The effect of drainage of fetal chylothorax on cardiac and blood vessel hemodynamics

Abstract

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...

Preload Index of the Inferior Vena Cava as a Possible Predictive Marker of Hydropic Changes in Fetuses With Ebstein Anomaly

“…Generally, the PLI-IVC decreases gradually with advancing gestational age. 12,21,22 Evaluation of the PLI-IVC or the percentage of reversed flow in the IVC has been reported to be useful in clinical decision making or for evaluation of the fetal circulatory state in cases of fetal impairment associated with conditions such as isolated fetal hydrothorax, [23][24][25] hydrops fetalis, [6][7][8]26 and intrauterine growth restriction. 26,27 The findings in our series suggest that the PLI-IVC can also be used for evaluation of the circulation in fetuses with Ebstein anomaly.…”

Functional echocardiography in the fetus with non-cardiac disease

“…Similar hemodynamic changes are also seen in other intrathoracic space occupying lesions, such as congenital high airway obstruction, pleural or pericardial effusions, and pericardial teratomas. [40][41][42][43][44][45] Although detection of hydrops in the previable period is an indication for fetal therapy, 46 detailed monitoring of fetal hemodynamics has no role in the clinical management of fetuses with congenital cystic adenomatoid malformations, and changes in cardiac output or ventricular filling alone are not indications for intervention. 47 Assessment of tumor size may be more indicative of the need for fetal therapy.…”

Congenital primary hydrothorax: effect of thoracoamniotic shunting on neonatal clinical outcome

“…In the foetal period, spontaneous regression has been described for small unilateral effusions especially if the disorder is diagnosed in the second trimester and if it is unilateral [11]; the effusion may become larger and bilateral, resulting in hydrops and pulmonary hypoplasia. Moreover, foetal hydrothorax may impair venous return with congestive cardiac failure and secondary foetal hydrops [12].…”