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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 7  |  Issue : 1  |  Page : 55-57

Isolated fetal ascites: A case report with review of literature


1 Department of Paediatric Surgery, KLE University's J.N. Medical College, Belgaum, Karnataka, India
2 Department of Paediatrics, KLE University's J.N. Medical College, Belgaum, Karnataka, India
3 Department of Surgery, KLE University's J.N. Medical College, Belgaum, Karnataka, India

Date of Web Publication2-Jul-2014

Correspondence Address:
Santosh B Kurbet
Department of Paediatric Surgery, KLE University's J.N. Medical College, Belgaum, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-5006.135048

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  Abstract 

Fetal ascites is commonly seen with hydrops fetalis. Historically, fetal ascites has been associated with significant mortality and morbidity. Primary isolated fetal ascites occurs independently as an isolated disease due to numerous congenital abnormalities. Extensive antenatal and postnatal evaluation for the detection of the cause is done in these cases, if found and appropriately treated have shown good results. In conclusion, even a rare case of fetal ascites can be managed successfully.

Keywords: Fetal ascites, hydrops fetalis, isolated fetal ascites


How to cite this article:
Kurbet SB, Mahantshetti NS, Patil PG, Patil MV, Singh D. Isolated fetal ascites: A case report with review of literature. Indian J Health Sci Biomed Res 2014;7:55-7

How to cite this URL:
Kurbet SB, Mahantshetti NS, Patil PG, Patil MV, Singh D. Isolated fetal ascites: A case report with review of literature. Indian J Health Sci Biomed Res [serial online] 2014 [cited 2019 Apr 22];7:55-7. Available from: http://www.ijournalhs.org/text.asp?2014/7/1/55/135048


  Introduction Top


Fetal ascites is commonly considered as a part or precursor of fetal hydrops, which has various etiologies. [1] Fetal ascites can also occur as an isolated disease without fluid accumulation in any other serosal cavities or subcutaneous tissues. [2],[3],[4] Overall prognosis is poor, but better with those with late gestational onset. Here, antenatal fetal sonography in mid third trimester detected isolated fetal ascites and was followed-up postnatally. The neonate at birth was diagnosed to have chylous ascites, which was managed successfully medically.

This article highlights the importance of antenatal diagnosis, workup, follow-up postnatally and its appropriate treatment leading to recovery. We report here such a case which was managed successfully and also review the literature.


  Case Report Top


A second gravida with one living child, at 30 weeks of gestation underwent routine sonography, which revealed isolated fetal ascites. Detailed ultrasound of fetal abdomen showed gross ascites, normal placenta and no other obvious pathology. Echocardiography of the fetus was normal. Complete blood count, normal titers for toxoplasmosis, rubella, cytomegalovirus, and herpes (TORCH), blood group, Rh typing, Venereal Disease Research Lab (VDRL), serum albumin and a Kleihauer-Betke stain of a peripheral blood smear of the mother were done and found to be normal. Subsequently sonography done every week showed persistent findings, with no evidence of subcutaneous edema, placentomegaly or fluid collections in pleural or pericardial cavities. A male neonate was born at term weighing 3.2 kg with good APGAR scores and had abdominal distension at birth. Per abdominal examination revealed distension with free fluid in abdomen [Figure 1].
Figure 1: Tense abdominal distension at birth

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Hemoglobin was 17.2 g%, total leucocyte count was 12,800 cells/cmm, platelet count was 3.2 lakhs/cmm and normal renal function tests and liver function tests subsequently. Plain X-ray abdomen showed free fluid in the abdomen with centrally located bowel loops [Figure 2].
Figure 2: X-ray abdomen showing ascites

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Paracentesis revealed clear straw colored fluid, proteins of 3.2 g%, 90 cells/high power field; 90% lymphocytes, normal (pH, glucose, lactate dehydrogenase, amylase, bilirubin, creatinine) culture negative and elevated triglycerides (200 mg%) establishing the diagnosis of chylous ascites. The neonate was initially kept nil orally, started on parenteral nutrition and later started with enteral feeds with low fat diet consisting of medium-chain-triglycerides. The neonate also received intravenous octreotide (3 μgm/kg/h) infusion for 5 days followed by subcutaneously thrice daily for 2 weeks. The ascites progressively resolved over 4 weeks. The infant was doing well with full oral feeds and good weight gain at follow-up at 6 months of age.


  Discussion Top


Isolated ascites is defined as abnormal fluid collection in the abdominal cavity without fluid accumulation in any other serosal cavities or subcutaneous tissue. [1],[2] The prevalence of fetal hydrops ranges from one in 800 to 3500 live births, whereas true prevalence of isolated fetal ascites is not known. A myriad of maternal, fetal and placental problems which are known to cause hydrops fetalis or fetal ascites can be identified in 70-90% of cases by extensive prenatal and postnatal evaluation. [1] The disease is associated with high mortality (30-95%) and significant morbidity. Conventionally are divided into immune and nonimmune hydrops fetalis. The maternal causes commonly include blood group and Rh incompatibilities and viral infections (TORCH, adenovirus, parvovirus, syphilis) in mother. [3] The most common demonstrable causes of this disorder in the fetus are cardiovascular ([congenital heart diseases and arrhythmias] 15-26%), fetal anemia (fetomaternal hemorrhage, G6PD deficiency, α-thalessemia), chromosomal disorders ([trisomy 21, trisomy 18 and monosomy X] 8-16%), congenital infections ([TORCH, adenovirus, parvovirus, syphilis] 2-4%), twinning, hepatic causes, metabolic storage disorders, thoracic causes (2.5-13%) urinary, gastrointestinal, lymphatic malformations, tumors, twin-twin transfusion syndrome and rest idiopathic (7-30%). [2] Multiple mechanisms have been explained for occurrence of ascites, such as abnormal lymphatic drainage; obstruction to venous return, cardiac failure; decreased plasma oncotic pressure, as in fetal anemia; hepatic insufficiency (storage diseases) or congenital nephrosis; increased capillary permeability; urinary tract obstruction and meconium peritonitis. [5]

A systematic approach to the prenatal workup of isolated fetal ascites includes investigations of the fetus and also of the mother; least invasive investigations such as ultrasound for diagnosis/follow-up and for structural abnormalities, fetal echocardiography to rule out congenital heart disease and arrhythmias, complete blood count, Kleihauer-Betke analysis to look for fetal red blood cells, serology, polymerase chain reactions, TORCH titers, other viral markers, VDRL testing for intrauterine infections, followed by more invasive techniques for chromosomal abnormalities and inborn errors of metabolism (DNA/enzyme analysis) by amniocentesis, cordocentesis, placental biopsy, chorionic villous biopsy, fetal paracentesis, and fetoscopy. [1],[2]

Although the detection and prognostic evaluation of isolated fetal ascites are improved by applying these methods, the overall prognosis for most fetuses with isolated fetal ascites is still guarded with only a few conditions causing the disorder amenable to treatment antenatally. Antenatal intervention is done if pulmonary hypoplasia is evident, and when uterine dystocia is expected which includes fetal abdominal paracentesis, thoraco-amniotic and peritoneo-amniotic shunting. Postnatal treatment includes medical and surgical therapies: Parenteral nutrition, diet restriction, low fat diet, somatostatin analogues for chylous ascites, paracentesis, peritoneo-venous shunting, corrective surgeries for cardiac, urinary, pulmonary, and gastrointestinal conditions. [2],[6],[7]

In an extensive paper which reviewed 47 series of hydrops fetalis (804 cases) and 610 individual cases of fetal hydrops of the 1980s, gave many details, which are used for the current management. [1] In an another retrospective cohort of patients with primary isolated fetal ascites from 1994 to 2009, divided into two; favorable(>30 weeks) and unfavorable groups(<30 weeks), seven patients had resolution with medical treatment in first group, five in second group required surgical intervention. Prognosis depended on gestational age at diagnosis and severity of fetal abdominal distension. [2] In a case series reported by Bishry of 12 patients with isolated fetal ascites, 10 survived after delivery; out of whom nine had no other anomalies detected on antenatal or postnatal ultrasound and only one had ileal atresia, which was surgically corrected. [4] In another report by Favre et al., ascites before 24 weeks of gestation indicated poor prognosis with mortality of 77% and excellent survival was reported for urinary and chylous ascites. [8] In another series of 18 cases with isolated fetal ascites 14 resolved in the antenatal period itself. [6] Nose et al. in their study have reported that gestational age is inversely correlated with the severity of the ascites at diagnosis and early diagnosis carries a major risk factor for prognosis with 86% surviving the disease if onset was beyond 30 weeks of gestation. [2] Seeds et al. were among the first to treat fetal ascites by antenatal shunt procedures. [7] Overall prognosis is good in those with late onset isolated fetal ascites, mild to moderate degree ascites and those causes which are amenable to surgical treatment. [1]

In summary isolated fetal ascites is a separate entity from hydrops fetalis and has a better prognosis compared with that of hydrops fetalis. Isolated fetal ascites with late gestational onset and negative infection screen carries an excellent prognosis with spontaneous resolution in most of these cases. However a extensive evaluation to determine the etiology is important for appropriate treatment, which will provide for successful outcome of the condition.

 
  References Top

1.Machin GA. Hydrops revisited: Literature review of 1,414 cases published in the 1980s. Am J Med Genet 1989;34:366-90.  Back to cited text no. 1
[PUBMED]    
2.Nose S, Usui N, Soh H, Kamiyama M, Tani G, Kanagawa T, et al. The prognostic factors and the outcome of primary isolated fetal ascites. Pediatr Surg Int 2011;27:799-804.  Back to cited text no. 2
    
3.Abdellatif M, Alsinani S, Al-Balushi Z, Al-Dughaishi T, Abuanza M, Al-Riyami N. Spontaneous resolution of fetal and neonatal ascites after birth. Sultan Qaboos Univ Med J 2013;13:175-8.  Back to cited text no. 3
    
4.El Bishry G. The outcome of isolated fetal ascites. Eur J Obstet Gynecol Reprod Biol 2008;137:43-6.  Back to cited text no. 4
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5.Arikana I, Baruta A, Harmaa M, Harmaa MI, Doganb S. Isolated foetal ascites: A case report. J Med Cases 2012;3:110-2.  Back to cited text no. 5
    
6.Zelop C, Benacerraf BR. The causes and natural history of fetal ascites. Prenat Diagn 1994;14:941-6.  Back to cited text no. 6
    
7.Seeds JW, Herbert WN, Bowes WA Jr, Cefalo RC. Recurrent idiopathic fetal hydrops: results of prenatal therapy. Obstet Gynecol 1984;64:30S-3.  Back to cited text no. 7
[PUBMED]    
8.Favre R, Dreux S, Dommergues M, Dumez Y, Luton D, Oury JF, et al. Nonimmune fetal ascites: A series of 79 cases. Am J Obstet Gynecol 2004;190:407-12.  Back to cited text no. 8
    


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