ABSTRACT NO : 160 ABSTRACT ID : IRIA A CASE REPORT ON IMMUNE HYDROPS FETALIS

INTRODUCTION Hydrops fetalis is a condition in the fetus characterized by an abnormal collection of fluid with at least two of the following: 1.Edema (fetal anasarca) 2.Ascites (usually surrounding urinary bladder) 3.Pleural effusion 4.Pericardial effusion ₍₁₎ Hydrops fetalis is found in about 1 per 700 births and is categorized as : Immune hydrops ~10-20% Nonimmune hydrops ~ 80-90% ₍₁ ₎

Hydrops fetalis is typically diagnosed during ultrasound evaluation for other complaints such as : 1.Polyhydraminos 2.Large for Gestational Age 3.Fetal tachycardia 4.Decreased fetal movement 5.Abnormal serum screening 6.Antenatal hemorrhage ₍₁₎

Immune hydrops foetalis results from haemolysis from isoimmunisation. Individuals who lack a specific red cell antigen (like Rh antigen) can potentially produce an antibody when exposed to that antigen The antibody may prove harmful to the individual in case of a blood transfusion or to a foetus when a mother (Rh negative) conceives. In these cases, the mother could be sensitized if enough erythrocytes from the Rh positive foetus reach her circulation to elicit an immune response(fig 1) ₍₁₎. Case report of a pregnant women is presented, where diagnosis of hydrops fetalis with was established during antenatal period FIG : 1

CASE REPORT A 27 year old female, pregnant for second time, reported to the hospital OPD for routine antenatal check up. Patient was in second trimester of pregnancy. She had history of an abortion in the past. Patient was not given any prophylactic anti-D immunoglobulin therapy after the abortion. The routine blood and urine investigations were normal. Her blood group was B negative. Indirect Coomb's test was positive. Serology for TORCH was negative both for IgG and IgM antibodies.

Increased amniotic fluid volumes(FIG:2) larger placental size (placentomegaly) / increased placental thickness (placental oedema) >6cm (FIG :2) FIG : 2 PLACENTA

presence of a foetal bilateral pleural effusion & Ascites(FIG:3) FIG: 3

An elevated peak systolic velocity (PSV) measured in the middle cerebral artery (MCA) is associated with 100% sensitivity in predicting moderate to severe anaemia non invasively. (FIG:4) FIG : 4

BPD is highly variable large for gestational age in this case (FIG : 6) Scalp Thickness more than 5mm (FIG:5) FIG :5 FIG : 6

Skin Thickness in abdomen >5mm with free fluid in the abdominal cavity (Ascites) (FIG : 7) Abdominal Circumference is also increased for gestational age (FIG:8) FIG : 7 FIG : 8

Sagittal section of abdomen showing gross Ascites surrounding the intestinal loops (FIG:09) FIG : 09

Coronal section of chest and abdomen showing Pleural effusion and Ascites (FIG:10) FIG : 10

3D image showing intrauterine fetus with hydrops fetalis (FIG:11) FIG : 11

Keeping in view the past history of abortion, Rh negative status of mother and ultrasonographic features described above, a diagnosis of immune hydrops fetalis was made. As per the desire of the couple, pregnancy was terminated in view of poor prognosis of the foetus. Anti-D immunoglobulin was administered to the patient immediately after termination of pregnancy.

DISCUSSION Pathological changes (depends on severity ) severely affected foetus subcutaneous oedema and effusion into the serous cavities the placenta is also markedly oedematous, boggy and enlarged ₍₂₎ Excessive haemolysis marked erythroid hyperplasia of the bone marrow and extramedullary haematopoiesis hepatosplenomegaly cause hepatic dysfunction ₍₂₎. Hydrothorax and Ascites compromise respiration after birth or lead to severe dystocia as a consequence of the greatly enlarged abdomen. ₍₂₎

Treatment  Choice of treatment depends upon the time of development, diagnosis and the severity of hydrops 1.If the condition is very severe, early pregnancy(less than 24 weeks of pregnancy),sinusoidal fetal heart rate Elective termination of pregnancy is considered 2.If the gestational age is between 24 and 34 weeks, fetal anemia correction of anemia with intrauterine transfusion is considered 3.If the gestational age is above 34 weeks,with confirmation of lung maturity fetus is delivered postnatal exchange transfusion is done ₍₃₎. 4. Transplacental drug therapy for treating arrhythmia like digoxin, amiodarone etc 5. Invasive procedures like ultrasound guided fetal blood/albumin transfusion, ultrasound guided drainage procedures for Ascites,pleural effusion etc  A team approach using obstetric imagers, maternal fetal medicine specialists, neonatologists and geneticists can help in case management ₍₃

Conclusion :  Hydrops represents a terminal stage for many conditions, majority of which are fetal in origin  Onset of hydrops signifies fetal decompensation  A comprehensive team approach must be done in management and future counseling  Prevention of the hydrops is by usage of Anti D immunoglobulin prophylaxis and prediction of fetal Rh status antenatally by fetal karyotyping

References: 1. Wilkins, I. Nonimmune hydrops. In Creasy and Resnick's Maternal Fetal- Medicine Principles and Practice sixth ed.Ed Creasy R et al., 2009, Saunders. pp Nicolini U, Nicolaides P, Tannirandorn Y, Fisk N, Nasrat H, Rodeck CH. Fetal liver dyfunction in Rh alloimmunization. Br J Obstet Gynaecol 1991 ; 98 : Bianchi DW, Crombleholme TM, D'Alton ME. Fetology: Diagnosis & Management of the Fetal Patient.1st ed McGraw-Hill Professional 2000 pp