Ultrasound
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Sonographic Diagnosis of Fetal Hydrops 1 E. George Kassner, M.D. and Ellen Cromb, R.N.
Sonograms obtained during the 32nd and 34th weeks of a pregnancy complicated by severe Rh isoimmunization demonstrated features diagnostic of fetal hydrops-scalp and body wall edema, ascites, hepatosplenomegaly and placental enlargement. The earliest sign that can be detected sonographicalIy is placental enlargement. INDEX TERMS:
Erythroblastosis, fetal. Fetus, ultrasound • Hydrops
Radiology 116:399-400, August 1975
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of Rho(D) immune globulin, severe Rh isoimmunization and fetal hydrops occasionally occur. The sonographic appearances of the dead and living hydropic fetus have been described (1-3), but no detailed description of the sonographic features of the living hydropic fetus is recorded in the English language literature.
D
ESPITE
USE
H. H., a 34-year-old white woman, was first seen during her fourth pregnancy. Her first baby had been jaundiced but had not required transfusion. The next two pregnancies terminated in spontaneous abortions. Rho(D) immune globulin had been administered at another hospital after the second abortion. On 8-22-72, in the tenth week of gestation, serum antl-D titer was 3:32; on 1-16-73 (32nd week) it was 1:256; on 2-2-73 (34th week) it was 1:4090. Amniocentesis on 1-19-73 revealed that the change in optical density of bilirubin at 450 mp, was 0.182 and the creatinine level was 0.8 mg/100 ml. Repeat amniocentesis on 2-2-73 revealed the bilirubin density had risen to 0.35, indicating marked isoimmunization of the fetus (7). The Creatinine level was 2.2 mg/100 ml. Serial sooographic examinations were performed (4). Scans on 1-19-73 demonstrated an anterior placenta of average size and a normal appearing active fetus of 31-32 weeks size (Fig. 1). Scans on 2-2-73 revealed no further fetal growth. The fetus was edematous and its abdomen was enlarged. The viscera were displaced centrally by ascitic fluid. The placenta was markedly enlarged (Fig. 2). Fetal activity was confirmed by subsequent monitoring with Doppler ultrasound. The mother was given a 24-hour course of betamecadron (to accelerate maturation of the fetal lung surfactant system) and labor was induced. A male infant weighing 2750 g was delivered. The placenta weighed 1020 g. The neonate was pale, edematous and in poor condition (Apgar score 1). The liver and spleen were enlarged and there was ascites (Fig. 3). The cord blood bilirubin level was 1.5 mg/100 ml, the hematocrit was 15 % and reticulocyte count was 14 %. The infant was placed in 100 % oxygen and 3 exchange transfusions were administered during the first 24 hours. Paracentesis removed more than 100 ml of ascitic fluid. The infant died on the fourth day after complications of hyaline membrane disease, seizures, heart failure, and a bleeding disorder. Autopsy revealed severe fetal hydrops.
Plain radiography has been a reliable method for detecting the hydropic fetus. According to Savignac (8), the main radiographic signs of hydrops are: straightening of the fetal trunk, extension of the fetal head and deflexion of the fetal extremities, indicating enlargement of the fetal abdomen and edema of its trunk and neck; large placenta; edema of the fetal soft tissues and loss of the subcutaneous fat stripe; and stigmata of third trimester fetal death. Hydramnios is an inconstant feature and difficult to identify in the presence of gross placental enlargement. Amniography increases diagnostic accuracy. Soft-tissue edema (particularly of the scalp), abdominal enlargement and increased placental thickness are readily demonstrated. De-
layed radiographs may show displacement of the opacified fetal gut by the enlarged liver and/or ascitic fluid. Nonopacification of the fetal gut suggests fetal death (6). Savignac (8) emphasized the importance of placental enlargement in the diagnosis of fetal hydrops; indeed, toto-ptecental hydrops is a better descriptive name for the disorder. Placental enlargement is readily detected on conventional sonograms and is the earliest sonographic sign of hydrops (3). While the upper limit of normal placental size is not known, measurements above 6 cm in thickness call for frequent follow-up sonographic examinations and close clinical correlation (1, 3). The main diagnostic features of fetal hydrops seen on radiographic examination-placental enlargement, scalp and body wall edema, and enlargement of the fetal abdomen due to hepatosplenomegaly and ascites-were detected by sonography in our patient. Hofmann and Hollander (3) demonstrated these sonographic signs in 9 hydropic fetuses. Sa et al. (1) diagnosed hydrops in 4 fetuses on the basis of ascites and placental enlargement but did not detect scalp or truncal edema in any of them. According to Gottesfeld (2), a "fluffy" or "coarse" outline of the torso or limbs is characteristic of sonograms of living or dead hydropic fetuses. A similar appearance may be observed in fetuses of diabetic mothers and in some instances of fetal death from other causes. Marked placental enlargement confirms the diagnosis of hydrops. The isolated finding of a "double outline" Of the fetal head is not diagnostic of fetal hydrops since this sonographic sign has been noted after fetal death (5) and in fetuses of diabetic mothers (2). Hydrops frequently results in fetal death. Absence of fetal cardiovascular activity may be detected on conventional sonograms obtained immediately after fetal death (2). Sonopraphic evidence of fetal deformity, comparable to radiographic signs (6), is generally not c1earcut within the first 12 hours after fetal death (2, 5). Doppler ultrasound (5) or real time scanners are more accurate than radiography in proving recent fetal death and confirming fetal viability. ACKNOWLEDGMENTS: The authors are indebted to Dr. Lajos von Micsky, under whose supervision the sonographic examinations were done, and to Dr. Peter Kottmeier and Dr. George Hermann who translated the German and Hungarian publications.
REFERENCES 1. Ba J, Sobel M, Falus M: Hydrops foetus universalis intrauterin diagnosisa ultrahanggal. Orv Hetil 112:1897-1898, 8 Aug 1971 (Hun) 2. Gottesfeld KR: The ultrasonic diagnosis of intrauterine fetal death. Am J Obstet GynecoI108:623-634, 15 Oct 1970 3. Hofmann 0, Hollander HJ: Die intrauterine Diagnostik des Hydrops fetus universalis mittels Ultraschall. Zentralbl Gynaekol 90: 667-669, 11 May 1968 4. Kobayashi M, Hellman LM, Cromb E: Atlas of Ultrasonography in Obstetrics and Gynecology. New York, Appleton-CenturyCrofts, 1972 5. Leopold GR, Asher WM: Ultrasound in obstetrics and gynecology. Radiol Clin North Am 12: 127-146, Apr 1974 6. Noonan CD: Antenatal diagnosis of fetal abnormalities. Radlol Clin North Am 12:13-27, Apr 1974 7. Powell LC Jr, Schreiber MH: Intrauterine fetal transfusion. Radiol Clin North Am 12:37-58, Apr 1974 8. Savignac EM: The prenatal roentgen diagnosis of fetal hydrops. Am J Roentgenol 80:673-680, Oct 1958
1 From the Department of Radiology, Kings County Hospital Medical Center, and the State University of New York, Downstate Medical Center, Brooklyn, N. Y. Accepted for publication in February 1975. dk
399
Fig. 1. Sonograms at 32 weeks. One scale division equals 3 cm . A. Longitudinal scan. The biparietal diameter of the fetal head (FH) is 7.8 em, consistent with 31-32 weeks of gestation. The fetal head is sharply outlined. B. Transverse scan . The maximum placental thickness (large arrows) is 5 cm . The fetus is in a transverse lie; the torso (small arrows) is not enlarged. Fig. 2. Sonograms at 34 weeks. The fetus is now in a cephalic lie. A. Transverse scan. The double line outline of the fetal head, which was also evident on longitudinal scans, indicates scalp edema. B. Transverse scan showing a transverse section of the fetal abdomen. The abdominal viscera (V) are displaced centrally by a large amount of ascitic fluid (A) . The body wall is thickened and its contour is indistinct. In this tracing the placenta is sectioned obliquely and its true thickness cannot be estimated (4). In other tracings the chorionic plate was visible and the maximum placental thickness perpendicular to the chorionic plate was 9 cm. Fig. 3 . Frontal (A) and lateral (B) radiographs of the neonate's chest and abdomen at 2 hours of age. The body wall is edematous. The flanks are bulging and the pelvis is opaque. The stomach and small bowel are displaced centrally. The heart is enlarged and air bronchograms are visible throughout both lungs.
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Sonographic Diagnosis of Fetal Hydrops 1 E. George Kassner, M.D. and Ellen Cromb, R.N.
Sonograms obtained during the 32nd and 34th weeks of a pregnancy complicated by severe Rh isoimmunization demonstrated features diagnostic of fetal hydrops-scalp and body wall edema, ascites, hepatosplenomegaly and placental enlargement. The earliest sign that can be detected sonographicalIy is placental enlargement. INDEX TERMS:
Erythroblastosis, fetal. Fetus, ultrasound • Hydrops
Radiology 116:399-400, August 1975
•
•
of Rho(D) immune globulin, severe Rh isoimmunization and fetal hydrops occasionally occur. The sonographic appearances of the dead and living hydropic fetus have been described (1-3), but no detailed description of the sonographic features of the living hydropic fetus is recorded in the English language literature.
D
ESPITE
USE
H. H., a 34-year-old white woman, was first seen during her fourth pregnancy. Her first baby had been jaundiced but had not required transfusion. The next two pregnancies terminated in spontaneous abortions. Rho(D) immune globulin had been administered at another hospital after the second abortion. On 8-22-72, in the tenth week of gestation, serum antl-D titer was 3:32; on 1-16-73 (32nd week) it was 1:256; on 2-2-73 (34th week) it was 1:4090. Amniocentesis on 1-19-73 revealed that the change in optical density of bilirubin at 450 mp, was 0.182 and the creatinine level was 0.8 mg/100 ml. Repeat amniocentesis on 2-2-73 revealed the bilirubin density had risen to 0.35, indicating marked isoimmunization of the fetus (7). The Creatinine level was 2.2 mg/100 ml. Serial sooographic examinations were performed (4). Scans on 1-19-73 demonstrated an anterior placenta of average size and a normal appearing active fetus of 31-32 weeks size (Fig. 1). Scans on 2-2-73 revealed no further fetal growth. The fetus was edematous and its abdomen was enlarged. The viscera were displaced centrally by ascitic fluid. The placenta was markedly enlarged (Fig. 2). Fetal activity was confirmed by subsequent monitoring with Doppler ultrasound. The mother was given a 24-hour course of betamecadron (to accelerate maturation of the fetal lung surfactant system) and labor was induced. A male infant weighing 2750 g was delivered. The placenta weighed 1020 g. The neonate was pale, edematous and in poor condition (Apgar score 1). The liver and spleen were enlarged and there was ascites (Fig. 3). The cord blood bilirubin level was 1.5 mg/100 ml, the hematocrit was 15 % and reticulocyte count was 14 %. The infant was placed in 100 % oxygen and 3 exchange transfusions were administered during the first 24 hours. Paracentesis removed more than 100 ml of ascitic fluid. The infant died on the fourth day after complications of hyaline membrane disease, seizures, heart failure, and a bleeding disorder. Autopsy revealed severe fetal hydrops.
Plain radiography has been a reliable method for detecting the hydropic fetus. According to Savignac (8), the main radiographic signs of hydrops are: straightening of the fetal trunk, extension of the fetal head and deflexion of the fetal extremities, indicating enlargement of the fetal abdomen and edema of its trunk and neck; large placenta; edema of the fetal soft tissues and loss of the subcutaneous fat stripe; and stigmata of third trimester fetal death. Hydramnios is an inconstant feature and difficult to identify in the presence of gross placental enlargement. Amniography increases diagnostic accuracy. Soft-tissue edema (particularly of the scalp), abdominal enlargement and increased placental thickness are readily demonstrated. De-
layed radiographs may show displacement of the opacified fetal gut by the enlarged liver and/or ascitic fluid. Nonopacification of the fetal gut suggests fetal death (6). Savignac (8) emphasized the importance of placental enlargement in the diagnosis of fetal hydrops; indeed, toto-ptecental hydrops is a better descriptive name for the disorder. Placental enlargement is readily detected on conventional sonograms and is the earliest sonographic sign of hydrops (3). While the upper limit of normal placental size is not known, measurements above 6 cm in thickness call for frequent follow-up sonographic examinations and close clinical correlation (1, 3). The main diagnostic features of fetal hydrops seen on radiographic examination-placental enlargement, scalp and body wall edema, and enlargement of the fetal abdomen due to hepatosplenomegaly and ascites-were detected by sonography in our patient. Hofmann and Hollander (3) demonstrated these sonographic signs in 9 hydropic fetuses. Sa et al. (1) diagnosed hydrops in 4 fetuses on the basis of ascites and placental enlargement but did not detect scalp or truncal edema in any of them. According to Gottesfeld (2), a "fluffy" or "coarse" outline of the torso or limbs is characteristic of sonograms of living or dead hydropic fetuses. A similar appearance may be observed in fetuses of diabetic mothers and in some instances of fetal death from other causes. Marked placental enlargement confirms the diagnosis of hydrops. The isolated finding of a "double outline" Of the fetal head is not diagnostic of fetal hydrops since this sonographic sign has been noted after fetal death (5) and in fetuses of diabetic mothers (2). Hydrops frequently results in fetal death. Absence of fetal cardiovascular activity may be detected on conventional sonograms obtained immediately after fetal death (2). Sonopraphic evidence of fetal deformity, comparable to radiographic signs (6), is generally not c1earcut within the first 12 hours after fetal death (2, 5). Doppler ultrasound (5) or real time scanners are more accurate than radiography in proving recent fetal death and confirming fetal viability. ACKNOWLEDGMENTS: The authors are indebted to Dr. Lajos von Micsky, under whose supervision the sonographic examinations were done, and to Dr. Peter Kottmeier and Dr. George Hermann who translated the German and Hungarian publications.
REFERENCES 1. Ba J, Sobel M, Falus M: Hydrops foetus universalis intrauterin diagnosisa ultrahanggal. Orv Hetil 112:1897-1898, 8 Aug 1971 (Hun) 2. Gottesfeld KR: The ultrasonic diagnosis of intrauterine fetal death. Am J Obstet GynecoI108:623-634, 15 Oct 1970 3. Hofmann 0, Hollander HJ: Die intrauterine Diagnostik des Hydrops fetus universalis mittels Ultraschall. Zentralbl Gynaekol 90: 667-669, 11 May 1968 4. Kobayashi M, Hellman LM, Cromb E: Atlas of Ultrasonography in Obstetrics and Gynecology. New York, Appleton-CenturyCrofts, 1972 5. Leopold GR, Asher WM: Ultrasound in obstetrics and gynecology. Radiol Clin North Am 12: 127-146, Apr 1974 6. Noonan CD: Antenatal diagnosis of fetal abnormalities. Radlol Clin North Am 12:13-27, Apr 1974 7. Powell LC Jr, Schreiber MH: Intrauterine fetal transfusion. Radiol Clin North Am 12:37-58, Apr 1974 8. Savignac EM: The prenatal roentgen diagnosis of fetal hydrops. Am J Roentgenol 80:673-680, Oct 1958
1 From the Department of Radiology, Kings County Hospital Medical Center, and the State University of New York, Downstate Medical Center, Brooklyn, N. Y. Accepted for publication in February 1975. dk
399
Fig. 1. Sonograms at 32 weeks. One scale division equals 3 cm . A. Longitudinal scan. The biparietal diameter of the fetal head (FH) is 7.8 em, consistent with 31-32 weeks of gestation. The fetal head is sharply outlined. B. Transverse scan . The maximum placental thickness (large arrows) is 5 cm . The fetus is in a transverse lie; the torso (small arrows) is not enlarged. Fig. 2. Sonograms at 34 weeks. The fetus is now in a cephalic lie. A. Transverse scan. The double line outline of the fetal head, which was also evident on longitudinal scans, indicates scalp edema. B. Transverse scan showing a transverse section of the fetal abdomen. The abdominal viscera (V) are displaced centrally by a large amount of ascitic fluid (A) . The body wall is thickened and its contour is indistinct. In this tracing the placenta is sectioned obliquely and its true thickness cannot be estimated (4). In other tracings the chorionic plate was visible and the maximum placental thickness perpendicular to the chorionic plate was 9 cm. Fig. 3 . Frontal (A) and lateral (B) radiographs of the neonate's chest and abdomen at 2 hours of age. The body wall is edematous. The flanks are bulging and the pelvis is opaque. The stomach and small bowel are displaced centrally. The heart is enlarged and air bronchograms are visible throughout both lungs.
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