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Antenatal Management of Second Trimester Oligohydramnios And ISSN: 2377-9004 Roshan et al. Obstet Gynecol Cases Rev 2020, 7:183 DOI: 10.23937/2377-9004/1410183 Volume 7 | Issue 6 Obstetrics and Open Access Gynaecology Cases - Reviews CASE REPORT Antenatal Management of Second Trimester Oligohydramnios and Evolving Abnormal Ultrasound Findings: Case Report Daniel Roshan, MD, FACOG, FACS*, Ellen Kolman, PA-C, Shira Plonka, MS CGC and Ilan Timor, MD, FACOG Check for Department of Obstetrics and Gynecology, New York University School of Medicine, New York, USA updates *Corresponding author: Daniel Roshan, MD, FACOG, FACS, Department of Obstetrics and Gynecology, New York University School of Medicine, 213 Madison Ave #1A, New York, NY 10016, USA, Tel: (212)-725-0123 ing and an unclear etiology, the leading initial hypoth- Abstract esis involved a possible intestinal perforation leaking Appropriate patient selection for prenatal intervention in the amniotic fluid into the abdominal cavity. With gradually setting of abnormal antenatal ultrasound findings remains challenging. This case illustrates the course of a complicat- declining amniotic fluid index (AFI), a second amnioin- ed pregnancy in a 35-year-old gravida 1 para 0 who pre- fusion was performed at 26.5 weeks, and a peritoneal sented to our Maternal-Fetal-Medicine clinic at 24.2 weeks amniotic shunt was placed using a double pigtail cathe- gestation with fetal ascites, scalp edema, and oligohydram- ter to bypass the suspected perforation. AFI was closely nios. Her first trimester ultrasound and genetic screening was normal. The patient was counseled that the observed monitored and appeared to stabilize. At 28.2 weeks, AFI findings carried a high chance for fetal demise or postna- began to decline, and a distended bladder with a distinct tal birth defects and complications. The patient chose to keyhole appearance was seen on ultrasound, consistent continue the pregnancy and opted for any necessary fetal with a fetal lower urinary tract obstruction (LUTO). Fetal interventions. Throughout the course of her pregnancy, mul- kidneys and bladder appeared increasingly pronounced tiple therapeutic interventions were performed in order to maintain a stable fetal environment, including intrauterine with bilateral hydronephrosis and bladder distension vi- paracentesis, transabdominal amnioinfusion, vesicocente- sualized on ultrasound. At 28.5 weeks, a third amnioin- sis, and placement of a peritoneal amniotic shunt. The pur- fusion along with a vesicocintesis was performed. Close pose of this case report is to investigate the role of fetal in- monitoring revealed gradually worsening hydronephro- tervention in second trimester abnormal ultrasound findings and improve the quality of future prenatal consultation and sis but stable low-normal AFI over the upcoming weeks. therapy. At 34.5 weeks, AFI abruptly dropped. Poor profusion to right fetal kidney, and a sudden change in fetal urinary Keywords output led to an emergent cesarean section due to con- Fetal intervention, Invasive fetal therapy, Oligohydramnios cern for pending renal failure. management, Intrauterine paracentesis, Transabdominal amnioinfusion, Peritoneal amniotic shunt, Case report Case Report The patient is a 35-year-old gravida 1 para 0 who Introduction presented for an urgent consult to our Maternal Fetal Throughout this case, intrauterine fluid was manipu- Medicine group at 24.2 weeks gestation. Routine ul- lated through multiple procedures due to evolving om- trasound with prior OB revealed sudden onset of fetal inous ultrasound findings. An intrauterine paracentesis ascites and scalp edema in the absence of any prior of ascites fluid was initially performed to decompress pregnancy abnormalities. Repeat ultrasound confirmed the fetal abdomen, alongside an amnioinfusion to cor- findings (Figure 1 and Figure 2). Fetal echo was also rect oligohydramnios. With all normal prenatal screen- performed at 24.2 weeks, and cardiac function was nor- Citation: Roshan D, Kolman E, Plonka S, Timor I (2020) Antenatal Management of Second Trimester Oligohydramnios and Evolving Abnormal Ultrasound Findings: Case Report. Obstet Gynecol Cases Rev 7:183. doi.org/10.23937/2377-9004/1410183 Accepted: December 01, 2020: Published: December 03, 2020 Copyright: © 2020 Roshan D, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Roshan et al. Obstet Gynecol Cases Rev 2020, 7:183 • Page 1 of 5 • DOI: 10.23937/2377-9004/1410183 ISSN: 2377-9004 Figure 1: Fetal ascites. Figure 2: Fetal scalp edema. Roshan et al. Obstet Gynecol Cases Rev 2020, 7:183 • Page 2 of 5 • DOI: 10.23937/2377-9004/1410183 ISSN: 2377-9004 Figure 3: Keyhole appearance of bladder. mal. The calculated gestational age corresponded to At 28.2 weeks, the fetal urinary bladder appeared the date of her amenorrhea. Nuchal translucency in the grossly over distended, and revealed a distinct “Key- first trimester was normal, and second trimester non-in- hole” sign (Figure 3). Bilateral hydronephrosis was also vasive prenatal screening was low risk. Amniocentesis observed, indicating a lower urinary tract obstruction was performed the following day, karyotype, microar- (LUTO). AFI appeared low-normal levels without ev- ray, Noonan syndrome panel testing was negative, and idence of oligohydramnios. At 28.5 weeks, hydrone- TORCH titers were negative; the fetal gender was male. phrosis was more pronounced, and a vesicocintesis was Fetal MRI was performed at 24.6 weeks, which revealed performed to further asses the kidney function. From oligohydramnios and suspected pulmonary hypoplasia. the fetal bladder, 120 cc of urine was removed; a third The patient was counseled on possible outcomes, in- amnioinfusion was completed using 250 cc of normal sa- cluding intrauterine fetal demise, multiple anomalies, line. Fetal urine was sent for biochemistry and resulted and poor long-term prognosis. The patient opted to pro- with elevated levels of beta 2 microglobulin; urine os- ceed with all life preserving therapeutic interventions. molality and sodium levels were normal. With a clearer clinical picture of a lower urinary tract obstruction, the At 25.6 weeks gestation, an intrauterine paracente- placement of a vesico amniotic shunt was considered. sis of ascites fluid was performed as both a diagnostic Ultimately not pursued as AFI had remained stable with and therapeutic procedure. From the fetal abdomen, a no sign of recurring oligohydramnios over the following 210 cc of yellow ascites fluid was aspirated, and 60 cc weeks. Betamethasone was administered surrounding was sent for cell count and culture. Additionally, 60 cc of the multiple procedures. room temperature, normal saline was infused into the amniotic cavity. Cultured ascites fluid was found to be Twice weekly fetal surveillance revealed develop- consistent with amniotic fluid. Fetal swallowing of am- ment of bilateral hydronephrosis, much more pro- niotic fluid was observed on ultrasound. At 26.3 weeks, nounced on right fetal kidney. Normal blood flow was both ascites and oligohydramnios returned. The leading noted within the left kidney, with decreased perfusion hypothesis was an intestinal perforation leaking amni- to right kidney (Figure 4). Fetal ascites and distended fe- otic fluid. At 26.5 weeks, a double pigtail catheter was tal bladder were also consistently noted. AFI lingered at placed to serve as a peritoneal amniotic shunt. At the low-normal limits, around 8-10%. At 34.5 weeks, a sono- same time, a second amnioinfusion was performed, and gram revealed a sudden drop in AFI (2%), in conjunction 450 cc of normal saline was again infused into the am- with resolving fetal ascites and smaller appearing blad- niotic cavity. Over the following two weeks, ascites and der; all signs pointed to decreased amniotic fluid pro- AFI gradually improved. duction and pending renal failure. Baby was delivered Roshan et al. Obstet Gynecol Cases Rev 2020, 7:183 • Page 3 of 5 • DOI: 10.23937/2377-9004/1410183 ISSN: 2377-9004 Figure 4: Right fetal kidney. via emergent cesarean section at 34.5 weeks gestation, any tobacco, alcohol, and drug use. weighing 2070 grams. APGARS were 8 and 9 at 1 and 5 minutes. Baby required respiratory support at birth due Discussion to increased work of breathing. At 21 days of life, baby We present this interesting case of PUV as it was was weaned off the respirator and was stable on room unique in its atypical initial ultrasound findings of fetal air. Renal US showed cystic dysplasia in the setting of ascites and scalp edema, as most cases of PUV present posterior urethral valves (PUV). Diagnosis of PUV was with increased bladder wall thickness, bladder disten- confirmed by voiding cystourethrogram (VCUG). Fetal sion, and hydronephrosis [1,2]. The majority of cases serum creatinine was trending up since birth, started at reported in the literature occur sporadically; however, 0.80 and reached 3.53 by day 4 of life. Posterior urethral there have been cases associated with autosomal reces- valve ablation was performed on day 4. The degree of sive, x-linked recessive and polygenic or multifactorial cystic dysplasia and echogenicity of kidneys appeared inheritance [3-5]. A full genetic workup was normal, and improved on sonogram, 1 week following procedure. the patient elected all minimally invasive procedures Baby was discharged home in stable condition at 8 available to keep the fetus alive.
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