What is the management approach for hydrops fetalis?

From the Guidelines

The management of hydrops fetalis requires a multidisciplinary approach focused on identifying and treating the underlying cause while providing supportive care, with the goal of improving morbidity, mortality, and quality of life outcomes. Initial evaluation should include detailed maternal history, comprehensive ultrasound, amniocentesis for karyotyping, and testing for infections like parvovirus B19, as recommended by the Society for Maternal-Fetal Medicine (1). For non-immune hydrops, management is cause-specific:

• Cardiac arrhythmias may require maternal administration of antiarrhythmics like digoxin (0.25-0.5 mg daily) or flecainide (100-300 mg daily) (1)
• Twin-twin transfusion syndrome might necessitate laser photocoagulation (1)
• Thoracentesis or shunt placement may be needed for pleural effusions or urinary tract obstructions (1)
• Fetal anemia secondary to parvovirus infection or fetomaternal hemorrhage may require fetal blood sampling followed by intrauterine transfusion (1) Timing of delivery depends on gestational age and fetal condition, with delivery generally recommended when the fetus reaches viability if hydrops is severe and unresponsive to treatment (1). Postnatal management includes respiratory support, fluid management, and treatment of specific conditions. The prognosis varies significantly based on etiology, with immune hydrops having better outcomes than non-immune cases when treated appropriately (1).

Some key points to consider in the management of hydrops fetalis include:

• The importance of detailed ultrasound and fetal echocardiogram in the initial evaluation (1)
• The role of amniocentesis and chromosomal microarray analysis in identifying underlying genetic causes (1)
• The use of middle cerebral artery Doppler evaluation for anemia (1)
• The consideration of fetal intrauterine transfusion for severe fetal anemia (1)
• The potential for delayed psychomotor development and abnormal neurological outcomes in survivors of hydrops fetalis (1)

From the Research

Management Approach for Hydrops Fetalis

The management approach for hydrops fetalis involves various treatments, including:

• Intrauterine intravascular transfusions, which have been shown to be effective in managing hydropic fetuses due to rhesus isoimmunization 2
• Plasmapheresis and intravenous immunoglobulin (IVIG) to delay intrauterine transfusion to a later gestational age in cases of severe Rh alloimmunization 3
• Symptomatic treatment and intensive care after birth, with the prognosis depending on the aetiology and gestational age at diagnosis and birth 4

Treatment Outcomes

The outcomes of these treatments vary, with:

• A survival rate of 88.9% reported in one study, associated with the severity of fetal hydrops 2
• Successful management of hemolytic disease and hydrops fetalis using intravenous immunoglobulins and intrauterine transfusions 5
• Mortality rates highest among neonates with congenital anomalies and lowest among those with congenital chylothorax, with factors such as younger gestational age and need for high levels of support associated with increased risk of death 6

Diagnostic Considerations

The diagnosis of hydrops fetalis is categorized into immune and non-immune forms, with genetic diagnostic tools becoming increasingly important in the diagnostic process 4