Fetal Hydrops & Congenital Infections PDF

ULTR‐3014 OBGYN Sonography 3 Module O.15: Fetal Hydrops & Congenital Infections 1 Fetal Hydrops & Congenital Infections 1 2 Fetal Hydrops textbook reference Module O.15 Fetal Hydrops & Congenital Infections 3 • • Rumack 5th Edition Chapter 41 4 Fetal Hydrops • • • • • • • • Introduction Ge...

ULTR‐3014 OBGYN Sonography 3 Module O.15: Fetal Hydrops & Congenital Infections 1 Fetal Hydrops & Congenital Infections 1 2 Fetal Hydrops textbook reference Module O.15 Fetal Hydrops & Congenital Infections 3 • • Rumack 5th Edition Chapter 41 4 Fetal Hydrops • • • • • • • • Introduction General classifications Nonimmune fetal hydrops Immune fetal hydrops Mirror syndrome Isolated fetal ascites Pitfalls of diagnosis Congenital infections 5 Fetal Hydrops 6 Fetal Hydrops AKA hydrops fetalis • An end‐stage process for a number of diseases • Redistribution of body fluids among the intravascular and interstitial compartments • Mortality of fetal hydrops is >70% Fetal hydrops – sonographic diagnosis Abnormal accumulation of fluid in at least 2 areas in the fetus • • • Hydrops fetalis Latin ‐ edema of fetus End‐stage Terminal; the last phase in the course of a progressive disease • Ascites Pleural effusion Pericardial effusion Massive edema (anasarca) Polyhydramnios and placentomegaly are also common findings, but not required for diagnosis 1 ULTR‐3014 OBGYN Sonography 3 Module O.15: Fetal Hydrops & Congenital Infections 1 Fetal Hydrops & Congenital Infections 7 8 Fetal Hydrops Fetal hydrops Fetal hydrops – sonographic features • Subcutaneous edema • Ascites • Pleural effusion • Pericardial effusion • Hepatosplenomegaly • Thickened placenta • Polyhydramnios autopsy 9 10 Anasarca • Massive edema • Skin thickness ≥ 5 mm • Generalized infiltration of edematous fluid into subcutaneous tissue • Associated with end‐stage hydrops fetalis • Probable impending fetal demise 11 Hydrops with anasarca • Skin thickness measured 8 mm • Polyhydramnios and ascites also seen 12 Hydrops – other associated sonographic features • Placental edema • > 4 cm diameter • Polyhydramnios • > 8 cm AFV • > 24 cm AFI • Abnormal biophysical profile score • See O.19 Antepartum Fetal Assessment General Classifications of Hydrops 2 ULTR‐3014 OBGYN Sonography 3 Module O.15: Fetal Hydrops & Congenital Infections 1 Fetal Hydrops & Congenital Infections 13 14 General Classifications 1. Nonimmune hydrops fetalis (NIHF) Most common 2. Immune hydrops fetalis (IHF) • Maternal/fetal blood incompatibility • Rh isoimmunization Rare 15 Nonimmune Hydrops Fetalis (NIHF) 16 Nonimmune Hydrops • No evidence of incompatibility between fetal and maternal blood • More common than immune fetal hydrops • Management may be affected if ultrasound can pinpoint the specific cause • Medical or invasive 17 Nonimmune hydrops – causes • At least 80 (as per Rumack) • Fetal cardiac anomalies • Chromosomal anomalies Second most common • Turner syndrome most common • A small number of cases are idiopathic Most common 18 Nonimmune hydrops – associated conditions • Cardiac • Chromosomal/genetic • Fetal anemia • Infection Many conditions under • Thoracic abnormalities each category • Twinning • Tumours • Miscellaneous Nonimmune hydrops • Axial fetal head shows significant scalp edema • Axial abdomen shows ascites 3 ULTR‐3014 OBGYN Sonography 3 Module O.15: Fetal Hydrops & Congenital Infections 1 Fetal Hydrops & Congenital Infections 19 20 Nonimmune hydrops • Profile in 3rd trimester fetus • Facial edema • Arrows mark surface of skin and bone • Swelling of soft tissues in the face Noniummune hydrops • Coronal fetus 1: gross ascites 2: thick placenta 3: pericardial effusion L: liver B: bowel See next slide . . . 21 2 3 1 L B 22 Nonimmune hydrops abdomen chest Noniummune hydrops • Same case • Axial fetal abdomen 4 1 2 1: gross ascites 2: thick placenta L: liver 3 2 1 L 1 Axial fetal chest shows 1: gross chest wall edema, 2: large ASD Axial fetal liver shows 3: gross body wall edema, 4: ascites See next slide . . . 23 24 Nonimmune hydrops • Sagittal fetal abdomen 1: gross body wall edema L: liver 2: ascites Noniummune hydrops 1 L • Sagittal placenta (10 cm) • Gross placental thickening due to edema 2 See next slide . . . 4 ULTR‐3014 OBGYN Sonography 3 Module O.15: Fetal Hydrops & Congenital Infections 1 Fetal Hydrops & Congenital Infections 25 26 Nonimmune hydrops – causes seen sonographically • Supraventricular tachycardia • Vein of Galen aneurysm • Central nervous system infection • Cystic hygroma • Congenital diaphragmatic hernia • Twin‐to‐twin transfusion syndrome • Large chorioangioma (placental tumour) Nonimmune hydrops • Coronal fetal chest and abdomen • Arrows: pericardial effusions Ascites • • Thick placenta and polyhydramnios 27 28 Supraventricular tachycardia • Vein of Galen aneurysm Abnormally high FHR originating in the atria or the AV node • Improper electrical activity in upper heart • Atrial heart rate was 250 bpm • Can cause hydrops • Pulsed Doppler shows turbulent flow • Large AV malformation • Can cause hydrops Diagnostic Ultrasound, 5th Edition (Rumack fig 41.20) 29 30 Cystic hygroma • Fetus had Turner syndrome • Aneuploidy is the second most common cause of NIFH See next slide . . . Same case anterior • Coronal fetus • Body wall edema (small arrows) • Ascites (curved arrow) • Pleural effusion (large arrow) L: liver B: bowel 5 ULTR‐3014 OBGYN Sonography 3 Module O.15: Fetal Hydrops & Congenital Infections 1 Fetal Hydrops & Congenital Infections 31 32 Twin‐to‐twin transfusion syndrome • Donor twin has IUGR • Recipient twin has NIHF Recipient P: polyhydramnios L: liver A: ascites S: stomach Donor Placental chorioangioma • Posterior lying placenta • Mass arising from fetal surface of placenta • Large chorioangiomas can cause hydrops See O.17 Multiple Pregnancy 33 See section 18.01 34 Immune Fetal Hydrops • Hydrops can be a fetal response to the maternal immune system • Incompatibility between maternal and fetal blood • Some basic terminology will aid with understanding Immune Fetal Hydrops 35 36 Immune fetal hydrops – terminology Antigen: Molecule capable of inducing an immune response Antibody: Plasma protein used by immune system to neutralize targets; identifies targets by their antigens Isoimmunization: Production of antibodies against the tissues of another individual of the same species Anemia: Deficiency in RBCs or hemoglobin 6 ULTR‐3014 OBGYN Sonography 3 Module O.15: Fetal Hydrops & Congenital Infections 1 Fetal Hydrops & Congenital Infections 37 38 Immune fetal hydrops Rh blood group system • A system for categorizing blood by antigens • Rh factor refers to the D antigen • An individual either has or does not have the Rh factor on the surface of their red blood cells • Classified as either Rh positive or Rh negative Textbook of Diagnostic Sonography, 7th Edition (Hagen‐Ansert fig 52‐1) 39 40 Maternal isoimmunization • Rh negative mother and Rh positive father may conceive a fetus that inherits father’s Rh positive blood • Fetal blood may mix with maternal blood • e.g. during labour and delivery • These blood types are incompatible • Maternal antibodies produced against Rh positive blood • Maternal “isoimmunization” or “sensitization” 41 Timing of immune response • Isoimmuniziation occurs with “1st” pregnancy • Regardless of outcome (e.g. normal or SA) • No problems arise with this fetus • Problems may arise with “2nd” pregnancy • Immune response to fetus if blood types are incompatible 42 “2nd” pregnancy response • Maternal‐fetal blood type incompatibility • Maternal antibodies cross placental blood barrier • Fetal RBCs are attacked • Causes fetal anemia and hydrops Pathogenesis of immune fetal hydrops • Maternal antibodies enter fetal circulation and destroy fetal RBCs • Hemolysis • Fetus develops hemolytic anemia • AKA erythroblastosis fetalis • Progressive fetal anemia leads to a chain reaction which causes hydrops 7 ULTR‐3014 OBGYN Sonography 3 Module O.15: Fetal Hydrops & Congenital Infections 1 Fetal Hydrops & Congenital Infections 43 44 Fetal hydrops – various causes Immune hydrops – treatment 45 • No treatment until 1968 • Now preventable with RhD immune globulin (WinRho) • WinRho administered at 28 and 40 weeks GA • Removes Rh positive fetal RBCs from maternal blood • Prevents antibodies forming against Rh positive blood 46 Immune hydrops – screening • Diagnosis of isoimmunization Maternal blood tested for antibodies • Most patients are now routinely screened 47 • Maternal serum antibody screening test • Negative → fetus not affected • Positive → fetus at risk for anemia and hydrops • If positive, fetus assessed for anemia and hydrops 48 Immune hydrops – risk assessment and management Immune hydrops – prevalence • Cordocentesis (PUBS) for fetal hemoglobin level • Percutaneous Umbilical Blood Sampling • Availability of WinRho decreases risk of immune hydrops fetalis (from 16% to 0.1%) • Sonographic findings • • Amniocentesis As a result, nonimmune fetal hydrops is now the more common form of hydrops 8 ULTR‐3014 OBGYN Sonography 3 Module O.15: Fetal Hydrops & Congenital Infections 1 Fetal Hydrops & Congenital Infections 49 50 Immune hydrops – classic sonographic progression Immune hydrops – sonographic assessment of anemia Polyhydramnios • Severity of polyhydramnios • Placental thickening (> 4 cm) • Placental thickness Fetal hepatosplenomegaly • • Fetal hepatosplenomegaly • Umbilical vein diameter • Fetal ascites • Various fetal Doppler waveforms • Hydrops • 51 52 Erythroblastosis fetalis • Erythroblastosis fetalis – treatment • Ultrasound guided fetal blood transfusions • Intravascular (usually umbilical vein in cord) • Intraperitoneal – no longer done Fetus with: • Immune fetal hydrops • Hemolytic anemia • Fetal RBCs destroyed by maternal antibodies youtu.be/TCfrpUlHw9k 1:46 (ultrasound guided fetal blood transfusion) 53 54 Erythroblastosis fetalis – blood transfusion • Fetal blood sampling/transfusion needle (arrow) • Enters umbilical blood vessel near placental cord insertion Mirror Syndrome P: placenta 9 ULTR‐3014 OBGYN Sonography 3 Module O.15: Fetal Hydrops & Congenital Infections 1 Fetal Hydrops & Congenital Infections 55 56 Mirror Syndrome Definition Fetal hydrops associated with severe maternal preeclampsia • Clinical signs of preeclampsia Fetal edema mirrors maternal edema Preeclampsia Hypertension with proteinuria and generalized edema 57 58 Isolated Fetal Ascites Definition Fetal ascites in the absence of fluid in other cavities or the skin Isolated Fetal Ascites • 59 Isolated ascites may be associated with: • GI tract obstruction with perforation • Meconium ascites • GU tract obstruction with perforation • Urinary ascites 60 Isolated fetal ascites • More favourable prognosis than hydrops • Requires follow‐up as it may be an early sign of hydrops e.g. urinary ascites • Coronal fetal abdomen • Decompressed fetal bladder (arrow) • Gross ascites 2° to rupture of bladder 10 ULTR‐3014 OBGYN Sonography 3 Module O.15: Fetal Hydrops & Congenital Infections 1 Fetal Hydrops & Congenital Infections 61 62 Pitfalls of Diagnosis Pitfalls for Misdiagnosing Hydrops Fetalis 63 Pitfall Nuchal fold thickening Hypoechoic myocardium Hypoechoic abdominal muscles Comparable hydrops feature Edema Pericardial effusion Ascites 64 Nuchal fold thickening • Measures 10 mm • Pitfall for generalized edema seen with hydrops • Fetus had trisomy 21 • Fetus did NOT have hydrops 65 Pseudopericardial effusion • Normal peripheral hypoechoic portion of myocardium (curved arrows) • Distinguishable from pericardial fluid by noting continuity with ventricular septum (straight arrow) 66 Pseudoascites • Hypoechoic abdominal musculature (arrows) at depth of ribs (open arrow) • Hypoechoic pseudoascites does not outline umbilical vein (uv) • Changing the fetal position can help confirm findings Pseudoascites • Sagittal fetus • Diaphragm (arrowheads) and abdominal muscles (arrow) simulate ascites s: stomach 11 ULTR‐3014 OBGYN Sonography 3 Module O.15: Fetal Hydrops & Congenital Infections 1 Fetal Hydrops & Congenital Infections 67 68 Congenital or Fetal Infections Definition Maternal infection transmitted to fetus across placental blood barrier Congenital Infections 69 • Diagnosis by testing maternal and fetal blood for antibodies and positive culture • Uncommon cause of nonimmune hydrops • Very few infections diagnosed with ultrasound 70 TORCH Infection – most common sonographic features • Toxoplasmosis (exposure to raw meat or cats) • Early onset, symmetrical IUGR • Others (syphilis, varicella‐zoster virus – chickenpox, parvovirus B19, hepatitis B, and HIV) • Nonimmune fetal hydrops • Hydrocephalus with periventricular calcification • Rubella (German measles) • Liver calcifications • Cytomegalovirus (CMV) • Microcephaly • Herpes simplex virus Most common 71 72 Infections – sonographic features Sonographic features – infections 12 ULTR‐3014 OBGYN Sonography 3 Module O.15: Fetal Hydrops & Congenital Infections 1 Fetal Hydrops & Congenital Infections 73 74 Toxoplasmosis Toxoplasmosis • Oblique axial abdomen • 33 weeks GA • Massive ascites with fluid surrounding liver and bowel • Axial abdomen • Ascites with hepatic calcifications (arrows) • Bright shadowing focus from liver calcification 75 SP: spine 76 Other – chickenpox (VZV) • Axial fetal liver • Multiple echogenic foci consistent with parenchymal calcification (arrows) • Gallbladder (GB) is filled with echogenic sludge 77 Other – parvovirus B19 Scalp edema and ascites • 78 Rubella • 12 weeks GA • Increased nuchal translucency (arrow) • EVS heart revealed signs of infection with pericardial effusion Rubella • 31 weeks GA • Transverse liver • Small, scattered areas of calcification (arrows) 13 ULTR‐3014 OBGYN Sonography 3 Module O.15: Fetal Hydrops & Congenital Infections 1 Fetal Hydrops & Congenital Infections 79 80 CMV • 34 weeks GA • Severe, chronic encephalitis (brain inflammation) • Asymmetric hydrocephaly with internal debris and periventricular calcifications 81 CMV • Hydrops • Pleural effusion (PE) • Pericardial calcifications (vertical arrow) • Skin edema 82 CMV CMV • Coronal head • Placentitis • Inflammation results in periventricular calcifications (arrow) • 36 weeks GA • Abnormal calcifications in thick placenta (arrows) 83 84 Resource • Recognizing TORCH on fetal ultrasound: bit.ly/2VoreC3 Module O.15 Fetal Hydrops & Congenital Infections END 14