NICU Management of HydropsHydrops Fetalis · PDF fileNICU Management of HydropsHydrops Fetalis...

NICU Management of NICU Management of HydropsHydrops FetalisFetalis

Sara Peeples, MDANGELS Perinatal ConferenceANGELS Perinatal Conference

May 5, 2010

uams.eduarpediatrics.orgarchildrens.org

image from White. Neonatal Newtork 1999; 18:25-29.

ObjectivesObjectivesObjectivesObjectives

DefinitionEtiologiesEtiologiesResuscitation of the hydropic infantManagement in the NICU


HydropsHydrops: Definition: DefinitionHydropsHydrops: Definition: DefinitionExcessive accumulation of extracllularExcessive accumulation of extracllularfluid in a fetusSubcutaneous edema (skin thickness >Subcutaneous edema (skin thickness > 5mm) plus two of the following:

A itAscitesPleural effusionP i di l ff iPericardial effusionPlacental enlargement


IncidenceIncidenceIncidenceIncidence

1 i 2500 t 3700 i1 in 2500 to 3700 pregnancies

May be as high at 1 in 800 pregnancies in referral centers

Rare but contributes to 3% of perinatalRare, but contributes to 3% of perinatal mortality


PathophysiologyPathophysiologyPathophysiologyPathophysiology

Sum of hydrostatic and osmotic forces determines net flow of fluid

Many different systemicMany different systemic disorders can affect these pressures and result in the clinical picture of hydrops


www.web-books.com

Etiology: Etiology: Wh D It M tt ?Wh D It M tt ?Why Does It Matter?Why Does It Matter?

Determines prognosis

Determines management of infant

Helps predict future recurrenceHelps predict future recurrence


EtiologyEtiologyEtiologyEtiology

ImmuneAnemia from

NonimmuneNo evidence of

vsAnemia from red cell alloimmunization

No evidence of red cellalloimmunization

10-20% hydrops 80-90% hydrops


ImmuneImmune HydropsHydropsImmune Immune HydropsHydropsAntigen incompatibility between mother andAntigen incompatibility between mother and

fetus Maternal sensitizationMaternal sensitization Fetal hemolysis and anemia

cardiac failuredecreased serum oncotic pressure p

Fetal hydrops


Urbaniak, Greiss. Blood Reviews 2000; 14:44-61.

ImmuneImmune HydropsHydropsImmune Immune HydropsHydropsWell-defined causeWell-defined causeEstablished diagnostic and therapeutic approachGood prognosisGood prognosisDecreased incidence since i t d ti f Rh (D) iintroduction of Rho (D) immune globulin


NonimmuneNonimmune HydropsHydropsNonimmuneNonimmune HydropsHydropsC di lCardiovascularChromosomalSyndromicI f tiInfectionHematologicThoracic/PulmonaryGUGUTumorsTTTSGIGIMetabolicIdiopathic


Inborn Errors of MetabolismHematologic Disorders

Infections

Cardiovascular DisordersHematologic Disorders

Obstructed Venous Return

Placental DisordersUrinary Flow Disorders

Lymphatic Dysplasia

Volume Overload

Liver Failure Heart Failure

LowPlasma

High Central

Reduced Lymph

OncoticPressure

VenousPressure

Flow

High Interstitial Fluid

Nonimmune Hydrops FetalisBellini, et al. Am J Med Gen Part A 2009; 149A: 844-851.

Clinical ConsequencesClinical ConsequencesClinical ConsequencesClinical Consequences

R i t iRespiratory compromiseCardiac dysfunctionySignificant edemaI t l l d l tiIntravascular volume depletionVery low reservey


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library med utah edu


library.med.utah.edu

Management of the Management of the H d iH d i I f tI f tHydropicHydropic Infant Infant

Preparation for delivery

Resuscitation

Management in the NICUManagement in the NICU


Preparation for Delivery:Preparation for Delivery:F il C liF il C liFamily CounselingFamily Counseling

Resuscitation procedures

Prognosis

Comfort careComfort care


Preparation for Delivery:Preparation for Delivery:A i t E i tA i t E i tAppropriate EquipmentAppropriate Equipment

I t b tiIntubationUmbilical LinesResuscitation medicationsP t iParacentesisThoracentesis and chest tube placement


Preparation for Delivery:Preparation for Delivery:A i t P lA i t P lAppropriate PersonnelAppropriate Personnel

N i d i t t ffNursing and respiratory staff

Neonatologist

Other pediatric subspecialistsp p


The ABCs of Resuscitation:The ABCs of Resuscitation:AiAiAirwayAirway

Soft tissue edemaedema

Airway malformationmalformation

www.sgrh.com/images


The ABCs of Resuscitation:The ABCs of Resuscitation:B thiB thiBreathingBreathing

I d til tIncreased ventilatory pressures necessaryParacentesis to relieve pressure on diaphragmdiaphragmThoracentesis and chest tube

l t f l l ff iplacement for pleural effusion


The ABCs of Resuscitation:The ABCs of Resuscitation:Ci l tiCi l tiCirculationCirculation

Myocardial dysfunctionIntravascular volume depletionIntravascular volume depletionHypotension and poor perfusionAnemia


Resuscitation: Resuscitation: Oth C id tiOth C id tiOther ConsiderationsOther Considerations

Temperature controlH l iHypoglycemiaAcidosisAssessment of oxygenation


Management in the NICUManagement in the NICUManagement in the NICUManagement in the NICU

Management of symptomsManagement of symptoms

Search for etiology

Counseling familiesg


Supportive CareSupportive CareSupportive CareSupportive Care

Respiratory CardiovascularFluids and electrolytesFluids and electrolytesHematologicInfectious disease


Diagnostic EvaluationDiagnostic EvaluationDiagnostic EvaluationDiagnostic Evaluation

Thorough physical examImaging studiesImaging studiesLaboratory studiesInfectious work-upAutopsyAutopsy


Hemolytic Disease of the Hemolytic Disease of the N bN bNewbornNewborn

Antenatal managementPrevention is keyMCA dopplersppIntrauterine transfusionMaternal plasma exchange/IVIGMaternal plasma exchange/IVIG


Images from Obstetrics and Gynecology,

vol 112 (1). July 2008.


Hemolytic Disease of the Hemolytic Disease of the NewbornNewborn

Postnatal managementTransfusionAggressive treatment of hyperbilirubinemiagg ypTreatment of late anemia


HyperbilirubinemiaHyperbilirubinemiaHyperbilirubinemiaHyperbilirubinemia

Adequate hydrationPhototherapyPhototherapyIVIGExchange transfusionMetalloporphyrinsMetalloporphyrins


Risk Risk NomogramNomogram for for HyperbilirubinemiaHyperbilirubinemia

AAP Clinical Practice Guidelines 2004



Guidelines for PhototherapyGuidelines for Phototherapy




Guidelines for Exchange TransfusionGuidelines for Exchange Transfusion



Prognosis of Prognosis of H dH d F t liF t liHydropsHydrops FetalisFetalis

M t lit f NIH f 50% tMortality for NIH ranges from 50% to 90% depending on underlying etiologyBest prognosis associated with HDN, fetal tachyarrhythmiasPoor prognosis with structural heart malformations, chromosomal abnormalities, syndromes


SummarySummarySummarySummaryHydrops fetalis is a rare but seriousHydrops fetalis is a rare but serious disorder with multiple possible etiologiesSignificant planning and preparation isSignificant planning and preparation is necessary prior to deliveryR it ti d NICU tResuscitation and NICU management present unique challengesImportant to search for and treat underlying cause


ReferencesReferencesReferencesReferencesBukowski R, Saade G. Hydrops fetalis. Clinics in Perinatology 2000; 27:1007-1027.

Norton M. Nonimmune hydrops fetalis. Seminars in Perinatology 1994; 18:321-332.

Apkon M. Pathophysiology of hydrops fetalis. Seminars in Perinatology 1995; 19:437-446.

White LE. Nonimmune hydrops fetalis. Neonatal Network 1999; 18:25-29.

Bellini C, Hennekam RCM, et al. Etiology of nonimmune hydrops fetalis: a systematic review. Am J Medical Genetics Part A 2009; 149A:844-851.

Jones D. Nonimmune fetal hydrops: diagnosis and obstetrical management. Seminars in Perinatology 1995; 19:447-461.

M M h M D J Th d li it ti f th h d i t S i iMcMahan M, Donovan J. The delivery room resuscitation of the hydropic neonate. Seminars in Perinatology 1995; 19:474-482.

Urbaniak SJ, Greiss MA. RhD haemolytic disease of the fetus and the newborn. Blood Reviews2000; 14:44-61.


;

ReferencesReferencesReferencesReferencesShisler Harrod K, Hanson L, et al. Rh negative status and isoimmunization update: a case-based

h t J P i t l N t l N i 2003 17 166 178approach to care. J Perinatal Neonatal Nursing 2003; 17:166-178.

Moise K. Management of rhesus alloimmunization in pregnancy. Obstetrics and Gynecology2008; 112:164-176.

Duerbeck NB, Seeds JW. Rhesus immunization in pregnancy: a review. Obstetrical and Gynecological Survey 1993; 48:801-810.

Mundy CA. Intravenous immunoglobulin in the management of hemolytic disease of the newborn. Neonatal Network 2005; 24:17-24.

Smits-Wingjens VEHJ, Walther FJ, Lopriore E. Rhesus haemolytic disease of the newborn: postnatal management, associated morbidity and long-term outcome. Seminars in Fetal and Neonatal Management 2008; 13:265-271.Neonatal Management 2008; 13:265 271.

AAP Clinical Practice Guideline, Subcommittee of Hyperbilirubinemia. Pediatrics 2004; 114:297-316.


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