 2 shows transverse scan of the fetal thorax with left-sided hydrothorax before placing of the thoraco-amniotic shunt. The video 3 shows inserted shunt within the hydrothorax after the procedure.

 
 
Two days later our ultrasonographic examination demonstrated that the shunt was completely displaced into the thoracic cavity and so another procedure was indicated during which the second thoracoamniotic shunt was successfully placed into the thoracic cavity.

Images 4, 5, and video 4: 27 weeks of gestation; the image one and video 4 show transverse scan of the fetal thorax with unilateral hydrothorax. The first thoracoamniotic shunt that unfortunately completely displaced into the thoracic cavity can be seen (arrow with the number 1). The second thoraco-amniotic shunt was successfully placed into the thoracic cavity (number 2). Image 5 shows the second thoracoamniotic shunt draining the hydrothorax into the amniotic cavity (arrows).

 


Following ultrasonographic examination at 32 weeks showed resolution of the hydrothorax with normally developed lungs (image 6 and video 5).

Image 6 and video 5: 32 weeks of gestation; 
resolution of the hydrothorax with normally developed lungs can be seen.

 

The newborn was delivered at 37 weeks by a cesarean section (male, 3100 g, Apgar 10) and was placed at Pediatric Surgery Department where the shunts were removed. Postnatal adaptation was normal and the newborn is doing well.


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