Chylothorax has been estimated to occur in 1 of every 10,000 deliveries,' and it is the most common cause of unilateral pleural effusion in the fetus. Chylothorax has been associated with hydrops fetalis,' and the pathophysiological process believed to be involved in the development of hydrops is congestive heart failure secondary to mediastinal shift and impaired venous r e t~r n .~ However, to the best of our knowledge, the hemodynamic events responsible for this process have never been reported.In the present study, we describe the effect of bilateral pleural effusion caused by chylothorax on fetal cardiac functions as evaluated by echocardiography, as well as the effect of its drainage on Doppler waveforms from the umbilical artery and vein, the carotid artery, the thoracic aorta, and the inferior vena cava. CASE REPORTA 31-year-old G-5 P-4 woman was followed with weekly ultrasound examinations from 29 weeks, menstrual age (MA) because of a fetal right pleural effusion and mild hydramnios. The pleural effusion occupied approximately 40% of the area of the right thoracic profile resulting in lung compression. No additional anomalies, mediastinal shift, nor signs of hydrops were noted. For 5 weeks no significant increase in the amount of pleural effusion was observed, fetal growth was normal, and the hydramnios was stable.At 34 weeks, MA, an ultrasound scan demonstrated an increase in the right pleural effusion, which now occupied approximately 80% of the right thorax. In addition, pleural effusion occu- pying approximately 30% of the left thorax was noted. Our concern was that the increased intrathoracic pressure could obstruct normal cardiac function and lead eventually to hydrops. We decided to drain the fluid, hoping that the rather stable state that had been observed between 29 weeks and 34 weeks would return following the alleviation of the intrathoracic pressure. Ultrasound-guided right thoracocentesis was performed and yielded 80 mL of clear, yellowish fluid having a cellular content of more than 90% lymphocytes. The lung readily expanded to occupy more than 80% of the right thoracic cavity. However, a repeat scan 24 hours later revealed severe bilateral hydrothorax occupying more than 80% of the thorax, resulting in compression of the lung and flattening of the diaphragm. At this stage we discussed the option of introducing an indwelling catheter for continuous drainage. We decided against it because we felt that delivery would be safer now that the MA was 34 weeks.The neonatologists recommended a repeat thoracocentesis prior to delivery, hoping that this would enable the newborn to breath spontaneously and obviate the need for emergency bilateral thorax drainage after delivery. Thus, a second thoracocentesis was performed. Both sides of the thorax were drained resulting in expansion of the lungs (Figure 11, and labor was induced by amniotomy and oxytocin. Repeated scans during labor showed gradual bilateral accumulation of fluid. Within 3 hours pleural effusion occupied approximately 30% to 40% of bot...

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The efficacy and safety of intracervical prostaglandin E2 (PGE2) gel for induction of labor in patients with premature rupture of the membranes (PROM) at term and with an unripe cervix were evaluated. Fifty-two patients who did not start labor 6 to 12 hours after PROM and who had an unripe cervix were randomized to one of two management protocols. Patients randomized to PGE2 received a single intracervical application of 0.5 mg PGE2. Patients randomized to the conservative protocol were managed expectantly for 24 hours. If labor was not established 6 hours after randomization in patients receiving PGE2 or 24 hours after PROM in patients managed expectantly, labor was induced with intravenous oxytocin. Of the patients receiving PGE2, 93% began labor after a single application, and the mean interval between prostaglandin application and delivery was 6.6 hours. In the conservative group, only 57% began labor within 24 hours, and more than half of them required augmentation with oxytocin. The mean latency between PROM and delivery was 15 hours in patients managed with PGE2 and 30 hours in patients managed conservatively (P < 0.01). There were no complications and pregnancy outcome was similar in the two groups. Intracervical PGE2 is safe and effective for inducing labor in patients with PROM and an unfavorable cervix.

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