1. Case Series of Hydrops Fetalis Secondary to Parvovirus B19 infection
Nur Farihan Mukhtar, Ng Beng Kwang, Lim Pei Shan. Department of Obstetrics and Gynaecology, UKM Medical Centre, Jalan Yaacob Latif, Kuala Lumpur.
Introduction
Case Series
Discussion
CASE 3
Another case was a 38 year-old, gravida 7. The mother’s blood group was O positive. Nuchal translucency scan was done at 12 weeks showed high risk for Down syndrome. Patient opted not to do non invasive prenatal testing (NIPT). Detailed scan at 22 weeks showed hydropic fetus with hyperplacentosis, unilateral congenital talipes equinovarus however no gross structural anomalies or soft marker seen. The median cerebral artery peak systolic velocity (MCA PSV) was raised. Blood investigations showed equivocal parvovirus IgM and positive parvovirus IgG. On examination, the neonate was a female, 985 gram, with generalized skin oedema and distended thorax and abdomen.
Non-immune hydrops fetalis (NIHF) secondary to parvovirus B19 infection is a rare fetal condition with a very high mortality in spite of advances in prenatal diagnostic testing, early detection and individualized management. Despite advancement in fetal therapy and rapidly developing new knowledge about the aetiology and prenatal diagnosis, its management remained controversial. Information on serological and virological findings of infection in the fetus is scarce.
Once in the fetal compartment, B19 virus dan infect erythroid progenitor cells in the liver and/or bone marrow exerting a cytotoxic effect by induction of apoptotic mechanism leading to the block of fetal erythropoiesis and resulting in anaemia, tissue hypoxia, non-immune hydrops and/or fetal death [4].
Fetal infection by human parvovirus B19 is a common cause of fetal anaemia, nonimmune hydrops fetalis and spontaneous abortion and can result in fetal death. PCR had a better sensitivity than IgM serology to diagnose B19V infection in the mother at the time of invasive prenatal diagnosis [5].
Precision of B19V diagnosis and management of pregnant women can be improved using supplementary serological assays such as IgG avidity and epitope-type specificity [5]. With that, fetal transfusion can be initiated and the fetal mortality from parvovirus infection can be prevented [6].
Methodology
This a review of 3 case series of NIHF secondary to parvovirus B19 infection in pregnancy. We obtained anti-B19V antibodies in maternal and fetal blood samples. Most foetuses presented with moderate to severe anaemia or hydrops.
Results
At the time of fetal blood sampling, all mothers are B19V-IgG positive.. B19V-IgM was detected in 2 out of 3 maternal blood samples. B19V-IgM of fetal blood samples was detected in 1 out of 3, and B19V-IgG of fetal blood samples were detected in 2 out of 3. The probability of a positive B19V-IgG or B19V-IgM finding in fetal blood increased with gestational age. B19V-IgG levels in maternal blood did not correlate with the likelihood of a positive B19V-IgG in the fetus
Case Series
Conclusion
CASE 1
Madam RMD, case of a 36 year-old woman, gravida 5, para 4 who was found to have hydrops fetalis on a routine sonographic examination for dating at 23 weeks’ gestation. Ascites, pericardial effusion and cardiomegaly were seen in combination with soft markers such as increase nuchal fold, hyperechoic bowel, short long bones. The amniotic fluid volume was excessive. She denied any fever, rash, cold symptoms and joint pain before and during pregnancy. The mother blood group was O positive. Maternal parvovirus B19 infection was confirmed by the finding of positive IgM and immunoglobulin G (IgG) in the serum. A maternal – fetal medicine specialist was consulted. After extensive counselling the family chose expectant management. At 28 weeks’ of gestation, a diagnosis of intrauterine fetal death was made and patient underwent elective caesarean section and bilateral tubal ligation. A baby girl with the weight of 1.2 kg was delivered, grossly oedematous with distended thorax and abdomen. Otherwise grossly normal fetus.
CASE 2
Madam SE, who was a 34-year-old primigravida with uneventful antenatal history, had her fetus diagnosed with hydrops fetalis since 22 weeks with the features of pericardial effusion, pleural effusion, scalp and generalized skin oedema. The mother blood group was O positive. Maternal parvovirus infection was confirmed by the finding of positive IgG however IgM was negative. Ultrasound at 26 weeks revealed hydrops fetalis, severe oligohydramnios and intrauterine fetal death. Patient was successfully induced and delivered a baby girl with the weight of 980 gram, grossly oedematous with distended thorax and abdomen and otherwise grossly normal.
Our case series demonstrated the differences in maternal and fetal serologic testing in managing fetal hydrops fetalis. All pregnancies complicated with nonimmune hydrops fetalis should be investigated by fetal blood sampling looking for evidence of parvovirus infection. A greater understanding of the natural history of human parvovirus infection is needed prior to deciding the optimum mode of therapy.
References
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Bonvicini, F., Bua, G., & Gallinella, G. (2017). Parvovirus B19 infection in pregnancy—awareness and opportunities. Current opinion in virology, 27, 8-14.
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Discussion
Hydrops fetalis is a serious fetal condition characterized by abnormal accumulation of fluid in fetal soft tissues and serous cavities. There are two types of hydrops fetalis – immune hydrops fetalis and nonimmune hydrops fetalis [1].
The incidence of fetal hydrops is 1.34 – 3 / 1000 births [1]. Hydrops fetalis secondary to parvovirus B19 infections is a rare condition. It is estimated that parvovirus B19 infection accounts for 8 – 10% of non-immune hydrops fetalis [2]. The transmission rate range from 17 to 33% [2]. 33% of fetus infected with parvovirus have spontaneous resolution with no adverse outcome [3].
Parvovirus is as single stranded virus and it cause hydrops fetalis by the P antigen expressed on fetal cardiac myocytes which enables the PV B19 to infect myocardial cells and produce myositis. It is responsible for fluid accumulations in the pericardial space [1].
Nur Farihan Mukhtar
O&G department, UKMMC