Intrauterine fetal transfusion is currently the therapy of choice in cases of severe anti-D isoimmunisation. However, its efficacy is reduced in patients with early severe hydrops fetalis due to the technical difficulties in performing this procedure before 20 weeks' gestation. The purpose of this study was to determine whether early onset of high-dose gammaglobulin therapy followed by intrauterine transfusions (IUTs) is more effective than IUTs alone in the treatment of very severe isoimmunised fetuses. The population studied in this retrospective clinical research was assigned to one of the following two groups: 1) Gamma group: 30 patients receiving gammaglobulin therapy before 21 weeks' gestation and IUTs after 20 weeks; or 2) IUT group: 39 patients receiving IUT treatment starting at a gestational age of 20-25 weeks. Both groups were statistically similar regarding history of perinatal deaths and anti-D antibody titers. The number of hydropic fetuses at the first IUT and of fetal deaths were significantly higher in the IUT than in the Gamma group. No significant differences were observed between the groups in fetal hematocrit at first IUT and at birth. However, the percentage of severely anemic fetuses was higher in the IUT group. Fetal mortality rate was 36% less in the Gamma group. Our results suggest that high-dose gammaglobulin therapy followed by IUTs may improve fetal survival in these severe cases. Further randomised clinical trials are needed to confirm these results.

Alimentary tract duplication cysts are rarely diagnosed in utero. We report two fetal patients that presented with intrathoracic alimentary tract duplication cysts, mediastinal shift and hydrops. In one fetus, the cyst continued into the fetal abdomen and pelvis through a left diaphragmatic hernia. Despite successful ultrasound-guided needle aspirations in both fetuses, there was rapid reaccumulation of the fluid and recurrence of the mediastinal shift, prompting the placement of a thoracoamniotic shunt. In one fetus, there was rapid resolution of the mediastinal shift with the disappearance of the hydrops within 2 weeks. The second fetus suffered an intrauterine demise 2 days after the shunt placement. Postnatal resection in the surviving infant revealed a large cyst consistent with an intrathoracic duplication of the stomach. The autopsy of the second fetus revealed an intrathoracic duplication cyst of the stomach and proximal small intestine.

A gravida 4, para 3, group 1 Rh (D) positive woman with a group O Rh (D) positive husband and without a history of obstetric or clinical pathology is presented. Fetal ascites and pericardial effusion were diagnosed through ultrasound at 22 weeks of amenorrhea. These findings were reconfirmed ultrasonically at 25 weeks, so the patient was referred to our hospital to corroborate diagnosis. Indirect Coombs test was negative and no irregular antibodies were detected. Non-immunological hydrops was then suspected and the following studies were proposed: fetal blood sampling by cordocentesis for genetic diagnosis, assessment of fetal hematologic and immunologic condition and TORCH; intrauterine intravascular treatment would then be indicated if required. Fetal blood sampling showed: fetal blood group A Rh (D) positive, a direct negative Coombs test, hematocrit 27%, hemoglobin 8.7 g%, total protein level 3 g%, a normal Karyotype and negative TORCH. Because of the low albumin levels, 4 albumin transfusions were administered (3 intravascular and 1 intracardiac). Adrenalin was infused into the fetus at each procedure. After the first 2 transfusions, total remission of hydrops was observed. A cesarean section was performed at 34 weeks and a live male, blood group A Rh (D) positive infant without ascites and weighing 1900 g was born. Coombs test was negative. No hepato or splenomegalla was observed. However, the neonate presented with respiratory distress syndrome, requiring mechanical ventilation for 3 days. Neonatal evolution was satisfactory (negative TORCH, normal ECG, normal abdominal echographic studies, negative blood culture). The advantages of intrauterine treatment are stressed and the possible etiology on nonimmunological hydrops is discussed.